Psychosomatics 46:11-18, February 2005
© 2005 The Academy of Psychosomatic Medicine
Personality Factors and Disordered Eating in Young Women with Type 1 Diabetes Mellitus
Stacey M. Pollock-BarZiv, M.A., Ph.D.(c), and
Caroline Davis, Ph.D.
Received Nov. 3, 2003; revision received Feb. 12, 2004; accepted March 10, 2004. From the Department of Kinesiology and Health Science, Faculty of Graduate Studies, York University/University Health Network (Toronto Hospital General Division). Address correspondence and reprint requests to Dr. Pollock-BarZiv, Division of Cardiology, Room 6429, The Hospital for Sick Children, 555 University Ave., Toronto, Ont. M5G 1X8; s.pollock.barziv{at}utoronto.ca (e-mail).
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ABSTRACT
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The authors examined the association between the presence of personality variables implicated in the pathogenesis of eating disorders and the presence of eating disorder symptoms in 51 women with type 1 diabetes. Subjects were assessed with interview instruments and self-report questionnaires, including scales measuring eating disorder symptoms, borderline personality characteristics, and perfectionism. Fourteen subjects displayed moderate to severe eating disorder symptoms. Perfectionism was related to attitudinal aspects of eating disorders (e.g., weight preoccupation), and borderline personality characteristics were related to disordered behaviors (e.g., insulin omission) and poor glycemic control. The results suggest that personality factors are related to disordered eating and poor glycemic control in diabetic women.
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INTRODUCTION
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Previous research has demonstrated a high likelihood of eating disorders, specifically bulimia nervosa, in adolescent females with type 1 (insulin-dependent) diabetes mellitus.1–12 Patients with both an eating disorder and diabetes face life-threatening acute and/or chronic complications.6 To integrate features salient to both eating disorders and diabetes mellitus, this study investigated associations between the presence of personality variables implicated in the pathogenesis of eating disorders and the presence of eating disorder symptoms in women with diabetes mellitus. Better understanding of the personality determinants of disordered eating in diabetes mellitus may help the practitioner with prevention and selection of appropriate interventions.
Diabetes mellitus is an endocrine disorder that affects approximately 0.1% of the population; patients are required to receive daily exogenous insulin.13,14 Reasons to expect increased frequency of eating disturbances in diabetes mellitus include the rigid dietary regimes, heightened emphasis on food, and weight gain that frequently accompanies the onset of insulin treatment.1–8,12 Reports have suggested that diabetes mellitus patients with eating disorders not only use typical purging methods, such as self-induced vomiting and laxatives, but also withhold insulin to produce glycosuria to lose weight.4,6–10 Eating disorders in diabetes mellitus are associated acutely with poorer glycemic control and diabetic ketoacidosis, as well as with longer-term physical complications, including retinopathy, neuropathy, and nephropathy.6–11 More rapid progression of complications (microvascular, macrovascular, and psychological) is observed in patients with poorer glycemic control.7–11,14
Bulimia nervosa is defined as recurrent binge eating episodes with out-of-control consumption of generally high-calorie foods in a discrete time period.16 It is characterized by compensatory behaviors, such as self-induced vomiting and/or use of laxatives or diuretics, and the awareness that eating is abnormal; binge eating episodes are frequently followed by depressed mood.16,17 Literature reports of bulimia in women with diabetes mellitus have specified greater difficulty with control of blood sugar as a result of bingeing, purging, or insulin manipulation.4,6
Several etiological studies have implicated certain personality characteristics, such as neuroticism, perfectionism, and impulsivity, all of which are in part biologically determined, in risk for the development and maintenance of eating disorders.18–22 Neuroticism, or proneness to anxiety, has been related to the emergence of eating disorders and has been strongly related to weight preoccupation.19,20 Neuroticism has been identified as the greatest psychological predictor of eating disorder pathology in clinical samples and one of the most consistent personality predictors of body dissatisfaction among women in the general population.19
Perfectionism, particularly neurotic perfectionism (the maladaptive aspect of a desire to be perfect), is believed to predispose individuals to the development of eating disorders and to contribute to the maintenance of these disorders.18,19,23,24 Normal perfectionism is associated with high self-esteem, while the excessive desire to be perfect may culminate in a need to establish control over one’s body and life.18,19,23 Heightened vulnerability for eating disorders may result from the maladaptive desire to be perfect in the diabetic patient who is already preoccupied with weight and diet.23
The cognitive view of eating disorders emphasizes that strict dieting predisposes individuals to disordered eating.17,21 Conventional dietary management in diabetes mellitus is based on total avoidance of high–sugar foods and strict limits on the intake of carbohydrates.14 Increased preoccupation with food—particularly with the restricted intake of carbohydrates in diabetic diets—may predispose diabetic patients to a carbohydrate phobia that has been considered a cardinal feature of patients with an eating disorder.3,8–12,14 Eating due to external cues—and not in response to internal cues such as hunger—can trigger dysregulation of eating patterns.7,17 Manipulation of insulin doses to lose weight is similar to purging and is considered a disordered behavior.7–12 Diabetic patients with an eating disorder may be aware that missing insulin doses results in weight loss, and the weight loss resulting from noncompliance with the insulin regimen may perpetuate the eating disorder.8–12
A significant number of patients with eating disorders—especially those with bulimia nervosa—also have concurrent borderline personality disorder.25 Borderline personality disorder is characterized by poor impulse control, low self-esteem, self-harm, and emotional lability.16,25 It has been shown that noncompliant diabetes mellitus patients often meet the criteria for borderline personality disorder and have poorer long-term clinical outcomes, as do eating disorder patients with borderline personality characteristics.21,22,26
Studies of personality in diabetic patients have examined the correlation of specific traits with treatment compliance or glycemic control.22,27,28 However, few personality traits have been examined for their role in relation to disordered eating and metabolic control in the diabetic population. To integrate factors salient to both eating disorders and diabetes mellitus, we conducted the present study to explore relationships between eating disorder symptoms and the influence of the aforementioned personality factors on eating disorder symptoms and glycemic control in patients with diabetes mellitus.
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METHOD
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Subjects
Fifty-one female volunteers with type 1 (insulin-dependent) diabetes mellitus (mean age=21.5 years; range=12–27 years) were recruited from the community. All subjects had received a medical diagnosis of type 1 diabetes mellitus at least 1 year before their participation in the study. Subjects were excluded if they had received a diagnosis of an eating disorder before participation. Thirty-one subjects were recruited from the community by advertisements in newspapers, university publications, and posters in the Toronto area. An additional 20 subjects were recruited from advertisements on diabetes-related Internet web sites (e.g., www.childrenwithdiabetes.com). No further inclusion/exclusion criteria were employed.
Measurements
Eating disorder symptoms were assessed with the Diagnostic Survey for Eating Disorders (modified for diabetics),29,30 a 28-item, self-report questionnaire that assesses behavioral and psychological characteristics of eating disorders. By using criteria utilized in previous research,11 subjects were classified into two groups on the basis of the presence or absence of behaviors related to eating disorders, as follows:
- Subjects with eating disorder symptoms included those in whom one or more of the following behaviors occurred at least twice a month during the preceding 3 months: binge eating, insulin omission or manipulation of an insulin dose to promote weight loss, self-induced vomiting, and laxative use.
- Subjects without eating disorder symptoms were those in whom eating disorder behaviors were absent or occurred less than twice a month in the preceding 3 months.
In addition, a 7-item self-rating measure derived from the Diagnostic Survey for Eating Disorders was used to assess behavioral factors related to compliance with diabetes management tasks. The behavioral factors were measured on a 9-point scale, on which 0 represents the best compliance and 9, the worst compliance. Behavioral factors include compliance with blood and urine testing for glucose levels, on-schedule insulin administration, dietary compliance, blood sugar maintenance, and obtaining treatment for insulin reactions.
Weight preoccupation was assessed as a measure of the attitudinal aspects of disordered eating. Weight preoccupation, including the relentless pursuit of thinness and the presence of distorted body image,16 was measured with 23 items from the drive-for-thinness, body-dissatisfaction, and bulimia subscales of the Eating Disorder Inventory.31 The Eating Disorder Inventory quantifies psychological and behavioral symptoms of eating disorder patients and is useful for assessing these symptoms in groups of nonclinical subjects. Respondents rate the frequency of occurrence on a 6-point scale, ranging from 1, never, to 6, always. Reported alpha coefficients for the drive for thinness, body dissatisfaction, and bulimia subscales are 0.85, 0.90, and 0.90, respectively, in eating disorder patients and 0.85, 0.91, and 0.83, respectively, in the university student comparison subjects.31 This composite scale has been used in previous research.32
Borderline personality characteristics were assessed with a 22-item scale developed by Claridge and Broks.33 This scale evaluates characteristics such as impulsivity and self-injury according to the DSM-III16 criteria for borderline personality disorder and has been used in nonclinical samples.32,34 The total score constitutes the level of borderline personality.
Neuroticism or anxiety-proneness was assessed with the 24-item, forced-choice neuroticism-stability scale of the Eysenck Personality Questionnaire–Revised.20 A high total score represents a high level of neuroticism.
Perfectionism was assessed with two scales:
- The Neurotic Perfectionism Questionnaire23 is a 42-item inventory used to assess attitudes and experiences associated with maladaptive perfectionism. Items are rated on a 5-point scale, ranging from 1, strongly disagree, to 5, strongly agree. The total score constitutes the level of neurotic (maladaptive) perfectionism. High scores reflect greater neurotic perfectionism.
- The Multidimensional Perfectionism Scale24 is a 45-item inventory composed of three subscales: 1) the self-oriented perfectionism subscale measures self-imposed expectations of perfectionism (unrealistically high standards for oneself), 2) the other-oriented perfectionism subscale examines expectations of perfectionism in others (unrealistically high standards for others), and 3) the socially prescribed perfectionism subscale assesses respondents’ perception of expectations of perfectionism that they face. Perception of socially prescribed perfectionism has been linked to psychopathology.24 Subjects rated their level of agreement for each item on a scale from 1, disagree, to 7, agree. Higher subscale scores indicate greater levels of perfectionism. The self-oriented perfectionism score was used as a measure of adaptive perfection on the basis of prior analyses.32 Reported alpha coefficients for the self-oriented perfectionism, other-oriented perfectionism, and socially prescribed perfectionism subscales are 0.86, 0.82, and 0.87, respectively.24
Glycemic control was quantified in terms of the self-reported value of the subject’s most recent hemoglobin A1c assay and the date the blood sample was obtained. The healthy reference range of glycosated hemoglobin values is 4% to 6%. We defined a hemoglobin A1c value  9% as poor glycemic control, based on criteria outlined by Rydall et al.11 To determine which factors predict glycemic control, subjects were categorized into two groups by using the 9% value as the cutoff; subjects with values <9% were considered to have targeted glycemic control, and subjects with values 9% were considered to have poor glycemic control.
Data on subjects’ diabetes history, including age at onset and insulin dose per day, were obtained during the interview.
Subjects’ body mass index (weight [kg]/height [m2]) was calculated by using weight and height measures obtained during the interview. Subjects who were interviewed by telephone were asked to self-report height and weight measured that day.
Procedure
Institutional research ethics board approval was obtained before commencing the study. Thirty-one subjects were interviewed individually by the researcher either at York University or at the Toronto Hospital. At the start of each interview, informed written consent was obtained. Parents of subjects under age 16 years were required to provide informed consent for the subject. Subjects completed a 45-minute questionnaire package and then completed a 20-minute structured interview that assessed diabetes history. Subjects were weighed, their height was measured, and they were asked to provide the date and value of their most recent hemoglobin A1c assay. Twenty subjects recruited from diabetes Internet sites were assessed. The questionnaire package was mailed to the subjects who met the inclusion criteria, and a telephone interview was conducted to assess diabetes history and obtain data on self-reported weight and height measured that day and date and value of the most recent hemoglobin A1c assay. Among subjects whose weight was measured during a face-to-face interview (N=31), no significant differences were found between the measured weight and subjects’ self-reports of weight (t=0.93, df=30, p=0.36). A strong, positive intraclass correlation existed between the measured weights and the self-reported weights in this group (r=0.988, p<0.001).
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RESULTS
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Descriptive Statistics
The 51 subjects were categorized into two discrete groups on the basis of eating disorder behaviors. Fourteen subjects had eating disorder symptoms, and 37 subjects had nondisordered eating behavior. Table 1 displays mean values and standard deviations for all dependent variables for the two groups. The mean body mass index of 24.6 for the subjects without eating disorder symptoms was comparable to values for the healthy population (i.e., 20–25),35 although at the high end of the healthy range; the mean body mass index of 26.1 for the group with eating disorder symptoms was slightly above the healthy range. For both groups, mean borderline personality and neuroticism scores were similar to normative values for samples of female subjects with similar age distributions.32,34 The eating disorder symptoms group had significantly higher scores for weight preoccupation and neurotic perfectionism, and the mean scores for the subjects without eating disorder symptoms were similar to the values for "normal perfectionists."23 Both groups’ mean values for socially prescribed perfectionism, other-oriented perfectionism, and self-oriented perfectionism were similar to those for female university students.24 The mean total eating disorder symptoms score was higher in the group with eating disorder symptoms than in the group without eating disorder symptoms, indicating poorer compliance with diabetes management tasks in the group with eating disorder symptoms. The mean hemoglobin A1c value for the eating disorder symptoms group was close to the 9% cutoff for unhealthy values, and 20 of those subjects had poor glycemic control (hemoglobin A1c 9%).
Subjects were also categorized on the basis of glycemic control to determine factors that predicted glycemic control. Subjects with hemoglobin A1c values <9% were classified as having targeted glycemic control (N=31), and those with values 9% as having poor glycemic control (N=20). There were significant differences in body mass index and borderline personality and neuroticism scores between the groups with targeted and poor glycemic control. Table 2 presents mean values and standard deviations for each group for all variables in the analysis. It is noteworthy that the mean neurotic perfectionism value for the group with poor glycemic control was similar to values reported among adult eating disorder patients.18,23
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TABLE 2. Characteristics of Women With Diabetes Mellitus With Targeted Glycemic Control and Poor Glycemic Controla
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Regression Analyses
Weight preoccupation
Forward stepwise multiple regression analysis was used to identify personality variables that predicted weight preoccupation. The independent variables were borderline personality, neuroticism, neurotic perfection, self-oriented perfectionism, socially prescribed perfectionism, and other-oriented perfectionism. Both neurotic perfectionism and socially prescribed perfectionism were positively related to weight preoccupation and accounted for 36% of the total variance. No variables added further to the percentage of the variance that was accounted for. Table 3 displays the results for the significant predictors of weight preoccupation identified in the regression analysis.
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TABLE 3. Multiple Regression Analysis of Predictors of Weight Preoccupation in Women With Diabetes Mellitus (N=51)a
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Eating disorder symptoms
The independent variables that were included in the analysis of weight preoccupation were used in a logistic regression analysis with group (subjects with eating disorder symptoms versus subjects without eating disorder symptoms) as the dependent variable (Table 4). Borderline personality score was the only variable that significantly predicted the probability of being classified as having eating disorder symptoms.
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TABLE 4. Logistic Regression Analyses of Predictors of Eating Disorder Symptoms and Glycemic Control in Women With Diabetes Mellitus (N=51)
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Glycemic control
Logistic regression was used to analyze the data by using glycemic control status (hemoglobin A1c values < 9% versus values 9%) as the dependent variable (Table 4). Borderline personality score was the only significant predictor of hemoglobin A1c groups.
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DISCUSSION
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An association between certain personality factors related to the pathogenesis of eating disorders and the presence of eating disorder symptoms was found in this cohort of women with diabetes mellitus. The results suggest that individuals with diabetes mellitus who are perfectionistic and who possess borderline personality characteristics are more likely to be weight preoccupied and to engage in medically risky behaviors. Perfectionism was related to attitudinal aspects of disordered eating, and borderline personality characteristics were related to behavioral aspects of disordered eating. Specifically, the neurotic and socially prescribed aspects of perfectionism emerged as significant predictors of weight preoccupation in the regression analysis. On the other hand, borderline personality was related to behaviors associated with eating disorders, such as insulin omission and binge eating, and to poor metabolic control in regression analyses. It is noteworthy that perfectionism and borderline traits are opposites on a continuum of impulsivity. Perfectionism relates to obsessive characteristics, and borderline personality is characterized by impulsivity and the tendency to engage in risky behaviors. Indeed, the regression analyses found that these two personality traits related to different aspects (attitudinal versus behavioral) of eating disorders.
Although a high score for weight preoccupation reflects attitudes about weight, subjects with weight preoccupation did not necessarily engage in behaviors associated with eating disorders. However, disordered behaviors, such as bingeing, purging, and insulin manipulation to control weight, pose a significant medical threat to diabetic women, as these behaviors may compromise glycemic control, increasing the risks for immediate and long-term medical problems.
The findings for borderline personality in the present study support earlier research linking dependent personality characteristics with poorer glycemic control.22,25,26,34 The disturbed glycemic control found in this cohort may be considered a manifestation of self-destructive behavior characteristic of subjects with borderline personality disorder; the presence of risky behaviors among the subjects with eating disorder symptoms in this study, including bingeing and insulin omission, is in line with these explanations. The borderline personality cluster reflects poor self-esteem and lack of impulse control,26,34 as well as poor adherence to medical therapy.22,26,34 Borderline traits are often expressed as food-related issues, since self-identity and physical appearance tend to be strongly related in women.26 High scores for impulsivity are found in individuals with bulimia and are reflected in these patients’ sudden decisions to binge without regard for risks incurred or the dysphoria that follows.25 The present results support these descriptions. For example, subjects in this study who had borderline characteristics were more likely to report disordered behaviors such as insulin manipulation and poorer glycemic control, as reflected in their hemoglobin A1c values.
Clinically and empirically, patients with eating disorders are often described as anxious and perfectionistic.18,19,21,22,36 The dichotomous view of perfectionism as "normal" or "neurotic"19 led to the distinction between healthy and maladaptive aspects of perfectionism. Normal perfectionism involves setting high, realistic goals and standards.19,36 Conversely, neurotic perfectionism represents maladaptive aspects of a desire to be perfect,23 including "setting unrealistic standards and stringent self-evaluation,"24 and is now recognized as a major predisposing factor in the development and maintenance of eating disorders.24 The results of this study linked neurotic perfectionism with attitudinal aspects of disordered eating, particularly a tendency to be weight preoccupied. However, our results suggest that in diabetes mellitus, neurotic perfectionism does not translate into maladaptive behaviors concerning weight and food. This finding may explain why the subjects with neurotic perfectionism who were weight preoccupied did not engage in behaviors such as insulin omission. In subjects with neurotic perfectionism, dissonance caused by the preoccupation with weight and by knowledge about the risks of diabetes mismanagement may preclude the development of an eating disorder.
Recently, multidimensional scales have been used to assess different aspects of perfectionism.24 The self-oriented dimension of perfectionism reflects intrapersonal aspects,24,36,37 and the other-oriented and socially prescribed dimensions reflect interpersonal aspects.24 Previous research has found that the socially prescribed dimension is most strongly associated with maladaptive aspects of perfectionism.24,37 Socially prescribed perfectionism is common in young women and is linked to magnified weight concern and emphasis on appearance.24 Our finding that socially prescribed perfectionism predicted weight preoccupation supports this view.
We found that neurotic and socially prescribed perfectionism—maladaptive aspects of perfectionism—together predicted weight preoccupation. Although both variables were designed to capture maladaptive perfectionism, there was only a 36% shared variance between them. The neurotic perfectionism scale was designed specifically for eating disorder research and reflects a motivational component or the intrinsic drive for perfection.24 Socially prescribed perfectionism reflects interpersonal aspects—the belief that others set extremely high standards.24 This belief—and the associated fear of negative social evaluations—may explain why the subjects with high scores for socially prescribed perfectionism, who also demonstrated a high level of weight preoccupation (an attitudinal component of eating disorders), tended not to engage in the behavioral aspects of eating disorders (e.g., insulin manipulation).
A limitation of this study was the relatively small cell sizes in the analyses. This limitation likely reduced the power of the statistical tests. In the regression analyses, the results for neuroticism approached significance. With a larger number of subjects, this variable may have emerged as a predictor of disordered eating in diabetes mellitus, as reported in other studies.28,38,39 In addition, we relied on subjects’ self-reports of hemoglobin A1c values, which may have been biased. However, this value is highly relevant because it indicates overall health status. We found that hemoglobin A1c values correlated significantly with reported disordered eating behaviors (p<0.01).
In conclusion, this study provides additional evidence that eating disorders are a concern in women with diabetes mellitus. We found that intentional manipulation of insulin—reported in 27.5% of the subjects over the preceding 3 months—was a common method of inducing weight loss. An even greater number of subjects indicated that they had used this method over the history of their illness. Availability of this weight loss tool may account for the low prevalence of other purging behaviors, such as use of laxatives and self-induced vomiting. The high frequency of insulin manipulation and treatment noncompliance in the study subjects is particularly troubling, because of the high incidence of medical complications in individuals with diabetes mellitus and concomitant eating disorders. The presence of borderline personality and perfectionism traits in association with disordered eating in women with diabetes mellitus warrants further investigation in prospective, longitudinal studies. Early identification and intervention may help prevent long-term consequences of eating disorders in at-risk individuals with diabetes mellitus.
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Disordered Eating: Identifying, Treating, Preventing, and Differentiating It From Eating Disorders
Diabetes Spectr,
July 1, 2007;
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[Abstract]
[Full Text]
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ABSTRACT
INTRODUCTION
