Insulin-Dependent Diabetes Mellitus and Eating Disorders: A Prevalence Study Pauline S. Powers, John I. Malone, Dale Lee Coovert, and Richard G. Schulman There have been numerous reports in the recent literature suggesting a relationship between diabetes mellitus and the eating disorders. In the current investigation, 97 pediatric diabetes patients were administered a modified version of the Eating Habits Questionnaire, which included items specific to diabetes mellitus based on DSM-III-R criteria. None of this sample were diagnosed as anorexic and only one patient was diagnosed as currently bulimic. Possible reasons for the higher prevalence rates reported for other samples are discussed. 0 1990 by W.B. Saunders Company.
I
N THE LAST 15 YEARS there have been numerous case reports of patients with insulin-dependent diabetes mellitus who also have anorexia nervosa or bulimia nervosa. In 1973, Bruch’ reported a patient with coexisting diabetes and anorexia nervosa. In 1977, Crisp’ postulated that the two conditions rarely occur together. From 1980 to 1983, there were 10 reports of a total of 31 patients who suffered from diabetes mellitus and an eating disorder; nine of the patients had bulimia and 22 had anorexia nervosa.3-‘2 In 1984, Hiliard and Hiliard13 summarized the primary clinical characteristics of 22 of these published case reports. They found that patients with diagnoses of both diabetes mellitus and eating disorders were usually young women, demographically similar to other eating disorder patients. Developmentally, the diabetes preceded the eating disorder by several years in all but one case. Anorexia nervosa and bulimia nervosa patients who also had diabetes mellitus not only used the typical purging methods of self-induced vomiting, laxative abuse, and overexercise, but also withheld insulin to produce glycosuria and vomiting and subsequent weight loss. These patients also had poor control of blood sugar and frequently elevated blood levels of glycosylated hemoglobin and major complications of their diabetes including ketoacidosis, retinopathy, and peripheral neuropathy. Blood sugar control was poorer in patients with diabetes mellitus who binge and purge, with or without anorexia nervosa, than in those diabetes mellitus patients with anorexia nervosa without bulimia. The prevalence of eating disorders among insulin-dependent diabetics has been a topic of speculation since the earliest reports. Although Crisp thought that the combination was probably rare, O’Gorman and Eyre3 suggested that those at risk for the development of anorexia nervosa may be more likely to do so if they already suffer from diabetes since withholding insulin provides a method of weight loss. Our
From the Departments of Psychiatry and Behavioral Medicine, University ofSouth Florida, Tampa, FL. Address reprint requests to Pauline S. Powers, M.D., USF Psychiatry Tampa, FL 33613. 0 I990 by W.B. Saunders Company. 0010-440x/90/3103-0007$03.00/0
Comprehensive
Psychiatry,
Vol. 3 1, No. 3 (May/June),
Pediatrics,
1990: pp 205-2
and Psychology.
Center, 3515 E Fletcher Ave.
10
205
206
POWERS ET AL
group’ found four of 100 anorexia nervosa patients had diabetes; using standard prevalence reports for both anorexia nervosa and diabetes, it was calculated that only two patients with both anorexia and diabetes would be expected in our geographic area and it was speculated that the coexistence of the two conditions might not be coincidental but that each might contribute to the development of the other. It was postulated that the heightened preoccupation with food, and especially with carbohydrate consumption that occurs in young patients learning to manage their illness, may predispose to the carbohydrate phobia that Crisp14 considers to be a cardinal feature of anorexia nervosa. Three recent studies have addressed the issue of prevalence of eating disorders among the young diabetic population. Rodin et al. l5 studied 46 female adolescents with diabetes mellitus. Patients completed the Eating Attitudes Test (EAT-26) and Eating Disorders Inventory (EDI) and 18 of 19 adolescents with elevated scores on either test were interviewed. Using DSM-III criteria,16 three patients were diagnosed as having anorexia nervosa (one also had bulimia) and three patients had bulimia. One additional patient was considered to have a partial syndrome of anorexia nervosa and two additional patients had a partial syndrome of bulimia nervosa. Thus, 13% of the sample met DSM-III criteria for eating disorders and 19% suffered from clinically significant eating or weight pathology. Hudson et al.” sent the Eating Habits Questionnaire to 264 insulin-dependent young women who attended either the Joslin Clinic (a large urban tertiary referral center) or a small-town rural practice setting. Eighty questionnaires (30%) were returned; 28 respondents (35% of the sampled 80 who completed the questionnaire) reported a history of bulimia by DSM-III criteria, but none reported a history of anorexia nervosa. The authors concluded that even if the respondents were the population at risk for eating disorders, and none of the nonrespondents had an eating disorder, the prevalence of bulimia was still higher (10.6%) than in other published reports of the prevalence of bulimia nervosa in the general female adolescent population. Steel et al.‘* studied 208 young women aged 16 to 25 years with insulin-dependent diabetes mellitus and found that 15 (7%) had a clinically apparent eating disorder. Although they used Russell’s criteria I9 for anorexia nervosa, 12 of the patients they described would meet both DSM-11116 and DSM-111-R” criteria; eight of these patients also binge-ate and purged; two patients met the criteria for bulimia and one additional patient binge ate and withheld insulin to lose weight. METHOD Subjects All patients who presented at the University of South Florida Diabetes Center were asked by Diabetes Center staff to fill out a brief questionnaire. Those who agreed to participate were asked to complete an Informed Consent form and were then immediately given the questionnaire.
Measures Subjects were administered a two-page 44-item paper-and-pencil questionnaire. This instrument was a modified version of the Eating Habits QuestionnaireZo with additional items specific to diabetes mellitus. Items assessed subjects’ behaviors and feelings regarding control of their diabetes and also addressed behaviors and feelings paralleling the DSM-IIIr6 and DSM-III-R” diagnostic criteria for anorexia and bulimia. Most items were presented in a multiple choice or yes/no format. Items were all face-valid.
DIABETES MELLITUS AND EATING DISORDERS
207
RESULTS
Description of Subjects From the available subject pool, 97 patients agreed to complete the questionnaire. Of these 97 subjects, 51 (52.6%) were male and 46 (47.4%) were female. The average age of male subjects was 15.7 years and of the females, 15.5 years. The average height and weight of the male subjects was 65.2 in (165.6 cm) and 129 lb (58.6 kg), respectively; the averages for the female subjects were 63.6 in (161.3 cm) and 120.9 lb (54.9 kg). Age at onset of the diabetes mellitus was 8.26 (SD = 3.98) years for the males and 9.78 (SD = 3.01) years for the females. Diabetes Information Data for both male and female patients is presented in Table 1. Note that, statistically, male patients tended to report an earlier age of onset than female patients (F = 4.404, df = 1,94, P = .039). In addition, male patients statistically were more likely to monitor their urine tests than were female patients (x2 = 11.922, df = 3, P = .008). Gender differences for the other variables presented in Table 2 were not statistically significant. Eating Disorders Data Based on DSM-III diagnostic criteria, none of the male patients met criteria for eating disorders. Of the female patients, none were diagnosed as anorexic and only two (4.3%) were assigned a diagnosis of bulimia. One female patient (2.2%) reported a past history of anorexia nervosa. Based on the more recent DSM-III-R diagnostic criteria, none of the female patients were diagnosed as currently anorexic and only one (2.2%) was diagnosed as currently bulimic. One female patient (2.2%) reported a past history of anorexia nervosa and one (2.2%) reported a past history of bulimia nervosa. Data obtained regarding binge-eating is as follows: Female patients were more likely than male patients to report having binged (x2 = 13.148, df = 1, P = .0003). Among those patients who reported a binge history, females tended to be older at Table 1. Questionnaire
Items Female Patients (n = 46)
Monitor urine tests7 Monitor blood sugar? Know HbA,, level? Will good control delay complications of DM? Control of own DM is Excellent Good Fair Poor
19.6%
64.4% 51.1% 79.5% 6.5% 47.8% 32.6% 13.0%
yes yes yes yes
Male Patients (n = 51) 36.7% 5 1 .O% 56.0% 86.0%
yes yes yes yes
21.6% 56.9% 21.6% 0.0%
NOTE. In some cases, not all patients responded to a particular question. Percentages are based on total number who responded. In no case did more than two patients fail to answer a particular question. Abbreviations: HbA,,, hemoglobin A,,; DM, diabetes mellitus.
208
POWERS
Table 2. Weight
Control and Purging Methods Female Paients
Method Laxatives Diuretics Diet pills Vomiting Exercise Fasting Withholding
(n =
insulin
ET AL
46)
2.3% 2.3% 11.6% 0.0% 40.0% 24.4% 14.0%
Male Patients (n = 51) 2.0% 0.0% 0.0% 0.0% 24.5% 2.0% 4.1%
NOTE. In some cases, not all patients responded to a particular question. Percentages are based on total number who responded. In no case did more than three patients fail to answer a particular question.
onset of binge eating than males (F = 4.207, df = 1, 27, P = .051) and differed significantly from males in that they were more likely to report post-binge depression (x2 = 2.215, df = 1, P = .1366); however, this difference is only marginally significant. Other gender differences failed to reach statistical significance. All of these patients denied having sought psychiatric help because of their binge eating. Data for questionnaire items assessing weight control and purging methods are summarized in Table 2. In general, patients tended to deny employing radical purgative methods, with both female and male patients choosing exercise and fasting with far greater frequencies than such methods as laxative and diuretic abuse. Female patients were more likely than male patients to abuse diuretics (x2 = 6.025, df = 1, P = .0141), and to diet excessively or fast (x2 = 10.573, df = 1, P = .OOl 1). Female patients also tended to report skipping insulin doses more frequently than male patients (x2 = 2.811, df = 1, P = .0036); this difference is marginally significant. There was also a tendency (marginally significant) for females to rely on excessive exercise more than male patients (x2 = 2.597, df = 1, P = .1071). None of the patients reported self-induced vomiting as a weight control strategy. DISCUSSION
Unlike previous studies, we did not find a higher prevalence of eating disorders among this sample of adolescent diabetes patients than is reported among the general adolescent population. Prevalence studies by Crisp et al.** found that about 0.5% of adolescent girls at private schools have anorexia nervosa and about 0.2% of adolescent girls in nonprivate schools have anorexia nervosa. Szmuklerz3 found that about one in 120 girls, aged 14 to 18 years, from upper socioeconomic classes had anorexia nervosa. Forty-six patients in this sample were female and only one reported a possible past history of anorexia nervosa. Prevalence studies of bulimia have yielded widely different rates, with one report from Halmi et a1.24 finding that 13% of the female co-ed population met the essential criteria for a probable diagnosis of bulimia. Recent careful studies suggest that prevalence among young women aged 15 to 25 years is probably closer to 4.5% (DSM-III-R, p. 68). In our sample of female diabetes patients, two (4.3%) met DSM-III criteria for bulimia and only one (2.2%) met the more stringent DSM-III-R criteria.
DIABETES MELLITUS AND EATING DISORDERS
209
The reasons for the low prevalence of diagnosable eating disorders among this group compared with other samples are unknown but may include the following. It may be that the prevalence of eating disorders is, in fact, no more common among young people with diabetes than among the general population. Possibly, more of our sample will develop eating disorders since they have not yet passed through the age of risk for the onset of either anorexia nervosa or bulimia. Another possible explanation is that the sample of patients may be significantly different from previously reported samples. This is unlikely since previous reports (except one of the samples in the report from Hudson et a1.17) are from tertiary care referral centers for diabetes as is our sample. In addition, it is possible that the management of diabetic patients differs at the tertiary care centers and accounts for the difference in prevalence. For example, Hudson et al.” reported a prevalence of bulimia of 39% in respondents who attended the Joslin Clinic; it is well known that one of the primary tenets of good diabetic control stressed by this clinic is nutritional restraint and avoidance of simple carbohydrates; emphasis on this facet of diabetes control may be an iatrogenic risk factor for the development of bulimia nervosa. Finally, differences in the criteria for diagnosing eating disorders may vary from study to study. Analysis of binge eating reported in this group revealed interesting gender differences that may have implications for the higher prevalence of bulimia among females. There was no significant gender difference in the current prevalence of binge eating among this sample, but females who binge ate were somewhat more likely to binge eat inconspicuously and significantly more likely to feel depressed after binge eating. Furthermore, females were significantly more likely to use diet pills, stringent diet, or excessive exercise to lose weight. In terms of management of their diabetes, only 14.4% of the total sample reported excellent control, although most (89%) believed excellent or perfect control would prevent complications. Furthermore, 92.6% thought that what they did made a difference in control of their diabetes. These findings probably have important ramifications in terms of compliance. The belief that perfect control of diabetes will prevent complications is known to be false and may result in inordinate guilt among these young diabetics. The more moderate idea that good control may reduce the probability of complications might facilitate cooperation with diabetic control regimens.
REFERENCES 1. Bruch H: Eating Disorders: Obesity, Anorexia and the Person Within. New York, NY, Basic Books, 1973, p 357 2. Crisp AH: The differential diagnosis of anorexia nervosa. Proc R Sot Med 70:686-690, 1977 3. O’Gorman EC, Eyre DG: A case of anorexia nervosa and diabetes mellitus. Br J Psychiatry 137:103, 1980 (letter) 4. Fairburn LG, Steel JM: Anorexia nervosa in diabetes mellitus. Br J Med 280:1167-l 168, 1980 5. Gomez J, Dally P, Isaacs AJ: Anorexia nervosa in diabetes mellitus. Br J Med 281:61-62, 1980 (letter) 6. Garner S: Anorexia nervosa in diabetes mellitus. Br J Med 281:1144, 1980 (letter) 7. Roland JM, Bhanji S: Anorexia nervosa occurring in patients with diabetes mellitus. Postgrad Med J 58:354-356, 1982 8. Powers PS, Malone JI, Duncan JA: Anorexia nervosa and diabetes mellitus. J Clin Psychiatry 44:133-1351983
210
POWERS ET AL
9. Hudson JI, Hudson MS, Wentworth SM: Self-induced glycosuria: A novel method of purging in bulimia. JAMA 249-250, 1983 10. Hudson MS, Hudson JI: Bulimia and diabetes. N Engl J Med 309:132, 1983 11. Szmukler GI, Russell GFM: Diabetes mellitus, anorexia nervosa and bulimia. Br J Psychiatry 142:305-308, 1983 12. Szmukler GI: Anorexia nervosa and bulimia in diabetics. J Psychosom Res 28:365-369, 1984 13. Hillard JR, Hillard PJA: Bulimia, anorexia nervosa and diabetes: Deadly combinations. Psychiatr Clin North Am 7:367-379, 1984 14. Crisp AH: Anorexia Nervosa: Let Me Be. Philadelphia, PA, Grune & Stratton, 1980 15. Rodin GM, Daneman D, Johnson LE, et al: Anorexia nervosa and bulimia in female adolescents with insulin dependent diabetes mellitus: A systematic study. J Psychiatry Res 19:381-384, 1985 16. Diagnostic and Statistical Manual of Mental Disorders, ed 3 (DSM-III). Washington, DC, American Psychiatric Association, 1980, pp 67-71 17. Hudson JI, Wentworth SM, Hudson MS, et al: Prevalence of anorexia nervosa and bulimia among young diabetic women. J Clin Psychiatry 46:88-89, 1985 18. Steel JM, Young RJ, Lloyd GS, et al: Clinically apparent eating disorders in young diabetic women: Associations with painful neuropathy and other complications. Br Med J 294:859-862, 1987 19. Russell GFM: Anorexia nervosa. Its identity as an illness and its treatment, in Price JH (ed): Modern Trends in Psychological Medicine 2. London, England, Butterworth, 1970, pp 13 1-164 20. Herman CP, Mack D: Restrained and unrestrained eating. J Personality 43:647-660, 1975 21. Diagnostic and Statistical Manual of Mental Disorders (ed 3, Revised) (DSM-III-R). Washington, DC, American Psychiatric Association, 1987 22. Crisp A, Palmer P, Kalucy R: How common is anorexia nervosa? A prevalence study. Br J Psychiatry 218:549-534, 1976 23. Szmukler G: Weight and food preoccupation in a population of English school girls, in Understanding Anorexia Nervosa and Bulimia. Report of the 4th Ross Conference on Medical Research. Columbus, OH, Ross Laboratories, 1985, pp 21-27 24. Halmi K, Falk J, Schwartz E: Binge-eating and vomiting: A survey of a college population. Psycho1 Med 11:697-706,198 1
I
N THE LAST 15 YEARS there have been numerous case reports of patients with insulin-dependent diabetes mellitus who also have anorexia nervosa or bulimia nervosa. In 1973, Bruch’ reported a patient with coexisting diabetes and anorexia nervosa. In 1977, Crisp’ postulated that the two conditions rarely occur together. From 1980 to 1983, there were 10 reports of a total of 31 patients who suffered from diabetes mellitus and an eating disorder; nine of the patients had bulimia and 22 had anorexia nervosa.3-‘2 In 1984, Hiliard and Hiliard13 summarized the primary clinical characteristics of 22 of these published case reports. They found that patients with diagnoses of both diabetes mellitus and eating disorders were usually young women, demographically similar to other eating disorder patients. Developmentally, the diabetes preceded the eating disorder by several years in all but one case. Anorexia nervosa and bulimia nervosa patients who also had diabetes mellitus not only used the typical purging methods of self-induced vomiting, laxative abuse, and overexercise, but also withheld insulin to produce glycosuria and vomiting and subsequent weight loss. These patients also had poor control of blood sugar and frequently elevated blood levels of glycosylated hemoglobin and major complications of their diabetes including ketoacidosis, retinopathy, and peripheral neuropathy. Blood sugar control was poorer in patients with diabetes mellitus who binge and purge, with or without anorexia nervosa, than in those diabetes mellitus patients with anorexia nervosa without bulimia. The prevalence of eating disorders among insulin-dependent diabetics has been a topic of speculation since the earliest reports. Although Crisp thought that the combination was probably rare, O’Gorman and Eyre3 suggested that those at risk for the development of anorexia nervosa may be more likely to do so if they already suffer from diabetes since withholding insulin provides a method of weight loss. Our
From the Departments of Psychiatry and Behavioral Medicine, University ofSouth Florida, Tampa, FL. Address reprint requests to Pauline S. Powers, M.D., USF Psychiatry Tampa, FL 33613. 0 I990 by W.B. Saunders Company. 0010-440x/90/3103-0007$03.00/0
Comprehensive
Psychiatry,
Vol. 3 1, No. 3 (May/June),
Pediatrics,
1990: pp 205-2
and Psychology.
Center, 3515 E Fletcher Ave.
10
205
206
POWERS ET AL
group’ found four of 100 anorexia nervosa patients had diabetes; using standard prevalence reports for both anorexia nervosa and diabetes, it was calculated that only two patients with both anorexia and diabetes would be expected in our geographic area and it was speculated that the coexistence of the two conditions might not be coincidental but that each might contribute to the development of the other. It was postulated that the heightened preoccupation with food, and especially with carbohydrate consumption that occurs in young patients learning to manage their illness, may predispose to the carbohydrate phobia that Crisp14 considers to be a cardinal feature of anorexia nervosa. Three recent studies have addressed the issue of prevalence of eating disorders among the young diabetic population. Rodin et al. l5 studied 46 female adolescents with diabetes mellitus. Patients completed the Eating Attitudes Test (EAT-26) and Eating Disorders Inventory (EDI) and 18 of 19 adolescents with elevated scores on either test were interviewed. Using DSM-III criteria,16 three patients were diagnosed as having anorexia nervosa (one also had bulimia) and three patients had bulimia. One additional patient was considered to have a partial syndrome of anorexia nervosa and two additional patients had a partial syndrome of bulimia nervosa. Thus, 13% of the sample met DSM-III criteria for eating disorders and 19% suffered from clinically significant eating or weight pathology. Hudson et al.” sent the Eating Habits Questionnaire to 264 insulin-dependent young women who attended either the Joslin Clinic (a large urban tertiary referral center) or a small-town rural practice setting. Eighty questionnaires (30%) were returned; 28 respondents (35% of the sampled 80 who completed the questionnaire) reported a history of bulimia by DSM-III criteria, but none reported a history of anorexia nervosa. The authors concluded that even if the respondents were the population at risk for eating disorders, and none of the nonrespondents had an eating disorder, the prevalence of bulimia was still higher (10.6%) than in other published reports of the prevalence of bulimia nervosa in the general female adolescent population. Steel et al.‘* studied 208 young women aged 16 to 25 years with insulin-dependent diabetes mellitus and found that 15 (7%) had a clinically apparent eating disorder. Although they used Russell’s criteria I9 for anorexia nervosa, 12 of the patients they described would meet both DSM-11116 and DSM-111-R” criteria; eight of these patients also binge-ate and purged; two patients met the criteria for bulimia and one additional patient binge ate and withheld insulin to lose weight. METHOD Subjects All patients who presented at the University of South Florida Diabetes Center were asked by Diabetes Center staff to fill out a brief questionnaire. Those who agreed to participate were asked to complete an Informed Consent form and were then immediately given the questionnaire.
Measures Subjects were administered a two-page 44-item paper-and-pencil questionnaire. This instrument was a modified version of the Eating Habits QuestionnaireZo with additional items specific to diabetes mellitus. Items assessed subjects’ behaviors and feelings regarding control of their diabetes and also addressed behaviors and feelings paralleling the DSM-IIIr6 and DSM-III-R” diagnostic criteria for anorexia and bulimia. Most items were presented in a multiple choice or yes/no format. Items were all face-valid.
DIABETES MELLITUS AND EATING DISORDERS
207
RESULTS
Description of Subjects From the available subject pool, 97 patients agreed to complete the questionnaire. Of these 97 subjects, 51 (52.6%) were male and 46 (47.4%) were female. The average age of male subjects was 15.7 years and of the females, 15.5 years. The average height and weight of the male subjects was 65.2 in (165.6 cm) and 129 lb (58.6 kg), respectively; the averages for the female subjects were 63.6 in (161.3 cm) and 120.9 lb (54.9 kg). Age at onset of the diabetes mellitus was 8.26 (SD = 3.98) years for the males and 9.78 (SD = 3.01) years for the females. Diabetes Information Data for both male and female patients is presented in Table 1. Note that, statistically, male patients tended to report an earlier age of onset than female patients (F = 4.404, df = 1,94, P = .039). In addition, male patients statistically were more likely to monitor their urine tests than were female patients (x2 = 11.922, df = 3, P = .008). Gender differences for the other variables presented in Table 2 were not statistically significant. Eating Disorders Data Based on DSM-III diagnostic criteria, none of the male patients met criteria for eating disorders. Of the female patients, none were diagnosed as anorexic and only two (4.3%) were assigned a diagnosis of bulimia. One female patient (2.2%) reported a past history of anorexia nervosa. Based on the more recent DSM-III-R diagnostic criteria, none of the female patients were diagnosed as currently anorexic and only one (2.2%) was diagnosed as currently bulimic. One female patient (2.2%) reported a past history of anorexia nervosa and one (2.2%) reported a past history of bulimia nervosa. Data obtained regarding binge-eating is as follows: Female patients were more likely than male patients to report having binged (x2 = 13.148, df = 1, P = .0003). Among those patients who reported a binge history, females tended to be older at Table 1. Questionnaire
Items Female Patients (n = 46)
Monitor urine tests7 Monitor blood sugar? Know HbA,, level? Will good control delay complications of DM? Control of own DM is Excellent Good Fair Poor
19.6%
64.4% 51.1% 79.5% 6.5% 47.8% 32.6% 13.0%
yes yes yes yes
Male Patients (n = 51) 36.7% 5 1 .O% 56.0% 86.0%
yes yes yes yes
21.6% 56.9% 21.6% 0.0%
NOTE. In some cases, not all patients responded to a particular question. Percentages are based on total number who responded. In no case did more than two patients fail to answer a particular question. Abbreviations: HbA,,, hemoglobin A,,; DM, diabetes mellitus.
208
POWERS
Table 2. Weight
Control and Purging Methods Female Paients
Method Laxatives Diuretics Diet pills Vomiting Exercise Fasting Withholding
(n =
insulin
ET AL
46)
2.3% 2.3% 11.6% 0.0% 40.0% 24.4% 14.0%
Male Patients (n = 51) 2.0% 0.0% 0.0% 0.0% 24.5% 2.0% 4.1%
NOTE. In some cases, not all patients responded to a particular question. Percentages are based on total number who responded. In no case did more than three patients fail to answer a particular question.
onset of binge eating than males (F = 4.207, df = 1, 27, P = .051) and differed significantly from males in that they were more likely to report post-binge depression (x2 = 2.215, df = 1, P = .1366); however, this difference is only marginally significant. Other gender differences failed to reach statistical significance. All of these patients denied having sought psychiatric help because of their binge eating. Data for questionnaire items assessing weight control and purging methods are summarized in Table 2. In general, patients tended to deny employing radical purgative methods, with both female and male patients choosing exercise and fasting with far greater frequencies than such methods as laxative and diuretic abuse. Female patients were more likely than male patients to abuse diuretics (x2 = 6.025, df = 1, P = .0141), and to diet excessively or fast (x2 = 10.573, df = 1, P = .OOl 1). Female patients also tended to report skipping insulin doses more frequently than male patients (x2 = 2.811, df = 1, P = .0036); this difference is marginally significant. There was also a tendency (marginally significant) for females to rely on excessive exercise more than male patients (x2 = 2.597, df = 1, P = .1071). None of the patients reported self-induced vomiting as a weight control strategy. DISCUSSION
Unlike previous studies, we did not find a higher prevalence of eating disorders among this sample of adolescent diabetes patients than is reported among the general adolescent population. Prevalence studies by Crisp et al.** found that about 0.5% of adolescent girls at private schools have anorexia nervosa and about 0.2% of adolescent girls in nonprivate schools have anorexia nervosa. Szmuklerz3 found that about one in 120 girls, aged 14 to 18 years, from upper socioeconomic classes had anorexia nervosa. Forty-six patients in this sample were female and only one reported a possible past history of anorexia nervosa. Prevalence studies of bulimia have yielded widely different rates, with one report from Halmi et a1.24 finding that 13% of the female co-ed population met the essential criteria for a probable diagnosis of bulimia. Recent careful studies suggest that prevalence among young women aged 15 to 25 years is probably closer to 4.5% (DSM-III-R, p. 68). In our sample of female diabetes patients, two (4.3%) met DSM-III criteria for bulimia and only one (2.2%) met the more stringent DSM-III-R criteria.
DIABETES MELLITUS AND EATING DISORDERS
209
The reasons for the low prevalence of diagnosable eating disorders among this group compared with other samples are unknown but may include the following. It may be that the prevalence of eating disorders is, in fact, no more common among young people with diabetes than among the general population. Possibly, more of our sample will develop eating disorders since they have not yet passed through the age of risk for the onset of either anorexia nervosa or bulimia. Another possible explanation is that the sample of patients may be significantly different from previously reported samples. This is unlikely since previous reports (except one of the samples in the report from Hudson et a1.17) are from tertiary care referral centers for diabetes as is our sample. In addition, it is possible that the management of diabetic patients differs at the tertiary care centers and accounts for the difference in prevalence. For example, Hudson et al.” reported a prevalence of bulimia of 39% in respondents who attended the Joslin Clinic; it is well known that one of the primary tenets of good diabetic control stressed by this clinic is nutritional restraint and avoidance of simple carbohydrates; emphasis on this facet of diabetes control may be an iatrogenic risk factor for the development of bulimia nervosa. Finally, differences in the criteria for diagnosing eating disorders may vary from study to study. Analysis of binge eating reported in this group revealed interesting gender differences that may have implications for the higher prevalence of bulimia among females. There was no significant gender difference in the current prevalence of binge eating among this sample, but females who binge ate were somewhat more likely to binge eat inconspicuously and significantly more likely to feel depressed after binge eating. Furthermore, females were significantly more likely to use diet pills, stringent diet, or excessive exercise to lose weight. In terms of management of their diabetes, only 14.4% of the total sample reported excellent control, although most (89%) believed excellent or perfect control would prevent complications. Furthermore, 92.6% thought that what they did made a difference in control of their diabetes. These findings probably have important ramifications in terms of compliance. The belief that perfect control of diabetes will prevent complications is known to be false and may result in inordinate guilt among these young diabetics. The more moderate idea that good control may reduce the probability of complications might facilitate cooperation with diabetic control regimens.
REFERENCES 1. Bruch H: Eating Disorders: Obesity, Anorexia and the Person Within. New York, NY, Basic Books, 1973, p 357 2. Crisp AH: The differential diagnosis of anorexia nervosa. Proc R Sot Med 70:686-690, 1977 3. O’Gorman EC, Eyre DG: A case of anorexia nervosa and diabetes mellitus. Br J Psychiatry 137:103, 1980 (letter) 4. Fairburn LG, Steel JM: Anorexia nervosa in diabetes mellitus. Br J Med 280:1167-l 168, 1980 5. Gomez J, Dally P, Isaacs AJ: Anorexia nervosa in diabetes mellitus. Br J Med 281:61-62, 1980 (letter) 6. Garner S: Anorexia nervosa in diabetes mellitus. Br J Med 281:1144, 1980 (letter) 7. Roland JM, Bhanji S: Anorexia nervosa occurring in patients with diabetes mellitus. Postgrad Med J 58:354-356, 1982 8. Powers PS, Malone JI, Duncan JA: Anorexia nervosa and diabetes mellitus. J Clin Psychiatry 44:133-1351983
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