Do we care about eating problems suciently in adolescent Type 1 Diabetes?

Background Eating problems have been shown to be common in adolescents with T1DM. We aimed to examine the association of eating problems with emotional problems, behavioral attitudes towards treatment and diet adherence. Method: The study was conducted with 132 participants, of them 72 were with T1DM (T1DM group) and 60 were healthy controls group. Participants were evaluated using a data form and self-report scales which were Children's Depression Scale (CDI), Screen for Child Anxiety Related Disorders (SCARED) and the Eating Attitude Test (EAT). Rates of having and history of refusing insulin had higher rates of having signicant for CDI Having signicant was to who makes the insulin injections 0.05) and the child's diet adherence < There was a positive correlation between EAT and CDI scores (r p = 0.008; p < 0.01).

treatment, at least two-thirds of adolescents and young adults have insu cient treatment adherence [3]. Besides the biological determinants, psychosocial factors have important roles in adherence to the nutritional regimen during adolescence, and stress and psycho-physiological processes may result in impaired disease control [5].
Studies on adolescents with T1DM demonstrate that, these patients have poorer psychosocial adjustment and higher rates of psychiatric disorders such as depression, anxiety, and eating disorders compared to healthy peers [6,7]. Two mechanisms have been thought to cause these negative psychological and psychiatric outcomes. These are the impaired brain functions caused by the micro and macrovascular complications of the disease, and the increased psychosocial burden of the disease [8]. The disease's psychological burden is associated with its chronic course and its treatment requiring frequent invasive procedures and restrictive diet A restrictive diet in terms of content and timing is a challenging stressor especially in adolescence which is characterized by increased autonomy, withdrawal from parental authority, weakness in impulse control and increased self-focus in body appearance [9].
Eating disorders (ED) are behavioral conditions characterized by severe and persistent disturbances in eating behaviors and associated distressing thoughts and emotions. The major risk factors associated with ED are; adolescence period, female gender, higher physical activity, low self-esteem, and concerns and even preocupations about being underweight [10,11]. Limited number of studies have shown that eating-related problems are more common in adolescents with T1DM. The standard treatment regimen for T1DM requires a focus on eating habits, which can result in eating-related preocupations. It has been reported that these factors combined with the psychological burden of chronic disease management and depression may contribute to ED in adolescents with T1DM [12,13]. Commissariat et al reported that problems in psychosocial adjustment are important causes of eating problems in adolescents with T1DM [14]. However studies on ED frequency speci cally in adolescence period is limited in number and existing ones show inconsistant results in terms of the association of ED with emotional problems and treatment attitudes in T1DM.
In this study, we aimed to examine the frequency of emotional and eating problems in adolescents diagnosed with T1DM. We hypothesized that compared to their healthy peers these patients had higher levels of eating problems and depression, anxiety. Our second hypothesis was that eating problems were associated with depression and anxiety.

Method
This cross-sectional descriptive study was conducted in the Pediatric Endocrinology Outpatient Clinic with T1DM diagnosed adolescents. Inclusion criteria were; being at 13-18 years of age, using insulin treatment for at least 6 months, and being volunteered to participate in the study (both participants and their parents). Patients with another chronic disease, genetic/syndromic disease or severe psychiatric disease (such as ASD, MRI, psychotic disorder, bipolar afective disorder, substance use disorder) leading cognitive impairment were not included in the study. Participants were evaluated using a data form and self-report scales which were Children's Depression Scale (CDI), Screen for Child Anxiety Related Disorders (SCARED) and the Eating Attitude Test (EAT). (T1DM-group) and 60 were healthy controls (Control group). In the T1DM-group; the average age was 14.72 years and 61.1% were girls. Groups were similar in terms of age, gender and familial characteristics of the participants. The demographic characteristics of the groups about themselves and their families are presented in Table 1.
Findings related to clinical characteristics of the participants in T1DM group showed that; 36.1% (n = 26) had irregular outpatient clinic follow-up, 16.7% (n = 12) had no diet adherence at all and 30.5% refused insulin injections at least rarerly. In 27.8% (n = 20) of participants insulin injections were being done by only parents.
The distribution of characteristics of the participants in the DM-group regarding the disease and its treatment is presented in Table 2.
The groups were compared according to scores of the scales (Table 3). In T1DM group scores of all scales (except for SCARED-PA and SCARED-SA) and rates of getting signi cant scores from all scales were signi cantly higher compared to the control group (p <0.05).
In the DM-group; examination of the relationship between sociodemographic data and the getting signi cant scores from scales showed that there were statistically signi cant relation between SCARED and family type (p = 0.003); between CDI and family type (p = 0.001) and paternal education (p = 0.036); between EAT and the age (p = 0.037), maternal education (p = 0.011) and paternal education (p = 0.025) (Table4). In DM-group participants ratios of getting signi cant scores from SCARED and CDI were higher in patients who rejected insulin injections, who had irregular outpatient follow-ups, and who were hospitalized for diabetes in the previous 3 months (p <0.05). In addition, the ratio of getting a signi cant scores from CDI was higher in those with diabetes complications compared to others (p = 0.023; p <0.05) ( Table 5 &Table 6).
In DM-group, getting signi cant scores from EAT was related to person who makes the insulin injections (p = 0.017; p <0.05) and the child's diet adherence (p = 0.001; p <0.01). Ratio of getting signi cant scores from EAT was lower among the participants who make their own insulin injections and higher among those who always adhere to diabetic diet (Table 5).

Dıscussıon
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 [5]. The authors reports that among patients 36.9% had depression; 32.1% had anxiety. Another cross-sectional study involving adolescents and young adults (11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25) years) similarly showed higher rates of depression (11.3%) and anxiety (21.3%) compared to healthy controls [21]. In a recent review, 14 studies on children and adolescents were examined and con rmed that T1DM is associated with high depression and anxiety symptoms [22]. It is estimated that T1DM in adolescents is associated with twice risk for depression [7]. 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 di cult and deterioration in treatment adherence is more evident in adolescence period. As a matter of fact, we found that signi cant portion of the patients participating in our study had no regular clinic follow-ups and in a signi cant portion diet adherence poor, which indicates their poor disease management.
Disease management is important for the prognosis of the disease. Any di culty 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 di culties [3]. 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 nding, which shows the relationship between emotional problems and poor disease management, supports the literature knowledge. Another important nding 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 ndings 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 identi ed, 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 [23]. In our study the eating problem was signi cantly higher in adolescents diagnosed with T1DM compared to their healthy peers. Almost one third of the cases had eating problems. Our nding 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 [25]. In the presence of T1DM there is an excessive family focus on food and weight [12]. This excessive mental focus on food and feding and weight is among the major risk factors of eating disorders. Our nding 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 [10]. 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, con ict, and low parental involvement in the care of adolescents, which further lead eating problems in our participants.
The last important nding 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 foodrelated 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 di cult. 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.

Conclusion
Treatment in type 1 DM requires adherence to medication and diet. However, the chronic course of T1DM, including a restricted diet and frequent interventional procedures, may cause di culties for the patient in psychosocial context. This study demonstrated that T1DM adolescents are at high risk for eating disorders and also for emotional problems. Further analysis showed that increasing age, low parental educational level, not taking the responsibility of insulin treatment, strict adherence to diabetic diet and depressive symptomatology were the associated risks for ED in T1DM. Eating disorders should given extra attention for T1DM because its treatment is diet dependent and any diffuculty in the diet will worsen the patients clinic. So awareness of these factors in clinical settings is important. In the clinical follow-up of adolescents with T1DM, it is important to assess their emotional state, eating habits and attitudes apart from physical well being and laboratory ndings.
Besides the pediatric professionals, primary healthcare providers have the potential to provide close monitoring and support adolescents with diabetes. Early screening for psychiatric comorbidity in chronic diseases and regular follow-up from diagnosis are necessary for the clinical outcome of the disease. In T1DM adolescents, it is important to direct the cases at risk in terms of emotional and eating problems to mental health specialists as soon as possible.
What is already known on this subject?
Eating disorders are behavioral conditions characterized by persistent disturbances in eating behaviors and associated distressing thoughts and emotion. Studies about ED frequency speci cally in adolescence period is limited in number and existing ones show inconsistant results in terms of the association of ED with emotional problems and treatment attitudes in T1DM.

What does the study add?
This study demonstrated that T1DM adolescents are at high risk for eating disorders and also for emotional problems In the follow-up of T1DM adolescents, it is important to evaluate them in terms of emotional and eating problems as well as laboratory ndings, and refer the cases at risk to mental health specialists as soon as possible.