Toulia I, Grammatikopoulou MG, Foscolou A, Gioxari A, Paschalidou EG, Karagiannopoulou E, Daskalou E, Androutsos O, Goulis DG, Tsiroukidou K. Diagnosis of type 1 diabetes mellitus triples the odds of screening positive for eating disorders: A case-control study. World J Clin Pediatr 2025; 14(4): 109619 [DOI: 10.5409/wjcp.v14.i4.109619]
Corresponding Author of This Article
Maria G Grammatikopoulou, PhD, Assistant Professor, Immunonutrition Unit, Department of Rheumatology and Clinical Immunology, University General Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis Campus, Argonafton & Filellinon Street, Larissa GR-42110, Greece. mgrammat@uth.gr
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Pediatrics
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Case Control Study
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Dec 9, 2025 (publication date) through Oct 31, 2025
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World Journal of Clinical Pediatrics
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Toulia I, Grammatikopoulou MG, Foscolou A, Gioxari A, Paschalidou EG, Karagiannopoulou E, Daskalou E, Androutsos O, Goulis DG, Tsiroukidou K. Diagnosis of type 1 diabetes mellitus triples the odds of screening positive for eating disorders: A case-control study. World J Clin Pediatr 2025; 14(4): 109619 [DOI: 10.5409/wjcp.v14.i4.109619]
Ilektra Toulia, Maria G Grammatikopoulou, Eleni G Paschalidou, Eirini Karagiannopoulou, Kyriaki Tsiroukidou, Pediatric Endocrinology Unit, 3rd Department of Pediatrics, Hippokration General Hospital of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki GR-54124, Greece
Maria G Grammatikopoulou, Immunonutrition Unit, Department of Rheumatology and Clinical Immunology, University General Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis Campus, Larissa GR-42110, Greece
Alexandra Foscolou, Aristea Gioxari, Department of Nutritional Science and Dietetics, School of Health Sciences, University of the Peloponnese, Kalamata GR-24100, Antikalamos, Greece
Efstratia Daskalou, Department of Nutrition, General Hospital of Thessaloniki "G. Gennimatas", Thessaloniki GR-54635, Greece
Odysseas Androutsos, Lab of Clinical Nutrition and Dietetics, Department of Nutrition and Dietetics, School of Physical Education, Sport Sciences and Dietetics, University of Thessaly, Trikala GR-42132, Greece
Dimitrios G Goulis, Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Faculty of Health Sciences, Medical School, Aristotle University of Thessaloniki, Thessaloniki GR-54124, Greece
Co-first authors: Ilektra Toulia and Maria G Grammatikopoulou.
Author contributions: Toulia I also contributed to reviewing and editing the manuscript; Grammatikopoulou MG contributed to the methodology, conceptualization, writing, reviewing and editing of the manuscript; Foscolou A and Gioxari A contributed to the formal analysis, reviewing and editing the manuscript; Daskalou E and Androutsos O contributed in reviewing and editing the manuscript; Paschalidou EG and Karagiannopoulou E collected the data, analyzed the dietary data and created the database used for the analyses; Goulis DG and Tsiroukidou K contributed to reviewing, editing and supervising the work; All authors contributed to the interpretation of the study and approved the final version to be published. Toulia I and Grammatikopoulou MG contributed equally to this work.
Institutional review board statement: Ethical approval for the study was granted by the Scientific board of the Hippokration General Hospital (307/12-07-2024).
Informed consent statement: The parents and guardians or all participants provided consent to participation.
Conflict-of-interest statement: No conflicts of interest declared.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Data sharing statement: All data are available upon request to the senior author.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Maria G Grammatikopoulou, PhD, Assistant Professor, Immunonutrition Unit, Department of Rheumatology and Clinical Immunology, University General Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis Campus, Argonafton & Filellinon Street, Larissa GR-42110, Greece. mgrammat@uth.gr
Received: May 18, 2025 Revised: June 12, 2025 Accepted: August 25, 2025 Published online: December 9, 2025 Processing time: 167 Days and 14.5 Hours
Abstract
BACKGROUND
A diagnosis of a chronic disease has been shown to predispose patients to the development of feeding and eating disorders (FEDs).
AIM
To screen children and adolescents with type 1 diabetes mellitus (T1DM) for FEDs and compare them to their counterparts with short stature.
METHODS
A total of 110 children and adolescents (55 with T1DM and 55 with short stature) were enrolled in the study. The SCOFF questionnaire was used to screen for possible FEDs, while anthropometric and dietary data were also collected.
RESULTS
Approximately 60% of the children with T1DM screened positive for FEDs compared to 30.9% of the children with short stature. Having a T1DM tripled the chances of screening positive for FEDs and halved the annual growth rate of children with T1DM. No differences were noted in the dietary intake between groups.
CONCLUSION
The results necessitate the education of pediatric endocrinologists and diabetologists on proper screening and identification of children at risk for developing FEDs. A prompt diagnosis might help children catch up growth and attain their genetically predisposed height.
Core Tip: We showed that children with type 1 diabetes mellitus (T1DM) have a heightened risk for feeding and eating disorders (FEDs) and should be screened when red flags are apparent. A dual FEDs and T1DM diagnosis can halt the linear growth of children, making it difficult for them to reach their genetic potential according to parental height. In parallel, children with short stature also exhibit a high risk for FEDs. Collectively, the results indicate that pediatricians, pediatric endocrinologists and diabetologists should be educated on triage for FEDs, using valid tools to support a prompt identification and management.
Citation: Toulia I, Grammatikopoulou MG, Foscolou A, Gioxari A, Paschalidou EG, Karagiannopoulou E, Daskalou E, Androutsos O, Goulis DG, Tsiroukidou K. Diagnosis of type 1 diabetes mellitus triples the odds of screening positive for eating disorders: A case-control study. World J Clin Pediatr 2025; 14(4): 109619
Feeding and eating disorders (FEDs) are disabling and costly mental disorders, often associated with a high mortality rate[1,2]. FEDs do not only affect mental health, but can also impair physical functioning. The increasing prevalence of FEDs during the past decades[1] was also propelled by the social disruption during the coronavirus disease 2019 pandemic[3], increased social media use[4] and the overall rise in mental health issues[5]. Adolescent girls appear to be particularly prone to developing FEDs[2,6], similarly to those having a chronic disease diagnosis[7,8].
Of particular concern is the combination of a type 1 diabetes mellitus (T1DM) diagnosis with a FED, commonly known as "diabulimia"[7,9]. This dual condition is characterized by poor metabolic control[10], complicated diabetes management[11], a threefold increase in the risk of diabetic retinopathy[12], as well as several acute and longitudinal physical consequences[13]. Among children and adolescents, a FEDs diagnosis can also negatively affect growth, with FED patients being, on average, shorter than control (healthy) subjects, independently from the age of onset[14-16].
According to the Guidance on Recognizing and Managing Medical Emergencies in Eating Disorders[17], distinct diagnostic criteria exist for the diagnosis of FEDs in T1DM, and the prompt identification of affected individuals consists of a crucial factor for better diabetes management, growth and other health outcomes. What is important, is that often, adolescents with T1DM and FEDs present a normal body weight, making it difficult to suspect the underlying disordered eating behaviors (DEB) with the naked eye. Red flags indicating a possible FED include insulin omission or misuse[13], frequent episodes of hypoglycaemia requiring assistance, body dissatisfaction, a drive for thinness[18], avoidance of carbohydrate-rich foods, bingeing, etc. Among the FEDs, bulimia nervosa (BN) and binge-eating disorder seem to be more prevalent in patients with T1DM, as opposed to anorexia nervosa (AN)[13]. Nonetheless, screening with sensitive tools consists of an important step towards timely management. Although the problem exists, literature is still scarce on the factors associated with FEDs in T1DM and the effects of a dual diagnosis on linear growth.
The present case-control study aimed to screen pediatric patients with T1DM for FEDs and compare them to similar-age patients with short stature.
MATERIALS AND METHODS
Sample recruitment
Children and adolescent patients who visited the Pediatric Endocrinology Unit situated at Hippokration General Hospital, both in Thessaloniki, were recruited during December 2023 until May 2024. Inclusion criteria involved: (1) Children and adolescents aged between 7-16 years old; (2) Willing to participate in the study; (3) With parental/guardian consent; (4) With a diagnosis of T1DM or short stature; and (5) Able to communicate in the Greek language adequately to understand the questions and reply effortlessly. No exclusion criteria were imposed, thus, all children visiting the pediatric endocrinology unit, with a diagnosis of T1DM or short stature were eligible for participation. A total of 110 children and adolescents fulfilled the criteria and were included in the sample. Characteristics of the participants are presented in Table 1. Ethical approval for the study was granted by the Scientific board of the Hippokration General Hospital (307/12-07-2024). The parents and guardians of all participants provided consent to participation.
Table 1 Characteristics of the sample (n = 110 children and adolescents), mean ± SD, n (%).
The Greek version of the SCOFF questionnaire (G-SCOFF)[19] was used to assess possible FEDs among participants, with the parents/guardians being present at the interview, providing assistance wherever required. The questionnaire employs five items to capture the central features of AN and BN[20]. The title of the questionnaire is an acronym corresponding to the five domains it addresses: Sick, control, one stone, fat, and food. Each positive response is assigned one point, and a total score of 2 or more (SCOFF ≥ 2) indicates a possible FED case (tool specificity: 87.5%; sensitivity: 100%)[18,19] and adherence to DEB.
A positive SCOFF screen indicates the necessity for additional clinical evaluation, but it does not necessarily confirm an eating disorder diagnosis, as it consists of a validated screening tool rather than a diagnostic instrument. The questionnaire has already been translated and used in the Greek language[19]. The tool is well validated as an effective screener for possible FEDs[20] and is characterized by its simplicity, memorability, and ease of scoring[19,20].
Anthropometric indices
Measurements of body weight and height were obtained to the nearest gram and centimeter, respectively, during the early morning, with subjects barefoot and wearing light clothing only. One experienced dietitian (Paschalidou EG) trained in anthropometry, performed all body weight measurements during morning hours. Regarding body height, two experienced dietitians were employed (Karagiannopoulou E and Paschalidou EG) for its measurement. A standardized procedure was followed for weighing and measuring body height, in order to minimize measurement error. In addition, frequent calibration of the scale was performed with portable fixed weights, in order to ensure accuracy of the measurements. The weighing and measuring procedures were explained beforehand to the parents/guardians and to the children, to help minimize possible discomfort. Measurements were obtained with a mechanical scale (Seca 700, Seca, Hamburg, Germany) and a wall stadiometer (Harpenden, Holtain, Crymych, United Kingdom), both situated in the Department of Pediatric Endocrinology.
Body mass index (BMI) was calculated for each participant as body weight (kg) divided by height squared (m2). Growth and development were assessed using the World Health Organization (WHO) Anthro software v.3.2 (WHO, Geneva, Switzerland), which also generated BMI z-scores (BMIz), weight-for-age z-scores (WAZ), and height-for-age z-scores (HAZ). The Anthro software uses the WHO child growth standards and reference curves[21,22]. Weight status was defined according to the WHO as underweight (BMIz ≤ -1.00, 15th percentile), normoweight (BMIz between -0.99 and 0.99), overweight (BMIz ≥ 1.00, 85th percentile), and obesity (BMIz ≥ 2.00, 98th percentile).
Dietary intake
Previous day 24 hours diet recalls were collected from each participant by experienced dietitians, with the help of the parents/guardians. Food atlases, with realistic food portion sizes were employed to facilitate this process. Dietary data were analyzed by experienced dietitians with the use of the Cronometer software (Web-version, Cronometer Software Inc., Vancouver, BC, Canada).
Statistical analyses
When normally distributed, continuous variables were presented as means with their standard deviations, or as medians with interquartile ranges when not normally distributed. Categorical variables were presented as counts with their respective percentages. The Kolmogorov-Smirnov test was used to test normality. Differences between continuous, normally distributed variables were assessed using the independent samples t-test and the Mann-Whitney U test when distributions were skewed. Associations between categorical variables were tested using the χ2 test.
Internal consistency of the G-SCOFF was assessed using the Kuder-Richardson Formula 20, appropriate for dichotomous data[23]. Multiple binary logistic regression models were used to evaluate the association between children’s diagnosis (i.e., T1DM vs short stature) (independent variable) and screening positive in G-SCOFF (≥ 2 positive responses) (dependent variable). The first model was unadjusted; the second model was adjusted for age and sex; the fully adjusted model additionally included weight status (BMI tier), pubertal stage (Tanner stage of pubic hair development), and daily energy intake (kcal/day), as covariates. The results were presented as OR, with their respective 95%CI, and calculated P values.
The SPSS software (version 29) was used for all analyses (IBM Statistics, Greece) and the level of statistical significance was set at α = 0.05.
RESULTS
Following the exclusion of one G-SCOFF item due to zero variance, the internal consistency of the remaining four items was 0.376, suggesting low internal consistency in this specific pediatric cohort.
Table 2 details the anthropometric and G-SCOFF results of participants in each group. As expected, greater WAZ, HAZ and BMIz scores were observed in the T1DM group compared to patients with short stature. The prevalence of distinct weight status tiers was also different between groups. Notably, children and adolescents with short stature demonstrated an increased annual growth rate compared with their peers with T1DM, a finding that may be attributable to recombinant growth hormone (GH) therapy, which most were receiving. With regards to the SCOFF, a greater proportion of patients with T1DM screened positive for possible FEDs and, as a result, median SCOFF score was also greater in this group, as compared to patients with short stature. Approximately 60% of patients with T1DM and nearly 1/3 of patients with short stature screened positive for possible FEDs (Table 2). In the total sample, nearly half of the participants screened positive for possible FEDs indicating that both T1DM and short stature patients are at increased risk for DEB.
Table 2 Comparison of anthropometric indices and G-SCOFF results between children and adolescents with type 1 diabetes mellitus (n = 55) vs children with short stature (n = 55), n (%).
Within the T1DM group, those screening positive for FEDs had a lower annual growth rate (3.2 ± 2.6) compared to those who were FEDs-free (6.0 ± 3.1, p£0.001). No differences were noted in the HbA1c between patients with T1DM with SCOFF ≥ 2 and those without FEDs. Table 3 compares the dietary intake between the two groups. Overall, children with T1DM consumed more dietary fiber and less trans fatty acids compared to the children with short stature. No other differences were noted in the dietary intake of the two groups.
Table 3 Comparison of the dietary intake between children and adolescents with type 1 diabetes mellitus (n = 55) vs children with short stature (n = 55), n (%).
Table 4 presents the regression analyses explaining a G-SCOFF score ≥ 2. In all models, having a T1DM diagnosis tripled the odds of screening positive for FEDs.
Table 4 Results from logistic regression models evaluating the association between children’s diagnosis (type 1 diabetes mellitus vs short stature) and the screening positive for feeding and eating disorders.
The present study revealed that a high proportion of young patients with T1DM (60%) and patients with short stature (nearly 1/3) are screening positive for FEDs. It also revealed that a T1DM diagnosis nearly triples the chance of screening positive for FEDs. Linear growth appears greatly affected among young patients with T1DM screening positive for FEDs, with their annual growth rate being half of that of their FEDs-free counterparts.
According to a recent meta-analysis[24], FEDs symptoms affect 24% of patients with insulin-dependent diabetes mellitus. Overall, primary studies reveal a 0% to 32% prevalence of a dual FED-T1DM diagnosis. The present study revealed an even greater prevalence among young patients with T1DM, in line with the fact that adolescence consists of a critical period for the development of FEDs. It has been shown that 21% of adults with a dual FED-T1DM diagnosis tend to omit insulin doses in order to reduce consumed glucose calories through the urine glucose excretion, leading to weight loss[25]. Unfortunately, no such data were collected herein.
In parallel, research has showed that insulin therapy is often associated with involuntary weight gain among patients with T1DM and is associated with poorer glycemic control[26-28]. The pathway via which this weight gain occurs is complex and multifactorial. Insulin replacement therapy leads to peripheral hyperinsulinemia, insulin profiles not matching basal or meal-time insulin requirements, defensive snacking and overeating for avoidance of hypoglycaemic episodes, all of which drive the accumulation of body fat and propel weight gain[26]. As a result, many adolescent patients with T1DM demonstrate body image issues and experience body dissatisfaction[29] with girls in particular, appearing pressured by family and media to attain a thin body and improve their appearance[30]. This leads to a high prevalence of DEB, with reports suggesting that approximately 43% of adolescents with T1DM engage in DEB[31].
An important finding of the study is the reduced annual growth rate of patients with T1DM and FEDs symptoms compared to the FEDs-free patients. According to Downey[32], the impact of restrictive FEDs on growth and development cannot be overstated, particularly with regards to pre- and peripubertal patients. Eating disorders have been associated with lower bone age compared to chronological age in girls[33], reduced growth and pubertal delay[34]. Underweight in FEDs is related to a plethora of endocrine abnormalities involving key growth axes[35], GH resistance, thyroid abnormalities[36], reduced levels of insulin-like growth factor-1 (IGF-1)[37], disrupted GH-IGF-1 axis[38], and central gonadotrophic inhibition[34,35]. In parallel, the concentrations of IGF-1 and gonadotrophins are not only mediated by underweight and restrictive eating, but also by a plethora of psychological factors[34,39]. Time of onset, duration of diagnosis and pubertal status are important aspects influencing the ability to achieve genetic height potential once weight gain is restored. The opportunity to catch up growth may be irreversibly lost if identification of at-risk children is not performed in a timely manner.
The present study also revealed the high prevalence of FEDs symptoms in children with short stature. To our knowledge, no other study has assessed this thus far. Although we acknowledge that FEDs are associated with short stature, screening for FEDs in children with short stature has never been performed. The high prevalence of FEDs positive children with short stature indicates that for some, idiopathic short stature might be the result of an underlying FED.
At the moment we are unsure if T1DM is driving FEDs or if common physiological/immunological pathways exist. Emerging evidence links FEDs with several autoimmune diseases with different genetic backgrounds[40,41], indicating a possible common autoantibody mechanism[42] and the activation of immune response in neuropsychiatric disease[43]. Recent research suggests that FEDs-in particularly AN- and autoimmune diseases have a bidirectional relationship based on common immunopathological mechanisms[41]. This indicates that patients with FEDs should be screened for autoimmune diseases, whereas, on the other hand, patients with autoimmune diseases should also be screened for FEDs.
In the present sample, the G-SCOFF showed a low internal consistency, indicating that the included questions don't correlate well with each other. Previous studies have also revealed low internal consistency of the Greek[19] and English versions[44,45] of the tool. Research in adults[46] has suggested that SCOFF scores of 2 and 3 are optimal for assessing FEDs among men and women, respectively, in order to enhance sensitivity of the tool. Furthermore, recently, research on Italian adolescents[47] has also suggested a cut-off of ≥ 3. However, research in young people has suggested a high screening ability for assessing the risk of AN and BN when applying the cut-off score of ≥ 2, presenting 100% sensitivity[6,20]. Furthermore, a systematic review of all published studies applying the SCOFF also suggested the use of the ≥ 2 cut-off in young individuals[48]. In parallel, we have to consider that most validation studies have been performed in small samples, comprising mainly of females[46]. Nonetheless, research in adolescents has revealed that those screening positive using the SCOFF are more likely to report eating disorders and suffer from depression in young adulthood[49]. Furthermore, in Italy[47], screening positive at SCOFF was associated with bad family relationships, being bullied and experiencing high levels of distress.
Limitations of the present study involve mainly the inherited limitations of the tool used to screen for FEDs, namely the SCOFF, as well as the limitations of the cross-sectional study design. According to Tanner et al[50], the development and testing of novel potential pediatric screening tools that are inclusive of all FEDs, able to be used at any weight are anticipated, in order to improve screening practices. At the moment, the SCOFF does not discriminate between AN and BN[51,52] and it also fails to discriminate between AN subtypes (restrictive or binge-eating/purging type). Furthermore, the sample does not represent the Greek adolescent population, as it only includes patients with T1DM or short stature. Therefore, generalizations regarding the results should be avoided, as studies on healthy adolescent populations indicate lower FEDs prevalence[6,53,54] compared to herein.
T1DM and short stature are two common conditions within pediatric endocrinology clinics, both of which were shown to have a high prevalence of FEDs symptoms. This alarming finding indicates that pediatric endocrinologists should be educated and trained to recognize FEDs in order to feel confident in screening patients and conclude on a diagnosis. According to a recent study[55], more than 60% of healthcare professionals related to diabetes management fail to express confidence in the identification of co-morbid FEDs, with 78% reporting unawareness of relevant screening tools to triage patients. For this, most practitioners rely on clinical interviews to detect FEDs[51]. Furthermore, screening in primary care has been suggested to be more efficient for the early detection of FEDs compared to the tertiary care, due to busy clinic practices, the lack of personnel and the patients who may withhold information, in an effort to avoid detection[51]. Although pediatricians might promptly identify an emaciated child/adolescent with a FED, those who binge or purge do not necessarily exhibit significant changes in body weight and might be easily unidentified[51]. The 2021 American Academy of Pediatrics Clinical Report on Eating Disorders in Children and Adolescents, identifies pediatricians as being in “a unique position to detect FEDs early and interrupt their progression”[52], using well-validated FED screening tools targeting all youth[50]. Any noted weight loss should prompt a thorough assessment of dietary and exercise habits, with screening for unhealthy weight-control methods before offering positive reinforcement, as this may unintentionally support maladaptive behaviors[52]. Failure to detect FEDs at an early stage can result in an increase in severity, further weight loss and growth disruption[56].
CONCLUSION
T1DM triples the chances of FEDs symptoms in children and adolescents and a dual FEDs-T1DM diagnosis is associated with a disrupted linear growth. Children with short stature are also at great risk for developing DEB. A great number of patients within the pediatric endocrinology units exhibit FEDs symptoms and for this, pediatric endocrinologists should be adequately educated to triage patients for eating disorders and recognize red flags in a timely manner.
Footnotes
Provenance and peer review: Invited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Pediatrics
Country of origin: Greece
Peer-review report’s classification
Scientific Quality: Grade B, Grade C
Novelty: Grade B, Grade C
Creativity or Innovation: Grade B, Grade C
Scientific Significance: Grade B, Grade C
P-Reviewer: Hasan N, MD, United States; Hu ZY, PhD, Assistant Professor, China S-Editor: Qu XL L-Editor: A P-Editor: Yu HG
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