Vous êtes sur la page 1sur 5

Sample Four: Critical Review of Four Essays Using APA Style

SPECIAL NOTES: This critical review of four professional journal essays is in APA format. There is no
bibliography, as all sources are sufficiently referenced in this semi-formal paper. Main subtitles are
underlined; sub-subtitles have all letters capitalized.

A Critical Review of Studies Showing the Prevalence


of Disordered Eating and Insulin Misuse among IDDM Patients
by Anonymous
Introduction
This critical review discusses four studies that examine the prevalence of eating disorders and
eating problems among insulin-dependent diabetes mellitus (IDDM) patients and the misuse of insulin
involved. In the British Medical Journal article Eating Disorders in Young Adults with Insulin-dependent
Diabetes Mellitus: A Controlled Study, the findings of Christopher Fairburn, Robert Peveler, Beverly
Davies, J. I. Mann, and Richard Mayou suggest that eating disorders are not more common among IDDM
patients compared to non-diabetics. The results presented by Anne Rydall, Gary Rodin, Marion Olmsted,
Robert Denenyi, and Denis Daneman (1997) in the New England Journal of Medicine article Disordered
Eating Behavior and Microvascular Complications in Young Women with Insulin-dependent Diabetes
Mellitus, imply that there is a common coexistence of eating disorders and IDDM among young females
(p. 1849). In the Journal of the American Dietetic Association article Insulin Misuse by Women with Type
1 Diabetes Mellitus Complicated by Eating Disorders Does Not Favorably Change Body Weight, Body
Composition, of Body Fat Distribution, Sandra Affenito, Nancy Rodriquez, Jeffrey Backstrand, Garry
Welch, and Cynthia Adams suggest that there is a high prevalence of eating disorders among the IDDM
population. In the Journal of American Academy of Child and Adult Psychiatry article Eating Disorders
and Maladaptive Dietary Insulin Management among Youths with Childhood-onset Insulin-dependent
Diabetes Mellitus Myrna Pollock, Maria Kovacs, and Denise Charron-Prochownik suggest that eating
disorders and problems are not as common among young adults as it is thought. All of the articles imply
that insulin misuse is a common method for controlling weight among IDDM patients with eating disorders
or problems. Two of the studies have strong elements that are worth noting. Each study has at least one
weakness. These include bias, contradiction, and limits of the study.
Background
According to the World Book Encyclopedia (1995), people with insulin-dependent diabetes
mellitus (IDDM or type 1 diabetes) have insufficient amounts of insulin in their bodies, and they are unable
to use and store glucose quickly. This leads to buildup of glucose in the blood. Injecting insulin allows
the body to use glucose normally. Despite a strict diet, the daily dose of insulin may cause rapid weight
gain in some IDDM patients, and this may trigger and eating disorder. The combination of IDDM and
eating disorders is quite common. According to Bonnie Irvin (1997), it is not known if eating disorders
are more common among diabetics, but it is highly probable (p. 28). Eating disorders pose a serious
health risk to those with IDDM. Lowering or skipping insulin doses gives these people a special method
of losing weight. According to Cheryl Rock and Kathryn Zerbe (1995), the dietary restrictions focus on
food, and increased body awareness of diabetics are risk factors for an eating disorder. Insulin
withholding can cause severe health complications, and diabetes heightens the risks of mortality
associated with eating disorders (Rock & Zerbe, 1995, p. 81). According to Irvin (1997), insulin purging,
(reducing or withholding insulin to control ones weight) is now recognized in DSM IVs diagnostic criteria
for bulimia (p. 28).
Summary

This sections provides a quick glance at each study. All of the studies varied in the subjects and
methods used. Some specifically studied eating disorders, while others looked at eating problems or
disordered eating. Some studied both. All of the studies also examined other aspects associated with
eating disorders or diabetes. (Note: this critical review specifically focuses on eating problems and/or
disorders, diabetes, and insulin misuse because these are the common elements in these studies.)
Eating Disorders in Young Adults with Insulin-dependent Diabetes Mellitus: A Controlled Study
compared the prevalence of eating disorders among a sample of IDDM patients and a sample of nondiabetics. The diabetic group consisted of 46 men and 54 women, and the control group consisted of 67
non-diabetic women only. Each subject was given an eating disorder examination to measure clinical
features of eating disorders. Those with diabetes were given an interview adapted to distinguish behavior
simply motivated by diabetes. All subjects also completed an eating attitudes test. Fairburn et al. found
no significant difference in the prevalence of eating disorders among diabetic women and non-diabetic
women. None of the men met criteria for an eating disorder. Many of the diabetic women underused
insulin to control their weight, and 4 out of the 6 currently doing so had an eating disorder.
In Disordered Eating Behavior and Microvascular Complications in Young Women with Insulindependent Diabetes Mellitus, young women with IDDM were studied at baseline and four to five years
later to find the prevalence and persistence of disordered eating behavior (Rydall et al., 1997, p. 1849).
The participants were 121 girls, ranging in age from 12-18, with IDDM. Each completed a self-report
survey of eating attitudes and behavior at baseline. According to Rydall et al. (1997), behavior relating to
eating and weight psychopathology was assessed at baseline and at follow-up with the Diagnostic
Survey for Eating Disorders (p. 1850). This questionnaire was adapted to include items specifically
relating to diabetes. According to Rydall et al. (1997), eating behavior at baseline and follow-up was
categorized into three mutually exclusive, hierarchical categories: highly disordered, moderately
disordered, and nondisordered eating (p. 1850). Ninety-one women participated at follow-up.
Rydall et al. (1997) found intentional omission or underdosing of insulin and dieting for weight
loss increased in prevalence from baseline to follow-up (p. 1852). At baseline, 26 of the 91 young women
had highly disordered eating behavior that persisted in 16 and improved in 10. Of the 65 with normal
eating at baseline 14 had disordered eating at follow-up. 12 subjects at baseline and 30 at follow-up
reported omission or underdosing of insulin to lose weight.
In the article, Insulin Misuse by Women with Type 1 Diabetes Mellitus Complicated by Eating
Disorders Does Not Favorably Change Body Weight, Body Composition, of Body Fat Distribution, the
relationship between improper use of insulin among type 1 diabetics mellitus (IDDM) and eating disorders
was investigated. Subjects were 90 women who had type 1 diabetes for at least one year. They were
divided into three groups: clinical (all DSM-III-R criteria met), subclinical (criteria partially met), and control
(free of eating disorders). Diagnoses of eating disorders were based on DSM-III-R criteria and confirmed
by clinical interview using the validated Eating Disorder Examination. According to Affenito et al. (1998),
the Bulimia Test Revised was administered to each subject to assess severity and frequency of bulimic
behavior (p. 687). Attitudes and behaviors regarding insulin misuse were determined by clinical
interview. The results showed the women with eating disorders (clinical and subclinical) misused insulin
to a greater extent to control weight than those without eating disorders. Nearly half of the women with
eating disorders reported misuse of insulin.
The objective of Eating Disorders and Maladaptive Dietary Insulin Management among Youths
with Childhood-onset Insulin-dependent Diabetes Mellitus was to determine the prevalence of eating
disorders and insulin misuse among IDDM youths. Girls and boys ranging in age from 8-13 were
assessed on various measures two to three weeks after IDDM onset and at various follow-ups over the
next eight to fourteen years. Eating disorders were diagnosed by using the Interview Schedule for
Children and Adolescents (ICS) which contains symptoms that are flags for possible eating disorders. 3
of the 79 subjects had a DSM-III eating disorder. Pollock et al. (1995) further reported that each of the 3
had serious dietary indiscretion and repeated insulin omission (p. 294). Six others had symptoms of

problematic eating behavior. According to Pollock et al. (1995) every one of the youths with eating
problems had at least one episode of pervasive noncompliance with diabetes care (p. 295).
Implications
POPULAR AND ACCEPTED IMPLICATIONS
This section discusses the implications of these studies, showing how they vary in popularity and
rationale. Most of the articles had results that one might expect. Fairburn et al., Rydall et al., and Affenito
et al. all implied that eating disorders and/or problems are fairly common among the IDDM population.
This is in accordance with the expectations formed from the empirical relationship between IDDM and
eating disorders. It seems logical that eating disorders would be common among this population due to
the special diet imposed on diabetics and their elevated body awareness. Those with diabetes also have
a method of controlling weight by reducing insulin doses readily available to them.
UNPOPULAR IMPLICATIONS
Some implications of these articles are not accepted so easily. Pollock et al. (1995) suggest that
only a small percentage of young adults have a combination of diabetes and eating disorders or eating
problems. This idea is not only unpopular because it goes against the common expectations mentioned
above, but also because eating disorders are thought to be the most common among the subjects age
range (16-26 years old when assessed for eating disorders) of this study.
Another implication that is unpopular is Fairburn et al.s (1991) conclusion that eating disorders
are not more common among diabetic women than non-diabetic women. The findings and implications of
this study contrast those of many other studies on this topic. It can be argued that these results are due
to the efforts of the experimenters to study a representative diabetic sample and a non-diabetic control
group. According to Fairburn et al. (1991), there are no satisfactory data on the prevalence of eating
disorders in the community and few other studies have included control groups. It is possible that these
methodological differences account for the findings of this study and the implications drawn from them.
One common implication among all of the studies is not well recognized by the public. Although
the misuse of insulin among IDDM subjects was common in all of these studies, it is not seen as a
common problem outside of the medical profession. According to Fairburn et al. (1991), insulin misuse is
not generally thought to be common, and omission or underuse of insulin specifically for weight control
has received little attention outside clinical reports of patients with eating disorders (p. 21). These
studies suggest that the practice is widespread among IDDM patients (mostly women), and according to
Affenito et al. (1998), it is not confined to those that have a clinical eating disorder. The misuse of insulin
may seem logical due to the increased risk of eating disorders among diabetics and their access to
insulin.
SIMILARITIES IN STUDIES, DIFFERENT IMPLICATIONS
Some of the studies had similar methods and/or subjects, but different results and implications.
The subjects in Eating Disorders in Young Adults with Insulin-dependent Diabetes Mellitus: A Controlled
Study and the subjects at follow-up in Eating Disorders and Maladaptive Dietary Insulin Management
among Youths with Childhood-onset Insulin-dependent Diabetes Mellitus were similar in sex and age, but
the findings were different. Fairburn et al. (1991) found that many of the diabetic women had eating
disorders and disturbed eating, while no men did. Pollock et al. (1995) contrastly found only a small
percentage of the IDDM subjects had eating disorders or problems, and one-third of the subjects with
eating problems were male.
The difference in prevalence of eating disorders and problems suggested in these studies may
be due to the criteria that Pollock et al. used to determine an eating disorder and eating problem. For the
purpose of their study Pollock et al. (1995) determined that an eating problem required the joint presence
of maladaptive eating and repeated insulin misuse (p. 293). In the Fairburn et al. study, insulin misuse
was not required for an eating problem. One might argue that a diabetic may have disordered eating

without misusing insulin, and therefore it should not be a requirement. Pollock et al. (1995) used
comprehensive psychiatric evaluations and differential diagnosis to determine eating disorders (p. 293).
This method of assessment is more extensive than what would be done in a clinical setting. The criteria
and methods used by Pollock et al. may have excluded subjects that would otherwise be considered for
an eating problem or disorder. Pollock et al. (1995) also considered misuse of insulin as the total
omission of insulin rather than the omission or reduction of insulin like most other studies. Contrastly, in
the Fairburn et al. (1991) study misuse of insulin was defined as underusing or even omitting insulin
specifically to control weight (p. 18). The difference in criteria used for insulin misuse may also explain
the differences found on this measure.
Fairburn et al. (1991) and Affenito et al. (1995) both compared the misuse of insulin among IDDM
patients with eating disorders and IDDM patients without eating disorders. According to Fairburn et al.
(1991) there was no significant difference in the misuse of insulin among the groups. Affenito et al.s
results suggest that the misuse of insulin is more common among diabetics with eating disorders than
among those without them. One could argue that the difference found by Affenito et al. is due to
demographic differences between the groups. Affenito (1998) et al. found the women without eating
disorders were more educated, had more professional occupations, and were more likely to be married
compared to those without eating disorders (p. 687). No significant differences existed between the
groups in the Fairburn et al. study. It can be argued that these differences are due to differences in the
comparison groups and that no real differences exist.
Evaluation
This section evaluates the quality of each study. Some of the studies have strong elements that
are worth mentioning. Each of these studies have at least one weakness that lowers the value of their
findings.
STRONG ELEMENTS
In two of the studies special concern was given to the instruments used to measure eating
disorders and problems among the diabetic subjects. Fairburn et al. (1991) made intensive efforts to go
beyond the shortcomings of similar studies. According to Fairburn et al. (1991), the Eating Disorder
Examination used was adapted to distinguish behavior motivated by having diabetes and the demands of
treatment from that attributable to an eating disorder (p. 18). Rydall et al. (1997) used the Diagnostic
Survey for Eating Disorders that was modified to include diabetes-related items (p. 1850). By taking
these extra steps, the authors avoid attributing eating problems and other behaviors to eating disorders
when they could simply be the result of the diabetes.
Another important part of the study conducted by Fairburn et al. (1991) is that they strived to use a
more representative sample of diabetics, and they also used a control group of non-diabetics that few
other studies have used. The use of a control group is important because, according to Irvin (1997) the
prevalence of clinical eating disorders in non-diabetic people is uncertain (p. 17).
BIAS
Two of the studies did not making the studies blind when it may have been more effective to do
so, and the result of this may have been bias. In Insulin Misuse by Women with Type 1 Diabetes Mellitus
Complicated by Eating Disorders does not Favorably Change Body Weight, Body Composition, or Body
Fat Distribution by Affenito et al. (1998), the Bulimia Test Revised and a determination of attitudes and
behavior regarding misuse of insulin were conducted by clinical interview (p. 687). The subjects were
broken into three groups, and the interviewer knew if each subject was part of the clinical, subclinical, or
control group. According to Fairburn et al. (1991), in Eating Disorders in Young Adults with Insulindependent Diabetes Mellitus: A Controlled Study the eating examination was conducted by investigators,
and the investigators knew if the subjects were diabetic or not. The interpreters and interviewers of both
of these studies may have had expectations and stereotypes concerning eating disorders and diabetes.
These may have influenced how they rated, scored, or interpreted the subjects on the measures used.

CONTRADICTION
Fairburn et al. contradict the purpose of their study. According to Fairburn et al. (1991), the
purpose of their study was to estimate the prevalence of eating disorders in the entire diabetic and nondiabetic population, but men were only included in the diabetic sample. By only studying women in the
non-diabetic sample, the non-diabetic population is not fairly represented. The absence of males in the
control group may have influenced the results.
LIMITS
A few of the studies were limited by problems with their samples. In Eating Disorders and
Maladaptive Dietary Insulin Management among Youths with Childhood-onset Insulin-dependent Diabetes
Mellitus the number of subjects found to have eating problems was too small to detect differences on
different variables between those with and without eating problems. This limited the authors ability to
suggest what factors cause eating problems among IDDM patients. According to Rydall et al. (1997), a
drawback of their study was that they lost participants that had highly or moderately disordered eating at
baseline. The information provided by these subjects could have contributed greatly to the results. The
loss of participants is a drawback in any study.
The experimenters could have avoided other limits of these studies. In the Pollock et al. (1995)
study the authors did not focus on all manifestations of diabetes-specific eating problems, and they may
have underestimated the rate of these difficulties (p. 297). Unlike Fairburn et al. and Rydall et al., they did
not acknowledge the eating problems that may be caused by the diabetes.
In the Rydall et al. article the authors could have avoided some of the limits of the study. First of
all, according to Rydall et al. (1997), eating behavior was only assessed twice over a four to five year
period. This is a big gap of time to allow when measuring eating disorders among young women. Many
changes may have occurred in these girls lives in between assessments that the authors did not take
into consideration. By the time of follow-up more of the subjects had reached the age of higher risk for
eating disturbances, and this alone may have influenced the results. Another limit was that, according to
Rydall et al. (1997), the self-report measure (a questionnaire) had limited established reliability (p.
1853). An important part of every study is to use an instrument with high reliability and validity. If such
instruments are not used, little faith can be put in the results.
Conclusion
This critical review examined four studies on IDDM patients and the prevalence of eating
disorders and insulin misuse among them. Special concern seems warranted among diabetics, because,
according to Irvin (1997), diabetes can be a natural jumping off place for an eating disorder and a
perfect mask for the disorder once it starts (p. 28). Fairburn et al., Rydall et al., and Affenito et al. all
agreed that eating disorders occur at a great rate among IDDM patients. Pollock et al. concluded that
eating problems and disorders were not very common among IDDM patients. All of the studies found a
high occurrence of insulin misuse among diabetic subjects with eating problems. Arguments can be
made against and in defense of the findings of these studies. Despite a few strong elements in a few of
the studies, each study had at least one weakness of bias, contradiction, or limits of the study.