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Adjusting to diabetes can be tough. But for teenage girls with diabetes it can be potentially fatal. Researchers have found that societal influences on teen boys and girls can affect their diabetes, and that in most cases girls suffer the most from these influences.
One disturbing pattern researchers have found is that teenage girls with diabetes have more cases of overall poor glycemic control and ketoacidosis.
A study conducted in California analyzed 924 female adolescents and 752 males who were hospitalized with a principal diagnosis of type 1 over the course of 1991. In this study published in the November 1997 issue of Diabetes Care, Barbara Cohn, PhD, Piera M. Cirillo et al. found that young girls ages 9 and up had forty percent more episodes of ketoacidosis and hospitalizations than boys.
Many doctors believe the reason for this alarmingly high percentage of DKA among girls is insulin omission.
Gary Rodin, MD, psychiatrist in chief at the Toronto Hospital in Ontario estimates that for every 10 girls who have an eating disorder such as omitting insulin, there will be one boy with an eating disorder. He believes that, "20 percent of young girls with type 1 have problematic eating disorders which put them at risk and 5 to 10 percent more have serious psychiatric eating disorders."
Instead of vomiting or taking diuretics a person with diabetes can omit insulin in order to lose weight. Omitting insulin produces high blood sugar and causes a person to lose a large number of calories. This also causes the breakdown of muscle and fat adding to further weight loss from dehydration.
For many young women, omitting insulin is too hard to resist. "The frightening thing about omitting insulin to lose weight is that it works so well," says William H. Polonsky, PhD, a psychologist and CDE in San Diego.
However, omitting insulin is a deadly game. Stuart Brink, MD, senior endocrinologist at New England Diabetes and Endocrinology Center (NEDEC) explains, "if insulin omission occurs for too long a period of time, death from resulting diabetic ketoacidosis is possible. Perhaps as a suicide gesture gone too far, perhaps from merely miscalculating insulin omission, failing to monitor BGs or not checking ketones in the urine. Other complications that can occur are blindness, kidney failure, early hypertension, nerve damage, heart attacks and strokes."
Brink and former associate Harold Starkman, MD have even coined a term for this condition which they have encountered so frequently "diabulimia."
Are Girls with Diabetes at a Higher Risk?
According to statistics approximately four percent of young women have eating disorders in the United States. Is the incidence of eating disorders higher among girls with diabetes?
Many say yes. Stuart Brink estimates that, "eating disorders are a likely problem in as many as 30 percent of our population of adolescent and young adult patients." In Scotland, Ray Newton, MD, Stephen Greene MD, et al. found the same estimate of 30 percent among their patients.
Could the higher rates of DKA and poor glycemic control in girls have a metabolic connection or is it primarily psychosocial?
The Metabolic Connection
Research has shown that there is increased insulin resistance during puberty in both boys and girls. Could menstrual changes in estrogen and progesterone cause girls more difficulty with their diabetes than boys? Hormonally, boys experience a much steadier ride due to testosterone. Brink suggests, "It is possible that differences in hormone changes related to menstrual cycling make women more prone to episodes of poor control since boys do not have the same hormonal flux."
In her study, Cohn also points to biological factors, "Changes in glucose metabolism during the menstrual cycle, including premenstrual hyperglycemia and decline in insulin sensitivity during ovulation, have been observed in adult women with IDDM."
However, Rodin believes that a metabolic connection is unlikely. "The primary cause we've found is not taking insulin," says Rodin. "It's a specific problem due to young girls' pursuit of perfectionism."
Psychological Factors - The Other Side of the Coin
After achieving good control a person may gain an average of 10 pounds in one month. This weight increase coupled with the escalating trend of thinness being portrayed in the media can be disastrous for a young girl's self esteem. "Girls often become far more depressed over a ten pound weight gain than boys," says Jean Betschart, MN, RN, CDE a pediatric specialist at Children's Hospital in Pittsburgh.
According to a recent poll conducted by the popular national magazine People, "women are three times as likely as men to have a negative view of their bodies - and the younger they are the unhappier they are." According to a study published in The Journal of Adolescent Health, 40 percent of young girls at the ages of 9 to 10 are already trying to lose weight.
In the same People poll, statistics showed that boys expressed dissatisfaction with their appearance at half the rate of girls.
"If anything, boys are usually more concerned with being too skinny," says Gary Rodin, MD. "They want to work out and bulk up."
Many health care professionals like Denis Daneman, MD at the Hospital for Sick Children at the University of Toronto have a difficult time even finding boys with diabetes and eating disorders to participate in their studies. "We did a study a few years back," he says, "but couldn't find any boys with eating disorders to include."
Interestingly enough, research also shows that Native-American and African-American girls tend to be more content with their body image than Caucasian girls. In a 1995 University of Arizona survey, seventy percent of high school age African-American girls said they were satisfied with their bodies. Two reasons for this are Brink writes in his editorial in the November 1997 Diabetes Care, "African-Americans prefer a significantly heavier ideal body size compared to whites. And whites' preferences for body size are more influenced by peers, while those of African-Americans are more influenced by family members."
What Can We Change?
According to a recent study given at the ADA's 45th annual Postgraduate Courses, Rodin and Daneman found girls with type 1 reported a significantly higher drive for thinness, more shame about their bodies, more anxiety about eating in public and a tendency to eat secretly.
Daneman likens the effect of current diabetes treatments on girls with eating disorders as putting a lid on a pressure cooker that's ready to blow. When a diabetes team encounters a patient with poor compliance they will often recommend more insulin, more BG testing. "This is counterintuitive to what the patient needs," says Daneman. "We need to take the pressure off of diabetes," he says. "Instead of taking 4 shots how about 2 or 3 so there will be less temptation not to take their insulin. And get the girls to stop weighing and measuring food and try to focus on a healthy diet instead."
"I think from ages 14 on especially, doctors should inquire openly about binge eating and not taking a full amount of insulin if they suspect a patient may be suffering from an eating disorder," says Rodin.
Polonsky suggests that a more open atmosphere when a patient meets with her doctor would be helpful. "I've had many patients come and see me who have been told by health care professionals if they don't stop omitting insulin they will die. This may be true but it's not helpful or constructive," he says.
Daneman agrees. "Many teens know the consequences of omitting insulin - but, it just doesn't hit home," he says. "They can't see life in terms of 30 or 40 years down the road. They are more concerned with the next 30 or 40 minutes."
What does hit home for many teenage girls is the fear of gaining weight compounded by the stress of already being "different" because they have diabetes.
Perhaps, what more health care professionals need to do is really listen in a non-judgmental way to their young patients and work out a diet/insulin regimen which preserves their health with as little weight gain as possible. Because, the alarming rate of DKA and poor glycemic control among teenage girls and its debilitating consequences are too serious to ignore.
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