The Diabetologist #24+25

ADDITIONAL CONSIDERATIONS
Disordered Eating Behaviors, Eating Disorders,
and Other Age-Related Concerns
Body image and weight-management issues in T1D
adolescents and young adults with T1D may lead
to eating disorders and disordered eating behaviors
(see chapter 8, Psychosocial Issues in Type 1 Diabetes).
It is unclear if there is an increased prevalence
of diagnosable eating disorders and disordered
eating behaviors in T1D patients compared
with the general population. Some studies show a
higher rate in T1D patients, while others have found
the same or lower rates.78 Estimates in T1D adolescent
and young adult females range from 3.8 to
27.5% for patients classified as bulimic or having
binge eating disorder. When insulin omission is considered
purging, the estimate is as high as 38-40%.
The presence of eating disorders has been associated
with increases in retinopathy, neuropathy, transient
lipid abnormalities, hospitalizations for diabetic
ketoacidosis, and poor short-term metabolic control.
Adolescents with diabetes should be screened
regularly for signs of potential eating issues and concerns
with weight and body image as well as insulin
omission. After screening, issues can be addressed
and action can be taken to prevent the development
of an eating disorder, which is very complicated to
treat especially when it coexists with T1D. Warning
signs that suggest an eating disorder in adolescents
include inadequate weight gain or growth, significant
weight loss without illness, suboptimal overall
glycemic control, and recurrent diabetic ketoacidosis.
If signs of disordered eating and weight or body
image concerns are present, they need to be addressed;
referral to a dietitian and psychotherapist
or psychologist is recommended. If a patient is at
high risk of an eating disorder, the patient should
be referred to an eating disorder program for an assessment
and treatment, if necessary.10
Finally, adolescents with diabetes may experiment
with alternative eating patterns, such as vegetarianism
or nutritional supplement use. Practical information
on these topics will enable adolescents to make
wise choices for their health.10
NUTRITION THERAPY FOR CELIAC
DISEASE AND T1D
Celiac disease (CD) is an important entity to consider
since those with T1D are also at increased risk
for developing CD. Individuals diagnosed with both
CD and T1D should seek the care of an RD familiar
with the nutritional management of both entities.
The RD should also provide comprehensive support
and education about gluten-free diets (GFD).
The Gluten-Free Diet
Since nutritional deficiencies have been reported
with long-term GFD, comprehensive nutrition assessments
must be done to ensure adequate nutrient
intake.79,80 A GFD can be extremely challenging,
since ongoing monitoring of ingredients in foods
and food processing are intricate parts of nutrition
interventions.81
For newly diagnosed children and adults with CD,
studies report that adherence to a gluten-free eating
pattern results in significant improvements in serum
Hb, iron, zinc, and calcium, as a result of intestinal
healing and improved absorption. However, adherence
to the gluten-free eating pattern may result in a
diet that is high in fat and low in carbohydrates, fiber,
iron, folate, niacin, vitamin B12, calcium, phosphorus,
and zinc. A small number of adult studies show
a trend toward weight gain after diagnosis.81,82
Several studies report that patients with CD (treated
and untreated) are more likely to experience gastrointestinal
symptoms such as diarrhea, constipation,
abdominal pain and bloating, nausea or vomiting,
reduced gut motility, and delayed gastric emptying
than healthy control subjects. However, long-term
adherence to a GFD has been shown to reduce the
prevalence of these symptoms.81,82
Implementing the Gluten-Free Diet
A GFD can be more expensive than a normal diet
and requires extensive, repeated counseling and
RD instruction. Patients with CD must be meticulous
label readers and knowledgeable about food
processing, preparation, and handling practices to
avoid cross-contamination with gluten-containing
grains. As little as 10 mg gluten (1/50th a slice of
bread) can cause significant mucosal inflammation in
some individuals. Therefore, it is recommended that
contaminating gluten should be kept to