Distribution of eating disorders in subjects with type 1 and type 2 diabetes mellitus: a description of two cases

Abstracts

A presença de alterações do comportamento alimentar parece estar aumentada no diabetes melito (DM). Entretanto, a distribuição das diversas categorias de transtornos alimentares tende a se distinguir de acordo com a fisiopatologia do diabetes. O objetivo dessa apresentação é discutir dois casos distintos de ocorrência de transtornos alimentares no DM do tipo 1 (DM1) e no DM do tipo 2 (DM2). A paciente A é do sexo feminino, tem 19 anos e apresenta DM1 desde os 13 anos. Evidenciava sintomas depressivos proeminentes e, há 2 anos, passou a apresentar episódios de compulsão alimentar seguidos de vômitos auto-induzidos e omissão das doses de insulina com o objetivo de evitar ganho de peso. Em função desse comportamento, apresentou diversas internações associadas a uma piora do controle glicêmico. Após o uso de fluoxetina, houve remissão da psicopatologia alimentar e melhora do controle do DM. A paciente B possui 42 anos e é portadora do DM2 há 6 anos. Apresenta obesidade grau II e vinha exibindo, antes mesmo do diagnóstico do DM2, episódios de compulsão alimentar na ausência de comportamentos compensatórios, que prejudicavam o controle metabólico do diabetes. Foi iniciada fluoxetina até a dose de 60 mg/dia, com remissão do descontrole alimentar, perda ponderal e redução da hemoglobina glicosilada. A incidência de transtornos alimentares no DM1 estaria associada com um aumento da preocupação com a forma corporal e a possibilidade da omissão do uso da insulina como comportamento compensatório. No DM2, a obesidade seria um dos fatores associados ao desenvolvimento da psicopatologia alimentar.

Diabetes melito; transtorno alimentar; depressão.

CASE REPORT

Distribution of eating disorders in subjects with type 1 and type 2 diabetes mellitus: a description of two cases

Marcelo Papelbaum^I; José Carlos Appolinário^I; Rodrigo de Oliveira Moreira^II; Mônica Duchesne^I; Rosane Kupfer^II; Walmir Ferreira Coutinho^II

^IGrupo de Obesidade e Transtornos Alimentares, Instituto Estadual de Diabetes e Endocrinologia do Rio de Janeiro, Rio de Janeiro, RJ. Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ

^IIGrupo de Obesidade e Transtornos Alimentares, Instituto Estadual de Diabetes e Endocrinologia do Rio de Janeiro, Rio de Janeiro, RJ

^{Correspondence}

ABSTRACT

The presence of changes in eating behavior seems to be increased in diabetes mellitus (DM). However, the distribution of varied categories of eating disorders tends to be distinguished according to the physiopathology of diabetes. The objective of this report is to discuss two distinct cases of eating disorders in type 1 (T1DM) and type 2 diabetes mellitus (T2DM). Patient A is a 19–year–old female who has had T1DM since she was 13 years old. She presented prominent depressive symptoms and 2 years ago she started presenting binge eating episodes followed by self–induced vomits and insulin omission to avoid weight gain. Due to this behavior, she had several hospitalizations associated with worse glycemic control. After treatment with fluoxetine, there was remission of eating psychopathology and improvement in DM control. Patient B is a 42–year–old female who has had T2DM for 6 years. She has grade II obesity and had been showing, even before the diagnosis of T2DM, binge eating episodes in the absence of compensatory behaviors that jeopardized the metabolic control of DM. She started a treatment with fluoxetine up to 60 mg/day, with remission of binge eating, weight loss and reduction in glycosylated hemoglobin. The incidence of eating disorders in T1DM seems to be associated with an increase in concern with body shape and the possibility of insulin omission as a compensatory behavior. In T2DM, obesity seems to be one of the factors associated with the development of eating psychopathology.

Keywords: Diabetes mellitus, eating disorder, depression.

Introduction

Diabetes mellitus (DM) is a chronic disease characterized by persistent hyperglycemia.¹ Despite all efforts to control this disease, a group of patients with DM remains with high glucose levels, even following specific medical guidance. The presence of a psychiatric comorbid condition has been one of the suggested possibilities when a patient with DM presents complications during treatment.

A large body of evidence suggests that there is an increase in psychopathology in patients with DM.^2–4 Depression and eating disorders (ED) are among the psychiatric disorders that raise great interest in clinicians and researchers working with patients with DM. Using a meta–analysis, Nielsen⁵ demonstrated an increased occurrence of subclinical bulimia nervosa (BN) and ED among women with type 1 DM (T1DM) when compared with individuals without DM. In another study, Jones et al.⁶ observed an increase in binge eating episodes (BEE) among adolescents with T1DM, besides an 11% rate of omission of insulin doses, with the aim of avoiding weight gain. As to type 2 DM (T2DM), some studies found high rates of binge eating disorder (BED) among individuals with DM.^7,8

Many studies have investigated the impact of psychiatric disorders in metabolic control and occurrence of clinical complications associated with DM.^9,10 Presence of depression seems to be associated with higher prevalence of microvascular complications in patients with DM.¹⁰ As to ED, the presence of an alteration in eating behavior in T1DM has been associated with poor metabolic control. In T2DM, there are few studies assessing such association, but, in general, no negative impact of ED in clinical control of the disease has been demonstrated.⁴

The objective of this report is to discuss two distinct cases of ED in T1DM and T2DM.

Clinical case 1

Patient A is a 19–year–old female who has had DM1 since she was 13 years old. She reports recurrent periods of sadness, despondency and irritability, influencing global functioning, especially her eating behavior. Two years ago, she started manifesting BEE more frequently (an average of two to three times a week), with ingestion of large amounts of sweets in a short period of time, associated with a feeling of loss of control. The patient showed great concern about her body shape and was afraid that the treatment of DM would result in weight gain. Therefore, to avoid weight gain, the patient self–induced vomiting or underused insulin after BEE. She already presented several episodes of diabetic ketoacidosis, many of them resulting in hospitalization. During one of her hospitalizations, the patient started taking fluoxetine up to 40 mg/day with regular psychiatric follow–up. She presented remission of BEE and improvement in mood and no longer showed compensatory behaviors. There was reduction in hospitalizations, which were restricted to the periods in which the patient was not properly taking the antidepressant.

Clinical case 2

Patient B is a 41–year–old female who has had grade II obesity and T2DM for 6 years. Even before the diagnosis of DM, the patient showed frequent episodes of binge eating, which, according to her, made the proper follow–up of dietary guidance prescribed for the treatment of obesity difficult. Practice of associated compensatory behaviors was not observed. Fluoxetine was administered up to 60 mg/day, with remission of BEE. The patient started showing major weight loss and improvement in metabolic control (Table 1). Since there was an increase in episodes of hypoglycemia, daily insulin dose had to be reduced.

Discussion

Both reported cases are examples of the occurrence of changes in eating behavior in patients with DM. As observed by Herpertz et al.,⁷ the distribution of ED between both patients described herein seemed to have occurred differently according to type of DM. Patient A already had T1DM when BEE started. Increased concern about eating habits and about the possible weight gain associated with insulin therapy could have predisposed the occurrence of BN in this patient. However, female gender and presence of excessive concern about body shape are also risk factors associated with the development of ED. Therefore, casual occurrence of BN, with no direct relationship with presence of DM, is a possible explanation. On the other hand, patient B already showed BEE before diagnosis of T2DM. The need of food restriction imposed by T2DM treatment could have enhanced eating psychopathology.¹¹ Due to high BEE rates in obese individuals (up to 30%¹²) and to the fact that the patient already showed eating symptoms at DM diagnosis, the occurrence of BED in patient B could be directly associated with presence of weight excess.

Therefore, as observed by Papelbaum et al.,⁸ BN seems to be the most frequent ED among individuals with T1DM, and BED in those with T2DM.

Presence of general psychopathology is also quite frequent among individuals with DM. One out of three patients with DM has clinical depression (independent of DM type).³ Patient A showed a recurrent depressive disorder, with worsening of eating symptoms during periods of worsening of depressive symptoms.

Both patients achieved remission of eating symptoms using pharmacological therapy. Use of selective serotonin reuptake inhibitors (SSRI) proved to be efficacious in reducing BEE and depressive symptoms.^13–15 However, there are no studies investigating the use of these drugs in exclusive samples of patients with DM and associated ED. Some studies assessed the use of antidepressants to treat depression on patients with DM.³ Nortriptyline was the first antidepressant to be assessed in the treatment of depression in these patients.¹⁶ Despite the improvement in depressive symptoms, it presented a direct hyperglycemic effect. SSRI, on the other hand, such as sertraline and fluoxetine, do not seem to cause this type of metabolic effect. In addition, SSRI seem to increase peripheral sensitivity to insulin activity.¹⁷

In the cases presented herein, the presence of an ED seemed to have had a negative impact in DM clinical course. In the first case, the patients had frequent episodes of diabetic ketoacidosis, due to inadequate use of insulin therapy. In the second case, the presence of BEE could make adherence to nutritional guidance specific for DM difficult, resulting in weight gain associated with hyperphagia.

Presence of an ED has been associated with increased clinical complications of T1DM. Using a meta–analysis, Nielsen⁵ observed an increased risk of 33% in retinopathy among women with T1DM and one ED, when compared with individuals without ED. It seems that, due to the ED category, the impact on T1DM clinical course can be different. Takki et al.¹⁸ demonstrated a worse metabolic control in patients with T1DM and BN than in individuals with BED. Insulin omission as a predominant purgative method among individuals with BN could justify higher impairment rates in metabolic control of T1DM. In T2DM, however, the presence of an ED has not been associated with an increase in DM–related complications. Absence of purgative behaviors and BED fluctuating course could explain the negative findings.

On the other hand, improvement in eating psychopathology by using fluoxetine had a positive impact on DM therapy in both clinical cases described herein. The patient with T1DM improved her adherence to insulin therapy, reducing the frequency of recurrent hospitalizations. The patient with T2DM showed objective improvement in metabolic control and significant weight loss. Moreover, reduction in daily total insulin dose used by this patient after use of antidepressants should be stressed. Weight loss associated with the treatment and a possible increase in peripheral sensitivity to insulin activity by using fluoxetine could justify this finding. However, it should be considered that remission of depressive symptoms by using SSRI could also justify improvement in clinical evolution of DM, through an increase in adherence to medical and nutritional guidance and a possible direct metabolic effect.¹⁹

Conclusions

These cases are examples of the comorbid condition between DM and ED. In general, ED seem to have different manifestations in T1DM and T2DM. BN has been observed as the predominant ED in T1DM, and BED in T2DM. Furthermore, omission of insulin doses seems to be the predominant compensatory method among patients with T1DM who show changes in eating behavior. Although ED may cause worsening of clinical control of T1DM, treatment of eating symptoms could improve the metabolic control of patients with T1DM and T2DM. Studies assessing the treatment of ED in exclusive samples of patients with DM are necessary.

References

Received January 2, 2007

Accepted March 21, 2007.

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Publication Dates

• Publication in this collection
  06 Sept 2007
• Date of issue
  Apr 2007

History

• Accepted
  21 Mar 2007
• Received
  02 Jan 2007