Read the article below and identify the type of study chosen (qualitative or quantitative).
a) Identify the main characteristics of this type of research study evident in the article chosen.
b) Identify limitations in the research study chosen and how they could be addressed by the researchers.
c) Was the study done in a laboratory setting or a naturalistic setting? Discuss the differences between both types of research settings.
d) Define reactive and nonreactive observation. Did the study utilize either one? If so, how?
e) Define systematic observation, and address how it was used in the study you chose.
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Individuals with type 1 diabetes are at increased risk of developing an eating disorder, the effects of which can be physically and psychologically damaging. Early detection of an eating disorder and appropriate treatment is therefore essential. This article explores the possible factors that may increase the risk of people with type 1 diabetes developing an eating disorder, and highlights the signs and symptoms to help healthcare professionals detect people at risk so they can encourage them to accept appropriate help.
Diabetes, eating disorders, low self-esteem, mental health
EATING DISORDERS are a type of mental illness that can be divided into three diagnostic categories: anorexia nervosa, bulimia nervosa and eating disorders not otherwise specified (EDNOS). The common feature of all eating disorders is that the individual is unduly concerned about his or her body weight and/or shape. This can be characterised by a drive to become thin and/or a fear of fatness, and is compounded by a distorted body image. People with anorexia nervosa are driven to maintain a body weight and/or continue to lose weight below that which is healthy for them. Those with bulimia nervosa engage in recurrent episodes of binge eating followed by compensatory calorie purging behaviour such as self-induced vomiting, laxative misuse, slimming pills, excessive exercise, fasting, diuretics and misuse of medication/substances. EDNOS is a category that covers eating disorders that do not meet formal diagnostic criteria for anorexia nervosa or bulimia nervosa but may compromise the patient’s health and quality of life. It includes the diagnostic category of binge eating disorder, in which the individual does not engage in the compensatory behaviours associated with bulimia nervosa.
Eating disorders in people with type 1 diabetes
Individuals with type I diabetes are at increased risk of developing an eating disorder. Jones et al (2000) found that adolescent girls with type 1 diabetes were twice as likely to have an eating disorder as their non-diabetic peers. Goodwin et al (2003) stated that diabetes is the only physical illness that is associated with increased risk of developing an eating disorder and that an eating disorder is the main psychiatric problem of people diagnosed with type 1 diabetes. Polonsky et al (1994) found that 31% of a sample of 341 women aged 15-30 with type 1 diabetes intentionally restricted and/or omitted their insulin for weight control purposes. The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) includes the misuse of medications for weight loss as an ‘inappropriate compensatory purging behaviour’ in the criteria for bulimia nervosa and EDNOS (American Psychiatric Association 2000). Neumark-Sztainer et al (2002) confirmed that the most favoured means of weight control in people with type 1 diabetes was the deliberate omission and/or underuse of insulin.
When considering why someone develops an eating disorder a multifactorial approach is favoured (Striegel-Moore and Bulik 2007). This involves considering several factors including genetic and biological vulnerability, as well as environmental and cultural factors (Fairburn and Brownell 2002). Other empirically supported risk factors include the internalisation of the cultural ideal of thinness, body dissatisfaction, increased body mass index, history of dieting, depression, low self-esteem and perfectionism (Striegal-Moore and Bulik 2007). The development and maintenance of an eating disorder is different for each individual and so there is no ‘one size fits all’ approach to understanding its onset or its treatment.
Beat, a national charity for eating disorders, estimates that at least 1.6 million people have an eating disorder in the UK and that around 20% are male (Beat 2012). Eating disorders generally develop between the ages of 12 and 25; however, there have been cases in children as young as six years and some people develop eating disorders later in adulthood.
This article aims to explore the factors that increase the risk of people with type 1 diabetes developing an eating disorder and to highlight the warning signs to other healthcare professionals who are not specialists in this field so that they can identify potential cases and refer them appropriately.
People who have diabetes have externally imposed dietary rules that may disregard hunger and satiety. These rules are often linked with timing, quantity and type of food, and encourage food avoidance. Such restriction in itself can leave an individual vulnerable to eating disorder behaviours. Dietary restriction is a precursor to bingeing and purging (Fairburn et a1 2003). Rodin and Daneman (1992) suggested that the dietary restriction associated with diabetes and the need to control food intake can lead to internal conflict. This is due to an inability to eat freely and join in with peers, as well as external conflict in families, when parents may need to be active in managing food intake as advised by healthcare professionals. This can cause young people to feel they are losing an element of control over their lives, which may trigger a cycle of food restriction that leads to bingeing and purging.
Diet rules are often imposed by family members and healthcare professionals, which can cause conflict and result in the individual feeling a loss of control (Starkey and Wade 2010). This conflict can increase as the young person reaches adolescence and attempts to gain independence. Parental or healthcare professional control may then be experienced negatively by the child, who is attempting to develop his or her sense of control. The young person may attempt to regulate his or her body weight and shape as a means of dealing with the perceived conflict and external control. There appears to be a link between the rigidity of food portions and weight in those with diabetes and in those who have an eating disorder (Daneman et al 1998). This may be reinforced by family and healthcare professionals and may result in an increased risk of internalising emotions.
Individuals often lose weight before their diabetes is diagnosed. Insulin treatment can then lead to rapid weight gain (Starkey and Wade 2010). Those with type I diabetes are likely to be heavier than their peers who do not have diabetes (Jones et a1 2000). A study by the Diabetes Control and Complications Trial Research Group (2001) showed that to maintain a near normal blood glucose level and reduce the risk of health problems, the average individual with type 1 diabetes gained more than 10lbs and struggled to lose this when reviewed in long-term follow up. Individuals express concerns about insulin treatment causing weight gain (Thompson et al 1996).
Having a higher body mass index may increase a person’s dissatisfaction with his or her body and increase their desire to be thin (Bryden et al 1999). This may be further exacerbated in our culture, in which thinness is portrayed as the ideal body shape. Stice (1994) discussed a sociocultural model of bulimia nervosa, in which social pressures and corresponding internal beliefs that thinness is desirable leads to dissatisfaction with one’s own body and may result in dietary restraint. As discussed, this dietary restraint can leave some people vulnerable to binge eating. The experience of shame and disgust following such behaviour can result in the need for some form of compensation. This is as much about getting rid of calories as it is about managing the emotional experience. Omitting and/or restricting insulin is a compensatory behaviour available to the individual that can be well hidden in the short term. Therefore the individual may perceive it to be within his or her control. A high body mass index is an important predictor of body dissatisfaction and a desire to be thin. This is then exacerbated in adolescence when body weight and shape are changing and appearance is crucial to self-esteem (Starkey and Wade 2010).
Darbar and Mokha (2008) discussed the effects of injecting insulin and how this can cause bruising and lumpiness that may be perceived to be unattractive. This may compound existing body concerns and low self-esteem and provide further rationale for the omission of insulin treatment.
Effect of developing a medical condition
The onset of type 1 diabetes tends to occur between the ages of ten and 14 (Starkey and Wade 2010). Individuals at this age are extremely vulnerable; they are likely to be going through puberty and experiencing the associated physical, psychological, social and cognitive changes. Coming to terms with having a chronic condition such as diabetes and coping with management of the disease is associated with increased stress for the individual and the family (Starkey and Wade 2010). Chronic medical conditions can hinder the development of healthy self-esteem and body image. Wolman et al (1994) found that people with medical conditions such as diabetes tended to have lower self-esteem and poorer body image than those without diabetes. Stice (1994) suggested that developing a chronic medical condition can leave an individual vulnerable to developing depression. De Groot et al (2001) confirmed that people with diabetes have twice the risk of developing depression as people without diabetes. Low self-esteem, poor body image and depressed mood are all risk factors for developing an eating disorder (Fairburn et al 2003).
In the author’s clinical experience, developing a chronic medical condition requires a major adjustment for the individual and the family and no doubt increases anxiety in the home environment. Changes in the way these individuals are dealt with and/or perceived in relation to their eating can leave them vulnerable to developing an eating disorder. They fear that the way in which they are treated may also change. Being different can be hard for young people who may want to ‘fit in’. This may lead to a need to control weight and shape or to regain control of something in their life when all else around them appears beyond their control.
Complications associated with an eating disorder and diabetes
To omit or take reduced doses of insulin induces glycosuria. This behaviour is associated with long-term psychological and medical morbidity (Johnson et al 2002). People with diabetes who are diagnosed with an eating disorder are three times more likely to develop retinopathy (Rydall et al 1997), are at increased risk of neuropathy, have higher rates of hospital admission (Goebel-Fabbri 2009), and have increased risk of kidney and nerve damage (Takii et a1 2002). There are also complications associated with poor metabolic control and delayed growth. These physical problems are experienced alongside the usual physical complications associated with any other eating disordered behaviours, such as those listed in Box 1.
Those who withhold insulin tend to have a higher rate of psychological distress. They are likely to be more concerned with dieting and appear to have an increased fear of weight gain with a higher degree of body image disturbance (Biggs et al 1994). This may hamper an individual’s engagement in psychological treatment. Ramifications of such behaviour can be devastating. Mortality is three times higher in people who restrict their insulin (Goebel-Fabbri et al 2008). Their symptoms are likely to develop over time and individuals are likely to ignore the long-term effects (Martin 2008).
Denial is often associated with eating disorders and people may be good at hiding or concealing their behaviour; eating disorders may therefore be difficult for family members and health professionals to identify. As both eating disorders and mismanaged diabetes leave an individual at great risk physically and psychologically, recognising the signs and symptoms and identifying an eating disorder as a problem is crucial in supporting an individual to accept help. Using disturbed eating as the only indicator is not sufficient (Goebel-Fabbri 2009). Some of the warning signs and symptoms of eating disorders in people with diabetes are listed in Box 2.
Diagnosis and treatment
There is currently no validated screening tool specific to diabetes and eating disorders. However, Goebel-Fabbri et al (2008) found that women with type 1 diabetes who responded ‘yes’ to the question ‘Do you take less insulin than you should?’ were at increased risk of mortality. This suggests that asking such a simple question may be helpful. How such a question is asked and how further information is gathered is something that healthcare professionals need to consider if they come into contact with an individual whom they suspect may be struggling with an eating disorder.
The author works in a community eating disorder service where attendees have already either identified that they have a problem or others (family, friends and/or healthcare professionals) have identified that the individual may have an eating disorder and have supported them in accessing help. It is likely to be the practice nurse, diabetes nurse and/or dietician, GP or hospital consultant who may have noticed some of the symptoms listed in Box 2. It may be that a family member or friend contacts a healthcare professional with concerns. Patient denial is an important aspect of all eating disorders and should be managed sensitively.
Physical complications associated with eating disorders
* Disturbance in menstrual cycle in women, which may result in
* Disturbance in hormone levels in men.
* Dental problems.
* Feelings of tiredness and lethargy.
* Cardiac problems and poor circulation.
* Sleep disturbances.
* Skin problems.
* Sore throat.
* Mouth ulcers.
* Thinning of the hair.
* Lanugo hair, most commonly on the face or back.
* Swelling of the salivary glands.
Before an eating disorder can be identified, the healthcare professional should have a discussion with the patient. The individual should be encouraged to talk about any body concerns. Although it may be tempting to educate the individual about the dangers and risks, it is essential to put this aside and try to understand the patterns of insulin use. Providing a context of care and concern may help to reduce the person’s feelings of denial and enable him or her to be more open and trusting about seeking help. Healthcare professionals should be clear about their own sphere of competence and ensure that this is communicated clearly to individuals and their families. It is important that professionals are aware of where their role begins and ends. For example, it would be unhelpful for a specialist nurse in eating disorders to start offering advice on insulin regimens as doing so is likely to be outside that nurse’s clinical competency.
Warning signs and symptoms of eating disorders in patients with
type 1 diabetes
* High HbA1c.
* Frequent hospitalisation for diabetic ketoacidosis, hyperglycaemia
* Lack of blood glucose testing and/or reluctance to test.
* Assigning moral qualities to food, such as labelling certain foods
‘bad’ and others ‘good’.
* Eating more but losing weight.
* Severe fluctuations in weight.
* Injecting in private or insisting on injecting out of view.
* Fear of injecting.
* Distress at injecting.
* Avoidance of diabetes-related appointments.
* Anxiety or distress at being weighed at appointments.
* A fundamental belief that insulin makes you fat.
* Frequent requests to change meal plans.
* Frequent trips to the toilet.
* Frequent episodes of thrush or urinary tract infections.
* Nausea and stomach cramps.
* Drinking abnormal amounts of fluid.
* Dental problems.
* Early-onset diabetic complications.
* Delay in puberty or sexual maturation.
* Irregular periods or amenorrhea.
* Mood swings, depression, anxiety, self-hatred, irritability.
* Isolation and avoidance in general.
* Changes in peer relationships.
* Unusual patterns of intense exercise.
* Extreme concerns about weight and shape.
* Being overcritical about their appearance.
(Adapted from Diabetics With Eating Disorders (2012) with
Early detection and intervention is important (Goebel-Fabbri 2009), therefore accessing appropriate help is essential. Insulin restriction may get worse as an individual reaches late adolescence and early adulthood. Once a pattern of insulin restriction has been established, the eating disorder, along with associated negative feelings and poor diabetes management, can be difficult to treat (Goebel-Fabbri 2009).
There are no outcome studies that have examined the efficacy of treatment for those who have type 1 diabetes and eating disorders. The National Institute for Clinical Excellence (2004) suggested that a multidisciplinary approach to treatment is important. The appropriate professional should oversee diabetes management, and any other physical care needs, with the patient alongside someone specialised in the treatment of eating disorders who can provide evidence-based interventions. Goebel-Fabbri (2009) suggested that other psychiatric symptoms should be managed by the appropriate mental health practitioner.
Goebel-Fabbri (2009) stressed the importance of communication between team members, and with the patient, to maintain continuity and a transparent treatment approach. In the author’s community team, staff have developed and maintain links with local diabetes services. This enables diabetes staff to contact the service with their concerns and to receive advice, support and/or formal consultation. Staff can also access information, advice and support about patients who may be frightened or apprehensive about attending appointments related to their diabetes. Colleagues also try to hold joint review appointments in both settings so that patients are aware of colleagues working collaboratively as a team. This helps to prevent misinterpretation of information from the patient’s perspective. It has also proved helpful in maintaining clear boundaries, and in assisting professionals to work within their sphere of clinical competency.
Goebel-Fabbri (2009) encouraged practitioners to consider setting small, achievable, incremental goals that the patient feels able to work towards, with medical safety being the priority. Such a goal may be to start recording blood glucose levels accurately and regularly, and sharing these in order to begin to consider safety issues. For others, their first goal may be to record dietary intake accurately and to share this. For others, it may be to attend appointments regularly. Over time and as trust develops alongside new coping skills, small goals for improving food intake and reducing purging behaviours may be appropriate for the patient.
By gaining a sense of achievement the individual may become more confident. Goals should be decided by the individual with the support of the multidisciplinary team. Developing a working alliance based on honesty will support the patient’s progress (Goebel-Fabbri 2009).
Developing type 1 diabetes can leave an individual vulnerable to developing an eating disorder. The effect of changes to an individual’s dietary intake and the loss of control associated with this, in addition to the effects of treatment on body weight and shape, may be contributory factors. The restriction and omission of insulin can be an effective, discreet means of weight control that can have devastating physical and psychological effects and increase the risk of death. Detecting the signs and symptoms of an eating disorder is vital to support an individual in acknowledging their problem and to receive appropriate help as early detection reduces the risks of these problems becoming chronic. Small achievable goals are favoured within the context of a multidisciplinary treatment package
Date of acceptance: March 27 2012.
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Clinical nurse specialist, Northamptonshire Community Eating Disorder Service, Northampton.
Correspondence to: Kathryn.firstname.lastname@example.org
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Source Citation (MLA 7th Edition)
Weaver, Kathryn. “Eating disorders in people with type 1 diabetes.” Nursing Standard 26.43 (2012): 43+. Academic OneFile. Web. 15 May 2015.