Comorbidity of Type 1 Diabetes and Anorexia Nervosa in a 6-Year-Old Girl

A high prevalence of eating disorders has been described in female adolescents with type 1 diabetes as being almost twice as high as that found in their nondiabetic peers (1–3). Weight gain caused by insulin therapy, dietary restraint, and food preoccupation may predispose diabetic girls to develop a clinical or subclinical eating disorder (4–6); intentional insulin omission is the most common symptom underlying an eating disorder (7). The coexistence of these conditions could lead to poor metabolic control and increase the risk of microvascular complications (8).

Very few reports have been published on eating disorders in childhood (9,10), and in only one report this condition was also described in diabetic children, starting from the age of 8 years (4). We describe the successful treatment of a 6-year-old girl with comorbid type 1 diabetes and anorexia nervosa. This case underlines that children with diabetes, as well as adolescents, may be prone to develop a disorder of eating behavior, and that an early diagnosis and multidisciplinary approach are fundamental for a positive outcome.

R.F. was diagnosed to be affected by type 1 diabetes at the age of 4.5 years at the Department of Pediatrics of University Federico II in February 1995. She presented a partial remission of diabetes, lasting 16 months; she was treated with two daily doses of insulin (0.2–0.3 units · kg⁻¹ · day⁻¹), and her HbA_1c ranged from 5.0 to 6.2% (normal values <6%).

In July 1996, when her HbA_1c rose to 9.6%, she was treated with 0.8 units · kg⁻¹ · day⁻¹ of insulin in three daily doses. Her height and weight were in the normal range (50th percentile according to Tanner growth charts). In October 1996, her HbA_1c was 6.6%. One month later, she began to first refuse several foods and then any kind of food. Consequently, she presented severe weight loss and frequent hypoglycemic crises; therefore, her insulin dose was reduced. Chronic bowel diseases, tumors, and other endocrine or autoimmune diseases were excluded.

Diagnosis of anorexia nervosa was performed according to the DSM IV criteria. The personality profile was characterized by a defensive system set up against depression, which hindered the girl from recognizing the state of the disease through a denial and splitting mechanism. In addition, her mother was affected by depression and required pharmacological treatment, and the parental couple was in violent conflict.

Medical treatment of anorexia was based on enteral nutrition from January to June of 1997. Subsequently, the girl accepted and maintained a normal and complete oral nutrition, which has persisted until present (10.5 years of age). She presents a normal growth and a good control of diabetes (HbA_1c 6.9–7.5%).

Psychiatric treatment consisted of intensive individual psychoanalysis that the patient is still receiving. In the first year, she presented a progressive decrease of anguish relative to weight gain and food ingestion; anorexia completely disappeared. Successively, she expressed the fear of “intrusion inside her body” by very severe obsessive-phobic symptoms. At the present time, she has several fantasies connected to diabetes acceptance. Treatment is actually addressed to give support to the “self.”

Diabetes is a complex disease that affects all aspects of the daily life, in particular, eating behaviors. Dietary restraint and food preoccupation break into all of the daily events of life, leading to important changes in the aspects of conviviality and social relationships. Food may become the main enemy of the child or the main reason of contrast with parents.

In our patient, symptoms of anorexia started immediately after the “honey-moon” period, when dietary regimen is often poorly stressed and parental surveillance on diabetic management is less stringent. Successively, recurrence of hyperglycemia and the increased insulin requirement might have been a trigger to precipitate an eating disorder in a prone subject. Moreover, the environmental demands related to the concomitant beginning of schooling may have exerted an additional role.

Anorexia in a very young child does not lead to insulin omission, as in adolescents, because children are still under their parents’ surveillance. On the contrary, undernutrition is the main clinical problem at this age, causing recurrent hypoglycemic crises and troubles in insulin management. Furthermore, whereas in otherwise healthy children appropriate evaluation and treatment may precociously stop an eating disorder, in diabetic children treatment is complicated by the lifelong persistence of diabetes, with its rules regarding food regulation, multiple glycemic controls, and insulin injections. However, early diagnosis of eating disorder and long-term multidisciplinary treatment are very important in a diabetic child in order to avoid the risk of persistence until adolescence or adulthood, when it may be potentially fatal.