Insulin and Clinical Eating Disorders in Diabetes

The research on the concurrence of an eating disorder and type 1 diabetes has been done since about 1980. As with eating disorders in the general population, an eating disorder concurrent with type 1 diabetes is most commonly seen in young women: The prevalence has been reported to be about 10% of young, female type 1 diabetic patients. This clinical condition brings about significant difficulties in the course of diabetes such as nonadherence to the diabetes self-care regimen, marked deterioration of metabolic control, and an increased risk of the long-term complications of diabetes. Moreover, the quality of life of these patients tends to become quite miserable, with severe psychological distress in addition to medical problems. Eating disorders are generally considered to have multiple etiologies including biological, psychological, familial, cultural, and social factors. Along with these general factors, factors peculiar to type 1 diabetes may increase the risk of developing an eating disorder. For example, chronic dietary restraint, weight gain associated with appropriate diabetes self-care, psychosocial problems related to diabetes, and insulin omission as an easy and effective method for weight control. Eating disorders associated with binge eating, such as bulimia nervosa and binge-eating disorder, are the most common types of eating disorders among girls with diabetes. Although insulin omission is pervasive in females with type 1 diabetes, insulin omission by a patient with an eating disorder is especially marked in degree and frequency and brings about significant problems with metabolic control and the development of complications. Studies related to the treatment of the eating disorder of diabetes patients are comparatively few, and most have reported that significant improvement is extremely difficult. Based on our experience in the treatment of over 150 type 1 diabetes patients with a clinical eating disorder over the past 15 years, we have made a step-by-step treatment system according to the severity of the psychopathology. Although most patients have responded to the therapy, it often takes much time and energy before the eating disorder and diabetic control become sufficiently improved. Some patients never recover satisfactorily. The creation of effective methods for preventing the development of an eating disorder is critical and is the future challenge of researchers in this field. Self-destructive behaviors, such as recurrent diabetic ketoacidosis, frequent severe hypoglycemic attacks, and brittle diabetes, are often closely associated with severe insulin omission or insulin manipulation, seem to coincide with severe psychological disturbance and often overlap with eating disorders.