with diabetes (Ackard 2008).
Bulimic behaviors and insulin omission are the most commonly reported DEB in patients with T1D (Goebel-Fabbri 2008, Alice Hsu 2009), whereas caloric restriction/restraint and binging are more commonly reported by women with T2D (Herpertz 2001, Young-Hyman 2010). Rates of DEB in boys with diabetes have been shown to be considerably lower than those found for women (Meltzer 2001, Neumark-Sztainer 2002a) but may be increasing (Svensson 2003). Higher prevalence of T2D in minority populations could potentially be associated with increased rates of DEB but this relationship has not yet been demonstrated. Studies that compare occurrence of DEB in patients with type 1 versus type 2 diabetes show similar rates; however, types of behaviors reported differ. “Drive for thinness” and “body dissatisfaction” are more common in individuals with T2D. Intentional insulin omission (to cause glycosuria) is more common in patients with T1D (Herpertz 1998b, Herpertz 2001).
Among overweight young women attempting weight loss, both with (type 1) and without diabetes, weight status is a strong predictor of DEB (Striegel-Moore 1992, Vamado 1997, Arriaza 2001, Sherwood 2001, Neumark-Sztainer 2002b, Rodin 2002, Decaluwe 2003, de Man Lapidoth 2006, Shisslak 2006). In studies reporting BMI, type 1 cohorts have been significantly heavier than healthy control subjects, with average BMI above the normal range. Elevation in weight, independent of diagnosis, would in itself predict higher rates of DEB (Engstrom 1999, Jones 2006). However, few studies of diabetes cohorts have compared rates of DEB with healthy control groups matched for age, sex, and weight (Engstrom 1999, Colton 2004, Jones 2006). When subjects matched for BMI were used to compare overweight and obese patients having T2D with obese nondiabetic patients seeking weight loss and an obese nonclinical sample (Battaglia 2006), low levels of binge eating disorder were diagnosed overall (<5% in all groups). However, obese patients with diabetes had the lowest scores on the Eating Disorder Examination, but the highest scores on the Restraint scale (Mannucci 2002). Higher scores on the Restraint scale were attributed to treatment behaviors. Although there is robust documentation that behavior generally considered subclinical DEB using DSM criteria such as binge eating, purging (defined as intentional insulin omission), and caloric restriction are commonly reported by patients with diabetes (Fairburn 1991, Bryden 1999, Jones 2006), it is not known how much these reports reflect cognitions based on attempted adherence to the diabetes care regimen.
Weight gain consequent to good blood glucose control could be a driver of weight concerns (Meltzer 2001, Battaglia 2006) and is known to be a side effect of successful treatment (Steel 1990). Although the presumption is that DEB in this population is associated with elevated BMI levels, only one study stratified the diabetes cohort (both type 1 and 2 diabetes, men and women, age range 18–65 years) by weight status. Three percent of under- and normal weight women had a current ED, whereas 6.8% of the overweight and 10.3% of obese women reported DEB (Herpertz 1998b). These rates are similar to samples with equivalent BMIs seeking weight loss (Vamado 1997). A conflict may exist between the need to control weight and achieve good glycemic control (in patients with both T1D and T2D). In particular, young adult and adolescent women have been shown to use insulin omission specifically for weight control (Biggs 1994, Khan 1996). Fear of improved glycemic control “because I will gain weight” and diabetes-specific distress predict intentional insulin omission (Polonsky 1994). Although one goal of medical nutrition therapy (MNT) is to prevent weight gain (Nathan 2005), supervised weight management programs are not routinely available when weight gain occurs secondary to successful treatment with insulin.
Etiology of ED and DEB in the Diabetes Population: Psychiatric Symptoms, Regimen Compliance (or Noncompliance), or Physiologic Dysregulation
Primary risk factors for ED and DEB (in the nondiabetic population) are weight and size concerns, early eating problems and dieting, the presence of other forms of psychopathology, sexual abuse and other adverse life experiences, and low self-worth (Jacobi 2004). Except for weight concerns and depression, the relationships between these risk factors and occurrence of DEB in the diabetic population have received little attention.
Establishing the occurrence of DEB attributable to having diabetes and managing the disease is complicated by the paucity of studies that concurrently assess psychiatric symptoms, psychological adjustment to illness, and sequelae of the diabetes care regimen. Bryden et al. (1999) tracked BMI along with weight and shape concerns in adolescents and young adults with T1D; as both men and women became overweight, DEB increased. However, baseline and ongoing psychological status, independent of weight concerns, was not assessed. In contrast, Pollock et al. (1995) followed new-onset girls and boys with T1D (ages 8–13 years) from diagnosis for up to 14 years. The presence of DEB, compliance with medical regimen, and psychiatric symptoms were assessed, including weight concerns. Low rates of DSM-III diagnosable ED (3.8%) were found; however “youths with eating problems were nine times more likely to have had a psychiatric disorder than the rest of the patients” (p. 291). A recent study found that onset of insulin restriction in women with T1D was associated with fear of weight gain and problems with the self-management regimen (Goebel-Fabbri 2011). Problematic eating behavior specific to the diabetes care regimen appears to be part of a constellation of pervasive noncompliance associated with higher psychiatric morbidity or poorer adjustment to illness (Pollock 1995, Wilfley 2000, Pollock-BarZiv 2005, Goebel-Fabbri 2011).
Two studies demonstrated an association between psychiatric morbidity and DEB in patients with T2D independent of weight status. In one study, overweight and obese patients had more diagnosable ED, and patients with ED had significantly more anxiety disorders and trended towards being more depressed. In the second, DEB was also strongly associated with psychopathology such as depression, low self-esteem, and general psychopathology but not weight (Herpertz 1998b, Papelbaum 2005). Given the known comorbidity between emotional disorders (depression in particular) (Anderson 2001) and diabetes, and between emotional disorders and DEB in the healthy population (Telch 1998, Stice 1999, Stice 2000, Stice 2001, Stice 2002), DEB could be part of a constellation of poor psychological adjustment and/or poor adjustment to illness, which is comorbid with overweight and T2D (Herpertz 1998a).
Behaviors considered triggers for and pathognomonic of DEB are embedded in the diabetes treatment regimen (Bantle 2006). Lack of success with MNT can leave patients feeling out of control of both eating behavior and glycemia (Surgenor 2002). Feeling out of control of eating behavior, preoccupation with food, and calorie restriction are DSM-IV-TR diagnostic criteria for bulimia, binge eating disorder, and eating disorder not otherwise specified (American Psychiatric Association 2000). Primary criteria for binge eating disorder include subjective self-evaluation of repeatedly eating amounts of food in a short period of time that are “definitely larger than most individuals would eat under similar circumstances.” Making this subjective determination (when an amount of food is large or excessive) for an individual with diabetes could be attributable to failure to adhere to MNT prescription, especially in the context of treatment of hypoglycemia. Other possibilities exist for misattribution of adherent behavior as DEB (Polonsky 1999). As caloric restraint is prescribed as part of treatment, inaccuracies in judgment regarding appropriateness of food intake can occur in the context of carbohydrate counting, falling blood glucose level, misjudgment of the causes of symptoms (Johnson 2000, Hay 2003, Davis 2004), or excessive nutrition intake related to exercise.
Hormonal evidence for dysregulation of hunger and satiety in patients with diabetes suggests difficulty controlling food intake and consequent blood glucose levels. Further, nonphysiologic dosing of insulin impacts appetite regulation (Young-Hyman 2010). Hormonal dysregulation (including loss of endogenous insulin and amylin secretion) (Koda 1992, Kruger 1999), dysregulation of incretin production, which contributes to metabolism in the gut (Dupre 2005, Higgins 2007), complications of the disease such as gastroparesis (Parkman 2004), and fluctuations in blood glucose level, particularly hypoglycemia (ADA 2002), may predispose vulnerable patients to adoption of maladaptive weight management strategies (such as insulin manipulation) to control hunger and associated weight gain.
Measurement of ED and DEB
Most studies to date have used measurement tools
