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Disordered Eating Behaviors Among Turkish Adolescents With and Without Type 1 Diabetes
INTERNATIONAL PEDIATRIC NURSING Column Editor: Bonnie Holaday, DNS, RN, FAAN
Disordered Eating Behaviors Among Turkish Adolescents With and Without Type 1 Diabetes Rukiye Pinar, PhD
The aim of this comparative study was to determine the prevalence of disordered eating behaviors (DEBs) and its affecting factors among adolescents with Type 1 diabetes. Subjects were 45 diabetic adolescents and 55 nondiabetic healthy control subjects. The main outcome measures used were the Eating Attitudes Test and the Body Image Scale (BIS). Findings suggest that DEBs are almost four times as common in diabetic adolescents as in their nondiabetic peers ( p b .001). Strict diet restriction and insulin misuse ( p b .01) were related to DEBs. Disordered eating behaviors make a significant contribution to menstrual problems ( p b .001) and poor metabolic control ( p b .001). There was a nonsignificant negative correlation between DEBs and the BIS score. Health care professionals should be aware of the potential effect of subclinical and clinical DEBs including insulin misuse and strict diet in weight-conscious people with Type 1 diabetes who have poor metabolic control and menstrual problems. n 2005 Elsevier Inc. All rights reserved.
INCE THE EARLY 1980s, a growing number of studies have supplied epidemiological information about the incidence and prevalence of eating disorders/disordered eating behaviors (DEBs) in many countries, mostly those of the Western world. Disordered eating behaviors pose a serious risk to individuals with metabolic disorders such as Type 1 diabetes (Marcus & Wing, 1990). Disordered eating behaviors are apparently more common in diabetic patients (particularly young women) than in the general population (Pickup & Williams, 1991). Depending on the different assessment approaches and definitions of eating problems, rates of eating problems among youths with diabetes have been reported to be as high as 38% (Hudson, Wentworth, Hudson, & Pope, 1985). Specific aspects of diabetes and its management (e.g., weight gain associated with initiation of insulin treatment or improved metabolic control and dietary restraint) may trigger body dissatisfaction and drive for thinness that accompany DEBs (Engstro¨m et al., 1999; Jones, Lawson, Daneman, Olmsted, & Rodin, 2000; Marcus & Wing, 1990; Szmukler & Patton, 1995; Verrotti, Catino, De Luca, Morgese, & Chiarelli, 1999). Adolescents normally experience a conflict between dependence and independence. Powers,
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Malone, and Duncan (1983) stated that young adolescents with diabetes, however, are naturally dependent on their insulin and diabetic regimen and that the conflict is therefore greatly intensified. They may not want to confront the difficulties of becoming an adult and the responsibilities that accompany it and may develop low self-esteem as a result. These conflicts with autonomy, dependence, and low self-esteem can predispose them to develop DEBs (Love & Seaton, 1991). Disordered eating behaviors mostly affect young women (Daneman & Rodin, 1999) but also affect young men (Comerci, 1988; Halmi, 2000; Halmi, Falk, & Schwards, 1981; Johnson, 1985; Rosmark et al., 1986). Disordered eating behaviors in young women with diabetes are persistent and are associated with poor metabolic control (Crow, Keel, & Kendall, 1998; Jones et al., 2000; Rodin, From the College of Nursing, Marmara University, Istanbul, Turkey. Address correspondence and reprint requests to Rukiye Pinar, PhD, Tu¨tu¨ncu¨ Mehmet Efendi Cad, Kaptan I˙hsan Sk, Seniha Apt, No: 6, D: 1, 34700 Go¨ztepe/Istanbul, Turkey. E-mail: [email protected] 0882-5963/$ - see front matter n 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.pedn.2005.07.001
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Craven, Littlefield, Murray, & Daneman, 1991; Takii et al., 1999), diabetes-related microvascular complications, and menstrual problems (Daneman, Olmsted, Rydall, Maharaj, & Rodin, 1998; Rydall, Rodin, Olmsted, Devenyi, & Daneman, 1997; Steel, Young, Lloyd, & Clarke, 1987). The development of DEBs has been explained by biopsychosocial multifactorial models; it is suggested that DEBs should be viewed as a multidimensional construct with some core symptom dimensions including body image concern (Striegel-Moore & Huydic, 1993; Szmukler & Patton, 1995). Although there is a further wave of articles exploring DEBs with diabetic adolescents around the world, there is no study with this group in Turkey. Therefore, the aims of this study are to determine the prevalence of DEBs in Turkish adolescents with Type 1 diabetes as compared with that in their nondiabetic peers and to determine relationships between DEBs and body satisfaction and metabolic control.
METHODS
Subjects One hundred subjects aged between 12 and 18 years were recruited. Of these subjects, 45 had Type 1 diabetes and 55 were nondiabetic healthy control subjects. The diabetic group was from an outpatient diabetes clinic of a teaching and research hospital in Istanbul. Participants with diabetes had been diagnosed with Type 1 diabetes at least 1 year before their study participation. Of the potential 70 adolescents who were being seen in the outpatient diabetes clinic, 45 completed the surveys, yielding a response rate of 64.3%. The healthy control group was composed of high school students age matched from the same socioeconomic status as the diabetic patients. The diabetic and nondiabetic groups were compared by sex, age, and body mass index (BMI). The study population was equally split by sex (50% girls and 50% boys). The mean age of the total sample was 15.49 F 1.39 years (range, 12–18 years) and the mean BMI was 20.30 F 2.77 (range, 16 –30). Age and BMI were not different between the two groups. In the diabetic group, the mean duration of diabetes was 4.73 F 2.78 years (range, 1 – 9 years). Their hemoglobin A 1c (HbA1c) level ranged from 5% to 17% (M F SD, 8.47% F 2.68%).
Instruments Three questionnaires were administered: the Basic Information Form (BIF), the Eating Attitudes Test (EAT), and the Body Image Scale (BIS). The BIF consisted of two parts. In the first part, there were four questions on sex, age, BMI, and menstrual problems. The questions in the second part were for diabetic patients and were related to diabetes and adherence to diabetes regimen. These questions were on duration of diabetes, level of HbA1c, adherence to recommended diet, strict diet restriction, and intentional insulin misuse to lose weight. This study used the EAT developed by Garner and Garfinkel (1979) to determine disordered eating attitudes. The EAT, which includes 40 items, had been previously translated into Turkish and validated in Turkey by Erol and SavasVr (1989). The minimum cutoff score for disordered eating in the EAT is 30. The BIS (Secord & Jourand, 1953) was used to measure the level of concern about body shape. The BIS includes 40 items; its score ranges from 40 to 200 (the higher the score, the greater the body image satisfaction). In 1990, Hovardaogˇlu performed the Turkish translation and checked the validity and reliability of the BIS. In this study, an internal reliability test for both the EAT and the BIS was conducted; Cronbach a coefficients were found to be .89 and .87, respectively.
Study Protocol All subjects were given an identical brief stating that the purpose of the study was to evaluate eating attitudes. Participation was voluntary and strict confidentiality was ensured by giving each participant an individual code number accessible only by the researcher. Before the study began, approval from the hospital’s research ethics committee and informed verbal consent from each participant and his or her parent, when required, were obtained. The BIF collected information regarding sociodemographic and diabetes-related variables. Afterward, the sample was asked to self-complete the EAT and the BIS. Height and weight were measured and then BMI was calculated. Metabolic control was determined with HbA1c. Blood was obtained by finger prick from each diabetic subject to measure HbA1c. All samples were analyzed at the hospital’s laboratory with a BioRad (Biorad Laboratories, Hertfordshire, UK) variant high-pressure
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liquid chromatography assay (reference range, 4–7%).
Statistical Analysis Statistical analysis was performed with the Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL). Independent paired t tests were used for two-group comparisons of continuous variables. v 2 Analysis was used for data presented as proportions. Pearson’s correlation coefficients were used to examine associations between two continuous variables. Statistical significance for all analyses was taken at the 5% level. RESULTS
Prevalence of DEBs Most of the diabetic patients (73.3%) said that they adhered to their recommended diet. Seventyfive percent of them explained that they were doing strict diet restrictions from time to time to control body weight. In this study, 18 (40%) of the diabetic patients reported skipping insulin or taking less insulin as a way to control weight. The EAT scores of the diabetic patients were higher than those of the control subjects (M F SD, 33.57 F 9.54 vs. 21.76 F 12.21); the difference between the two groups was so significant (t = 5.3, p b .001). When the EAT was evaluated by the cutoff score, 31 adolescents (68.9%) in the diabetic group and 12 (21.8%) in the nondiabetic group had scores higher than the cutoff score. In the diabetic group, DEBs as assessed with the EAT tended to be higher among girls than boys, although differences were not statistically significant (t = .568, p N .05). Seventeen of the diabetic girls (70.8%) had EAT scores higher than the cutoff criterion. The EAT score was different between girls in the diabetic group and those in the control group (t = 4.96, p b .001). The EAT scores of the boys in the diabetic group were higher than those of the boys in the control group (M F SD, 31.04 F 11.34 vs. 21.57 F 12.39), but the difference between the two groups was not significant (t = 2.56, p N .05). Fourteen of the diabetic boys (66.7%) had EAT scores higher than the cutoff criterion. The EAT score was higher in diabetic patients who did strict diet restrictions (M F SD, 35.61 F 7.91 vs. 13.00 F 18.38, t = 3.69, p b .01) and misused the insulin (M F SD, 34.42 F 5.67 vs. 19.00 F 18.30, t = 3.40, p b .01) to lose weight.
Disordered Eating and Metabolic Control The positive relationship between the EAT score and mean HbA1c value was statistically significant (r = .670, p b .001). The HbA1c values in 28 diabetic patients (62.2%) were 7% and higher. In 21 of these patients (75%), the EAT score exceeded the cutoff criterion. Therefore, disordered eating was predictive of poor metabolic control.
Disordered Eating and Menstrual Problems Thirty percent of all the girls had menstrual problems. In the diabetic group, girls had more menstrual problems than expected and there was a significant statistical difference between the two groups (v 2 = 9.25, p b .01). Twelve of the diabetic girls (50%) had menstrual problems, and eight of them (66.7%) had EAT scores higher than the cutoff criterion. Three of the healthy girls (11.5%) also had menstrual problems, and two of them (66.7%) had EAT scores higher than the cutoff criterion. When evaluated as a whole, the EAT score was higher in girls who had menstrual problems than in those who did not (M F SD, 35.20 F 10.01 vs. 24.28 F 11.50) and the difference between them was significant (t = 3.19, p b .01). Again, disordered eating was predictive of menstrual problems in diabetic girls.
Disordered Eating and Body Image Satisfaction The BIS score was lower in the diabetic patients than in the control subjects (M F SD, 153.97 F 19.82 vs. 158.25 F 23.32), but the difference between the two groups was not significant (t = 1.86, p N .05). Diabetic girls had significantly lower BIS scores as compared with boys (M F SD, 145.08 F 18.28 vs. 164.14 F 16.64, t = 3.64, p b .001). There was a nonsignificant negative correlation between the BIS score and the EAT score in both diabetic patients and control subjects (r = .155, r = .080, respectively, p N .05). The relationship between BMI and the BIS score was also nonsignificant (r = .192, p N .05). DISCUSSION
Prevalence of DEBs This study has shown that disordered eating meeting the EAT cutoff criterion is approximately four times as common in diabetic adolescents as in
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their nondiabetic peers ( p b .001). Although there was no significant difference, girls in diabetic group had higher EAT scores than boys and most of them (70.8%) had DEBs. The percentage of DEBs was higher in diabetic girls than in nondiabetic girls ( p b .001). It is known that DEBs are apparently more common in diabetic patients, especially in females (Hudson et al., 1985; Levine & Marcus, 1997; Pickup & Williams, 1991). Engstro¨m et al. (1999) found a significant increase in DEBs in diabetic patients as compared with control subjects based on self-report measures. The result of this study is consistent with those of others (Engstro¨m et al., 1999; Hudson et al., 1985; Levine & Marcus, 1997; Pickup & Williams, 1991). It was also recognized that Type 1 diabetes usually preceded the onset of DEBs. The actual precipitant for DEBs in patients with Type 1 diabetes may be the typical weight gain after initiating insulin therapy. Especially in predisposed adolescent females, this weight gain may trigger the onset of DEBs, often with omission of insulin; chronic dietary restraint and preoccupation with carbohydrate restriction may further foster the development of DEBs (Garner & Garfinkel, 1997; Neumark-Sztainer et al., 2002; Rosmark et al., 1986). The cardinal feature of clinical DEBs is selfinduced weight loss. Deliberate insulin misuse and chronic dietary restraints are also common behaviors to lose weight (Garner & Garfinkel, 1997; Neumark-Sztainer et al., 2002). The most common and best-known misuse of insulin is dose omission or reduction, causing glycosuria and weight loss. In this study, 75% of the patients who adhered to their recommended diet explained that they were doing strict diet restrictions from time to time to control body weight. The number of diabetic patients who misused insulin was 18 (40%), and the EAT scores were higher in these groups ( p b .01). There are very limited studies on DEBs in diabetic boys. Furthermore, present studies show that diabetic boys have eating attitudes similar to those of nondiabetic patients (Hoffman, 2001; Neumark-Sztainer et al., 2002). In this study, 66.7% of diabetic boys exceeded the EAT cutoff score. This result needs further investigation to explore effects of some other factors (e.g., family functions about disordered eating in boys).
Disordered Eating and Metabolic Control The principal effect of a DEB on Type 1 diabetes is to worsen glycemic control as a consequence of
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excessive dieting, binge eating, vomiting, using diuretics or laxatives, and self-induced glycosuria (Rodin & Daneman, 1992; Rydall et al., 1997; Steel et al., 1987). In the present study, it has been confirmed that DEBs tend to be highly predictive of poor metabolic condition in adolescents with Type 1 diabetes ( p b .001). Similar to this study’s result, in many studies, the relationship between eating disturbances and poor metabolic control has been well established (Birk & Spencer, 1989; Fairburn, Peveler, Davies, Mann, & Mayou, 1991; Jones et al., 2000; Rodin et al., 1991; Rydall et al., 1997; Steel, Young, Lloyd, & Macintyre, 1989; Straub, Lamparter-Lang, Palitzsch, & Scholmerich, 1996; Szmukler & Russell, 1983; Vila et al., 1995; Wing, Nowalk, Marcus, Koeske, & Finegold, 1986). In this study, the mean HbA1c levels of most diabetic participants were higher than the clinic goals for adolescents at the endocrinology clinic. These findings suggest that even without a clinically significant eating disorder, the use of unhealthy weight control practices such as strict diet restrictions and insulin misuse may have serious consequences for metabolic control among adolescents with Type 1 diabetes.
Disordered Eating and Menstrual Problems It is known that girls with DEBs have some menstrual disturbances. The changes in neurotransmitter levels that result from irregular food intake can cause menstrual disturbances. Developed amenorrhea is caused by diminished secretion of growth hormones, which in turn diminishes the pituitary secretion of follicle-stimulating hormones and luteinizing hormones, which is responsible for abnormally lower levels of estrogen (Halmi, 2000). In the present study, it has been shown that diabetic girls had more menstrual problems ( p b .01) and that DEBs were predictive of menstrual problems. These findings are similar to those of several previous studies (Demir, EralpDemir, Kayaalp, & Bu¨yu¨kkal, 1998; Halmi, 2000).
Disordered Eating and Body Image Satisfaction Body image disturbance plays a prominent role in the psychopathology of DEBs. Diabetes, with its pervasive impact on most aspects of daily living, may interfere with normal developmental processes, leading to poor self-esteem and impaired ego development and body image (Hauser, Jacobson, Noam, & Powers, 1983; Jacobson et al., 1986;
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Neumark-Sztainer et al., 2002). Neumark-Sztainer, Story, Resnick, Garnick, and Blum (1995) found that adolescents with a chronic disease reported higher body dissatisfaction than control subjects. Women are more dissatisfied with their bodies and frequently engage in weight loss. In adolescent and young females at risk, the weight gain and dietary restriction of diabetes may trigger or augment typical body dissatisfaction and drive for thinness that accompany eating disturbances. Women with eating disorders will often spontaneously admit to bfeeling fat,Q being fearful of gaining weight, or being dissatisfied with their weight or specific body parts (Garner & Garfinkel, 1997; Levine & Marcus, 1997). Furthermore, young women in western cultures are also susceptible to family, peer, and societal pressures to achieve a particular body shape and weight and to unduly link selfesteem to thinness and physical appearance (Daneman et al., 1998; Striegel-Moore & Huydic, 1993). In the present study, the BIS score was lower in the diabetic patients than in the control subjects, although the difference between the two groups was not significant. In the diabetic group, the BIS scores of the girls were lower than those of the boys and statistical differences were significant ( p b .001). The results are consistent with those in related literature (Daneman et al., 1998; Garner & Garfinkel, 1997; Hauser et al., 1983; Jacobson et al., 1986; Levine, & Marcus, 1997; NeumarkSztainer et al., 2002; Neumark-Sztainer et al., 1995; Striegel-Moore & Huydic, 1993). In conclusion, adolescents with Type 1 diabetes, especially girls, are at increased risk for DEBs. Disordered eating behaviors make a significant contribution to menstrual problems and inevitably lead to poor metabolic control. This study had a number of strengths that increase the utility of the findings. The inclusion of boys in the study population expands the current body
of literature, as most studies examining eating disorders/disordered eating among individuals with Type 1 diabetes have included only girls. The use of different measures of weight control practices such as diet restriction and insulin misuse/disordered eating and, in particular, the use of the EATenhanced this study’s ability to draw conclusions from the data. Other strengths include the assessment of BMI, body satisfaction perception by the BIS, and HbA1c values using previously validated tools. A major study limitation was the relatively small sample size. Thus, prevalence of data on disordered eating and unhealthy weight control behaviors among adolescents with Type 1 diabetes should be interpreted cautiously. Furthermore, although diabetic patients and nondiabetic subjects were similar in terms of sex, age, and BMI, their small number makes it difficult to draw firm conclusions regarding the lack of sociodemographic differences in weight control/DEBs. Findings from the present study have implications for research and practice. The findings suggest a need for further research to explore the reasons why adolescents with Type 1 diabetes engage in unhealthy weight control practices despite the serious consequences of these behaviors. This study’s findings suggest that special attention should be directed toward girls, adolescents with menstrual problems, and adolescents with poor metabolic control. Finally, health care professionals should be aware of the potential effect of subclinical and clinical eating behaviors, including insulin misuse and strict diet, on weightconscious people with Type 1 diabetes who have poor metabolic control and menstrual problems. ACKNOWLEDGMENT I thank Dr. Halim ˙IYsever for the statistical analyses.
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Pickup, J. C., & Williams, G. (1991). Textbook of diabetes (p. 827). London: Blackwell Scientific Publication. Powers, P. S., Malone, J. I., & Duncan, J. A. (1983). Anorexia nervosa and diabetes mellitus. Journal of Clinical Psychiatry, 44, 133 – 135. Rodin, G. M., Craven, J., Littlefield, C., Murray, M., & Daneman, D. (1991). Eating disorders and intentional insulin under treatment in adolescent females with diabetes. Psychosomatics, 32, 171 – 176. Rodin, G. M., & Daneman, D. (1992). Eating disorders and IDDM: A problematic association. Diabetes Care, 15, 1402 – 1412. Rosmark, B., Berne, C., Holmgren, L., Lago, C., Renholm, G., & Sohlberg, S. (1986). Eating disorders in patients with insulin-dependent diabetes mellitus. Journal of Clinical Psychiatry, 47, 547 – 550. Rydall, A. C., Rodin, G. M., Olmsted, M. P., Devenyi, R. G., & Daneman, D. (1997). Disordered eating behavior and microvascular complications in young women with insulindependent diabetes mellitus. New England Journal of Medicine, 336, 1849 – 1854. Secord, P. F., & Jourand, S. M. (1953). The appraisal of bodycathexis. Journal of Consulting Psychology, 17, 313 – 317. Steel, J. M., Young, R. J., Lloyd, G. G., & Clarke, B. F. (1987). Clinically apparent eating disorders in young diabetic women: Associations with painful neuropathy and other complications. British Medical Journal, 294, 859 – 862. Steel, J. M., Young, R. J., Lloyd, G. G., & Macintyre, C. C. (1989). Abnormal eating attitudes in young insulin-dependent diabetics. British Journal of Psychiatry, 155, 515 – 521. Straub, R. H., Lamparter-Lang, R., Palitzsch, K. D., & Scholmerich, J. (1996). Association between eating behavior and current glycaemic control, body mass or autonomic nervous function in long-term Type 1 and Type 2 diabetic patients. European Journal of Clinical Investigation, 26, 564 – 568. Striegel-Moore, R. H., & Huydic, E. S. (1993). Problem drinking and symptoms of disordered eating in female high school students. International Journal of Eating Disorders, 14, 417 – 425. Szmukler, G. I., & Patton, G. (1995). Sociocultural models of eating disorders. In C. Szmukler, C. Dare, & J. Treasure (Eds.), Handbook of eating disorders: Theory, treatment and research (pp. 177 – 192). Chiester: John Wiley and Sons. Szmukler, G. I., & Russell, G. F. M. (1983). Diabetes mellitus, anorexia nervosa and bulimia. British Journal of Psychiatry, 142, 305 – 308. Takii, M., Kornaki, G., Uchigata, Y., Maeda, M., Ornori, Y., & Kubo, C. (1999). Differences between bulimia nervosa and binge-eating disorders in females with Type 1 diabetes: The important role of insulin omission. Journal of Psychosomatic Research, 47, 221 – 223. Verrotti, A., Catino, M., De Luca, F. A., Morgese, G., & Chiarelli, F. (1999). Eating disorders in adolescents with Type 1 diabetes mellitus. Acta Diabetologia, 36, 21 – 25. Vila, G., Robert, J. J., Nollet-Clemencon, C., Vera, L., Crosnier, H., & Rault, G., et al. (1995). Eating and emotional disorders in adolescent obese girls with insulin-dependent diabetes mellitus. European Journal of Child and Adolescent Psychiatry, 4, 270 – 279. Wing, R. R., Nowalk, M. P., Marcus, M. D., Koeske, R., & Finegold, D. (1986). Subclinical eating disorders and glycemic control in adolescents with Type 1 diabetes. Diabetes Care, 9, 162 – 167.
Disordered Eating Behaviors Among Turkish Adolescents With and Without Type 1 Diabetes Rukiye Pinar, PhD
The aim of this comparative study was to determine the prevalence of disordered eating behaviors (DEBs) and its affecting factors among adolescents with Type 1 diabetes. Subjects were 45 diabetic adolescents and 55 nondiabetic healthy control subjects. The main outcome measures used were the Eating Attitudes Test and the Body Image Scale (BIS). Findings suggest that DEBs are almost four times as common in diabetic adolescents as in their nondiabetic peers ( p b .001). Strict diet restriction and insulin misuse ( p b .01) were related to DEBs. Disordered eating behaviors make a significant contribution to menstrual problems ( p b .001) and poor metabolic control ( p b .001). There was a nonsignificant negative correlation between DEBs and the BIS score. Health care professionals should be aware of the potential effect of subclinical and clinical DEBs including insulin misuse and strict diet in weight-conscious people with Type 1 diabetes who have poor metabolic control and menstrual problems. n 2005 Elsevier Inc. All rights reserved.
INCE THE EARLY 1980s, a growing number of studies have supplied epidemiological information about the incidence and prevalence of eating disorders/disordered eating behaviors (DEBs) in many countries, mostly those of the Western world. Disordered eating behaviors pose a serious risk to individuals with metabolic disorders such as Type 1 diabetes (Marcus & Wing, 1990). Disordered eating behaviors are apparently more common in diabetic patients (particularly young women) than in the general population (Pickup & Williams, 1991). Depending on the different assessment approaches and definitions of eating problems, rates of eating problems among youths with diabetes have been reported to be as high as 38% (Hudson, Wentworth, Hudson, & Pope, 1985). Specific aspects of diabetes and its management (e.g., weight gain associated with initiation of insulin treatment or improved metabolic control and dietary restraint) may trigger body dissatisfaction and drive for thinness that accompany DEBs (Engstro¨m et al., 1999; Jones, Lawson, Daneman, Olmsted, & Rodin, 2000; Marcus & Wing, 1990; Szmukler & Patton, 1995; Verrotti, Catino, De Luca, Morgese, & Chiarelli, 1999). Adolescents normally experience a conflict between dependence and independence. Powers,
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Journal of Pediatric Nursing, Vol 20, No 5 (October), 2005
Malone, and Duncan (1983) stated that young adolescents with diabetes, however, are naturally dependent on their insulin and diabetic regimen and that the conflict is therefore greatly intensified. They may not want to confront the difficulties of becoming an adult and the responsibilities that accompany it and may develop low self-esteem as a result. These conflicts with autonomy, dependence, and low self-esteem can predispose them to develop DEBs (Love & Seaton, 1991). Disordered eating behaviors mostly affect young women (Daneman & Rodin, 1999) but also affect young men (Comerci, 1988; Halmi, 2000; Halmi, Falk, & Schwards, 1981; Johnson, 1985; Rosmark et al., 1986). Disordered eating behaviors in young women with diabetes are persistent and are associated with poor metabolic control (Crow, Keel, & Kendall, 1998; Jones et al., 2000; Rodin, From the College of Nursing, Marmara University, Istanbul, Turkey. Address correspondence and reprint requests to Rukiye Pinar, PhD, Tu¨tu¨ncu¨ Mehmet Efendi Cad, Kaptan I˙hsan Sk, Seniha Apt, No: 6, D: 1, 34700 Go¨ztepe/Istanbul, Turkey. E-mail: [email protected] 0882-5963/$ - see front matter n 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.pedn.2005.07.001
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Craven, Littlefield, Murray, & Daneman, 1991; Takii et al., 1999), diabetes-related microvascular complications, and menstrual problems (Daneman, Olmsted, Rydall, Maharaj, & Rodin, 1998; Rydall, Rodin, Olmsted, Devenyi, & Daneman, 1997; Steel, Young, Lloyd, & Clarke, 1987). The development of DEBs has been explained by biopsychosocial multifactorial models; it is suggested that DEBs should be viewed as a multidimensional construct with some core symptom dimensions including body image concern (Striegel-Moore & Huydic, 1993; Szmukler & Patton, 1995). Although there is a further wave of articles exploring DEBs with diabetic adolescents around the world, there is no study with this group in Turkey. Therefore, the aims of this study are to determine the prevalence of DEBs in Turkish adolescents with Type 1 diabetes as compared with that in their nondiabetic peers and to determine relationships between DEBs and body satisfaction and metabolic control.
METHODS
Subjects One hundred subjects aged between 12 and 18 years were recruited. Of these subjects, 45 had Type 1 diabetes and 55 were nondiabetic healthy control subjects. The diabetic group was from an outpatient diabetes clinic of a teaching and research hospital in Istanbul. Participants with diabetes had been diagnosed with Type 1 diabetes at least 1 year before their study participation. Of the potential 70 adolescents who were being seen in the outpatient diabetes clinic, 45 completed the surveys, yielding a response rate of 64.3%. The healthy control group was composed of high school students age matched from the same socioeconomic status as the diabetic patients. The diabetic and nondiabetic groups were compared by sex, age, and body mass index (BMI). The study population was equally split by sex (50% girls and 50% boys). The mean age of the total sample was 15.49 F 1.39 years (range, 12–18 years) and the mean BMI was 20.30 F 2.77 (range, 16 –30). Age and BMI were not different between the two groups. In the diabetic group, the mean duration of diabetes was 4.73 F 2.78 years (range, 1 – 9 years). Their hemoglobin A 1c (HbA1c) level ranged from 5% to 17% (M F SD, 8.47% F 2.68%).
Instruments Three questionnaires were administered: the Basic Information Form (BIF), the Eating Attitudes Test (EAT), and the Body Image Scale (BIS). The BIF consisted of two parts. In the first part, there were four questions on sex, age, BMI, and menstrual problems. The questions in the second part were for diabetic patients and were related to diabetes and adherence to diabetes regimen. These questions were on duration of diabetes, level of HbA1c, adherence to recommended diet, strict diet restriction, and intentional insulin misuse to lose weight. This study used the EAT developed by Garner and Garfinkel (1979) to determine disordered eating attitudes. The EAT, which includes 40 items, had been previously translated into Turkish and validated in Turkey by Erol and SavasVr (1989). The minimum cutoff score for disordered eating in the EAT is 30. The BIS (Secord & Jourand, 1953) was used to measure the level of concern about body shape. The BIS includes 40 items; its score ranges from 40 to 200 (the higher the score, the greater the body image satisfaction). In 1990, Hovardaogˇlu performed the Turkish translation and checked the validity and reliability of the BIS. In this study, an internal reliability test for both the EAT and the BIS was conducted; Cronbach a coefficients were found to be .89 and .87, respectively.
Study Protocol All subjects were given an identical brief stating that the purpose of the study was to evaluate eating attitudes. Participation was voluntary and strict confidentiality was ensured by giving each participant an individual code number accessible only by the researcher. Before the study began, approval from the hospital’s research ethics committee and informed verbal consent from each participant and his or her parent, when required, were obtained. The BIF collected information regarding sociodemographic and diabetes-related variables. Afterward, the sample was asked to self-complete the EAT and the BIS. Height and weight were measured and then BMI was calculated. Metabolic control was determined with HbA1c. Blood was obtained by finger prick from each diabetic subject to measure HbA1c. All samples were analyzed at the hospital’s laboratory with a BioRad (Biorad Laboratories, Hertfordshire, UK) variant high-pressure
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liquid chromatography assay (reference range, 4–7%).
Statistical Analysis Statistical analysis was performed with the Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL). Independent paired t tests were used for two-group comparisons of continuous variables. v 2 Analysis was used for data presented as proportions. Pearson’s correlation coefficients were used to examine associations between two continuous variables. Statistical significance for all analyses was taken at the 5% level. RESULTS
Prevalence of DEBs Most of the diabetic patients (73.3%) said that they adhered to their recommended diet. Seventyfive percent of them explained that they were doing strict diet restrictions from time to time to control body weight. In this study, 18 (40%) of the diabetic patients reported skipping insulin or taking less insulin as a way to control weight. The EAT scores of the diabetic patients were higher than those of the control subjects (M F SD, 33.57 F 9.54 vs. 21.76 F 12.21); the difference between the two groups was so significant (t = 5.3, p b .001). When the EAT was evaluated by the cutoff score, 31 adolescents (68.9%) in the diabetic group and 12 (21.8%) in the nondiabetic group had scores higher than the cutoff score. In the diabetic group, DEBs as assessed with the EAT tended to be higher among girls than boys, although differences were not statistically significant (t = .568, p N .05). Seventeen of the diabetic girls (70.8%) had EAT scores higher than the cutoff criterion. The EAT score was different between girls in the diabetic group and those in the control group (t = 4.96, p b .001). The EAT scores of the boys in the diabetic group were higher than those of the boys in the control group (M F SD, 31.04 F 11.34 vs. 21.57 F 12.39), but the difference between the two groups was not significant (t = 2.56, p N .05). Fourteen of the diabetic boys (66.7%) had EAT scores higher than the cutoff criterion. The EAT score was higher in diabetic patients who did strict diet restrictions (M F SD, 35.61 F 7.91 vs. 13.00 F 18.38, t = 3.69, p b .01) and misused the insulin (M F SD, 34.42 F 5.67 vs. 19.00 F 18.30, t = 3.40, p b .01) to lose weight.
Disordered Eating and Metabolic Control The positive relationship between the EAT score and mean HbA1c value was statistically significant (r = .670, p b .001). The HbA1c values in 28 diabetic patients (62.2%) were 7% and higher. In 21 of these patients (75%), the EAT score exceeded the cutoff criterion. Therefore, disordered eating was predictive of poor metabolic control.
Disordered Eating and Menstrual Problems Thirty percent of all the girls had menstrual problems. In the diabetic group, girls had more menstrual problems than expected and there was a significant statistical difference between the two groups (v 2 = 9.25, p b .01). Twelve of the diabetic girls (50%) had menstrual problems, and eight of them (66.7%) had EAT scores higher than the cutoff criterion. Three of the healthy girls (11.5%) also had menstrual problems, and two of them (66.7%) had EAT scores higher than the cutoff criterion. When evaluated as a whole, the EAT score was higher in girls who had menstrual problems than in those who did not (M F SD, 35.20 F 10.01 vs. 24.28 F 11.50) and the difference between them was significant (t = 3.19, p b .01). Again, disordered eating was predictive of menstrual problems in diabetic girls.
Disordered Eating and Body Image Satisfaction The BIS score was lower in the diabetic patients than in the control subjects (M F SD, 153.97 F 19.82 vs. 158.25 F 23.32), but the difference between the two groups was not significant (t = 1.86, p N .05). Diabetic girls had significantly lower BIS scores as compared with boys (M F SD, 145.08 F 18.28 vs. 164.14 F 16.64, t = 3.64, p b .001). There was a nonsignificant negative correlation between the BIS score and the EAT score in both diabetic patients and control subjects (r = .155, r = .080, respectively, p N .05). The relationship between BMI and the BIS score was also nonsignificant (r = .192, p N .05). DISCUSSION
Prevalence of DEBs This study has shown that disordered eating meeting the EAT cutoff criterion is approximately four times as common in diabetic adolescents as in
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their nondiabetic peers ( p b .001). Although there was no significant difference, girls in diabetic group had higher EAT scores than boys and most of them (70.8%) had DEBs. The percentage of DEBs was higher in diabetic girls than in nondiabetic girls ( p b .001). It is known that DEBs are apparently more common in diabetic patients, especially in females (Hudson et al., 1985; Levine & Marcus, 1997; Pickup & Williams, 1991). Engstro¨m et al. (1999) found a significant increase in DEBs in diabetic patients as compared with control subjects based on self-report measures. The result of this study is consistent with those of others (Engstro¨m et al., 1999; Hudson et al., 1985; Levine & Marcus, 1997; Pickup & Williams, 1991). It was also recognized that Type 1 diabetes usually preceded the onset of DEBs. The actual precipitant for DEBs in patients with Type 1 diabetes may be the typical weight gain after initiating insulin therapy. Especially in predisposed adolescent females, this weight gain may trigger the onset of DEBs, often with omission of insulin; chronic dietary restraint and preoccupation with carbohydrate restriction may further foster the development of DEBs (Garner & Garfinkel, 1997; Neumark-Sztainer et al., 2002; Rosmark et al., 1986). The cardinal feature of clinical DEBs is selfinduced weight loss. Deliberate insulin misuse and chronic dietary restraints are also common behaviors to lose weight (Garner & Garfinkel, 1997; Neumark-Sztainer et al., 2002). The most common and best-known misuse of insulin is dose omission or reduction, causing glycosuria and weight loss. In this study, 75% of the patients who adhered to their recommended diet explained that they were doing strict diet restrictions from time to time to control body weight. The number of diabetic patients who misused insulin was 18 (40%), and the EAT scores were higher in these groups ( p b .01). There are very limited studies on DEBs in diabetic boys. Furthermore, present studies show that diabetic boys have eating attitudes similar to those of nondiabetic patients (Hoffman, 2001; Neumark-Sztainer et al., 2002). In this study, 66.7% of diabetic boys exceeded the EAT cutoff score. This result needs further investigation to explore effects of some other factors (e.g., family functions about disordered eating in boys).
Disordered Eating and Metabolic Control The principal effect of a DEB on Type 1 diabetes is to worsen glycemic control as a consequence of
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excessive dieting, binge eating, vomiting, using diuretics or laxatives, and self-induced glycosuria (Rodin & Daneman, 1992; Rydall et al., 1997; Steel et al., 1987). In the present study, it has been confirmed that DEBs tend to be highly predictive of poor metabolic condition in adolescents with Type 1 diabetes ( p b .001). Similar to this study’s result, in many studies, the relationship between eating disturbances and poor metabolic control has been well established (Birk & Spencer, 1989; Fairburn, Peveler, Davies, Mann, & Mayou, 1991; Jones et al., 2000; Rodin et al., 1991; Rydall et al., 1997; Steel, Young, Lloyd, & Macintyre, 1989; Straub, Lamparter-Lang, Palitzsch, & Scholmerich, 1996; Szmukler & Russell, 1983; Vila et al., 1995; Wing, Nowalk, Marcus, Koeske, & Finegold, 1986). In this study, the mean HbA1c levels of most diabetic participants were higher than the clinic goals for adolescents at the endocrinology clinic. These findings suggest that even without a clinically significant eating disorder, the use of unhealthy weight control practices such as strict diet restrictions and insulin misuse may have serious consequences for metabolic control among adolescents with Type 1 diabetes.
Disordered Eating and Menstrual Problems It is known that girls with DEBs have some menstrual disturbances. The changes in neurotransmitter levels that result from irregular food intake can cause menstrual disturbances. Developed amenorrhea is caused by diminished secretion of growth hormones, which in turn diminishes the pituitary secretion of follicle-stimulating hormones and luteinizing hormones, which is responsible for abnormally lower levels of estrogen (Halmi, 2000). In the present study, it has been shown that diabetic girls had more menstrual problems ( p b .01) and that DEBs were predictive of menstrual problems. These findings are similar to those of several previous studies (Demir, EralpDemir, Kayaalp, & Bu¨yu¨kkal, 1998; Halmi, 2000).
Disordered Eating and Body Image Satisfaction Body image disturbance plays a prominent role in the psychopathology of DEBs. Diabetes, with its pervasive impact on most aspects of daily living, may interfere with normal developmental processes, leading to poor self-esteem and impaired ego development and body image (Hauser, Jacobson, Noam, & Powers, 1983; Jacobson et al., 1986;
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Neumark-Sztainer et al., 2002). Neumark-Sztainer, Story, Resnick, Garnick, and Blum (1995) found that adolescents with a chronic disease reported higher body dissatisfaction than control subjects. Women are more dissatisfied with their bodies and frequently engage in weight loss. In adolescent and young females at risk, the weight gain and dietary restriction of diabetes may trigger or augment typical body dissatisfaction and drive for thinness that accompany eating disturbances. Women with eating disorders will often spontaneously admit to bfeeling fat,Q being fearful of gaining weight, or being dissatisfied with their weight or specific body parts (Garner & Garfinkel, 1997; Levine & Marcus, 1997). Furthermore, young women in western cultures are also susceptible to family, peer, and societal pressures to achieve a particular body shape and weight and to unduly link selfesteem to thinness and physical appearance (Daneman et al., 1998; Striegel-Moore & Huydic, 1993). In the present study, the BIS score was lower in the diabetic patients than in the control subjects, although the difference between the two groups was not significant. In the diabetic group, the BIS scores of the girls were lower than those of the boys and statistical differences were significant ( p b .001). The results are consistent with those in related literature (Daneman et al., 1998; Garner & Garfinkel, 1997; Hauser et al., 1983; Jacobson et al., 1986; Levine, & Marcus, 1997; NeumarkSztainer et al., 2002; Neumark-Sztainer et al., 1995; Striegel-Moore & Huydic, 1993). In conclusion, adolescents with Type 1 diabetes, especially girls, are at increased risk for DEBs. Disordered eating behaviors make a significant contribution to menstrual problems and inevitably lead to poor metabolic control. This study had a number of strengths that increase the utility of the findings. The inclusion of boys in the study population expands the current body
of literature, as most studies examining eating disorders/disordered eating among individuals with Type 1 diabetes have included only girls. The use of different measures of weight control practices such as diet restriction and insulin misuse/disordered eating and, in particular, the use of the EATenhanced this study’s ability to draw conclusions from the data. Other strengths include the assessment of BMI, body satisfaction perception by the BIS, and HbA1c values using previously validated tools. A major study limitation was the relatively small sample size. Thus, prevalence of data on disordered eating and unhealthy weight control behaviors among adolescents with Type 1 diabetes should be interpreted cautiously. Furthermore, although diabetic patients and nondiabetic subjects were similar in terms of sex, age, and BMI, their small number makes it difficult to draw firm conclusions regarding the lack of sociodemographic differences in weight control/DEBs. Findings from the present study have implications for research and practice. The findings suggest a need for further research to explore the reasons why adolescents with Type 1 diabetes engage in unhealthy weight control practices despite the serious consequences of these behaviors. This study’s findings suggest that special attention should be directed toward girls, adolescents with menstrual problems, and adolescents with poor metabolic control. Finally, health care professionals should be aware of the potential effect of subclinical and clinical eating behaviors, including insulin misuse and strict diet, on weightconscious people with Type 1 diabetes who have poor metabolic control and menstrual problems. ACKNOWLEDGMENT I thank Dr. Halim ˙IYsever for the statistical analyses.
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