Eating Disorder in Type 1 Diabetes Can Be Unmasked by Information Technology

To the Editor: In patients affected by type 1 diabetes mellitus (T1DM), the use of continuous subcutaneous insulin infusion (CSII) therapy has markedly increased in the last few years. In the medical literature, many studies demonstrated the efficacy of this therapeutic approach.¹ However, some disadvantages must be mentioned, such as weight gain and increased risk of ketoacidosis.²

Case Report

We report on an 11-year-old female patient diagnosed as T1DM without ketoacidosis and treated with multiple daily injections (MDI). Because of confirmed positivity for celiac disease markers (EMA, IgA antitTG), after intestinal biopsy, a gluten-free diet (GFD) was started. During the first 3 years after T1DM diagnosis, the girl showed multiple glycemic fluctuations, with HbA1c mean values: 7.9% (HbA1c target values, according to ISPAD guidelines,³ ≤7.5%). Moreover, her body weight increased: BMI (kg/m²) was 19 (BMI-SDS= +0.8) 2 months after diabetes onset; 3 years later, it increased to 26.6 (BMI-SDS= +2). At the age of 14, she was introduced to the CSII pump (Roche Accu-Chek Combo®).

Her insulin requirement was 48 U/day (0.7 U/kg/day), specifically, 19.2 U as basal dosage and 28 U as pre-meal boluses. At the first control check after CSII beginning, three pre-meal boluses were reported in the logbook, as prescribed. With the use of the Accu-Chek Smartpix system®, the glucose data and the pump's data were transferred to the electronic record (Accu-Chek 360°®). The summing-up chart showed a clear imbalance between basal insulin and boluses: 22% versus 78%. The electronic diary showed data quite different from the personal logbook. The patient confirmed the intake of frequent and improper additional boluses, very close to each other (Figure 1). Every additional bolus was followed by food intake. The patient started weekly psychotherapeutic support, and a problematic relationship with food was identified. Binge-eating was diagnosed according to DSM-IV staging criteria.⁴

Comment

Adolescents with T1DM have an increased risk (8%–30%) of developing eating disorders. Eating disorders in DSM-IV are classified as: 1) anorexia nervosa; 2) bulimia nervosa; and 3) eating disorder, not otherwise specified.⁴ Diagnostic criteria have been developed for binge-eating disorder to describe the many individuals who have problems with recurrent binge eating but do not engage in the characteristic compensatory behaviors of bulimia nervosa (vomiting, use of laxatives, excessive physical activity).⁴ Psychosocial support in T1DM is mandatory; the patient's emotional past has an important role for quality of life because it influences diabetes self-management and relationships with relatives or friends. The memory provided in insulin pumps and their record are a useful source of information about insulin therapy in young patients on CSII. Reported data are available regarding missed mealtime boluses as well as errors in programming of the basal insulin rate.⁵ Moreover, pump data download can explain the reason for severe hypoglycemic episodes due to excess of insulin administration. In conclusion, CSII and datadownload allowed us to reveal the presence of concealed self-administration of insulin boluses and to unmask binge-eating, focusing attention on the psychological aspects connected with eating.