In this clinical study we examined emotional and eating problems in adolescents with T1DM diagnosis and found that compared to their healthy peers these adolescents had more emotional and eating problems. Refusing insulin injections and having irregular outpatient follow-up, recent hospitalization and diabetes complications, which indicated lower disease management, were associated with increased emotional problems. Besides, increasing age, low parental educational level, not to take the responsibility of insulin treatment, strict adherence to diabetic diet and depressive symptomatology were associated with increased risk for eating problems in these adolescent patients.
In literature we see that many studies examining the emotional problems in patients with T1DM have samples including both children and adolescent. Khandelwal S et al, in their case-control study, showed that the prevalence of psychosocial problems in children and adolescents (6-14 years) with T1DM was 55.95%, and this rate was almost three times higher than their healthy peers . The authors reports that among patients 36.9% had depression; 32.1% had anxiety. Another cross-sectional study involving adolescents and young adults (11-25 years) similarly showed higher rates of depression (11.3%) and anxiety (21.3%) compared to healthy controls . In a recent review, 14 studies on children and adolescents were examined and confirmed that T1DM is associated with high depression and anxiety symptoms . It is estimated that T1DM in adolescents is associated with twice risk for depression . Similar to these studies, we showed higher anxiety (52.8%) and depression (36.1%) ratios in T1DM adolescents compared to healtyh controls (21.7%, 8.3%, respectively). These ratios are even higher than the ones reported in previous studies. We think that the most important reason for these higher rates are due to the fact that our study included only adolescents, not the young children. Adolescence is the last period of childhood; in which the child had weaker impulse control, more oppositional behavior and refuses the external parental control. Therefore, diabetes management becomes more difficult and deterioration in treatment adherence is more evident in adolescence period. As a matter of fact, we found that significant portion of the patients participating in our study had no regular clinic follow-ups and in a significant portion diet adherence poor, which indicates their poor disease management.
Disease management is important for the prognosis of the disease. Any difficulty in adaptation to disease and its treatment lead deterioration in this process. In T1DM, disease management itself is reported to cause additional problems in the form of emotional and psychological difficulties . Managing T1DM in the presence of anxiety is challenging. In our study, we found that emotional problems were more common in adolescents with T1DM. Moreover, those who refused insulin injections, had irregular follow-ups, diabetes complications, and recently hospitalized had higher emotional problems. In other words, we showed that those with poor diabetes management had more risk for emotional problems. This finding, which shows the relationship between emotional problems and poor disease management, supports the literature knowledge. Another important finding about the emotional state of these adolescents was that those with separate parents and low parental education had more emotional problems. It is well known that childhood adversities are the important risk factors for psychopathology. Our findings related to family characteristics drew attention to the importance of evaluation of the adolescents with his families, not alone, in their clinical follow-ups. If negative familial factors are identified, early interventions will be valuable for the psychosocial and so for the physical health of the adolescent.
Eating problems have been shown to be increased in T1DM patients [12,13]. Bernstein et al. reported that among T1DM patients 20.7% had irregular eating attitudes . Scheuing et al. Demonstrated that among 52,215 diabetic patients 467 had clinical ED diagnosis . In our study the eating problem was significantly higher in adolescents diagnosed with T1DM compared to their healthy peers. Almost one third of the cases had eating problems. Our finding related to the association of eating problems with some sociodemographic factors was striking. Eating problems were similar in ratio in each genders, but were increasing in frequency with age, and were associated with low parental education level. In general ED is more common in girls, especially between the ages of 13 and 14 for girls and over 16 for boys [13,24]. In T1DM, female gender and increasing age have been reported to be associated with increased risk for irregular eating behavior . In the presence of T1DM there is an excessive family focus on food and weight . This excessive mental focus on food and feding and weight is among the major risk factors of eating disorders. Our finding related to parental education level is contrary to the literature. In general population EA is more common in patients with higher educational levels. In particular, poorer communication with parents and poor trust relationships were reported among girls with T1DM than those with eating disorders . We thought that the relationship between low parental education and eating problem may be due to an indirect link; low parental educational level may cause negative consequences such as problems in parent-adolescent communication, conflict, and low parental involvement in the care of adolescents, which further lead eating problems in our participants.
The last important finding of this study showed that adolescents with T1DM had higher risk for eating problems compared to their healthy peers. Besides, depressive mood, strict adherence to diet and not taking the primary responsibility for insulin injections were the associated factors for this increased risk. We think that there may be various reasons why T1DM carries an extra risk in terms of eating disorders in adolescence. T1DM management requires focusing on timing and content of meals, and calori monitoring. Inapropriate approaches in this management, by health services or parents, may predispose to malfunctioning eating patterns in the patient. Beacuse in the etiopathogenesis of ED there is over focusing to body image and appearance and preoccupations with content and calori of meals are the main symptoms. It has been shown that higher levels of health and food-related anxiety may lead to ED. Similarly psychiatric disorders such as depression and anxiety are shown risk factors for ED in T1DM diagnosed adolescents [13,24]. In particular, early recognization and treatment of emotional problems and will enable the early handling of eating disorder which makes diabetes management more difficult. The fact that eating problems are higher in those with strict diet compliance draws attention to the presence of food and diet-related concerns that these patients and their parents frequently experience.