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Eating-Disordered Behaviour in Adolescents with Type 1 Diabetes
ARTICLE IN PRESS Can J Diabetes xxx (2015) 1–6
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Original Research
Eating-Disordered Behaviour in Adolescents with Type 1 Diabetes Sónia Gonçalves PhD *, Vânia Barros MPsy, A. Rui Gomes PhD School of Psychology, University of Minho, Braga, Portugal
a r t i c l e i n f o
a b s t r a c t
Article history: Received 11 September 2014 Received in revised form 11 September 2015 Accepted 17 September 2015
Objectives: To evaluate dysfunctional eating behaviour, self-esteem, social physique anxiety and quality of life in adolescents with type 1 diabetes who have differing desired weights and to evaluate the predictors of dysfunctional eating behaviour in these adolescents, with a focus on personal and psychological variables. Methods: We evaluated 79 adolescents with type 1 diabetes (mean age of 15.71 years) of both sexes (58.2% females) using the Eating Disorders Examination Questionnaire (EDE-Q), the Rosenberg Self-Esteem Scale (RSES), the Social Physique Anxiety Scale (SPAS-R) and the Diabetes Quality of Life (DQoL) measure. Results: Of the adolescents, 44 with type 1 diabetes reported the desire to maintain or increase their current weight, and 35 reported the desire to reduce their current weight. The participants with the desire to weigh less were mainly females who exercised regularly and demonstrated more frequent binge eating and purging. Additionally, this group exhibited an increased frequency of eating disturbances, such as restraint and eating, weight and shape concerns. Moreover, this group demonstrated increased social physique anxiety and decreased diabetes quality of life in relation to the impact of diabetes, worries about diabetes and satisfaction with life. Finally, predictors of eating disturbances included the desire for lower weight, higher social physique anxiety and lower diabetes-related quality of life. Conclusions: The desire for a lower weight in adolescents with type 1 diabetes may increase problems related to eating behaviour and general quality of life. © 2015 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.
Keywords: adolescents desired weight eating disordered behaviour quality of life type 1 diabetes
r é s u m é Mots clés : adolescents poids désiré troubles du comportement alimentaire qualité de vie diabète de type 1
Objectifs : Évaluer les comportements alimentaires dysfonctionnels, l’estime de soi, l’anxiété sociale liée à l’apparence physique et la qualité de vie des adolescents souffrant du diabète de type 1 dont les poids souhaités diffèrent et évaluer les prédicteurs des comportements alimentaires dysfonctionnels de ces adolescents en insistant sur les variables personnelles et psychologiques. Méthodes : Nous avons évalué 79 adolescents souffrant du diabète de type 1 (âge moyen de 15.71 ans) des deux sexes (58.2% de sexe féminin) à l’aide du questionnaire EDE–Q (Eating Disorders Examination Questionnaire), de l’échelle d’estime de soi de Rosenberg (ÉESR), de l’échelle SPAS–R (Social Physique Anxiety Scale) et de l’échelle DQoL (Diabetes Quality of Life). Résultats : Parmi les adolescents souffrant du diabète de type 1, 44 faisaient part de leur volonté de maintenir ou d’augmenter leur poids actuel et 35 faisaient par de leur volonté de réduire leur poids actuel. Les participants ayant la volonté de perdre du poids étaient principalement des filles qui faisaient régulièrement de l’exercice et manifestaient plus fréquemment des épisodes d’orgies alimentaires et de purges. Par ailleurs, ce groupe montrait une augmentation de la fréquence des troubles de l’alimentation comme les restrictions alimentaires, les préoccupations liées à l’alimentation, au poids et à la forme. De plus, ce groupe démontrait une augmentation de l’anxiété sociale liée à l’apparence physique et une diminution de la qualité de vie liée au diabète en ce qui concerne les conséquences du diabète, les inquiétudes liées au diabète et la satisfaction à l’égard de la vie. Finalement, les prédicteurs des troubles de l’alimentation étaient les suivants : la volonté de réduire leur poids, l’augmentation de l’anxiété sociale liée à l’apparence physique et la diminution de la qualité de vie liée au diabète. Conclusions : La volonté des adolescents souffrant du diabète de type 1 de réduire leur poids peut augmenter les problèmes liés aux comportements alimentaires et à la qualité de vie générale. © 2015 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.
* Address for correspondence: Sónia Gonçalves, PhD, Universidade do Minho, Escola de Psicologia, Campus de Gualtar, Braga 4710-057, Portugal. E-mail address: [email protected] 1499-2671 © 2015 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjd.2015.09.011
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Introduction Diabetes mellitus is one of the most common chronic diseases worldwide, and it is characterized by chronic hyperglycemia, which leads to macrovascular and microvascular complications. People with diabetes are responsible for multiple self-care tasks, such as the administration of insulin injections and oral medications, adherence to specific diets, exercise, weight reduction, the monitoring of injection sites and foot care (1). Type 1 diabetes is caused by autoimmune destruction of beta-pancreatic cells, and it has been reported predominantly in children younger than 15 to 18 years of age. The incidence of type 1 diabetes has been increasing by approximately 2% to 5% per year worldwide (2,3). Disordered eating, especially subthreshold eating disorders, is a common psychological problem in people with type 1 diabetes and is associated with poor diabetes control, complications and increased mortality rates. Several studies have compared the prevalences of unhealthy weight-control practices and other disordered eating behaviours among adolescents with and without type 1 diabetes, but the findings have been inconsistent; in some studies, the prevalence of unhealthful weight-control practices was higher among youth with type 1 diabetes (4–6), but in other studies, no differences were found (7,8). In a systematic review (9) of controlled studies of female patients with diabetes compared with controls without diabetes, the prevalence of anorexia nervosa was not significantly higher (0.27% vs. 0.06%), but that of bulimia nervosa was significantly greater (1.73% vs. 0.69%). When both conditions were considered together, the prevalence of diabetes was also significantly higher (2.00% vs. 0.75%). Eating attitudes and behaviours defined as subthreshold/subclinical or disordered eating are nearly twice as common in young females with diabetes (14%) compared with controls without diabetes (8%) (5). However, the general perception that there are increased prevalences of both disordered eating and eating disorders in persons with type 1 diabetes remains controversial (10). For example, a recent meta-analysis has reported that eating problems and eating disorders are more common in adolescents with type 1 diabetes than in their peers; however, restricted analysis involving measures adapted for diabetes has reported that these differences are not significant (11). Several studies have also identified risk factors for the development of disordered eating attitudes and behaviours in adolescents with diabetes (e.g. female gender, ages between 13 and 14 years for girls and above 16 years for boys, body weight and body dissatisfaction, constant food preoccupation and the presence of other psychiatric disorders, such as depression, anxiety or substance use) (12–15). Another important factor that affects the physical and mental health of adolescents with type 1 diabetes is their perception of the desired weight, namely the perception of their weight as being acceptable or unacceptable. In this study, the importance of perception of the desired weight on the personal and psychological wellbeing of adolescents with type 1 diabetes was assessed. In fact, some empirical evidence demonstrates that this variable can have an
impact on eating-disordered behaviours in exercise and sports contexts (16,17). However, considerably less research has been performed concerning the role of desired weight on the personal and psychological well-being of adolescents with type 1 diabetes. Thus, this study examined the relationships between the desired weights of adolescents with type 1 diabetes and a broad set of variables, including personal (e.g. gender and body mass index [BMI]), exerciserelated (e.g. attraction to exercise and frequency of exercise behaviour), psychological (e.g. social physique anxiety, diabetes quality of life and general self-esteem) and eating-behaviour variables. In addition, this study analyzed the predictors of dysfunctional eating behaviours in adolescents with type 1 diabetes that are assumed to be predictors of some of the described personal (e.g. gender, BMI and desired ideal weight) and psychological (e.g. social physique anxiety, diabetes quality of life and self-esteem) variables of the participants in this study. Overall, by analyzing these aspects, this study aimed to increase the understanding of some variables that ultimately can be included in interventions to prevent or diminish the onset of eating problems and eating disorders (18).
Methods Participants In this study, 79 adolescents with type 1 diabetes were evaluated (46 females, 58.2%) who ranged in age from 12 to 19 years (M=15.71; SD=2.23). The participants were divided according to the desired ideal weight. The majority (55.7%, n=44) of the participants reported the desire to maintain or increase their current weight, and 44.3% (n=35) reported the desire to reduce their current weight (Table 1). No significant differences in age were found in these groups (t [77]=54; p=59). However, significant differences in BMIs were observed (t[74]=3.42; p<.01). The group that desired lower weight had higher BMIs than the group with the same or higher desired weight (M=24.2, SD=2.75 vs. M=22.0, SD=2.84). Measures Demographic and exercise information Personal (e.g. gender, age, weight, height and desired ideal weight) and exercise (e.g. attraction to exercise and exercise frequency per week) information were assessed. The Eating Disorders Examination Questionnaire The Eating Disorders Examination Questionnaire (EDE-Q) (19,20) is a 41-item self-report questionnaire that asks specific questions pertaining to the presence and frequency of eating-disorder behaviours and thoughts and feelings about the body over the past 28 days. Higher scores indicate greater pathology across the 4 subscales of restraint: alpha=.82 for this study; eating concern alpha=.86 for this study; weight concern alpha=.82 for this study and shape concern alpha=.76 for this study. It is also possible to
Table 1 Ages, body mass indices and genders of the participants
Age BMI
Gender BMI, body mass indices.
Lower weight (n=35) M (SD)
Same or higher weight (n=44) M (SD)
Total (n=79) M (SD)
15.86 (1.97) 24.21 (2.75)
15.59 (2.43) 22.04 (2.84)
15.71 (2.23) 23.00 (2.99)
Female n (%)
Male n (%)
Female n (%)
Male n (%)
Female n (%)
Male n (%)
26 (56.5%)
9 (27.3%)
20 (43.5%)
24 (72.7%)
46 (41.7%)
33 (58.3%)
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calculate a global score from the average of the 4 subscale scores (alpha=.91 for this study). In addition, the EDE-Q includes 6 items used to evaluate specific behaviours related to eating disorders; 4 of these items are used to evaluate binge eating and compensatory behaviours over the past 28 days.
weight, multivariate analysis of variance was used for the subscales of the multidimensional instruments, and t tests for independent samples were used for the global score of the instruments. To predict disordered eating behaviour (EDE-Q total score), blocked entry regression analysis was applied.
Social Physique Anxiety Scale The Social Physique Anxiety Scale (SPAS-R) (21,22) contains 9 items that evaluate anxiety experienced by people when their body/physique is evaluated by others (alpha=.92 for this study). The scores range from 12 to 60, with a high score indicating more concern about others’ evaluations of one’s body.
Associations between desired ideal weight and personal and exercise variables In the first set of analyses, we tested the associations between the desired ideal weights (i.e. the desire to maintain or increase the current weight and the desire to decrease the current weight) and the participants’ gender, attraction to exercise and frequency of exercise behaviour. We found a significant association between the desired ideal weight and the participants’ gender (chi-square[1]=6.66; p<.01); 56.5% of the female participants demonstrated a desire for lower weight, and 55.7% of the male participants demonstrated a desire for the same or higher weight. No association was found between the desired ideal weight and attraction to exercise (chisquare[1]=0.8; p=.78). In the third analysis, we found a significant association between the desired ideal weight and the frequency of exercise behaviour (chi-square[1]=.10; p<.01). In this case, 67.4% of the participants with lower exercise frequencies (i.e. a maximum of 2 exercise sessions per week) demonstrated the desire to maintain or increase their current weight, and 60.6% of those with regular exercise frequencies (i.e. 3 or more exercise sessions per week) demonstrated the desire to reduce their weight.
Diabetes Quality of Life The Diabetes Quality of Life (DQoL) questionnaire (23,24) contains 52 items that evaluate the following 4 dimensions: the impact of diabetes (alpha=.84 for this study); worries about diabetes (alpha=.86 for this study); satisfaction with life (alpha=.79 for this study) and health perception (alpha=.78 for this study). The questions are scored from 1 to 5, except for health perception, which is scored from 1 to 4. A lower score indicates a better quality of life. It is also possible to calculate a global score by summing the scores for the 4 dimensions (alpha=.83 for this study). Rosenberg Self-Esteem Scale The Rosenberg Self-Esteem Scale (RSES) (25,26) is a 10-item questionnaire that assesses overall self-esteem and self-worth (alpha=.79 for this study), and the scores range from 10 to 40. Higher scores indicate higher self-esteem. Procedures This study was reviewed and approved by the internal review board of the Research Centre of Psychology (University of Minho, Braga, Portugal) and conformed to both national and European regulations concerning the conducting of research with human participants and the management of personal data. The participants of this study were adolescents with diabetes who were registered with a local Portuguese diabetes association (Minho Association). The initial contact was made by the president of this association, an endocrinologist. After the initial contact, all of the adolescents were contacted by e-mail. The e-mail provided information regarding the aims and methods of the study. The Association of Minho Diabetics had 350 associates; however, only 79 were adolescents. All of them answered the questionnaires and provided written informed consent before participating in this study. Data analysis First, exploratory data analysis was performed to evaluate parametric test assumptions, and no violations were observed in most cases. In cases in which normality was not assumed, we computed parametric test statistics and their nonparametric equivalents, as recommended by Fife-Schaw (27). The results of both tests allowed us to make the same general conclusions. So we present only the parametric test results because they are more robust and allow for the use of multivariate analyses, thereby reducing the number of tests conducted and the probability of a type I error. To evaluate the associations between the nominal variables (e.g. the desire for ideal weight vs. personal and exercise variables and the desire for ideal weight vs. eating disorders), chi-square tests were performed. To assess the differences in eating behaviours according to the desired ideal weight, multivariate analysis of variance was used for the subscales of the EDE-Q, and t tests for independent samples were used for the EDE-Q global score. To evaluate the differences in psychological variables according to the desired ideal
Associations between desired ideal weight and eating disorders For this analysis, we examined the associations between the desired ideal weight and specific behaviours related to eating disorders, as assessed by the EDE-Q (Diagnostic items). We found significant differences for 2 of the 6 items, suggesting problems related to binge eating and purging (e.g. self-induced vomiting and laxative use). In fact, there was a significant association between the desired ideal weight and self-induced vomiting (chi-square[1]=23, 75; p<.01); only 2.3% of the participants reported this behaviour in the group of individuals who demonstrated the desire to maintain or increase their weight, and 48.6% of the participants reported this behaviour in the group of individuals who demonstrated the desire to decrease their weight. Additionally, significant differences were found between the desired ideal weight and laxative use (chi-square[1]=13, 43; p<.01); 11.4% of the participants with this behaviour reported the desire to maintain or increase their weight, and 48.6% reported the desire to decrease their weight. Differences in eating behaviours The purpose of this analysis was to assess the differences between the desired ideal weights (i.e. the desire to maintain or increase the current weight and the desire to decrease the current weight) in terms of eating behaviours. The results revealed significant differences between the groups (Wilks lambda=0.43, F[4,74]=24.80; p<.001). Univariate analyses showed that the group with the desire to decrease their weight demonstrated more restraint and more eating, weight and shape concerns. Additionally, this group had higher EDE-Q global scores (t[77]=6.61; p<.001). These differences are presented in Table 2. Differences in psychological variables The purpose of this analysis was to assess the differences between the desired ideal weights (i.e. the desire to maintain or increase the current weight and the desire to decrease the current weight) in terms of psychological functioning. The results revealed significant differences in social physique anxiety as determined by the SPAS-R scores (t[77]=7.01; p<.001). Higher scores were found in the group with the desire to decrease their current weight. We found significant differences in DQoL between the groups (Wilks
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Table 2 Differences between the groups in eating disorder behaviours Dimensions
Lower weight (n=35) M (SD)
Same or higher weight (n=44) M (SD)
F (1.77)
t
EDE-Q: Restraint EDE-Q: Shape concern EDE-Q: Eating concern EDE-Q: Weight concern EDE-Q: Global score
13.37 19.23 8.94 15.89 57.42
5.95 14.09 3.98 7.11 31.34
43.97*** 8.63*** 22.72*** 66.38*** —
— — — — 6.61***
(4.47) (8.72) (5.61) (6.06) (20.15)
(5.28) (6.83) (3.60) (3.28) (15.19)
EDE-Q, Eating Disorders Examination Questionnaire. *** p<.001.
Table 3 Differences between the groups in psychological variables Dimensions
Lower weight (n=35) M (SD)
Same or higher weight (n=44) M (SD)
F (1,77)
t
SPAS-R: Social physique anxiety DQoL: Impact of diabetes DQoL: Worries about diabetes DQoL: Satisfaction with life DQoL: Health perception DQoL: Global score RSES: Self-esteem scale
29.80 24.49 29.69 20.45 31.62 106.42 24.82
19.68 21.67 24.95 17.05 29.84 93.72 25.68
— 5.91* 10.63** 10.69** 2.25n.s. — —
7.01*** — — — — 4.84*** −1.49n.s.
(6.37) (5.19) (6.57) (4.49) (3.50) (12.58) (2.64)
(6.37) (5.09) (6.28) (4.70) (6.31) (10.72) (2.44)
DQoL, Diabetes Quality of Life; n.s., not significant; RSES, Rosenberg Self-Esteem Scale; SPAS-R, Social Physique Anxiety Scale. * p<.05; ** p<.01; *** p<.001.
Table 4 Regression model for prediction of global scores on the Eating Disorders Examination Questionnaire
Block 1: Gendera Block 2: BMI Block 3: Desired ideal weight
R2 (R2 adjusted)
F
.03 (.02)
(1.77) 2.53 n.s. (2.76) 2.10 n.s. (3.75) 14.55*** (4.74) 21.06*** (5.73) 21.85*** (6.72) 23.63***
.05 (.03) b
.37 (.34)
Block 4: SPAS-R: Social physique anxiety (global score)
.53 (.51)
Block 5: DQoL: Diabetes quality of life (global score)
.60 (.57)
Block 6: RSES: Self-esteem scale (global score)
.66 (.64)
Beta
t
.18
1.59 n.s.
.14
1.28 n.s.
−.63
6.12***
.52
5.10***
.31
3.50**
−.28
−3.69***
BMI, body mass index; n.s., not significant. a Gender: 0, male; 1, female. b Desired ideal weight: 0, lower than the current weight; 1, same as or higher than the current weight. ** p<.01; *** p<.001.
lambda=0.71, F[4,74]=7.35; p<.001). Univariate analyses showed that the group with the desire to decrease their current weight scored higher on the dimensions related to the impact of diabetes, worries about diabetes and satisfaction with life. Additionally, this group had higher DQoL global scores (t[77]=4.84; p<.001). No differences were found with the self-esteem instrument RSES (t[77]=−1.49; p=.14). All of these results are presented in Table 3. Predictors of eating disturbance In the final set of analyses, we predicted disordered eating behaviours (EDE-Q global score) using personal (e.g. gender, BMI and desired ideal weight) and psychological (e.g. social physique anxiety, diabetes quality of life and self-esteem) variables as predictors. Regarding the personal variables, gender and BMI were not significant predictors of disordered eating behaviour. However, desired ideal weight was a significant predictor, and the model accounted for 34% of the variance associated with this behaviour. A desire to decrease the current weight was predictive of disordered eating behaviour.
Regarding the psychological variables, social physique anxiety (the SPAS-R instrument) was a significant predictor, and this model explained 51% of the variance associated with disordered eating behaviour. Higher social physique anxiety predicted this behaviour. Diabetes quality of life (the DQoL instrument) was also a significant predictor, and the model explained 57% of the variance associated with disordered eating behaviour. Lower DQoL predicted this behaviour. In the last block, self-esteem (the RSES instrument) was a significant predictor, and the final model explained 64% of the variance associated with disordered eating behaviour. Lower selfesteem predicted this behaviour. These results are presented in Table 4.
Discussion To our knowledge, this is the first study to evaluate dysfunctional eating behaviours and other psychological variables, such as self-esteem, social physical anxiety and quality of life, in adolescents with type 1 diabetes who have differing desired weights.
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According to our results, the desire for lower weight seems to be associated with regular exercise routines (3 or more exercise sessions per week) in adolescents with type 1 diabetes. Exercise offers many health-promoting benefits for these adolescents. With the increased prevalence of overweight and obesity in these individuals, exercise is encouraged as an important component of weightmanagement strategies. Notably, 10% to 20% of hypoglycemic episodes in the pediatric population are associated with exercise that is generally of greater than usual intensity, duration or frequency (28). Intervention is, therefore, critical to enhance exercise in a safe manner to promote health benefits and to prevent increases in medical risks or the risks for morbidity and mortality. It is not surprising that our results show that the desire for lower weight was higher in adolescent females compared with males. These findings parallel findings in other studies of adolescents (29) and of adolescents with type 1 diabetes (30). We also found that the adolescents with type 1 diabetes who reported the desire for lower weight tended to present more frequently with eating disturbances, such as eating restraint, weight and shape concerns and binging and purging behaviours. A substantial proportion of the adolescents with type 1 diabetes who reported the desire for lower weight reported binge-purge behaviours. Several well-controlled studies (13,30,31) have suggested that disordered eating is more common in individuals with type 1 diabetes than in those without type 1 diabetes, but until now, no study has shown that disturbed eating behaviours are more common in adolescents with lower desired weight. This finding has important clinical implications because it suggests that adolescents with the desire for lower weight may be at a higher risk for developing disturbed eating behaviours than their peers who desire to maintain or increase their weight. Therefore, interventions focused on helping adolescents with type 1 diabetes to develop positive feelings about their weight and appearance may protect them from developing these behaviours (18). Additionally, the present results show that adolescents with type 1 diabetes and with lower desired weight report higher social physical anxiety and lower qualities of life. Diabetes may be associated with psychosocial difficulties among adolescents, given the normative challenges that adolescents face and the additional challenges posed by self-care and metabolic control. Several literature reviews (e.g. (32,33)) have indicated that diabetes is associated with some psychosocial difficulties. However, other studies (34,35) have shown that this disease is not associated with psychosocial difficulties. Our results suggest that adolescents with type 1 diabetes who desire lower weight experience problems with social physical anxiety and quality of life. Weight concerns may, therefore, increase the risk for psychosocial difficulties in these adolescents. High BMIs, depression, weight and shape concerns, low global and physical self-worth and low self-esteem have been postulated to be important risk factors for the development of disturbed eating behaviours in adolescents with type 1 diabetes (13,18). The findings of this study do not support high BMI or the female gender as being predictors of eating disturbances among adolescents with type 1 diabetes. These findings highlight the fact that weight concerns, per se, may partially explain the increased risk for eating disturbances. The present study has several limitations. First, the crosssectional design does not allow for conclusions to be drawn about the direction of influence among variables. Second, the small sample size does not permit generalizations in this population. Third, the screening measure for eating disorders (EDE-Q) has not been developed for use in youth with diabetes. Fourth, the higher BMIs in the subgroup with reportedly lower desired weight could partially explain some of the observed differences. Fifth, the lack of assessment of any medical indicators for type 1 diabetes and the absence of a measure of diabetes control represented further limitations.
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Conclusions In summary, the desire for lower weight in adolescents with type 1 diabetes is associated with some healthful behaviours such as exercise and also with some disordered eating behaviours, such as binging and purging. This finding is particularly important considering that adolescents with diabetes may have a greater desire for weight loss than their healthy peers (36) and that these eatingdisordered behaviours may be related to poor glycemic control. On the other hand, concern with weight may amplify problems related not only to dietary intake but also to quality of life and psychological problems. Future research should focus on the identification of moderators between the desire for lower weight and the use of unhealthy weight-control methods by youth with type 1 diabetes.
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Original Research
Eating-Disordered Behaviour in Adolescents with Type 1 Diabetes Sónia Gonçalves PhD *, Vânia Barros MPsy, A. Rui Gomes PhD School of Psychology, University of Minho, Braga, Portugal
a r t i c l e i n f o
a b s t r a c t
Article history: Received 11 September 2014 Received in revised form 11 September 2015 Accepted 17 September 2015
Objectives: To evaluate dysfunctional eating behaviour, self-esteem, social physique anxiety and quality of life in adolescents with type 1 diabetes who have differing desired weights and to evaluate the predictors of dysfunctional eating behaviour in these adolescents, with a focus on personal and psychological variables. Methods: We evaluated 79 adolescents with type 1 diabetes (mean age of 15.71 years) of both sexes (58.2% females) using the Eating Disorders Examination Questionnaire (EDE-Q), the Rosenberg Self-Esteem Scale (RSES), the Social Physique Anxiety Scale (SPAS-R) and the Diabetes Quality of Life (DQoL) measure. Results: Of the adolescents, 44 with type 1 diabetes reported the desire to maintain or increase their current weight, and 35 reported the desire to reduce their current weight. The participants with the desire to weigh less were mainly females who exercised regularly and demonstrated more frequent binge eating and purging. Additionally, this group exhibited an increased frequency of eating disturbances, such as restraint and eating, weight and shape concerns. Moreover, this group demonstrated increased social physique anxiety and decreased diabetes quality of life in relation to the impact of diabetes, worries about diabetes and satisfaction with life. Finally, predictors of eating disturbances included the desire for lower weight, higher social physique anxiety and lower diabetes-related quality of life. Conclusions: The desire for a lower weight in adolescents with type 1 diabetes may increase problems related to eating behaviour and general quality of life. © 2015 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.
Keywords: adolescents desired weight eating disordered behaviour quality of life type 1 diabetes
r é s u m é Mots clés : adolescents poids désiré troubles du comportement alimentaire qualité de vie diabète de type 1
Objectifs : Évaluer les comportements alimentaires dysfonctionnels, l’estime de soi, l’anxiété sociale liée à l’apparence physique et la qualité de vie des adolescents souffrant du diabète de type 1 dont les poids souhaités diffèrent et évaluer les prédicteurs des comportements alimentaires dysfonctionnels de ces adolescents en insistant sur les variables personnelles et psychologiques. Méthodes : Nous avons évalué 79 adolescents souffrant du diabète de type 1 (âge moyen de 15.71 ans) des deux sexes (58.2% de sexe féminin) à l’aide du questionnaire EDE–Q (Eating Disorders Examination Questionnaire), de l’échelle d’estime de soi de Rosenberg (ÉESR), de l’échelle SPAS–R (Social Physique Anxiety Scale) et de l’échelle DQoL (Diabetes Quality of Life). Résultats : Parmi les adolescents souffrant du diabète de type 1, 44 faisaient part de leur volonté de maintenir ou d’augmenter leur poids actuel et 35 faisaient par de leur volonté de réduire leur poids actuel. Les participants ayant la volonté de perdre du poids étaient principalement des filles qui faisaient régulièrement de l’exercice et manifestaient plus fréquemment des épisodes d’orgies alimentaires et de purges. Par ailleurs, ce groupe montrait une augmentation de la fréquence des troubles de l’alimentation comme les restrictions alimentaires, les préoccupations liées à l’alimentation, au poids et à la forme. De plus, ce groupe démontrait une augmentation de l’anxiété sociale liée à l’apparence physique et une diminution de la qualité de vie liée au diabète en ce qui concerne les conséquences du diabète, les inquiétudes liées au diabète et la satisfaction à l’égard de la vie. Finalement, les prédicteurs des troubles de l’alimentation étaient les suivants : la volonté de réduire leur poids, l’augmentation de l’anxiété sociale liée à l’apparence physique et la diminution de la qualité de vie liée au diabète. Conclusions : La volonté des adolescents souffrant du diabète de type 1 de réduire leur poids peut augmenter les problèmes liés aux comportements alimentaires et à la qualité de vie générale. © 2015 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.
* Address for correspondence: Sónia Gonçalves, PhD, Universidade do Minho, Escola de Psicologia, Campus de Gualtar, Braga 4710-057, Portugal. E-mail address: [email protected] 1499-2671 © 2015 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjd.2015.09.011
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Introduction Diabetes mellitus is one of the most common chronic diseases worldwide, and it is characterized by chronic hyperglycemia, which leads to macrovascular and microvascular complications. People with diabetes are responsible for multiple self-care tasks, such as the administration of insulin injections and oral medications, adherence to specific diets, exercise, weight reduction, the monitoring of injection sites and foot care (1). Type 1 diabetes is caused by autoimmune destruction of beta-pancreatic cells, and it has been reported predominantly in children younger than 15 to 18 years of age. The incidence of type 1 diabetes has been increasing by approximately 2% to 5% per year worldwide (2,3). Disordered eating, especially subthreshold eating disorders, is a common psychological problem in people with type 1 diabetes and is associated with poor diabetes control, complications and increased mortality rates. Several studies have compared the prevalences of unhealthy weight-control practices and other disordered eating behaviours among adolescents with and without type 1 diabetes, but the findings have been inconsistent; in some studies, the prevalence of unhealthful weight-control practices was higher among youth with type 1 diabetes (4–6), but in other studies, no differences were found (7,8). In a systematic review (9) of controlled studies of female patients with diabetes compared with controls without diabetes, the prevalence of anorexia nervosa was not significantly higher (0.27% vs. 0.06%), but that of bulimia nervosa was significantly greater (1.73% vs. 0.69%). When both conditions were considered together, the prevalence of diabetes was also significantly higher (2.00% vs. 0.75%). Eating attitudes and behaviours defined as subthreshold/subclinical or disordered eating are nearly twice as common in young females with diabetes (14%) compared with controls without diabetes (8%) (5). However, the general perception that there are increased prevalences of both disordered eating and eating disorders in persons with type 1 diabetes remains controversial (10). For example, a recent meta-analysis has reported that eating problems and eating disorders are more common in adolescents with type 1 diabetes than in their peers; however, restricted analysis involving measures adapted for diabetes has reported that these differences are not significant (11). Several studies have also identified risk factors for the development of disordered eating attitudes and behaviours in adolescents with diabetes (e.g. female gender, ages between 13 and 14 years for girls and above 16 years for boys, body weight and body dissatisfaction, constant food preoccupation and the presence of other psychiatric disorders, such as depression, anxiety or substance use) (12–15). Another important factor that affects the physical and mental health of adolescents with type 1 diabetes is their perception of the desired weight, namely the perception of their weight as being acceptable or unacceptable. In this study, the importance of perception of the desired weight on the personal and psychological wellbeing of adolescents with type 1 diabetes was assessed. In fact, some empirical evidence demonstrates that this variable can have an
impact on eating-disordered behaviours in exercise and sports contexts (16,17). However, considerably less research has been performed concerning the role of desired weight on the personal and psychological well-being of adolescents with type 1 diabetes. Thus, this study examined the relationships between the desired weights of adolescents with type 1 diabetes and a broad set of variables, including personal (e.g. gender and body mass index [BMI]), exerciserelated (e.g. attraction to exercise and frequency of exercise behaviour), psychological (e.g. social physique anxiety, diabetes quality of life and general self-esteem) and eating-behaviour variables. In addition, this study analyzed the predictors of dysfunctional eating behaviours in adolescents with type 1 diabetes that are assumed to be predictors of some of the described personal (e.g. gender, BMI and desired ideal weight) and psychological (e.g. social physique anxiety, diabetes quality of life and self-esteem) variables of the participants in this study. Overall, by analyzing these aspects, this study aimed to increase the understanding of some variables that ultimately can be included in interventions to prevent or diminish the onset of eating problems and eating disorders (18).
Methods Participants In this study, 79 adolescents with type 1 diabetes were evaluated (46 females, 58.2%) who ranged in age from 12 to 19 years (M=15.71; SD=2.23). The participants were divided according to the desired ideal weight. The majority (55.7%, n=44) of the participants reported the desire to maintain or increase their current weight, and 44.3% (n=35) reported the desire to reduce their current weight (Table 1). No significant differences in age were found in these groups (t [77]=54; p=59). However, significant differences in BMIs were observed (t[74]=3.42; p<.01). The group that desired lower weight had higher BMIs than the group with the same or higher desired weight (M=24.2, SD=2.75 vs. M=22.0, SD=2.84). Measures Demographic and exercise information Personal (e.g. gender, age, weight, height and desired ideal weight) and exercise (e.g. attraction to exercise and exercise frequency per week) information were assessed. The Eating Disorders Examination Questionnaire The Eating Disorders Examination Questionnaire (EDE-Q) (19,20) is a 41-item self-report questionnaire that asks specific questions pertaining to the presence and frequency of eating-disorder behaviours and thoughts and feelings about the body over the past 28 days. Higher scores indicate greater pathology across the 4 subscales of restraint: alpha=.82 for this study; eating concern alpha=.86 for this study; weight concern alpha=.82 for this study and shape concern alpha=.76 for this study. It is also possible to
Table 1 Ages, body mass indices and genders of the participants
Age BMI
Gender BMI, body mass indices.
Lower weight (n=35) M (SD)
Same or higher weight (n=44) M (SD)
Total (n=79) M (SD)
15.86 (1.97) 24.21 (2.75)
15.59 (2.43) 22.04 (2.84)
15.71 (2.23) 23.00 (2.99)
Female n (%)
Male n (%)
Female n (%)
Male n (%)
Female n (%)
Male n (%)
26 (56.5%)
9 (27.3%)
20 (43.5%)
24 (72.7%)
46 (41.7%)
33 (58.3%)
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calculate a global score from the average of the 4 subscale scores (alpha=.91 for this study). In addition, the EDE-Q includes 6 items used to evaluate specific behaviours related to eating disorders; 4 of these items are used to evaluate binge eating and compensatory behaviours over the past 28 days.
weight, multivariate analysis of variance was used for the subscales of the multidimensional instruments, and t tests for independent samples were used for the global score of the instruments. To predict disordered eating behaviour (EDE-Q total score), blocked entry regression analysis was applied.
Social Physique Anxiety Scale The Social Physique Anxiety Scale (SPAS-R) (21,22) contains 9 items that evaluate anxiety experienced by people when their body/physique is evaluated by others (alpha=.92 for this study). The scores range from 12 to 60, with a high score indicating more concern about others’ evaluations of one’s body.
Associations between desired ideal weight and personal and exercise variables In the first set of analyses, we tested the associations between the desired ideal weights (i.e. the desire to maintain or increase the current weight and the desire to decrease the current weight) and the participants’ gender, attraction to exercise and frequency of exercise behaviour. We found a significant association between the desired ideal weight and the participants’ gender (chi-square[1]=6.66; p<.01); 56.5% of the female participants demonstrated a desire for lower weight, and 55.7% of the male participants demonstrated a desire for the same or higher weight. No association was found between the desired ideal weight and attraction to exercise (chisquare[1]=0.8; p=.78). In the third analysis, we found a significant association between the desired ideal weight and the frequency of exercise behaviour (chi-square[1]=.10; p<.01). In this case, 67.4% of the participants with lower exercise frequencies (i.e. a maximum of 2 exercise sessions per week) demonstrated the desire to maintain or increase their current weight, and 60.6% of those with regular exercise frequencies (i.e. 3 or more exercise sessions per week) demonstrated the desire to reduce their weight.
Diabetes Quality of Life The Diabetes Quality of Life (DQoL) questionnaire (23,24) contains 52 items that evaluate the following 4 dimensions: the impact of diabetes (alpha=.84 for this study); worries about diabetes (alpha=.86 for this study); satisfaction with life (alpha=.79 for this study) and health perception (alpha=.78 for this study). The questions are scored from 1 to 5, except for health perception, which is scored from 1 to 4. A lower score indicates a better quality of life. It is also possible to calculate a global score by summing the scores for the 4 dimensions (alpha=.83 for this study). Rosenberg Self-Esteem Scale The Rosenberg Self-Esteem Scale (RSES) (25,26) is a 10-item questionnaire that assesses overall self-esteem and self-worth (alpha=.79 for this study), and the scores range from 10 to 40. Higher scores indicate higher self-esteem. Procedures This study was reviewed and approved by the internal review board of the Research Centre of Psychology (University of Minho, Braga, Portugal) and conformed to both national and European regulations concerning the conducting of research with human participants and the management of personal data. The participants of this study were adolescents with diabetes who were registered with a local Portuguese diabetes association (Minho Association). The initial contact was made by the president of this association, an endocrinologist. After the initial contact, all of the adolescents were contacted by e-mail. The e-mail provided information regarding the aims and methods of the study. The Association of Minho Diabetics had 350 associates; however, only 79 were adolescents. All of them answered the questionnaires and provided written informed consent before participating in this study. Data analysis First, exploratory data analysis was performed to evaluate parametric test assumptions, and no violations were observed in most cases. In cases in which normality was not assumed, we computed parametric test statistics and their nonparametric equivalents, as recommended by Fife-Schaw (27). The results of both tests allowed us to make the same general conclusions. So we present only the parametric test results because they are more robust and allow for the use of multivariate analyses, thereby reducing the number of tests conducted and the probability of a type I error. To evaluate the associations between the nominal variables (e.g. the desire for ideal weight vs. personal and exercise variables and the desire for ideal weight vs. eating disorders), chi-square tests were performed. To assess the differences in eating behaviours according to the desired ideal weight, multivariate analysis of variance was used for the subscales of the EDE-Q, and t tests for independent samples were used for the EDE-Q global score. To evaluate the differences in psychological variables according to the desired ideal
Associations between desired ideal weight and eating disorders For this analysis, we examined the associations between the desired ideal weight and specific behaviours related to eating disorders, as assessed by the EDE-Q (Diagnostic items). We found significant differences for 2 of the 6 items, suggesting problems related to binge eating and purging (e.g. self-induced vomiting and laxative use). In fact, there was a significant association between the desired ideal weight and self-induced vomiting (chi-square[1]=23, 75; p<.01); only 2.3% of the participants reported this behaviour in the group of individuals who demonstrated the desire to maintain or increase their weight, and 48.6% of the participants reported this behaviour in the group of individuals who demonstrated the desire to decrease their weight. Additionally, significant differences were found between the desired ideal weight and laxative use (chi-square[1]=13, 43; p<.01); 11.4% of the participants with this behaviour reported the desire to maintain or increase their weight, and 48.6% reported the desire to decrease their weight. Differences in eating behaviours The purpose of this analysis was to assess the differences between the desired ideal weights (i.e. the desire to maintain or increase the current weight and the desire to decrease the current weight) in terms of eating behaviours. The results revealed significant differences between the groups (Wilks lambda=0.43, F[4,74]=24.80; p<.001). Univariate analyses showed that the group with the desire to decrease their weight demonstrated more restraint and more eating, weight and shape concerns. Additionally, this group had higher EDE-Q global scores (t[77]=6.61; p<.001). These differences are presented in Table 2. Differences in psychological variables The purpose of this analysis was to assess the differences between the desired ideal weights (i.e. the desire to maintain or increase the current weight and the desire to decrease the current weight) in terms of psychological functioning. The results revealed significant differences in social physique anxiety as determined by the SPAS-R scores (t[77]=7.01; p<.001). Higher scores were found in the group with the desire to decrease their current weight. We found significant differences in DQoL between the groups (Wilks
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Table 2 Differences between the groups in eating disorder behaviours Dimensions
Lower weight (n=35) M (SD)
Same or higher weight (n=44) M (SD)
F (1.77)
t
EDE-Q: Restraint EDE-Q: Shape concern EDE-Q: Eating concern EDE-Q: Weight concern EDE-Q: Global score
13.37 19.23 8.94 15.89 57.42
5.95 14.09 3.98 7.11 31.34
43.97*** 8.63*** 22.72*** 66.38*** —
— — — — 6.61***
(4.47) (8.72) (5.61) (6.06) (20.15)
(5.28) (6.83) (3.60) (3.28) (15.19)
EDE-Q, Eating Disorders Examination Questionnaire. *** p<.001.
Table 3 Differences between the groups in psychological variables Dimensions
Lower weight (n=35) M (SD)
Same or higher weight (n=44) M (SD)
F (1,77)
t
SPAS-R: Social physique anxiety DQoL: Impact of diabetes DQoL: Worries about diabetes DQoL: Satisfaction with life DQoL: Health perception DQoL: Global score RSES: Self-esteem scale
29.80 24.49 29.69 20.45 31.62 106.42 24.82
19.68 21.67 24.95 17.05 29.84 93.72 25.68
— 5.91* 10.63** 10.69** 2.25n.s. — —
7.01*** — — — — 4.84*** −1.49n.s.
(6.37) (5.19) (6.57) (4.49) (3.50) (12.58) (2.64)
(6.37) (5.09) (6.28) (4.70) (6.31) (10.72) (2.44)
DQoL, Diabetes Quality of Life; n.s., not significant; RSES, Rosenberg Self-Esteem Scale; SPAS-R, Social Physique Anxiety Scale. * p<.05; ** p<.01; *** p<.001.
Table 4 Regression model for prediction of global scores on the Eating Disorders Examination Questionnaire
Block 1: Gendera Block 2: BMI Block 3: Desired ideal weight
R2 (R2 adjusted)
F
.03 (.02)
(1.77) 2.53 n.s. (2.76) 2.10 n.s. (3.75) 14.55*** (4.74) 21.06*** (5.73) 21.85*** (6.72) 23.63***
.05 (.03) b
.37 (.34)
Block 4: SPAS-R: Social physique anxiety (global score)
.53 (.51)
Block 5: DQoL: Diabetes quality of life (global score)
.60 (.57)
Block 6: RSES: Self-esteem scale (global score)
.66 (.64)
Beta
t
.18
1.59 n.s.
.14
1.28 n.s.
−.63
6.12***
.52
5.10***
.31
3.50**
−.28
−3.69***
BMI, body mass index; n.s., not significant. a Gender: 0, male; 1, female. b Desired ideal weight: 0, lower than the current weight; 1, same as or higher than the current weight. ** p<.01; *** p<.001.
lambda=0.71, F[4,74]=7.35; p<.001). Univariate analyses showed that the group with the desire to decrease their current weight scored higher on the dimensions related to the impact of diabetes, worries about diabetes and satisfaction with life. Additionally, this group had higher DQoL global scores (t[77]=4.84; p<.001). No differences were found with the self-esteem instrument RSES (t[77]=−1.49; p=.14). All of these results are presented in Table 3. Predictors of eating disturbance In the final set of analyses, we predicted disordered eating behaviours (EDE-Q global score) using personal (e.g. gender, BMI and desired ideal weight) and psychological (e.g. social physique anxiety, diabetes quality of life and self-esteem) variables as predictors. Regarding the personal variables, gender and BMI were not significant predictors of disordered eating behaviour. However, desired ideal weight was a significant predictor, and the model accounted for 34% of the variance associated with this behaviour. A desire to decrease the current weight was predictive of disordered eating behaviour.
Regarding the psychological variables, social physique anxiety (the SPAS-R instrument) was a significant predictor, and this model explained 51% of the variance associated with disordered eating behaviour. Higher social physique anxiety predicted this behaviour. Diabetes quality of life (the DQoL instrument) was also a significant predictor, and the model explained 57% of the variance associated with disordered eating behaviour. Lower DQoL predicted this behaviour. In the last block, self-esteem (the RSES instrument) was a significant predictor, and the final model explained 64% of the variance associated with disordered eating behaviour. Lower selfesteem predicted this behaviour. These results are presented in Table 4.
Discussion To our knowledge, this is the first study to evaluate dysfunctional eating behaviours and other psychological variables, such as self-esteem, social physical anxiety and quality of life, in adolescents with type 1 diabetes who have differing desired weights.
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According to our results, the desire for lower weight seems to be associated with regular exercise routines (3 or more exercise sessions per week) in adolescents with type 1 diabetes. Exercise offers many health-promoting benefits for these adolescents. With the increased prevalence of overweight and obesity in these individuals, exercise is encouraged as an important component of weightmanagement strategies. Notably, 10% to 20% of hypoglycemic episodes in the pediatric population are associated with exercise that is generally of greater than usual intensity, duration or frequency (28). Intervention is, therefore, critical to enhance exercise in a safe manner to promote health benefits and to prevent increases in medical risks or the risks for morbidity and mortality. It is not surprising that our results show that the desire for lower weight was higher in adolescent females compared with males. These findings parallel findings in other studies of adolescents (29) and of adolescents with type 1 diabetes (30). We also found that the adolescents with type 1 diabetes who reported the desire for lower weight tended to present more frequently with eating disturbances, such as eating restraint, weight and shape concerns and binging and purging behaviours. A substantial proportion of the adolescents with type 1 diabetes who reported the desire for lower weight reported binge-purge behaviours. Several well-controlled studies (13,30,31) have suggested that disordered eating is more common in individuals with type 1 diabetes than in those without type 1 diabetes, but until now, no study has shown that disturbed eating behaviours are more common in adolescents with lower desired weight. This finding has important clinical implications because it suggests that adolescents with the desire for lower weight may be at a higher risk for developing disturbed eating behaviours than their peers who desire to maintain or increase their weight. Therefore, interventions focused on helping adolescents with type 1 diabetes to develop positive feelings about their weight and appearance may protect them from developing these behaviours (18). Additionally, the present results show that adolescents with type 1 diabetes and with lower desired weight report higher social physical anxiety and lower qualities of life. Diabetes may be associated with psychosocial difficulties among adolescents, given the normative challenges that adolescents face and the additional challenges posed by self-care and metabolic control. Several literature reviews (e.g. (32,33)) have indicated that diabetes is associated with some psychosocial difficulties. However, other studies (34,35) have shown that this disease is not associated with psychosocial difficulties. Our results suggest that adolescents with type 1 diabetes who desire lower weight experience problems with social physical anxiety and quality of life. Weight concerns may, therefore, increase the risk for psychosocial difficulties in these adolescents. High BMIs, depression, weight and shape concerns, low global and physical self-worth and low self-esteem have been postulated to be important risk factors for the development of disturbed eating behaviours in adolescents with type 1 diabetes (13,18). The findings of this study do not support high BMI or the female gender as being predictors of eating disturbances among adolescents with type 1 diabetes. These findings highlight the fact that weight concerns, per se, may partially explain the increased risk for eating disturbances. The present study has several limitations. First, the crosssectional design does not allow for conclusions to be drawn about the direction of influence among variables. Second, the small sample size does not permit generalizations in this population. Third, the screening measure for eating disorders (EDE-Q) has not been developed for use in youth with diabetes. Fourth, the higher BMIs in the subgroup with reportedly lower desired weight could partially explain some of the observed differences. Fifth, the lack of assessment of any medical indicators for type 1 diabetes and the absence of a measure of diabetes control represented further limitations.
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Conclusions In summary, the desire for lower weight in adolescents with type 1 diabetes is associated with some healthful behaviours such as exercise and also with some disordered eating behaviours, such as binging and purging. This finding is particularly important considering that adolescents with diabetes may have a greater desire for weight loss than their healthy peers (36) and that these eatingdisordered behaviours may be related to poor glycemic control. On the other hand, concern with weight may amplify problems related not only to dietary intake but also to quality of life and psychological problems. Future research should focus on the identification of moderators between the desire for lower weight and the use of unhealthy weight-control methods by youth with type 1 diabetes.
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