The diagnosis of type 1 diabetes or that of an eating disorder is one of great difficulty. Sadly, evidence suggests that adolescents with type 1 diabetes are at an increased risk of developing anorexia nervosa (AN), due to their need to greatly restrict their diet.
As this is not commonly known, we want to bring it to the public attention. Additionally, as yoga can help in the management of type 1, and as yoga is increasingly used as part of treatment plans for those with eating disorders likewise, we hope that a yoga intervention may reduce symptoms and therefore this most unfortunate outcome.
Here’s the Link
Hypothalamic-pituitary-adrenal (HPA)-overactivity, the mechanism responsible for releasing cortisol the stress hormone, often results in disordered eating [3]. The incidence of diabetes type 1 in conjunction with eating disorders is well-known in women. In fact, women with type 1 diabetes have a 2-fold increased risk for developing an eating disorder, and a 1.9-fold risk of developing a sub-threshold eating disorder than women without diabetes.
These distorted eating behaviours are reported to occur in 31-40% of women with type 1 diabetes aged between 15 and 30 years [2], with a great proportion of adolescents (including those younger than 15) presenting with AN, due to the increased preoccupation with food, the need to have an acceptable body image [3], and the increased stress response (which is associated with disordered eating). Less is known about eating disorders in boys and men with type 1 diabetes [2].
This comorbidity complicates care and increases cost expenditure for treatment. An integrated approach is therefore a prime consideration [3]. Women with type 1 diabetes and eating disorders see poorer glycaemic control, with higher rates of hospitalisations and retinopathy, neuropathy, and premature death compared with similarly aged women with type 1 diabetes without eating disorders [2]. Children and adolescents with type 1 diabetes in conjunction with anxiety and disordered eating can also affect skeletal health and psychosomatic status [3].
To date, treatment methods applied in adolescents (and adult) patients with AN include drug and psychiatric treatment, medical nutrition therapy (MNT), inpatient care, as well as a variety of other “alternative” therapies such as yoga [3]. We believe that further integration of therapeutic yoga is an important consideration
Case Study
We came across a recent study by Tsakona et al (2021), who described the first case study of an adolescent patient diagnosed with type 1 diabetes mellitus (T1DM), anxiety disorder (AD), and AN.
“A 14-year-old girl with T1DM since the age of 12 years presented weight loss at age 13 years and 3 months and low body mass index (BMI), which did not improve despite dietary recommendations and adequate disease control.
Additionally, she presented menstrual disorders at the age of 12 years and 11 months (menstrual age 12 years and 1 month). A psychological evaluation of the teenager was conducted using a semi-structured interview that assessed perceived stress, health status, quality of life, and depression.”
Anxiety disorders and AN were diagnosed and the patient initiated an intervention focusing on psychological health and nutrition and which incorporated additional elements such as relaxation sessions, progressive muscle relaxation (‘squeeze & release’) and breathing exercises. All, we know, are key components of yoga practice.
Exercise can be useful in eating disorders in reducing stress, however as those with AN may over-exercise to l there are great concerns of its use in treatment. Instead, the addition of simple daily movement focusing on balance & flexibility, in association with diaphragmatic breathing exercises, as done in this case study, may be less risky and very helpful In this case, the patient showed improvements in physical health, concentration, and mental state.
After 3 months of treatment, the patient’s BMI was increased, and a normal menstrual cycle was apparent. These results have since remained consistent, suggesting that stress is an important precursor of AN, and physiotherapeutic programs could reduce stress and effectively reduce AN and AD within patients with type 1 diabetes.
How can Yoga Help?
Evidence reveals and at Minded we have experienced the stress-reducing benefits of yoga and yogic breathing techniques, such as diaphragmatic breathing. We are pleased to see that it can also work with complex cases where psychological issues and physiological pathways overlap such as anxiety, type-1 diabetes, and anorexia, which are known to present as a triad. Given that an increasing number of patients with complex health needs are left in distress and cost health system exorbitant amounts of money, we wish to highlight the importance of a comprehensive biopsychosocial approach like yoga.
References
- Diabetes Report (2014). https://www.diabetes.org.uk/resources-s3/2017-11/diabetes%20uk%20cost%20of%20diabetes%20report.pdf
- Ducat, L., Philipson, L. H., & Anderson, B. J. (2014). The mental health comorbidities of diabetes. JAMA, 312(7), 691–692. https://doi.org/10.1001/jama.2014.8040
- Tsakona, P., Dafoulis, V., Vamvakis, A., Kosta, K., Mina, S., Kitsatis, I., Hristara-Papadopoulou, A., Roilides, E., and Tsiroukidou, K. (2021). The Synergistic Effects of a Complementary Physiotherapeutic Scheme in the Psychological and Nutritional Treatment in a Teenage Girl with Type 1 Diabetes Mellitus, Anxiety Disorder and Anorexia Nervosa. Children 2021, 8, 443. https://doi.org/10.3390/children8060443
- Raveendran AV, Deshpandae A, Joshi SR. Therapeutic Role of Yoga in Type 2 Diabetes. Endocrinol Metab (Seoul). 2018;33(3):307-317. doi:10.3803/EnM.2018.33.3.307
- Chen, F., Zhou, L., Bai, Y., Zhou, R., & Chen, L. (2015). Hypothalamic-pituitary-adrenal axis hyperactivity accounts for anxiety- and depression-like behaviors in rats perinatally exposed to bisphenol A.Journal of biomedical research, 29(3), 250–258. https://doi.org/10.7555/JBR.29.20140058
