Eating disorders in type 1 diabetes

Transcription

1 J Nash, TC Skinner* Diabetes: eating to live or living to eat? Introduction Research indicates that the emphasis placed on dietary control in the management of type 1 diabetes may place a person with diabetes at an increased risk of some disturbance in eating behaviour. The fourth edition of the Diagnostic and Statistical Manual of Psychological Disorders (DSM-IV) 1 identifies three categories of eating disorder that have been implicated as more prevalent in the type 1 diabetes population: anorexia (refusing to maintain a normal body weight); bulimia (binge eating and inappropriate compensatory methods to prevent weight gain); and eating disorder not otherwise specified (EDNOS). The latter is eating disordered behaviour that does not quite meet the criteria for bulimia (less frequent binging or purging through insulin omission) or anorexia (e.g. still having periods). DSM-IV includes binge eating disorder (BED) as a provisional subcategory of EDNOS for further study, and so anyone who exhibits just binge eating behaviour is technically under the remit of EDNOS. The aetiology of eating disorders can be understood within a risk-factor model 2 in which any number of biological, psychological, familial and sociocultural factors may interact and lead to the development and maintenance of an eating disorder. Gowers and Shore 3 propose that most factors in the aetiology of eating disorders are mediated through weight and shape concern or need for restraint. Professionals supporting individuals with type 1 diabetes often emphasise the need for self-control in eating certain types and quantities of food, and in doing so may well make diabetes a ABSTRACT There is some debate in the literature as to whether there is an increased risk of developing eating disorders in individuals with type 1 diabetes. This review located 12 empirical studies of eating pathology in females with type 1 diabetes. Review of these papers indicates that there is no evidence for an increase in the rates of anorexia or bulimia, in females with type 1 diabetes. However, the data do suggest that eating disorders not otherwise specified (EDNOS) are more prevalent in individuals with type 1 diabetes. Key features of these articles are reviewed and discussed. Copyright 2005 John Wiley & Sons, Ltd. Practical Diabetes Int 2005; 22(4): KEY WORDS type 1 diabetes mellitus; eating disorders; prevalence; review risk factor for the development of eating disorders. The challenge of research in this area has been to enable accurate diagnosis of eating disorders among the diabetic population and quantify whether individuals with diabetes are at a greater risk for eating pathology. This paper has three aims. The first is to review the empirical literature. The second is to provide directions for future research. Finally, it aims to highlight the essential role that diabetes practitioners play in screening for eating disorders among their patients. Method The sample of interest to this review was adolescents and adults with type 1 diabetes and the focus was on empirical investigations. The literature to be reviewed was obtained using a structured search process. The terms anorexia OR bulimia OR eating disorders AND type 1 diabetes were entered into the PubMed (which incorporates Medline), Psychinfo and Embase databases and limits set to only include those studies conducted post PubMed located a total of 155 articles, Psychinfo located a total of 13 articles and Embase located a total of 29 articles. Of these, 12 empirical papers were identified as applicable to this review: two from Canada, four from England, two from Sweden, and four from the USA. One meta-analysis study was also reviewed. (See Table 1 for a detailed summary.) 4 16 Results Eating disorders are more prevalent Jones et al. 4 found that individuals with diabetes were 2.4 times more likely to have an eating disorder than non-diabetic controls. EDNOS was found to be the most common concern and anorexia failed to feature as a disorder that affected either those with diabetes or the controls. Engstrom et al. 8 reported no cases of anorexia or bulimia but 6.9% of their sample with diabetes had clinically significant disordered eating behaviour compared to none of the control group. Binge eating and purging behaviour was the most common finding. Engstrom et al. concluded that significantly more individuals with diabetes had disturbed eating behaviour, than controls. Stancin et al. 7 found that 58% of individuals with diabetes reported eating binges and 12% were classified as bulimic according to DSM-III criteria. Rodin et al. 5 found that Mrs J Nash, BSc Hons, South London & Maudsley NHS Trust, London, UK Dr TC Skinner, BSc Hons, PhD, University of Southampton, Southampton, UK *Correspondence to: Dr TC Skinner, School of Psychology, University of Southampton, Highfield, Southampton SO17 1BJ, UK; t.c.skinner@soton.ac.uk Received: 31 October 2004 Accepted in revised form: 11 April 2005 Pract Diab Int May 2005 Vol. 22 No. 4 Copyright 2005 John Wiley & Sons, Ltd. 139

2 19.5% of the sample with diabetes was considered to suffer from clinically significant eating pathology. They concluded that individuals with diabetes were more at risk for developing an eating disorder. Eating disorders are not more prevalent In contrast to these studies which have found that there is an increase in prevalence rates of individuals with diabetes suffering from eating disorders, four studies in this review found contrasting results. Meltzer and colleagues 10 stated that individuals with diabetes were not more at risk from eating disorders and that females with diabetes reported significantly less body dissatisfaction than the healthy population. This is in contrast to any other study; however, the authors did conclude that female patients aged years seemed to be at greatest risk for developing disordered eating patterns. Peveler et al. 11 concluded from their study of 76 individuals with diabetes, and age and sex matched controls, that those with diabetes were not more at risk from eating disorders. They state that these results should be interpreted cautiously due to a small sample size. The follow up to this study, conducted by Bryden et al., 12 also showed that those with diabetes (65 of the previous participants, now aged years) were not more at risk. Striegal-Moore et al. 13 found that individuals with diabetes were not more at risk but cited that most participants hadn t reached the peak age of risk for developing an eating disorder. However, it is evident that even these studies, which failed to find that those suffering from diabetes were more at risk from eating disorders, did identify a significant proportion who suffered from eating pathology. Discussion Summary of results Reviewing the literature reveals that eating disorders are present within a significant proportion of individuals with type 1 diabetes. However, there is some disparity in the literature findings and not all studies definitely found that those with diabetes were at an increased risk for eating pathology. This is likely to be attributable to some extent to the use of contrasting methodological approaches, particularly evident within the areas of assessment method, sample size and age range. Methodological issues The method of assessing and diagnosing eating behaviour is one of the most crucial aspects of research in the area of disordered eating. The three main measures that are currently used are the Eating Disorders Inventory (EDI), 17 the Eating Attitudes Test (EAT) 18 which are both self-report measures and the Eating Disorders Examination (EDE), 19 which is a semi-structured diagnostic interview. Many researchers have argued that self-report measures yield higher prevalence rates than interview based measures, as the criteria are not as specific and so more individuals fall into an eating pathology category. 20 The EDE offers a robust alternative to self-report measures and has been described as the gold standard for the standardised assessment of eating disorders. 21 It focuses on the symptoms and related behaviour of eating disorder psychopathology in order to establish the motivations behind eating behaviour whether they are for weight reasons or simply a part of the individual s diabetes care. In perhaps one of the most rigorous studies to date, 4 a self-report screening package consisting of the EDI, EAT and a further measure (the diagnostic survey for eating disorders modified) 22 was utilised. This enabled participants to be screened at the self-report stage and then participate in the EDE. Using this vigorous assessment procedure, Jones and colleagues 4 judged that DSM-IV and sub-threshold eating disorders are almost twice as prevalent in adolescent females with diabetes than age and sex matched non-diabetic people. Sample size A number of researchers have cited the use of small sample sizes as a major limitation of their work. For example, Stancin et al. 7 found that 58% of females with type 1 diabetes had regular eating binges and 12% were classified as bulimic, but cite that reliance on self-report measures, a small sample size and moderate response rate limits the generalisability of the results. Nielson 9 provided a quantitative summary of existing empirical investigations of the prevalence of eating disorders in females with type 1 diabetes. Odds ratios indicated that the risk for anorexia was not more increased, bulimia was marginally increased and EDNOS was highly increased. Power analysis demonstrated that 1000 cases and 1000 controls would be necessary in order to demonstrate a two-fold increase in the prevalence of eating disorders among individuals with diabetes. As this review reveals, all the current studies are far from this number. Age of sample In addition to a lack of adequate numbers of participants, there has been the tendency to sample a range of different ages, varying from eight years 13 up to 60 years. 15 Intuitively, one would expect that the parents and carers of younger individuals are still very involved in their child s diabetes routine, thus providing less opportunity to manipulate food intake and/or insulin regimen. Additionally, weight and shape concerns are unlikely to have manifested in those with diabetes who are of younger ages. Indeed, DSM-IV states that the peak onset of bulimia is in late adolescence/early adult life, which suggests that those studies that used this age range would be more sensitive to identifying bulimia symptomatology. This is reflected in the research those investigations that concluded that individuals with diabetes were more at risk had higher mean ages than those that found diabetic people were not more at risk (see Table 1). However, this does not mean that younger individuals do not suffer from eating pathology. Colton et al. 23 studied girls aged nine to 14 years and found that, although mild, eating disturbance was present and more common among those with diabetes than among controls. They suggest that screening and preven- 140 Pract Diab Int May 2005 Vol. 22 No. 4 Copyright 2005 John Wiley & Sons, Ltd.

3 tion programmes should begin in the pre-teen years. Directions for future research This paper has reviewed the results of the main studies that aim to assess whether those with diabetes are at a greater risk of developing eating disorders. It has discussed some of the pertinent methodological differences between these investigations, which may go some way to explain their differing outcomes. However, there are several issues that have been neglected in the research to date, which may predict vulnerability to developing an eating disorder. These are insulin regimen, age of onset and duration of diabetes. Insulin regimen Insulin regimens can vary from two to five injections daily, to wearing an insulin pump that provides a continual dose of insulin as required. There are advantages and disadvantages to each regimen. Multiple daily injections can provide more flexibility as the patient can alter their dose according to how much or little they have eaten at their mealtime. However, for a patient with diabetes combined with eating pathology this flexibility could prove detrimental, as the freedom exists to binge eat a large quantity of high calorific food and increase insulin dosage; or, in the case of those who omit insulin, to exclude insulin altogether to prevent weight gain. Two daily insulin injections, having one dose with breakfast and one with dinner, may lead to a sense of restriction on diet and lifestyle as, if the patient eats more than usual, blood glucose levels will be elevated if no compensatory physical activity occurs. A significant line of research would be to compare the prevalence of eating disorders among individuals who have differing insulin injection schedules. There is a need to examine the effects on eating behaviour of both routines and their associated perceived flexibility and restrictions, and any interactions with other personality variables such as need for control and autonomy. Both regimens have their advantages and clinicians take a range of factors into consideration when implementing a care plan. Therefore there is a clear need to examine how to tailor insulin regimens to the individual, as no one regimen will be optimal for all individuals. Age of onset of diabetes Age of onset of diabetes is a second factor that has been neglected in the research literature. Differences in vulnerability to eating disorders may exist between those diagnosed as young children and those as older adolescents or young adults. We might expect that there are peak ages of diagnosis that would place an individual at increased risk for developing an eating disorder due to the differing concerns of the maturing child and their development of schemas concerning food and eating. To date, no research has been conducted in this area. More research is needed to clarify the age group(s) at which eating disorders would have the most severe impact. Colton et al. 23 examined eating disorders among girls aged nine to 14 years and found that the younger girls did exhibit eating pathology and these symptoms were heightened for girls above 11 years. It is well accepted that eating disorders take hold within adolescence, with its associated developmental pressures. The extra weight that often accompanies diabetes diagnosis, accompanied by feeling overwhelmed by diabetes and its need for restraint, may lead to a loss of control expressed through eating pathology. Diabetes duration Diabetes duration is a further factor that may affect developing an eating disorder. It is natural that the longer an individual has diabetes, the more familiar and adept they become at monitoring it. However, this may give some patients the confidence to manipulate their treatment, possibly to the detriment of their control. Indeed, Meltzer et al. 10 report that longer duration of the disease was a predictor for poorer glycaemic control. There is a need for research into the susceptibility of individuals with differing diabetes durations to eating disorders in order for diabetes specialists to be alert to those individuals who are most vulnerable. Future directions in diabetes care Diabetes specialists play a major role in being attentive and vigilant for eating disorder symptomatology. The educational programme Dose Adjustment for Normal Eating (DAFNE) 24 looks set to have a positive impact on diabetes care. DAFNE aims to enable patients to take better control of their diabetes by educating them about how to adjust their insulin injections to fit their lifestyle, rather than having to alter their food and activity to a pre-set insulin regimen. This allows patients to eat late, skip a meal or eat more than usual, which they may previously have never been able to do without upsetting their glycaemic control. The results of the first UK DAFNE trial demonstrated that participants had significantly improved their blood glucose control within six months, HbA1c was significantly better in DAFNE patients (mean 8.4%) than in the control group (9.4%). 24 Participants in the UK trial commented that their dietary freedom and enjoyment of food improved greatly, as they did not feel guilty about eating certain foods any more. 24 However, this dietary freedom can be a problem too: one person from the UK trial commented that after years of being told what she could and could not eat she wanted to try all those foods she had been avoiding. She said this only lasted a few weeks, after she realised the negative effects weight gain would have on her health. 24 However, this is a concern for patients who may have other risk factors predisposing them to developing an eating disorder. Consequently, patients require support and follow up by their health care team within clinic visits in the short, medium and long term, in order to monitor emotional responses to their newly acquired dietary freedom. The long-term ideal is that all newly diagnosed people with diabetes would have access to DAFNE training. The flexibility in eating that DAFNE can provide may Pract Diab Int May 2005 Vol. 22 No. 4 Copyright 2005 John Wiley & Sons, Ltd. 141

4 Table 1. Summary of review of empirical literature 4 16 (Abbreviations: AN = anorexia nervosa; ED = eating disorder; Study Objectives Year/country No of Age Method of (reference no) research conducted? participants range (mean) obtaining sample EDs in females with and Determine prevalence of ED Identified from diabetes without T1D: cross in adolescent Canada F=All clinics in 3 cities sectional study (4) M=0 AN and bulimia in female Assessing rates of AN & major diabetes clinics in adolescents with IDDM: bulimia among IDDMs England F=All (17.2) the area, approached at a systematic study (5) M=0 regular clinic visit EDs in patients with IDDM (6) Comparing frequency of eating Seen in the diabetes disturbances in IDDMs & Sweden F=41 (F=28.3) clinic of a hospital normal males & females M=45 (M=28.4) Binge eating and purging in Describes binge eating & ?geographically identified young women with IDDM (7) purging behaviours reported USA F=All & asked to volunteer for by females with IDDM M=0 a study EDs in adolescent girls with Examine prevalence of ED Taken from 4 counties in IDDM: a population-based compared to controls Sweden F=All (16.3) Sweden, patients attending case control study (8) M=0 participating clinics EDs in females with T1D: an Provide a quantitative summary 2002 update of a meta-analysis (9) of existing studies on the N/A prevalence of ED in females with T1D Disordered eating, body mass Examine relationship between diabetes speciality and glycemic control in disordered eating attitudes & USA F=82 clinics adolescents with T1D (10) behaviours, BMI & glycaemic M=70 control in adolescents with T1D EDs in adolescents with Determine prevalence of ED in Register of hospital out- IDDM: a controlled study (11) adolescents with IDDM & a matched England F=33 (M=15.2) patient clinic that provides sample of non-diabetic people M=43 (F=15.3) specialist treatment for T1D Eating habits, body weight Examine ED, insulin misuse, Follow up from 75 and insulin misuse. A longi- weight change, & their relationships England F=26 (M=23.7) participants within Oxford tudinal study of teenagers and with glycaemic control & M=39 (F=23.9) hospital catchment area young adults with T1D (12) diabetic complications Prevalence of ED symptoms Assess attitudinal & behavioural Case register of the in preadolescent and symptoms of ED in IDDMs/non- USA F=All Yale Children s adolescent girls with IDDM (13) IDDMs M=0 Diabetes Center Prevalence of AN and bulimia Assess prevalence of AN & (18.4) Sample A: urban diabetes among young diabetic bulimia among diabetic women USA F=All referral centre; Sample B: women (14) using a questionnaire M=0 rural practice Insulin omission in women Describe extent of intentional Approached at time of with IDDM (15) insulin omission Canada F=All (33.1) medical visit to diabetes M=0 centre EDs in young adults with Determine prevalence of ED Routine diabetes IDDM: a controlled study (16) in IDDMs & controls England F=54 (F=21) clinic visit in Oxford M=46 (M=22) 142 Pract Diab Int May 2005 Vol. 22 No. 4 Copyright 2005 John Wiley & Sons, Ltd.

5 IDDM = insulin dependent diabetes mellitus; T1D = type 1 diabetes; T2D = type 2 diabetes) Control group? EDE EDI EAT Additional/alternative DSM III T1D more at risk? Note measures? or IV 1098 age matched Y Y Y BMI, HbA1c IV Yes 2.4 times as likely to have Possibility of selection controls from 3 schools an ED. EDNOS the most bias? Not truly population in same cities as common diagnosis. 1.9 times based, referral bias to the diabetes centres as likely to have a subthreshold paediatric diabetes clinics ED than controls may exist No Y Y Scores >20 on EAT or III Yes 19.5% of sample Statistical analysis? elevated scores on relevant considered to suffer from subscales of EDI interviewed clinically significant eating clinically to determine pathology whether the diagnosis of an ED could be confirmed on the basis of criteria Yes 93 controls Y III Female T1Ds had (students) similar in age, significantly higher scores weight & height for on EAT than normal females; normal controls females had higher weight & height for males No Y A bulimia screening form III 58% reported eating binges & Authors cite that reliance comprising DSM III criteria 12% were bulimic (DSM III) on self-report measures, a for bulimia, a diabetes small sample size & background form & a 90- moderate response rate item symptom checklist limit generalisability of of psychiatric symptoms results Yes age matched, Y BABA-T (Assessment of IV No cases of AN or bulimia but Cross cultural differences from 2 state schools, AN-bulimia Teenager significantly more T1Ds had in Sweden? n=97 version [Based on EDE]) disturbed eating behaviour Odds ratios show AN not more Power analysis indicates increased, bulimia marginally that 1000 cases & 1000 increased, EDNOS highly controls needed to increased demonstrate a 2-fold increase in the prevalence of ED in T1D-current studies far from this number Normative sample from Y Height, weight, BMI, HbA1c No found that females reported Similar population & Rosen et al. (1988) EAT: significantly less body methodology to 13 & 8 but Norms for adolescent dissatisfaction than the healthy controls in 8 had lower EDI girls & boys population scores than normal population Age & sex matched Y Y HbA1c III No (but authors state should be randomly from the interpreted cautiously due to lists of 2 general small sample size) practices General population Y III No states that because didn t Not specifically ED more use self-report measures which concerned about weight yield higher prevalence estimates change etc over 8-year follow up Local school children Y Y Diabetes quality of life III No but authors cite that most participants hadn t reached the peak age of risk for developing an ED No 2-page questionnaire which III Bulimia represents a common No statistical was a direct transcription of problem among diabetes analysis of results DSM III criteria for AN & bulimia No Bulimia Test-Revised (BULIT- Insulin omission is common R) & the Brief Symptom 31% reported intentional IO Inventory & Hypoglycemia but only 8.8% frequently Fear Survey & The Problem Areas in Diabetes Survey Yes 67 women, Y Y No, but 37% had matched for age & underused/omitted insulin father s social class, obtained from case registers of 1 urban & 1 rural general practice Pract Diab Int May 2005 Vol. 22 No. 4 Copyright 2005 John Wiley & Sons, Ltd. 143

6 positively influence the reduction of prevalence rates of eating disorders in the long term. Conclusion Research demonstrates that individuals with type 1 diabetes do not have increased risk of developing anorexia or bulimia. However, the increase seen in EDNOS is probably not a result of diabetes management practices causing patients to develop an eating disorder, but instead may arise from the extra focus the condition places on food which may trigger disordered eating in those individuals who may be at risk of developing such a disorder. It is tragic that in treating one disorder, another may develop. There is a need for further research that rigorously identifies those at risk in order to better inform diabetes practitioners and allow identification of those at risk. National Service Frameworks for Diabetes have been introduced in order to ensure standards in patient treatment are being met. They cite that screening for eating disorders needs to be undertaken as part of the annual check; 25 however, clinic settings may lack any formal screening methodology. There are three methods that need to be utilised: Monitoring of a high HbA1c, as this may be the first sign of disturbed eating behaviour. Discussing issues around weight management and disordered eating behaviour. Using an eating disorders screening tool such as the SCOFF questionnaire 26 at the patient s annual check would identify those patients with symptoms of eating pathology. The patient s health care team has a responsibility to provide open lines of communication with their patients regarding disordered eating within routine clinic visits. People with diabetes, particularly females, need support as individuals whose medical condition has caused an unnatural focus on food, which needs to be discussed openly as something that may be a natural consequence for those who are already at an increased risk for eating disorders. In order to provide Key points The evidence does not support an increased prevalence of anorexia or bulimia in people with type 1 diabetes The evidence does suggest a two to three fold increase in the prevalence of EDNOS Clinicians should be aware of the diagnostic criteria for EDNOS and refer individuals urgently to the appropriate services Screening of high risk populations is possibly warranted to facilitate early detection and referral this support the diabetes team needs to build a link with a member of the clinical psychology and/or psychiatry team in order to effectively refer on to a health professional with a special interest in diabetes. The presence of clinical nurse specialists in psychological medicine departments may provide this much needed link. In addition, it is advisable to limit referrals to one clinician at a time, as the patient may be confused by referral to both a dietician (in which the central focus will be food) and a psychologist (who may well be aiming to de-emphasise food). The hope is that the prevalence rates of binge eating and bulimia will decrease as new forms of diabetes education such as DAFNE are introduced and utilised in order to allow the diabetes lifestyle to become more closely aligned with that of individuals without diabetes. In the interim, it is imperative that diabetes specialists are aware of the effect that eating disorders can have both emotionally and medically, and provide open channels of communication with their patients in order to allow access to support and alleviate subsequent long-term consequences. Conflict of interest statement None. References 1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (4th edn). Washington DC: American Psychiatric Association, Johnson CL, Maddi K. The etiology of bulimia: Biopsychosocial perspectives. Annals of Adolescent Psychiatry 1986; 13: Gowers SG, Shore A. Development of weight and shape concerns in the aetiology of eating disorders. Br J Psychiatry 2001; 179: Jones JM, Lawson ML, Daneman D, et al. Eating disorders in adolescent females with and without type 1 diabetes: cross sectional study. BMJ 2000; 320: Rodin GM, Daneman D, Johnson LE, et al. Anorexia and bulimia in female adolescents with insulin dependent diabetes mellitus: A systematic study. J Psychiatric Research 1985; 19(2): Rosmark B, Berne C, Holmgren S, et al. Eating disorders in patients with insulin dependent diabetes mellitus. J Clin Psychiatry 1986; 47(11): Stancin T, Link DL, Reuter JM. Binge eating and purging in young women with IDDM. Diabetes Care 1989; 12(9): Engstrom I, Kroon M, Arvidsson CG, et al. Eating disorders in adolescent girls with insulin-dependent diabetes mellitus: a population-based casecontrol study. Acta Paediatr 1999; 88: Nielson S. Eating disorders in females with Type 1 diabetes: an update of a meta-analysis. Eur Eating Disorders Rev 2002; 10(4): Meltzer LJ, Banks RA, Bennett Johnson S, et al. Disordered eating, body mass and glycemic control in adolescents with type 1 diabetes. Diabetes Care 2001; 24(4): Peveler RC, Fairburn CG, Boller I, et al. Eating disorders in adolescents with IDDM: a controlled study. Diabetes Care 1992; 15(10): Bryden KS, Peveler RC, Neil A, et al. Eating habits, body weight and insulin misuse: A longitudinal study of teenagers and young adults with type 1 diabetes. Diabetes Care 1999; 22(12): Striegal-Moore RH, Nicholson TJ, Tamborlane WV. Prevalence of eating disorder symptoms in preadolescent and adolescent girls with IDDM. Diabetes Care 1992; 15(10): Pract Diab Int May 2005 Vol. 22 No. 4 Copyright 2005 John Wiley & Sons, Ltd.

7 14. Hudson JI, Wentworth SM, Hudson MS, et al. Prevalence of anorexia nervosa and bulimia among young diabetic women. J Clin Psychiatry 1985; 46(3): Polonsky WH, Anderson BJ, Lohrer PA, et al. Insulin omission in women with IDDM. Diabetes Care 1994; 17(10): Fairburn CG, Peveler RC, Davies B, et al. Eating disorders in young adults with IDDM: a controlled study. BMJ 1991; 303: Garner DM, Olmsted MP. Eating Disorder Inventory Manual. Odessa, Florida: Psychological Assessment Resources, Garner DM, Olmsted MP, Bohr Y, et al. The Eating Attitudes Test: psychometric features and clinical correlates. Psychological Med 1982; 12: Commentary Eating disorders: improved skills are needed in screening and initial care For those who work with young adults with type 1 diabetes, the challenges of helping this group are well known. We, as health care professionals, are becoming increasingly aware of the potential impact of our health related (hidden or otherwise) messages on those we try to serve. The need to focus on food (whether to restrict or to count carbohydrates) is unavoidable once diabetes is diagnosed. Food is one of the key pleasures (as well as a major health requirement!) in our society and it is not surprising that eating disorders occur in those with diabetes as well as those without. Nash and Skinner, in their review of eating pathology in people with type 1 diabetes, found that whilst there is not an increased risk of developing anorexia or bulimia, there is an increased risk of EDNOS (Eating 19. Cooper Z, Fairburn CG. The Eating Disorder Examination: a semi-structured interview for the assessment of the specific psychopathology of eating disorders. Int J Eating Disorders 1987; 6: Crow SJ, Keel PK, Kendall D. Eating disorders and insulin-dependent diabetes mellitus. J Consultation Liaison Psychiatry 1998; 37(3): Rosen JC, Vara L, Wendt S, et al. Validity studies of the eating disorder examination. Int J Eating Disorders 1990; 9: Johnson C. Initial consultation for patients with bulimia and anorexia nervosa. In Handbook of psychotherapy for anorexia nervosa and bulimia. Garner DM, Garfinkel PE (eds). New York: Guildford, 1985; Colton P, Olmsted M, Daneman D, et Disorders Not Otherwise Specified). This increase appears not to be caused by a focus on food, but to be a triggering of an underlying eating disorder by the increased focus on food. These findings encourage us, as health care professionals, to be increasingly aware of this potential in those for whom we provide care. Whilst more information is required to help us identify those at high risk, the authors suggest an initial screening approach: Awareness of those with recurrently raised HbA1c levels. Discussing issues around weight management and eating behaviours the recent NICE guidance on eating disorders 1 provided two simple questions that may be of help: Do you think you have an eating problem? and Do you worry excessively about your weight? Using an eating disorders screening tool at the annual check. What is clear is that we (those of us who have contact with young people with type 1 diabetes) need to al. Disturbed Eating Behaviour and Eating Disorders in Preteen and Early Teenage Girls with Type 1 Diabetes. Diabetes Care 2004; 27(7): DAFNE Study Group. Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes: dose adjustment for normal eating (DAFNE) randomised controlled trial. BMJ 2002; 325: National Service Frameworks for diabetes, Retrieved December 15, 2003, from Department of Health Online via: diabetes 26. Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ 1999; 319: develop improved skills in both screening and initial care of young people with eating disorders of any sort. In addition, whilst the authors suggest the development of clinical nurse specialists in psychological medicine departments, there is a clear need for these professionals to focus some of their efforts in skilling up the current workforce. Whether the prevalence rates of eating disorders will decrease with the development of self-management programmes such as DAFNE may be a matter of debate. Whilst these programmes remove the strictness of eating, they still focus on measuring food. The researchers of these programmes may wish to consider the changing attitudes to food in their outcome measures! Sue Cradock, Consultant Nurse in Diabetes, Portsmouth, UK Reference 1. NICE. Eating Disorder Guideline CG9. National Institute for Clinical Excellence, Erratum Autumn 2004 Meeting of the Association of British Clinical Diabetologists (ABCD). Pract Diabetes Int 2005; 22(3): The Publishers of Practical Diabetes International would like to express their sincere regret to Dr John Dean and the ABCD for printing Dr Dean s place of work as Boston rather than Bolton. This error occurred because of an American word check programme used in the typesetting process. Pract Diab Int May 2005 Vol. 22 No. 4 Copyright 2005 John Wiley & Sons, Ltd. 145