The relationship of disordered eating habits and attitudes to clinical outcomes in young adult females with type 1 diabetes

Disordered eating behaviors and associated factors in children and adolescents with type 1 diabetes

OBJECT

As part of their treatment, patients with type 1 diabetes mellitus (DM) have to be very careful with what they eat and with their insulin doses. Therefore, the risk of eating disorders increases in this patient group. In this study, we aimed to determine the disordered eating behaviors of patients with type 1 DM and to evaluate the sociodemographic characteristics, diabetes care behaviors, and quality-of-life scale results that these behaviors may be related to.

METHOD

The sociodemographic characteristics and diabetes treatment data of 191 patients aged 9-18 years with type 1 DM were analyzed. The Pediatric Quality of Life Inventory (PedsQL), the PedsQL 3.0 Diabetes Module, and the Diabetes Eating Problem Survey-Revised (DEPS-R) were applied.

RESULTS

The median DEPS-R score of the patients was 18 (19.00), and 44.5 % had a DEPS-R score above 20. A significant correlation was found between age, duration of diabetes, frequency of blood glucose measurement, hemoglobin A1c (HbA1c) level, body mass index standard deviation score (BMI-SDS), and DEPS-R score. There was no significant difference between girls and boys. Patients with a high DEPS-R score had low scores on the PedsQL and on the PedsQL 3.0 Diabetes Module.

CONCLUSION

The DEPS-R scale is a diabetes-specific, easy-to-use, and effective method for screening patients with type 1 DM for disordered eating behaviors. It can help prevent the progression of disordered eating behaviors to clinical eating disorders in patients with type 1 DM. It would be beneficial to use this scale as a routine screening, especially in clinics where access to a psychologist is not possible.

Perceived comfort with weight, body shape and eating pattern of young adults with type 1 diabetes and associations with clinical and psychological parameters in a clinical setting

BACKGROUND

Higher prevalence of disordered eating in young adults with type 1 diabetes (T1D) culminates in higher levels of morbidity and mortality. In addition to validated questionnaires for diabetes distress, depression/anxiety symptoms and emotional well-being, the Diabetes Psychosocial Assessment Tool (DPAT) includes three questions about comfort with weight, body shape and eating pattern (WSE), which were derived from literature and multidisciplinary team consensus. Recognising individuals with low comfort with WSE, is the first step towards identifying those who may be at risk of developing eating disorders.

AIMS

Observe comfort with WSE, in young adults with T1D, and its associations with demographic/clinical characteristics and psychological parameters.

METHODS

276 young adults, aged 15-26, who attended routine clinical care at a Young Adult Diabetes Clinic, completed the DPAT. The WSE questions were scored on a 5-point Likert scale (1 indicating lowest comfort). Linear regression analysed differences in comfort with weight and eating pattern by demographic and psychological parameters.

RESULTS

1 in 3 young adults (29%) reported low comfort with WSE (scores 1 or 2). In females, 40%, 41% and 35% had low comfort with weight, shape and eating patterns respectively, in comparison to males in whom it was 18.5%, 16% and 21.5%. Females reported lower comfort with weight and eating pattern (mean 2.9 and 3.0 respectively) than Males (mean 3.7 and 3.6 respectively), each p < 0.001. Lower comfort with weight (p < 0.001) and eating pattern (p = 0.001) was associated with higher body mass index (BMI). Young adults with low comfort with weight and eating pattern experienced elevated diabetes distress and depressive/anxiety symptoms (each p < 0.001), also when adjusted for sex and BMI.

CONCLUSIONS

The study has shown that low comfort with WSE is common among young adults with T1D. Adding these questions into routine care, can allow for easy and early identification of low comfort, initiation of a therapeutic dialogue and implementation of focused management strategies.

A cognitive behavioural model of the bidirectional relationship between disordered eating and diabetes self care in adult men with Type 1 diabetes mellitus

AIMS

This qualitative study aimed to develop the first cognitive behavioural (CBT) model outlining the development and maintenance of disordered eating in adult men living with Type 1 diabetes to improve on previous theoretical models of Type 1 diabetes and disordered eating and to draw comparisons to women with Type 1 diabetes and disordered eating.

METHODS

Twenty-seven men (n = 16 with Type 1 diabetes and disordered eating, n = 11 with Type 1 diabetes without disordered eating) participated in semi-structured interviews. Data were analysed using thematic analysis and individual CBT formulations were developed for each participant to inform the model.

RESULTS

Men with Type 1 diabetes and disordered eating experience negative thoughts about food, insulin, weight/shape and diabetes itself, which cause negative emotions such as fear and vulnerability and difficulties with diabetes self care such as problems with hyper and hypoglycaemia and problems accessing structured education and technology result in men feeling more dissatisfied about their body weight/shape.

CONCLUSIONS

This CBT model of disordered eating in men with Type 1 diabetes can guide new interventions.

Reliability and validity of a parent-reported screening tool for disordered eating in children and young people with type 1 diabetes

BACKGROUND

There is a high prevalence and complex overlap between type 1 diabetes (T1D) and disordered eating. However, screening for disordered eating in children and young people (CYP) with T1D is not routinely conducted, with reluctance reported by both professionals and parents. This study aimed to validate a parent-reported version of a validated disordered eating screening tool for CYP with T1D (the Diabetes Eating Problems Survey-Revised; DEPS-R).

METHODS

The existing DEPS-R was adapted for parental use. Eighty-nine parents of CYP with T1D aged 11-14 years completed the parent-reported DEPS-R and other questionnaires related to demographics, child eating behaviours and parental well-being. CYP of parents were invited to participate, with 51 CYP completing the validated CYP-reported DEPS-R for comparison.

RESULTS

The parent-reported DEPS-R demonstrated good internal consistency (Cronbach's α = 0.89). Moderate to good inter-rater reliability was found between the parent-reported DEPS-R and CYP-reported DEPS-R (ICC 0.746, 95% CI = 0.554-0.855, p < 0.001), indicating good convergent validity. Construct validity with hypothesised variables, including specific eating behaviours, diabetes-related distress, well-being, CYP BMI, gender and parental worry about CYP disordered eating, suggested validity of the measure. However, some hypothesised variables did not significantly correlate with the parent-reported DEPS-R as expected.

CONCLUSIONS

The parent-reported DEPS-R has demonstrated good reliability and validity, and it may provide clinical benefit by increasing screening and early detection of disordered eating in CYP with T1D. Whilst novel and providing stepped increase in our knowledge, these findings would benefit from further validation (e.g. in a larger sample and responsiveness).

PRIORITY Trial: Results from a feasibility randomised controlled trial of a psychoeducational intervention for parents to prevent disordered eating in children and young people with type 1 diabetes

AIMS

Children and young people (CYP) with type 1 diabetes (T1D) are at increased risk of disordered eating. This study aimed to determine the feasibility and acceptability of a novel, theoretically informed, two-session psychoeducational intervention for parents to prevent disordered eating in CYP with T1D.

METHODS

Parents of CYP aged 11-14 years with T1D were randomly allocated to the intervention or wait-list control group. Self-reported measures including the Diabetes Eating Problem Survey-Revised (DEPS-R), Problem Areas in Diabetes Parent Revised (PAID-PR), Child Eating Behaviour Questionnaire subscales (CEBQ), Warwick Edinburgh Mental Wellbeing Scale (WEMWBS), clinical outcomes (e.g. HbA1c, BMI, medication and healthcare utilisation) and process variables, were collected at baseline, 1-and 3-month assessments. Acceptability data were collected from intervention participants via questionnaire.

RESULTS

Eighty-nine parents were recruited, which exceeded recruitment targets, with high intervention engagement and acceptability (<80% across domains). A signal of efficacy was observed across outcome measures with moderate improvements in the CEBQ subscale satiety responsiveness (d = 0.55, 95% CI 0.01, 1.08) and child's BMI (d = -0.56, 95% CI -1.09, 0.00) at 3 months compared with controls. Trends in the anticipated direction were also observed with reductions in disordered eating (DEPS-R) and diabetes distress (PAID-PR) and improvements in wellbeing (WEMWBS).

CONCLUSIONS

This is the first study to have co-designed and evaluated a novel parenting intervention to prevent disordered eating in CYP with T1D. The intervention proved feasible and acceptable with encouraging effects. Preparatory work is required prior to definitive trial to ensure the most relevant primary outcome measure and ensure strategies for optimum outcome completion.

Prevalence of eating disorder symptoms in people with insulin-dependent-diabetes: A systematic review and meta-analysis

AIMS

To examine the prevalence of eating disorder symptoms (EDS) in 16 years and older individuals with insulin-dependent diabetes including both clinical and subclinical eating disorder symptoms.

METHODS

We searched PubMed, Embase, Scopus, PsycINFO, and CINAHL databases to discover studies reporting prevalence of eating disorder symptoms in patients with insulin-dependent diabetes (both type 1 and type 2). We performed a meta-analysis to estimate the pooled prevalence of eating disorder symptoms and an independent meta-analysis to estimate the prevalence of insulin omission.

RESULTS

A total of 45 studies were included in the meta-analysis of eating disorder symptoms. Diabetes Eating Problem Survey (DEPS-R) was the most frequently used screening tool (in 43 % of studies, n = 20). The pooled prevalence of eating disorder symptoms was 24 % (95 % CI 0.21-0.28), whereas in studies using DEPS-R, it was slightly higher, 27 % (95 % CI 0.24-0.31), with the prevalence ratio (PR) of 1.1. The prevalence differed between screening tools (χ2 = 85.83, df = 8, p < .0001). The sex distribution was associated with the observed prevalences; in studies with a higher female prevalence (>58 %), the pooled eating disorder symptom prevalence was higher [30 % (95 % CI 0.26-0.34) vs. 18 % (95 % Cl 0.14-0.22), PR 1.7]. The prevalence of insulin omission was 21 % (95 % CI 0.13-0.33).

CONCLUSIONS

Eating disorder symptoms and insulin omission are common in patients with insulin-dependent diabetes regardless of age. DEPS-R is the most used screening tool. Studies with a higher proportion of female participants report higher prevalence rates.

Eating behaviors and estimated body fat percentage among adolescents with type 1 diabetes

AIMS

Estimate associations between select eating behaviors and estimated body fat percentage (eBFP) and explore effect modification by sex among adolescents with type 1 diabetes (T1D).

METHODS

This analysis included 257 adolescents (mean age 14.9 ± 1.14 years; 49.8 % female) with baseline hemoglobin A1c (HbA1c) between 8 and 13 % (64 mmol/mol-119 mmol/mol) from a randomized trial designed to improve glycemia. Eating behaviors and eBFP were determined from surveys and validated equations respectively. Linear mixed models were used to estimate associations. Effect modification was assessed via stratified plots, stratified associations, and interaction terms.

RESULTS

Disordered eating, dietary restraint, and eBFP were significantly higher among females while external eating was higher among males. Disordered eating (β: 0.49, 95 %CI: 0.24, 0.73, p = 0.0001) and restraint (β: 1.11, 95 %CI: 0.29, 1.92, p = 0.0081) were positively associated with eBFP while external eating was not (β: -0.19, 95 %CI: -0.470, 0.096, p = 0.20). Interactions with sex were not significant (p-value range: 0.28-0.64).

CONCLUSION

Disordered eating and dietary restraint were positively associated with eBFP, highlighting the potential salience of these eating behaviors to cardiometabolic risk for both female and male adolescents. Prospective studies should investigate whether these eating behaviors predict eBFP longitudinally to inform obesity prevention strategies in T1D.

Evaluation of a novel eating disorder prevention program for young women with type 1 diabetes: A preliminary randomized trial

OBJECTIVE

Evaluate whether the Body Project prevention program adapted for young women with type 1 diabetes (Diabetes Body Project) reduces eating disorder (ED) risk factors and symptoms.

METHODS

Young women (aged 15-30) at high-risk for EDs due to having type 1 diabetes and body image concerns (N = 55) were randomized to virtually delivered Diabetes Body Project groups or an educational control condition, completing measures at pretest, posttest, and 3-month follow-up.

RESULTS

Diabetes Body Project versus the control participants showed significantly greater reductions in thin-ideal internalization, body dissatisfaction, diabetes distress, diabetes eating pathology, and ED symptoms by posttest, and greater reductions in diabetes eating pathology and ED symptoms, and greater improvements in quality of life by 3-month follow-up, which were medium to large effects (d's ranged from -0.43 to -0.90). Although control participants showed a worsening of glycemic control (time in range) verses Diabetes Body Project participants, this difference was non-significant (d = 0.26).

CONCLUSIONS

Virtually delivered Diabetes Body Project decreased ED risk factors and symptoms in young women with type 1 diabetes. A well powered randomized controlled trial is warranted to evaluate this intervention over longer follow-up.

Prevalence and Multidimensional Model of Disordered Eating in Youths With Type 1 Diabetes: Results From a Nationwide Population-Based Study

OBJECTIVE

The aim of this study was to report nationwide data of the prevalence of disordered eating behaviors (DEBs) in adolescents with type 1 diabetes (T1D) and to evaluate a multidimensional model of eating problems, analyzing how psychopathological problems are associated with DEBs and with metabolic control.

METHODS

This study was carried out using a cross-sectional design with a sample of 1,562 patients with T1D (812 male), aged 11-19 years. Participants were recruited from multiple pediatric diabetes centers (N = 30) located in northern, central, and southern Italy, and they individually completed the Diabetes Eating Problem Survey-Revised (DEPS-r) and the Youth Self-Report (YSR). Sociodemographic and clinical data were also gathered. Multiple-group structural equation modeling was used to investigate the relationships between internalizing/externalizing symptoms, DEBs, and glycosylated hemoglobin (HbA1c) values.

RESULTS

A total of 29.7% of the participants reported DEBs (DEPS-r scores ≥20), 42.4% reported insulin manipulation (IM). The prevalence of DEBs was higher for female participants (p ≤ .001). The model explains 37% of the variance in disordered eating, 12% in IM, and 21% in HbA1c values. Body mass index, externalizing symptoms, and internalizing symptoms were significantly and positively associated with DEBs, which in turn were significantly and positively associated with HbA1c values (all p ≤ .001). Externalizing (p ≤ .001) and internalizing (p ≤ .01) symptoms were also directly associated with HbA1c values.

CONCLUSION

Given the relevant prevalence of DEBs, their significant positive association with psychopathological symptoms, and their relationship with worse diabetes outcomes, regular psychological screening and support is needed to ensure the best care of adolescents with T1D.

Psychometric properties and factor structure of the diabetes eatıng problem survey- revised (DEPS-R) among adults with type 1 diabetes mellitus

BACKGROUND AND OBJECTIVE

Although many studies on the Diabetes Eating Problem Survey-Revised (DEPS-R) in adolescents with type 1 diabetes mellitus (T1D), the number of studies validating this questionnaire in adults with T1D is limited. Therefore, this study aimed to examine the factor structure of the Turkish version of the DEPS-R in adults with T1D and internal consistency and construct validity.

METHODS

A total of 100 patients with T1D, ages 18-50 years, completed the DEPS-R and EDE-Q. In addition to tests of validity, confirmatory factor analysis was conducted to investigate the factor structure of the 6-item Turkish version of DEPS-R.

RESULTS

The Cronbach's alpha coefficient of the DEPS-R Turkish version was 0.77, suggesting good internal consistency. The median (IQ) DEPS-R score was 15.0 (13.0) among all participants. DEPS-R score was significantly correlated with BMI (r = 0.210; p < 0.05) and EDE-Q (r = 0.586; p < 0.01). There was no correlation between the HbA1c values of participants and neither EDE-Q nor DEPS-R scores. The confirmatory factor analysis results show that the three-factor model was a good fit.

CONCLUSION

A short, self-administered diabetes-specific screening tool for disordered eating behavior is recommended be used routinely in the clinical care of adults with T1D, and Turkish version of DEPS-R has acceptable internal consistency and construct validity in adults with T1D.

LEVEL OF EVIDENCE

Level V, descriptive study.

CLINICALTRIALS

gov registration number NCT05346679/ 21.04.2022 (retrospectively registered).

Agenda-setting by young adults with type 1 diabetes and associations with emotional well-being/social support: results from an observational study

BACKGROUND

The Diabetes Psychosocial Assessment Tool (DPAT) was developed to assess the psychosocial well-being of young adults with type 1 diabetes in clinical practice. The DPAT includes three validated questionnaires (assessing diabetes distress, anxiety/depressive symptoms and emotional well-being) and an agenda-setting tool. It is currently used by the Queensland Statewide Diabetes Clinical Network (available at Clinical Excellence Queensland).

AIMS

To describe agenda items set by young adults with type 1 diabetes and investigate their association with emotional well-being/social support.

METHODS

The DPAT was completed by young adults attending routine diabetes outpatient appointments at the Mater Hospital (Brisbane) between November 2016 and January 2020. For the current analysis, data included responses on agenda-setting and outcomes from three validated questionnaires.

RESULTS

Responses of 277 young adults (15-26 years) were analysed. Ninety-four (34%) reported one to three agenda item(s). Common agenda items were diabetes technology and medications, but other topics raised included pregnancy, body image and eating concerns. Participants with moderate diabetes distress or anxiety symptoms were more likely to list at least one agenda item (P = 0.006; P = 0.002), as were females and older participants.

CONCLUSION

Several agenda items for young adults with type 1 diabetes were identified and were more likely to be raised by those with elevated diabetes distress and anxiety symptoms. The DPAT is a valuable and convenient tool that can be easily applied in routine clinical practice to enable clinicians to understand the concerns of the young adult population and deliver personalised medicine to optimise long-term outcomes.

Validation of the traditional Chinese version of the diabetes eating problem survey-revised and study of the prevalence of disordered eating patterns in Chinese patients with type 1 DM

BACKGROUND

Disordered eating behaviours (DEBs) in patients with type 1 diabetes mellitus (T1DM) are associated with an increased risk of complications and mortality. The Diabetes Eating Problem Survey-Revised (DEPS-R) was developed to screen for DEBs in T1DM patients. The objectives of this study were to develop a traditional Chinese version DEPS-R (electronic version) and to measure the prevalence of DEBs in a local population sample.

METHODS

The DEPS-R was translated into traditional Chinese, modified and developed into an electronic version. The psychometric properties of the C-DEPS-R were tested on T1DM patients from 15 to 64 years old. The factor structure of the traditional C-DEPS-R was examined by confirmatory factor analysis (CFA). The C-EDE-Q and the C-DES-20 were used for convergent and divergent validity testing, respectively. Module H of the CB-SCID-I/P was used as a diagnostic tool for eating disorders. A correlation study was conducted with the C-DEPS-R scores obtained and the clinical characteristics. Type 2 diabetic (T2DM) patients on insulin treatment were recruited as controls.

RESULTS

In total, 228 T1DM patients and 58 T2DM patients were recruited. There was good internal consistency of the traditional C-DEPS-R (electronic version), with the McDonald's omega of 0.825 and test-retest reliability of 0.991. A three-factor model of the traditional C-DEPS-R was confirmed by CFA. The cut-off score for the traditional C-DEPS-R was determined to be 24; 13.2% (95% CI 8.8%-17.5%) of T1DM patients were found to score above the cut-off score, while 7.5% (95% CI 4-10.9%) scored above the cut-off by the C-EDE-Q, and 4.4% (95% CI 2.1%-7.9%) were diagnosed with eating disorders by the CB-SCID-I/P Module H. Females with T1DM scored higher on the traditional C-DEPS-R. There was a significant correlation of the C-DEPS-R with BMI, occurrence of DKA, use of a continuous glucose monitoring system and positive diagnosis by the CB-SCID-I/P module H (p < 0.05).

CONCLUSION

The traditional Chinese-DEPS-R (electronic version) demonstrated good psychometric properties. It is a self-rated, time-efficient and reliable tool for the screening of disordered eating behaviours in T1DM patients in the Chinese population of Hong Kong. Disordered eating behaviours, such as insulin omission, are associated with an increased risk of diabetes mellitus-related complications and mortality. Generic screening tools for eating disorders may over- or underestimate such problems in diabetic patients. Type 1 diabetes mellitus patients are at particular risk of developing disordered eating behaviours or eating disorders, yet studies in Chinese populations are limited. This study developed and validated the traditional Chinese (electronic) version of the Diabetes Eating Problem Survey-Revised (DEPS-R). The traditional Chinese-DEPS-R is a self-rated, time-efficient and reliable tool for the screening of disordered eating behaviours in Type 1 diabetes mellitus patients in the Chinese population of Hong Kong. The study also estimated the prevalence of disordered eating behaviours in diabetic patients from the local Chinese population, and the clinical correlations of the symptoms and clinical parameters were explored. The study reflected a higher prevalence of eating problems in the Type 1 diabetes mellitus population and demonstrated significant correlations of eating problems with BMI as well as the occurrence of diabetic ketoacidosis. Correspondence: lcw891@ha.org.hk.

Associations of disordered eating with the intestinal microbiota and short-chain fatty acids among young adults with type 1 diabetes

BACKGROUND AND AIMS

Disordered eating (DE) in type 1 diabetes (T1D) includes insulin restriction for weight loss with serious complications. Gut microbiota-derived short chain fatty acids (SCFA) may benefit host metabolism but are reduced in T1D. We evaluated the hypothesis that DE and insulin restriction were associated with reduced SCFA-producing gut microbes, SCFA, and intestinal microbial diversity in adults with T1D.

METHODS AND RESULTS

We collected stool samples at four timepoints in a hypothesis-generating gut microbiome pilot study ancillary to a weight management pilot in young adults with T1D. 16S ribosomal RNA gene sequencing measured the normalized abundance of SCFA-producing intestinal microbes. Gas-chromatography mass-spectrometry measured SCFA (total, acetate, butyrate, and propionate). The Diabetes Eating Problem Survey-Revised (DEPS-R) assessed DE and insulin restriction. Covariate-adjusted and Bonferroni-corrected generalized estimating equations modeled the associations. COVID-19 interrupted data collection, so models were repeated restricted to pre-COVID-19 data. Data were available for 45 participants at 109 visits, which included 42 participants at 65 visits pre-COVID-19. Participants reported restricting insulin "At least sometimes" at 53.3% of visits. Pre-COVID-19, each 5-point DEPS-R increase was associated with a -0.34 (95% CI -0.56, -0.13, p = 0.07) lower normalized abundance of genus Anaerostipes; and the normalized abundance of Lachnospira genus was -0.94 (95% CI -1.5, -0.42), p = 0.02 lower when insulin restriction was reported "At least sometimes" compared to "Rarely or Never".

CONCLUSION

DE and insulin restriction were associated with a reduced abundance of SCFA-producing gut microbes pre-COVID-19. Additional studies are needed to confirm these associations to inform microbiota-based therapies in T1D.

Prevalence of mental disorders in people living with type 1 diabetes: A systematic literature review and meta-analysis

OBJECTIVE

Type 1 diabetes is associated with increased prevalence of individual categories of mental disorders. We aimed to systematically synthesise the prevalence of all the different categories of mental disorders to estimate the overall burden of psychiatric morbidity in the type 1 diabetes population.

METHOD

The electronic database of OVID was searched, and retrieved papers were screened for eligibility by two independent reviewers. Data were extracted using a standardised data extraction form and the quality of included papers was assessed. Where possible, comparisons with control groups without type 1 diabetes were made. Prevalence data were synthesised into Diagnostic and Statistical Manual of Mental Disorders version 5 categories, a narrative data-synthesis, and a subsequent meta-analysis where possible was conducted for mental disorder categories.

RESULTS

Thirty-eight articles were included. Depressive, anxiety, and feeding and eating disorders were the most examined mental disorders. Studies utilising diagnostic interviews reported higher prevalence of mental disorders than in studies utilising clinical registers, with an up to 24-fold difference respectively. In studies with a control group, the prevalence for nearly every mental disorder were increased for the type 1 diabetes samples.

CONCLUSIONS

There appears to be a high prevalence of mental disorders and associated need among people with type 1 diabetes, although the quality of research needs to improve.

SYSTEMATIC REVIEW REGISTRATION

This protocol was submitted for registration with the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42020221530).

Disordered eating and behaviors among young Egyptians with type 1 diabetes: risk factors and comorbidities

OBJECTIVES

The study aimed to assess occurrence of eating disorders and its nature, associated risk factors, and comorbidities in a cohort of adolescents with type 1 diabetes (T1D).

METHODS

In this cross-sectional study, 138 patients were recruited to complete three questionnaires for assessment of eating disorder (ED); Eating Attitude Test (EAT-26) and Eat Behavior questionnaire (ORTO-15) and Eating Disorder Examination Questionnaire version 6 (EDE-Q6) to assess diabetes-related medical outcomes.

RESULTS

Patients were categorized as having an ED according to predetermined cutoff value for each questionnaire. Of the 138 patients, 24 (17.4%) had risk for EDs by EAT-26 score, 53 (38.4%) have got orthorexia nervosa by ORTO-15 and 45 (32.6%) were having a disordered eating behavior by EDE-Q6. Patients with risk of EDs had lower mean ORTO-15 score (p=0.01), and higher mean Global EDE-Q6 (p<0.001). A positive correlation was found between EAT-26 scores and both age (p<0.0001) and body mass index (p<0.0001). ORTO-15 score was correlated with duration of diabetes (p=0.0418). Diabetic ketoacidosis, peripheral neuropathy, and microalbuminuria occurred frequently in patients with ED high score. Hypoglycemic episodes were reported more in those with high EAT-26 or Global EDE-Q6 scores.

CONCLUSIONS

Subclinical EDs and abnormal eating behaviors are common in Egyptian adolescents with T1D.

Disordered eating behaviours and eating disorders in adults with type 1 diabetes (DEBBI): rational and design of an observational longitudinal online study

INTRODUCTION

Disordered eating behaviours (DEB) and eating disorders (ED) are among the most common mental health comorbidities of type 1 diabetes. However, research on diabetes-specific risk and protective factors is limited. To this end, comprehensive characterisations of DEB and ED in type 1 diabetes, as well as longitudinal research on the course of DEB and ED, are needed to gain more insight. The 'Disordered eating behaviours and eating disorders in diabetes type I' (DEBBI) study aims to describe DEB/ED and their correlates in people with type 1 diabetes, to identify key diabetes-specific, psychosocial risk and protective factors, and to describe the course of DEB over time.

METHODS AND ANALYSIS

The DEBBI study is a longitudinal online survey with follow-up assessments after 6, 12 and 18 months, targeted at adults who have been diagnosed with type 1 diabetes for at least 12 months. The survey covers data on diabetes diagnosis and self-management (eg, diabetes treatment and complications), lifestyle (eg, eating habits, physical activity), psychosocial well-being (eg, anxiety, depressive symptoms) and demographic and medical information. It includes validated instruments and self-generated items. One key aspect of the data analysis will be latent profile analyses to determine latent subtypes of DEB manifestation in people with type 1 diabetes and their courses over time, including data on the clinical picture and symptoms, behaviours and diabetes-specific complications.

ETHICS AND DISSEMINATION

The study protocol was approved by the Ethics Committee of the State Medical Chamber of Rhineland-Palatine, Germany (ID 2021-16040). Participants give informed written consent before starting the survey. The DEBBI study will provide more clarity in the so far inconsistent empirical evidence base and will help to inform research on prevention and intervention strategies that are tailored to diabetes-specific needs.

TRIAL REGISTRATION NUMBER

The study is registered with DRKS German Clinical Trials Register (DRKS00028833).

Eating disorders and carbohydrate metabolism interrelations

Introduction: Eating disorders are characterised by persistent disturbances in eating behavior, resulting in severe carbohydrate homeostasis changes. The aim of the study is to review mutual correlations between eating disorders, with emphasis on anorexia nervosa, and carbohydrate metabolism, including glycemia and the levels of relevant hormones.

Material and methods: A priori general inclusion criteria were established and included patients with eating disorders or with glucose metabolism disorders. A MEDLINE database review was carried out. Relevant articles have been extracted and approved by supervisor.

Results: 40 studies got included in the review. Patients with active anorexia nervosa display low levels of fasting and postprandial glucose, decreased lipid metabolism, and decreased pancreatic endocrine activity. Insulin levels remain changed even after patient’s re-nourishment – insulin response tends to be delayed and decreased compared to patients without anorexia history. Eating disorders are associated with poorer glycemic control and a higher percentage of diabetic complications in patients with pre-existing diabetes – mostly type I. There are also reports of higher carbohydrate metabolism disturbances among patients with eating disorders.

Conclusions: Carbohydrate metabolism disorders and eating disorders are clearly interrelated, although data on the nature of these relationships are still lacking. Treatment of eating disorders is not possible without normalizing eating patterns, thus also carbohydrate metabolism. However, it is not usual to monitor the mental state in terms of eating disorders potential development in patients during the treatment of carbohydrate disorders. According to existing data, this approach should be changed due to the risk of anorexia nervosa and other eating disorders in this group.

Prevalence of disordered eating in adults with type 1 diabetes in an Australian metropolitan hospital

The purpose of this study is to establish the prevalence of disordered eating behaviours and establish its identifiable factors in adults with T1D attending a large tertiary hospital service. In this cross-sectional study, 199 participants with TID, aged 18-65 years, completed the revised Diabetes Eating Problem Survey-Revised (DEPS-R). Additional demographic and medical data obtained included age, sex, BMI, HbA1C, duration of diabetes and number of hospital admissions within 12 months (including diabetic ketoacidosis). A DEPS-R score of ≥20, indicative of disordered eating behaviour, was evident in 31% of participants. A DEPS-R score of ≥20 was associated with being female (39% females vs. 23.3% males; p = .016) and a high HbA1c (8.9% [7.8-10.2] vs. 8.0% [7.3-8.7], median [IQR], p < .001). The prevalence of disordered eating behaviours increased significantly with BMI, from 21.3% in the healthy BMI group (18.5-24.9 kg/m² ) to 37.1% in the group with BMI > 25 kg/m² (p = .02). A DEPS-R score of ≥20 was often driven by questions related to a desire to lose weight, meal patterns and glycaemic control. While these behaviours may be attributed to desirable self-management behaviours for adults with T1D, the DEPS-R is still a useful tool to identify patients with potential disordered eating behaviours and the need for dietetic intervention.

Depression in Diabetic Patients: What Is the Link With Eating Disorders? Results of a Study in a Representative Sample of Patients With Type 1 Diabetes

Background and Purpose

Comorbidity between diabetes and depression, and diabetes and eating disorders (ED) conveys significant diagnostic, clinical and therapeutic implications. The present study was conducted on a sample of adult outpatients affected by Type 1 Diabetes (T1DM) to assess lifetime prevalence of ED; current prevalence of depression and Disturbed Eating Behaviors (DEB) and their impact on glycemic control. We hypothesized that patients with depression would have higher rates of lifetime ED and current DEB. We hypothesized a significant and independent association between DEB and the prevalence of depression.

Materials and Methods

The study was carried out using a cross-sectional design in a sample of 172 diabetic patients with T1DM aged from 17 to 55 years. Lifetime prevalence of ED according to DSM-5 criteria was assessed by means of the Module H modified of the Structured Clinical Interview for DSM-IV Axis I Disorder (SCID-I). The following questionnaires were used: Beck Depression Inventory-IA version (BDI-IA) and Diabetes Eating Problems Survey-Revised (DEPS-R), to assess respectively the current presence of depression and DEB. Socio-demographic, clinical, and laboratory data were also collected.

Results

High rates of depression (35.5%) and DEB (19.2%) were observed in our sample of 172 adult outpatients with T1DM. Lifetime history of ED was present in 20.9% of the sample and was more frequently diagnosed in patients with current depression (34.4% vs. 13.9%, p = 0.002). Higher levels of DEB at DEPS-R significantly increased the odds of depression (adjOR: 1.09; 95% CI: 1.03-1.15; p = 0.003). The presence of DEB was associated with poor glycemic control. On the other hand, no association was found between depression and metabolic compensation.

Conclusion

Adult patients with T1DM and depression should be screened for ED and DEB. Treating DEB could positively impact both mood and glycemic control in this population. Further studies should be carried out on a larger patient population using a longitudinal design and an accurate method of evaluation to explore the complex relationship between diabetes, depression, ED, and DEB. Future research should investigate treatment strategies for DEB in T1DM patients and their impact on both psychopathological and metabolic outcomes.

Developing a novel intervention for type 1 diabetes and disordered eating using a participatory action design process: Safe management of people with Type 1 diabetes and EAting Disorders studY (STEADY)

AIMS

To develop a cognitive behavioural therapy-based intervention for people with type 1 diabetes and disordered eating using Experience-Based Co-Design as part of the Safe management of people with Type 1 diabetes and EAting Disorders studY (STEADY).

METHODS

Fifteen people with type 1 diabetes and experience of disordered eating (33 ± 11 years old, 22 ± 12 years diabetes duration) and 25 healthcare professionals working in type 1 diabetes or eating disorders (44 ± 9 years old; 14 ± 10 years of professional experience) attended six Experience-Based Co-Design workshops from July 2019 to March 2020 to collaboratively develop intervention content.

RESULTS

We developed a cognitive behaviour therapy intervention 'toolkit' that can be tailored for individual patient needs. Participants designed and revised toolkit materials to ensure acceptability and relevance for people with diabetes and disordered eating by engaging in guided discussion, brainstorming, and rapid testing to review toolkit prototypes in an iterative process. Workshop themes were 'Insulin titration'; 'Hypoglycaemia'; 'Coming to terms with diabetes'; 'Fear of weight gain'; 'Toolkit revision'; and 'Practical elements of STEADY therapy'. The intervention is focussed on improving diabetes self-care and embedded in a multidisciplinary healthcare approach. The intervention will be delivered in 12 sessions by a diabetes specialist nurse trained in cognitive behavioural therapy.

CONCLUSIONS

Through an iterative co-design process, people with type 1 diabetes and healthcare professionals collaboratively developed a novel intervention toolkit that can be used with a wide range of disordered eating presentations. The intervention will be tested in the STEADY feasibility randomised controlled trial.

PaRent InterventiOn to pRevent dIsordered eating in children with TYpe 1 diabetes (PRIORITY): Study protocol for a feasibility randomised controlled trial

AIMS

Increasing evidence suggests that children and young people with type 1 diabetes (T1D) are at greater risk of disordered eating compared to children without T1D. Disordered eating in T1D has been linked to impaired wellbeing, increased health service use and early mortality. To address this problem, we will co-develop a psycho-education intervention for parents of children and young people with T1D, informed by the Information Motivation Behavioural Skills model.

METHODS

The objective of this study is to assess the feasibility and acceptability of the intervention compared to a waitlist control group using a feasibility randomised controlled trial (RCT) design. We aim to recruit 70 parents of children and young people with T1D (11-14 years), 35 in each arm. Those assigned to the intervention will be invited to participate in two workshops of 2 h each. Parents will be asked to complete outcome measures regarding eating habits, diabetes management, as well as a questionnaire based on the Information Motivation Behavioural Skills model which provides a theoretical foundation for the intervention. These will be completed at baseline, 1- and 3-month post-intervention. Children and young people will be asked to complete questionnaires on their eating behaviours at the same time intervals. Parents randomised to receive the intervention will be invited to take part in interviews to feedback on the intervention and research protocol acceptability.

CONCLUSION

It is anticipated that the psycho-education intervention aimed at parents will help prevent the development of disordered eating in children and young people with T1D and improve parental wellbeing. The results of this feasibility trial will determine whether this intervention approach is acceptable to families living with T1D, and whether a definitive RCT of intervention effectiveness is justified. Qualitative findings will be used to refine the intervention and study protocols.

TRIAL REGISTRATION

This protocol has been registered with ClinicalTrials.gov [Identifier: NCT04741568].

Development and Theoretical Underpinnings of the PRIORITY Intervention: A Parenting Intervention to Prevent Disordered Eating in Children and Young People With Type 1 Diabetes

Children and young people (CYP) with type 1 diabetes (T1D) are twice as likely to develop disordered eating (T1DE) and clinical eating disorders than those without. This has significant implications for physical and mental health, with some eating disorders associated with repeated diabetic ketoacidosis and higher HbA1c levels, both of which are life threatening. There is currently limited psychological support for CYP and families with T1D but increasingly, policy and practice are suggesting disordered eating in T1D may be effectively prevented through psychological intervention. We describe the development and theoretical underpinnings of a preventative psychological intervention for parents of CYP aged 11-14, with T1D. The intervention was informed by psychological theory, notably the Information Motivation Behaviour Skills model and Behaviour Change Technique Taxonomy. The intervention was co-developed with an expert advisory group of clinicians, and families with T1D. The manualised intervention includes two online group workshops, and supplementary online materials. The intervention continues to evolve, and feasibility findings will inform how best to align the intervention with routine care in NHS diabetes teams. Early detection and intervention are crucial in preventing T1DE, and it is hoped that the current intervention can contribute to improving the psychological and physical wellbeing of young people and families managing T1D.

Insulin Restriction, Emotion Dysregulation, and Depressive Symptoms in Late Adolescents with Diabetes

OBJECTIVE

Insulin restriction occurs when an individual takes less insulin than recommended and is a serious concern for those with diabetes. General insulin restriction (IR) and insulin restriction for weight control (IRWC) have not been clearly distinguished in the literature, creating inconsistencies and limited understanding of factors that underlie this behavior. We examined whether these are distinct, and how emotion dysregulation and depressive symptoms relate to both forms of insulin restriction during late adolescence.

METHODS

As part of a larger study, late adolescents (ages 17-18) with type 1 diabetes (N = 236) completed measures of depressive symptoms (Center for Epidemiologic Studies-Depression Scale [CES-D]), facets of Difficulties In Emotion Regulation Scale (DERS), diabetes self-management behaviors, insulin restriction, and hemoglobin A1c (HbA1c).

RESULTS

IR and IRWC were not significantly associated with each other. IR was associated with self-management behaviors but not HbA1c, whereas the opposite was true for IRWC. All DERS subscales (M = 10.60-16.73) and CES-D (M = 16.56) were correlated with greater IRWC; CES-D and all but one DERS subscale were correlated with IR. Covariation with CES-D explained associations between DERS and IRWC. CES-D moderated associations with IR, indicating most subscales of the DERS were associated with IR only when CES-D was higher.

CONCLUSION

Emotion dysregulation and depressive symptoms are important correlates of the dangerous behavior of insulin restriction, but function differently when insulin is restricted specifically for weight control versus nonspecified reasons. Future research to understand these underlying processes will be necessary to develop emotion-based theory and evidence-based interventions for this dangerous behavior.

Diabetic Ketoacidosis and Mortality in People With Type 1 Diabetes and Eating Disorders

OBJECTIVE

To determine the risk of diabetic ketoacidosis (DKA) and all-cause mortality among adolescents and young adults with type 1 diabetes with and without an eating disorder.

RESEARCH DESIGN AND METHODS

With use of population-level health care administrative data covering the entire population of Ontario, Canada, all people with type 1 diabetes aged 10-39 years as of January 2014 were identified. Individuals with a history of eating disorders were age- and sex-matched 10:1 with individuals without eating disorders. All individuals were followed for 6 years for hospitalization/emergency department visits for DKA and for all-cause mortality.

RESULTS

We studied 168 people with eating disorders and 1,680 age- and sex-matched people without eating disorders. Among adolescents and young adults with type 1 diabetes, 168 (0.8%) had a history of eating disorders. The crude incidence of DKA was 112.5 per 1,000 patient-years in people with eating disorders vs. 30.8 in people without eating disorders. After adjustment for baseline differences, the subdistribution hazard ratio for comparison of people with and without eating disorders was 3.30 (95% CI 2.58-4.23; P < 0.0001). All-cause mortality was 16.0 per 1,000 person-years for people with eating disorders vs. 2.5 for people without eating disorders. The adjusted hazard ratio was 5.80 (95% CI 3.04-11.08; P < 0.0001).

CONCLUSIONS

Adolescents and young adults with type 1 diabetes and eating disorders have more than triple the risk of DKA and nearly sixfold increased risk of death compared with their peers without eating disorders.

A review of risk factors associated with insulin omission for weight loss in type 1 diabetes

Research suggests that as many as 60% of people with type 1 diabetes (T1D) admit to misusing insulin. Insulin omission (IO) for the purpose of weight loss, often referred to as diabulimia, is a behaviour becoming increasingly recognised, not least since prolonged engagement can lead to serious vascular complications and mortality. Several risk factors appear to be relevant to the development of IO, most notably gender, anxiety and depression and increased weight concerns and body dissatisfaction. Evidence suggests that women, especially young girls, are more likely to omit insulin as a method of weight loss compared to men. Mental health conditions such as anxiety and depression are increasingly prevalent in people with T1D compared to their peers, and appear to contribute to the risk of IO. Increased weight concerns and body dissatisfaction are further prominent risk factors, especially given increases in weight which often occur following diagnosis and the monitoring of weight by diabetes teams. This review presents evidence examining these risk factors which increase the likelihood of a person with T1D engaging in IO and highlights the complications associated with prolongment of the behaviour. Further research looking at the comorbidities of these risk factors, alongside other factors, would provide greater insight into understanding IO in people with T1D.

A cognitive behavioural model of the bidirectional relationship between disordered eating and diabetes self care in people with type 1 diabetes mellitus

AIMS

This qualitative study aimed to develop the first cognitive behavioural therapy model outlining the development and maintenance of disordered eating in type 1 diabetes and report on recovery strategies and resilience factors to improve previous theoretical models of type 1 diabetes and disordered eating.

METHODS

Twenty-three women (n = 9 with type 1 diabetes and disordered eating, n = 5 with type 1 diabetes recovering from disordered eating, and n = 9 with type 1 diabetes without disordered eating) participated in semi-structured interviews. Data were analysed using grounded theory and individual cognitive-behavioural formulations were developed for each participant to inform the development/maintenance and resilience models.

RESULTS

The development/maintenance model summarises commonly experienced vicious cycles of thoughts, feelings and behaviours in type 1 diabetes and disordered eating. The resilience model summarises strategies and knowledge acquired by those with type 1 diabetes in recovery from disordered eating and individuals with type 1 diabetes who did not develop disordered eating. Early adverse life events, past psychiatric history, perfectionist personality traits, difficult experiences around type 1 diabetes diagnosis and its relentless daily management sensitise individuals to eating, weight and shape cues. Alongside physical symptoms/complications, unhelpful interpersonal reactions and inadequate healthcare, vicious cycles of thoughts, feelings and behaviours develop. 'Good enough' psychological adaptation to type 1 diabetes, integrating type 1 diabetes into one's identity, self care and compassion around eating, weight and shape were key protective/post-traumatic resilience factors.

CONCLUSIONS

This first cognitive behavioural therapy model of type 1 diabetes and disordered eating informed by personal experience will inform an intervention for type 1 diabetes and disordered eating.

Instrument Context Relevance Evaluation, Translation, and Psychometric Testing of the Diabetes Eating Problem Survey-Revised (DEPS-R) among People with Type 1 Diabetes in China

Background: People with type 1 diabetes are susceptible to disordered eating behaviors. The American Diabetes Association recommends using the Diabetes Eating Problem Survey-Revised (DEPS-R) to screen them. There is no validated diabetes-specific screening measure in China. The objectives were to adapt DEPS-R into Mandarin Chinese and to test its psychometric properties among youths and adults with type 1 diabetes in China, respectively. Methods: This study was conducted in two phases. Phase 1 included context relevance evaluation and instrument translation. Phase 2 was psychometric testing of reliability and construct validity among 89 youths (8~17 years old) and 61 adults with type 1 diabetes. Result: The Context Relevance Index and Translation Validity Index of this instrument were good. Strong internal consistency reliability correlations and convergent validity were demonstrated among youths and adults. Discussion: The Chinese version of the DEPS-R is a valid and reliable tool for screening disordered eating behaviors in Chinese youths and adults with type 1 diabetes. The Context Relevance Index is advocated to evaluate the difference between the context in which an instrument was originally developed and the target context.

The Role of Disordered Eating in Type 2 Diabetes: A Pilot Study

Rates of type 2 diabetes mellitus continue to rise around the world, largely due to lifestyle factors such as poor diet, overeating, and lack of physical activity. Diet and eating is often the most challenging aspect of management and, when disordered, has been associated with increased risk for diabetes-related complications. Thus, there is a clear need for accessible and evidence-based interventions that address the complex lifestyle behaviors that influence diabetes management. The current study sought to assess the efficacy and acceptability of a pilot lifestyle intervention for women with type 2 diabetes and disordered eating. The intervention followed a cognitive behavioral therapy guided-self-help (CBTgsh) model and included several pillars of lifestyle medicine, including: diet, exercise, stress, and relationships. Ten women completed the 12-week intervention that provided social support, encouraged physical activity, and addressed eating behaviors and cognitions. Results indicate the lifestyle intervention was a feasible treatment for disordered eating behaviors among women with type 2 diabetes and was also associated with improved diabetes-related quality of life. The intervention was also acceptable to participants who reported satisfaction with the program. The current CBTgsh lifestyle intervention is a promising treatment option to reduce disordered eating and improve diabetes management.

A brief self-compassion intervention for adolescents with type 1 diabetes and disordered eating: a feasibility study

AIM

To examine the feasibility and acceptability of a brief self-compassion intervention for adolescents with type 1 diabetes and disordered eating behaviour.

METHODS

Twenty-seven adolescents with type 1 diabetes were recruited and randomized to receive the brief (two 2.5-h sessions) self-compassion intervention, either in the intervention group (n=11) or in a waitlist control group (n=8). The intervention was adapted from the standardized eight-session 'Making Friends with Yourself' programme, and sessions were delivered 1 week apart. Acceptability was assessed through qualitative questionnaires and feasibility was assessed based on session attendance and recruitment metrics. Possible changes to disordered eating behaviour, self-care behaviours, diabetes-related distress, self-compassion, stress and glycaemic control were also assessed.

RESULTS

Nineteen participants completed the study, and they reported an increased sense of common humanity (acknowledging that we are not alone), mindfulness, and coping resources. In terms of feasibility, recruitment took longer than expected (8 months) and not all participants were able to attend both sessions (nine could only attend one of the two sessions).

CONCLUSIONS

While self-compassion is a strong conceptual fit for the issues of type 1 diabetes and disordered eating behaviour in adolescence, and the intervention content appears acceptable, feasibility issues were such that brief self-compassion programmes will probably need to be adapted into digital interventions for future research. (Trial registration number: ANZCTR 12619000541101).

High prevalence of disordered eating behavior in Danish children and adolescents with type 1 diabetes

OBJECTIVE

A higher prevalence of disordered eating behavior (DEB) has been demonstrated in children and adolescents with type 1 diabetes (T1D) compared to healthy aged-matched peers. DEB is associated with higher HbA1c levels and increased risk of developing complications to T1D. The aim of this study was to determine the prevalence of DEB in a Danish cohort of children and adolescents with T1D aged 11 to 19 years and to characterize them regarding metabolic control and relevant clinical data.

RESEARCH DESIGN AND METHODS

In a cross-sectional study, we determined the prevalence of DEB using the revised Diabetes Eating Problem Survey (DEPS-R) questionnaire. HbA1c and relevant clinical data were obtained at the time they filled in the questionnaire.

RESULTS

Hundred and ninety-two children and adolescents (46% girls) aged 11 to 19 years with T1D were included from the pediatric diabetes outpatient clinic. A total of 40 participants (21%) had DEB. The prevalence was higher among girls compared with boys (34.1% vs 8.9%) and those who had DEB were older (16.7 vs 15.0 years, P < .001), had longer duration of T1D (7.5 vs 4.9 years, P < .001), higher BMI Z-scores (1.2 vs 0.3, P < .001), higher HbA1c (72.8 (8.8%) vs 62.0 (7.8%) mmol/mol, P < .001), higher total cholesterol (4.6 mmol/L vs 4.2 mmol/L, P = .0048), and LDL (2.7 vs 2.3, P = .001) compared with those with no signs of DEB.

CONCLUSION

As in other countries, the prevalence of DEB is high in Danish adolescents with T1D. Early detection of DEB is essential to prevent short- and long-term complications to T1D.

Clinical features of the diabetes eating problem survey-revised Turkish version in children and adolescent with type 1 diabetes

Objectives We aim to delineate clinical characteristics that place individuals with type 1 diabetes (T1DM) at risk of developing eating problems by using Turkish version of diabetes eating problem survey-revised (DEPS-R). Methods The patients aged 9-18 years with T1DM who came to the pediatric endocrine outpatient clinic for control between February and December 2019 completed Turkish version of DEPS-R. Clinical and laboratory findings were obtained from patient files. Cases with a questionnaire score ≥20 were considered to be at risk for eating disorders (ED). Parents were informed when the results of the screening were positive, and were offered to child psychiatrist. Results The median scores obtained with the Turkish version of DEPS-R for the total sample, for females and males were 15, 16, and 13 respectively. The score was significantly higher among females compared to males (p<0.001). DEPS-R score positive group had higher age (mean [SD]=14.6 [2.7], p=0.009), BMI (mean [SD]=21.4 [3.2], p<0.001), HbA1c % (mean [SD]=9.37[2.3], p<0.001) and year of diabetes duration (mean [SD]=5.5 [3.6], p<0.001) compared to the negative group. Conclusions Early recognition and adequate treatment of ED in T1DM is essential. DEPS-R is sensitive in identifying young people with ED.

Changes in disordered eating behaviors over 10 or more years: A meta-analysis

OBJECTIVE

The present meta-analysis evaluated changes in individuals' risk of engaging in distinct disordered eating behaviors (DEBs) in the long-term.

METHOD

Longitudinal studies assessing changes in DEBs via ≥2 assessments with a time lag of ≥10 years were included. Risk ratios were calculated for baseline to 10-14.9-year (M = 11.04) follow-up and baseline to ≥15-year (M = 18.62) follow-up changes in the use of binge eating, multiple purging, self-induced vomiting, laxatives, diuretics, diet pills, compensatory exercising, fasting/dieting, and multiple DEBs; Cohen's d was used for continuous binge-eating plus purging variable changes. Subgroup and meta-regression analyses tested whether eating disorder (ED) clinical sample versus nonclinical sample status, female versus male sex/gender, higher versus lower study bias, and baseline mean age and body mass index influenced overall effect magnitude for analyses with sufficient data.

RESULTS

Seventeen studies (26 [sub]samples) were included. Overall, individuals' risk of engaging in various restrictive eating and other compensatory behaviors decreased over time and the magnitudes of risk reductions for the use of certain compensatory DEBs were larger over longer follow-up durations. Specifically, for significant DEB change models, risk reductions spanned from 20.0-39.8% for 10-year follow-up and 24.7-74.8% for ≥15-year follow-up. However, nuances were found in the nature of these DEB changes as a function of DEB type, follow-up length, ED versus nonclinical sample composition, and baseline mean age.

CONCLUSIONS

These findings provide important information that can help identify treatment priorities and suggest that targeted and tailored preventative ED treatments warrant consistent implementation at the community-level, particularly for youth.

Gestörtes Essverhalten und psychosoziale Versorgungssituation junger Menschen mit Typ 1 Diabetes

Einleitung Gestörtes Essverhalten oder klinisch relevante Essstörungen in Verbindung mit Typ 1 Diabetes haben schwerwiegende Folgen für die Qualität der Stoffwechseleinstellung und die langfristige gesundheitliche Prognose Betroffener. Eine frühzeitige Diagnose und qualifizierte therapeutische Interventionen können bereits bei gestörtem Essverhalten dazu beitragen, vorzeitige mikrovaskuläre Schädigungen zu vermeiden. In dieser Studie wurden für eine Gruppe junger Menschen mit Typ 1 Diabetes, die an einem 4-tägigen Camp teilnahmen, die Prävalenz essgestörten Verhaltens und die spezifische psychosoziale Versorgungssituation untersucht.

Material und Methoden Während eines bundesweit ausgeschriebenen Diabetescamps für junge Menschen (16–29 Jahre) beantworteten die Teilnehmenden Fragen zu ihrer aktuellen Diabetesbehandlung, zu diabetesspezifischen Belastungen (PAID-5) sowie zur psychosozialen Versorgung im Rahmen der ambulanten Langzeittherapie. Symptome gestörten Essverhaltens wurden mit einem diabetesspezifischen Screeningfragebogen, dem Diabetes Eating Problem Survey-Revised (DEPS-R), erhoben. Eine lineare multiple Regression wurde berechnet, um Prädiktoren gestörten Essverhaltens zu identifizieren.

Ergebnisse An der Umfrage beteiligten sich 308 junge Menschen mit Typ 1 Diabetes (Alter 21,4±3,4 Jahre; 73% weiblich; Diabetesdauer 10,2±5,9 Jahre; 74% in internistischer Behandlung). Bei 28,2% der Befragten ergaben sich Hinweise auf ein gestörtes Essverhalten (17% der Männer, 32% der Frauen). Teilnehmende mit einem auffälligen Summenwert im DEPS-R wurden nur zu 7% entsprechend psychologisch betreut. Das HbA1c, der BMI, die diabetesspezifischen Belastungen, das Alter, die Diabetesdauer sowie das Geschlecht erwiesen sich als signifikante Prädiktoren für das Ausmaß gestörten Essverhaltens.

Diskussion Unter den Teilnehmenden eines Diabetescamps für junge Menschen zeigten sich bei über einem Viertel Hinweise auf ein gestörtes Essverhalten. Insgesamt waren davon junge Frauen häufiger betroffen, weitere relevante Risikofaktoren waren ein erhöhter BMI, ein höheres HbA1c und stärkere diabetesspezifische Belastungen. Nur ein sehr geringer Anteil der jungen Menschen mit Typ 1 Diabetes und gestörtem Essverhalten erhielt psychologische Unterstützung.

Schlussfolgerung In der ambulanten diabetologischen Versorgung sollten diabetesspezifische Screeninginstrumente und/oder gezielte Screeningfragen insbesondere bei jungen Frauen regelmäßig eingesetzt und die Ergebnisse mit den Betroffenen im Hinblick auf eine weiterführende Behandlung besprochen werden.

Factors predicting poor glycemic control in the first two years of childhood onset type 1 diabetes in a cohort from East London, UK: Analyses using mixed effects fractional polynomial models

BACKGROUND/OBJECTIVE

Poor early glycemic control in childhood onset type 1 diabetes (T1D) is associated with future risk of acute and chronic complications. Our aim was to identify the predictors of higher glycated hemoglobin (HbA1c) within 24 months of T1D diagnosis in children and adolescents.

METHODS

Mixed effects models with fractional polynomials were used to analyze longitudinal data of patients <19 years of age, followed from T1D diagnosis for up to 2 years, at three diabetes clinics in East London, United Kingdom.

RESULTS

A total of 2209 HbA1c observations were available for 356 patients (52.5% female; 64.4% non-white), followed from within 3 months of diagnosis during years 2005 to 2015, with a mean ± SD of 6.2 ± 2.5 HbA1c observations/participant. The mean age and HbA1c at diagnosis were 8.9 ± 4.3 years and 10.7% ±4.3% (or expressed as mmol/mol HbA1c mean ± SD 92.9 ± 23.10 mmol/mol) respectively. Over the 2 years following T1D diagnosis, HbA1c levels were mostly above the National Institute for Health, Care and Excellence (NICE), UK recommendations of 7.5% (<58 mmol/mol). Significant (P < .05) predictors of poorer glycemic control were: Age at diagnosis (12-18 years), higher HbA1c at baseline (>9.5%, ie, >80 mmol/mol), clinic site, non-white ethnicity, and period (pre-year 2011) of diagnosis. Additionally in univariable analyses, frequency of clinic visits, HbA1c at diagnosis, and type of insulin treatment regimen showed association with poor glycemic control (P < .05).

CONCLUSIONS

Major risk factors of poorer glycemic control during 3-24 months following childhood onset T1D are: diagnosis prior to 2011, higher HbA1c levels at baseline, age at diagnosis, non-white ethnicity, and clinic site.

25 Years of psychological research investigating disordered eating in people with diabetes: what have we learnt?

Disordered eating is a serious and under-recognized problem in people with diabetes. This narrative review summarizes the research contributions made by psychological science over the past 25 years to the study of disordered eating in people with type 1 or type 2 diabetes, and identifies gaps and future directions relevant to both healthcare professionals and researchers. Key focus areas of psychological research investigating disordered eating in people with diabetes have been: (1) defining and classifying types of disordered eating; (2) identifying demographic, diabetes-specific and psychosocial correlates of disordered eating, and developing theoretical models of disordered eating in people with type 1 diabetes; (3) identifying the physical and psychosocial consequences of disordered eating; and (4) developing screening measures to identify disordered eating in people with type 1 diabetes. Psychological science has made significant contributions over the past 25 years to our understanding of the nature of this problem and the multiple factors which may interrelate with disordered eating in people with diabetes. Key areas for further attention include: (1) a better definition of disordered eating subtypes in people with type 1 diabetes; (2) characterizing disordered eating in people with type 2 diabetes; and (3) developing multidisciplinary, evidence-based prevention and treatment interventions for comorbid disordered eating and diabetes.

Course of Disordered Eating Behavior in Young People With Early-Onset Type I Diabetes: Prevalence, Symptoms, and Transition Probabilities

PURPOSE

The aims of this study were to analyze the prevalence and course of disordered eating behavior (DEB) in adolescents with intensively treated type I diabetes, describe differences in age-specific DEB symptoms, and identify predictors of current DEB.

METHODS

Data were taken from 332/218 11- to 27-year-old participants (55.7% girls/women, mean age [SD] 17.8 [3.4] years, mean diabetes duration 14.9 [3.0] years) of two/three surveys of a Germany-wide longitudinal study on early-onset and long duration diabetes, respectively. A diabetes-adapted version of the SCOFF questionnaire was used to assess DEB. Both screening-based overall and age- and sex-specific prevalence of DEB and its symptoms were determined. To estimate transition probabilities between DEB states, first-order Markov transition models were implemented adjusting for previous sociodemographic, socioeconomic, and diabetes-specific covariates.

RESULTS

The overall screening-based DEB prevalence among all 1,318 observations was 10.8% (95% confidence interval [CI]: 9.2%, 12.6%) with age-specific differences in symptom prevalence. Transition probabilities for developing/persistent DEB were twofold higher among female than male participants (risk ratio [RR] 2.3 [1.4, 3.9]/2.1 [1.3, 3.4]). In multiple adjusted regression, previous DEB (odds ratio [OR] 2.8 [95% CI 1.4, 5.6]), follow-up time (OR_{per 1-year increase} 3.4 [1.4, 8.0]), and sex (OR_girls/women 2.1 [1.1, 3.9]) were the most important predictors of current DEB with further weaker associations for previous age and HbA_1c.

CONCLUSIONS

Our results contribute to better understanding the course of DEB in patients with early-onset diabetes and emphasize the relevance of regular DEB screenings including the age group of young adults.

Gut-Brain Interactions: Implications for a Role of the Gut Microbiota in the Treatment and Prognosis of Anorexia Nervosa and Comparison to Type I Diabetes

Anorexia nervosa has poor prognosis and treatment outcomes and is influenced by genetic, metabolic, and psychological factors. Gut microbes interact with gut physiology to influence metabolism and neurobiology, although potential therapeutic benefits remain unknown. Type 1 diabetes is linked to anorexia nervosa through energy dysregulation, which in both disease states is related to the gut microbiota, disordered eating, and genetics.

The relationship between attentional bias to food and disordered eating in females with type 1 diabetes

OBJECTIVE

Factors which may render females with type 1 diabetes mellitus (T1DM) vulnerable to disordered eating behavior or difficulties with dietary management require further investigation. Given prior associations observed between food-related attentional biases and eating behavior in groups without diabetes, this study explored the relationships between attentional bias to healthy and unhealthy pictorial food cues and disordered eating in young adult females with and without T1DM, aged 18-40yrs.

METHODS

97 participants (41 with T1DM, 56 without) completed an initial online survey assessing demographic and clinical information, and disordered eating via the Eating Disorders Examination- Questionnaire (EDE-Q). They subsequently attended an in-person session to complete a computer-based visual probe task to assess attentional bias to pictorial food cues.

RESULTS

Analyses of Variance (ANOVAs) adjusting for age and body mass index showed a unique significant relationship in the group with T1DM whereby greater attentional bias scores away from unhealthy foods was associated with greater disordered eating. No relationship was observed in the group without diabetes.

DISCUSSION

This study suggests that early attentional disengagement from food-related cues may be uniquely associated with eating-related outcomes for females with T1DM relative to those without diabetes. This should be further explored in future research with an aim to develop novel strategies for prevention and treatment of disordered eating behavior in this vulnerable group.

Disturbed Eating Behaviors in Adolescents and Emerging Adults With Type 1 Diabetes: A One-Year Prospective Study

OBJECTIVE

Disturbed eating behavior (DEB) is prevalent in youth with type 1 diabetes and is accompanied by an increased risk for complications, morbidity, and mortality. Prospective studies on DEB in the challenging transition to adulthood are scarce. This longitudinal study examined DEB over a 1-year period and investigated the directionality of effects linking DEB to diabetes-specific functioning and depressive symptoms in adolescents and emerging adults.

RESEARCH DESIGN AND METHODS

Three hundred youth (16-28 years old) with type 1 diabetes participated in a two-wave longitudinal study. Questionnaires measured DEB (Diabetes Eating Problem Survey-Revised [DEPS-R]), self-management, diabetes distress, and depressive symptoms. HbA_1c values were obtained from physicians. Mixed ANOVA and cross-lagged analysis were used to examine prospective changes and directionality of effects, respectively.

RESULTS

Mean DEB remained stable in the total sample, but significant individual differences were observed based on the cutoff score of the DEPS-R: 19% displayed persistent DEB and 8% increased and 7.3% decreased in DEB over time. The remaining individuals scored low on DEB over time. These four groups were differentiated based on insulin restriction, omission, diabetes-specific functioning, and depressive symptoms. Cross-lagged analyses indicated that DEB predicted relative increases in depressive symptoms over time, whereas reciprocal associations with glycemic control were found.

CONCLUSIONS

This longitudinal study highlights the substantial impact DEB may have in the transition to adulthood, with a substantial portion of youth with type 1 diabetes being at risk for clinical DEB. Prospective pathways linking DEB to functioning were found, emphasizing the clinical relevance of assessing DEB over time.

Factors associated with disordered eating behaviours in adolescents with Type 1 diabetes

AIMS

To assess the occurrence of disordered eating behaviours in teenagers with Type 1 diabetes and to compare characteristics according to level of disordered eating behaviours.

METHODS

In this cross-sectional study, we collected adolescents' demographic and diabetes management data by parent-youth interview and chart review. Teenagers completed psychosocial surveys, including the Diabetes Eating Problem Survey-Revised (DEPS-R), a diabetes-specific measure of disordered eating behaviours. We categorized teenagers according to level of disordered eating behaviours: low, DEPS-R score <10; moderate, DEPS-R score 10-19; and high, DEPS-R score ≥20.

RESULTS

The 178 teenagers (48% girls) were aged 14.9±1.3 years, with diabetes duration of 7.4±3.7 years. Most (59%) had low, 26% had moderate, and 15% had high levels of disordered eating behaviours. Several biomedical and psychosocial characteristics differed by level of disordered eating behaviours. There were more girls in the moderate (62%) and high (65%) than in the low level of disordered eating behaviours group (37%; P=0.003) and more obese teenagers in the moderate (13%) and high (27%) groups than in the low group (4%; P=0.0003). Frequency of daily blood glucose monitoring decreased (P=0.0006) and HbA_1c level increased (P=0.01) with greater level of disordered eating behaviours. A greater level of disordered eating behaviours was also associated with poorer treatment adherence, more negative affect regarding blood glucose monitoring, poorer quality of life, and more depressive symptoms (all P<0.0001), along with more diabetes-specific family conflict (P=0.01).

CONCLUSIONS

Identifying teenagers with Type 1 diabetes who have moderate and high levels of disordered eating behaviours may prevent progression to eating disorders and substantial morbidity by directing support and intervention efforts to those in need.

Assessing the clinical utility of the diabetes eating problem survey-revised (DEPS-R) in adolescents with type 1 diabetes

OBJECTIVE

Eating disorders are prevalent among adolescents with type 1 diabetes (T1D). We examined the clinical utility of the Diabetes Eating Problem Survey-Revised (DEPS-R), a brief self-report questionnaire developed for patients with T1D, to identify at-risk adolescents. We aimed to determine whether a positive DEPS-R screen was predictive of a formal diagnosis of an eating disorder as per the DSM-V. In addition, we assessed whether other variables including psychosocial characteristics and diabetes conflict were associated with an abnormal DEPS-R screen.

METHODS

Cross-sectional study of 116 T1D adolescents aged 12-17 years. All participants completed the DEPS-R screening; both participants and parents completed a questionnaire addressing psychosocial characteristics/conflict around diabetes management. Clinical variables were obtained from participant charts. Differences were examined between positive and negative DEPS-R groups. Adolescents who screened positive were offered a referral to a specialized eating disorder team for further assessment.

RESULTS

From 116 participants (mean age ± SD = 14.6 years ± 1.56), 21% (24/116) scored positive for DEPS-R More females than males had abnormal DEPS-R (75% vs 25%, P = 0.001). Those with positive DEPS-R score had higher HbA1c% (mean = 9.3 ± 1.3 vs 8.3 ± 1.2, P = 0.001). Positive DEPS-R group had higher conflict score for diabetes management in both parents' and children's assessments (both ps < 0.001). In regression analysis, being female (OR males = 0.07, 95%CI: 0.010-0.46, P = 0.006), older (OR = 2.01, 95%CI: 1.16-3.48, P = 0.040) and > child-reported conflict (OR = 1.78, 95%CI: 1.02-3.11, P = 0.044) were predictors of an abnormal DEPS-R score.

CONCLUSION

The DEPS-R score is a useful clinical tool for identifying T1D adolescents at risk for disordered eating behaviour, but has a low positive predictive value (PPV) for identifying adolescents who meet diagnostic criteria for an eating disorder. Female gender, suboptimal diabetes control and increased conflict in diabetes management are associated with an abnormal DEPS-R score.

Test of the modified dual pathway model of eating disorders in individuals with type 1 diabetes

OBJECTIVE

Adolescents and young adults with type 1 diabetes (T1D) demonstrate high rates of disordered eating behaviors (DEBs) and may experience physiological and psychological vulnerabilities not currently included in established risk models of DEBs. This study examined associations among constructs included in the recently proposed T1D-specific modified dual pathway model and examined age as a moderator of these associations.

METHOD

Participants included adolescents (n = 307; age M = 15.71, SD = 1.33), young adults (n = 313; age M = 21.20, SD = 2.10), and adults (n = 198; age M = 30.51, SD = 2.81) recruited via the T1D Exchange Clinic Registry. Data were collected from participants' medical records and from self-report questionnaires assessing dietary regimen, dietary restraint, body dissatisfaction, hunger/satiety, diabetes-specific negative affect, and DEBs. Multiple group path modeling was used to test hypotheses.

RESULTS

Approximately 31% of participants were at risk for an eating disorder. The original modified dual pathway model had poor model fit. The addition of three empirically defensible paths improved model fit. Diabetes-specific dietary regimen, diabetes-specific negative affect, and hunger/satiety disruption all were associated with DEBs. A fully varying multiple group model by age fit best; however, only the dietary restraint to DEBs pathway demonstrated a distinct pattern across age cohort, which attenuated from the adolescent to the adult cohort.

DISCUSSION

This study provides preliminary support for associations proposed in the modified dual pathway model and suggests potential for intervening on disease-specific risk factors of DEBs in a T1D population.

Worse Metabolic Control and Dynamics of Weight Status in Adolescent Girls Point to Eating Disorders in the First Years after Manifestation of Type 1 Diabetes Mellitus: Findings from the Diabetes Patienten Verlaufsdokumentation Registry

OBJECTIVE

To assess indications of eating disorders in girls with type 1 diabetes mellitus (T1DM).

STUDY DESIGN

In total 31 556 girls aged >6 months and <23 years of age with T1DM from the Diabetes Patienten Verlaufsdokumentation (DPV) cohort were analyzed including 155 (0.49%) girls with anorexia nervosa, 85 (0.27%) girls with bulimia nervosa, 45 (0.14%) girls with binge eating disorder, and 229 (0.73%) girls with eating disorders not otherwise specified. Patient characteristics, weight changes, numbers of patients with severe hypoglycemia and diabetic ketoacidosis (DKA), changes of glycosylated hemoglobin A1c (HbA1c) levels, use of pumps, and prevalence of celiac disease and autoimmune thyroiditis were compared between girls with and without eating disorders. Multiple logistic regression analyses were performed.

RESULTS

Eating disorders were significantly associated with late pubertal age, nonusage of pumps, no migration background, increased HbA1c levels, increased frequencies of DKA and severe hypoglycemia, and celiac disease were not related to eating disorders. Significant differences in HbA1c levels, prevalence of DKA and severe hypoglycemia between girls with and without eating disorders were already detectable in the first years after onset of T1DM. A decrease of body mass index (BMI)-SDS increased the risk for comorbid anorexia nervosa (7.1-fold [95% CI 3.6-14.3] compared with stable BMI-SDS, 6.9-fold [95%CI 3.4-14.1] compared with increase of BMI-SDS).

CONCLUSIONS

Poor metabolic control and increased rates of DKA and severe hypoglycemia in the first years after manifestation of T1DM can be hints for eating disorders in girls with T1DM, and weight loss is specific for anorexia nervosa. These clinical features should lead to screening for eating disorders especially at a late pubertal age.

Association of insulin-manipulation and psychiatric disorders: A systematic epidemiological evaluation of adolescents with type 1 diabetes in Austria

BACKGROUND/OBJECTIVE

The aim of this study was to systematically assess the association of insulin-manipulation (intentional under- and/or overdosing of insulin), psychiatric comorbidity and diabetes complications.

METHODS

Two diagnostic interviews (Diabetes-Self-Management-Patient-Interview and Children's-Diagnostic-Interview for Psychiatric Disorders) were conducted with 241 patients (age 10-22) with type 1 diabetes (T1D) from 21 randomly selected Austrian diabetes care centers. Medical data was derived from medical records.

RESULTS

Psychiatric comorbidity was found in nearly half of the patients with insulin-manipulation (46.3%) compared to a rate of 17.5% in patients, adherent to the prescribed insulin therapy. Depression (18.3% vs 4.9%), specific phobia (21.1% vs 2.9%), social phobia (7.0% vs 0%), and eating disorders (12.7% vs 1.9%) were elevated in patients with insulin-manipulation. Females (37.7%) were more often diagnosed (P = 0.001) with psychiatric disorders than males (18.4%). In females, the percentage of psychiatric comorbidity significantly increased with the level of non-adherence to insulin therapy. Insulin-manipulation had an effect of +0.89% in HbA1c (P = <0.001) compared to patients adherent to insulin therapy, while there was no association of psychiatric comorbidity with metabolic control (HbA1c 8.16% vs 8.12% [65.68 vs 65.25 mmol/mol]). Ketoacidosis, severe hypoglycemia, and frequency of outpatient visits in a diabetes center were highest in patients with insulin-manipulation.

CONCLUSIONS

This is the first study using a systematic approach to assess the prevalence of psychiatric disorders in patients who do or do not manipulate insulin in terms of intentional under- and/or overdosing. Internalizing psychiatric disorders were associated with insulin-manipulation, especially in female patients and insulin-manipulation was associated with deteriorated metabolic control and diabetes complications.

Psychometric properties and factor structure of the diabetes eating problem survey - revised (DEPS-R) among adult males and females with type 1 diabetes

BACKGROUND

Although an increasing amount of research has now established good psychometric properties and a three-component factor structure of the Diabetes Eating Problem Survey - Revised (DEPS-R) in pediatric samples with type 1 diabetes (T1D), research using adult samples has been limited and divergent. This study therefore aimed to investigate psychometric properties and test a three-factor model of the DEPS-R among adults with T1D.

METHODS

A total of 282 adults with T1D aged 18-79 years participated in the study. Measures included the DEPS-R, the Eating Disorder Examination Questionnaire (EDE-Q), and clinical data from the Norwegian Quality Improvement of Laboratory Examinations (NOKLUS) system.

RESULTS

The DEPS-R total mean score (SD) for the total sample, males, and females were 13.8 (9.2), 11.2 (7.8), and 15.6 (9.6) respectively. Good fit indices for the confirmatory factor analysis were found. The Cronbach's alpha of the DEPS-R was .84, suggesting good internal consistency. The DEPS-R correlated significantly with the EDE-Q among both males (.52, p < .01) and females (.68, p < .001). Also, the DEPS-R correlated significantly with BMI in both genders (.33, p < .001 in females and .35, p < .001 in males). HbA1c correlated significantly with the DEPS-R in females (.27, p < .01), but not in males.

CONCLUSIONS

Good fit for a three-factor structure of the DEPS-R was confirmed. Further, the DEPS-R demonstrated good psychometric properties among adults with T1D, and can be recommended for clinical use for this patient group.

Health-risk Behaviors and Type 1 Diabetes Outcomes in the Transition from Late Adolescence to Early Emerging Adulthood

This study examined within- and between-person associations between health-risk behaviors (smoking, drinking, insulin withholding) and type 1 diabetes (T1D) outcomes (adherence and HbA1c) during the high-risk transition from late adolescence to early emerging adulthood utilizing a 2-year longitudinal study. Beginning in the senior year of high school, participants (n = 197) with T1D completed measures of health-risk behaviors, adherence, and HbA1c annually at three time points. Health-risk behaviors were associated with poorer diabetes outcomes during the transition from late adolescence to early emerging adulthood. These results highlight the importance of monitoring health-risk behaviors regularly and intervening to reduce health-risk behaviors during this important developmental transition.

Obesity in Type 1 Diabetes: Pathophysiology, Clinical Impact, and Mechanisms

There has been an alarming increase in the prevalence of obesity in people with type 1 diabetes in recent years. Although obesity has long been recognized as a major risk factor for the development of type 2 diabetes and a catalyst for complications, much less is known about the role of obesity in the initiation and pathogenesis of type 1 diabetes. Emerging evidence suggests that obesity contributes to insulin resistance, dyslipidemia, and cardiometabolic complications in type 1 diabetes. Unique therapeutic strategies may be required to address these comorbidities within the context of intensive insulin therapy, which promotes weight gain. There is an urgent need for clinical guidelines for the prevention and management of obesity in type 1 diabetes. The development of these recommendations will require a transdisciplinary research strategy addressing metabolism, molecular mechanisms, lifestyle, neuropsychology, and novel therapeutics. In this review, the prevalence, clinical impact, energy balance physiology, and potential mechanisms of obesity in type 1 diabetes are described, with a special focus on the substantial gaps in knowledge in this field. Our goal is to provide a framework for the evidence base needed to develop type 1 diabetes-specific weight management recommendations that account for the competing outcomes of glycemic control and weight management.

Emotional and Psychological Needs of People with Diabetes

Diabetes is a chronic metabolic disorder that impacts physical, social and mental including psychological well-being of people living with it. Additionally, psychosocial problems that are most common in diabetes patients often result in serious negative impact on patient's well-being and social life, if left un-addressed. Addressing such psychosocial aspects including cognitive, emotional, behavioral and social factors in the treatment interventions would help overcome the psychological barriers, associated with adherence and self-care for diabetes; the latter being the ultimate goal of management of patients with diabetes. While ample literature on self-management and psychological interventions for diabetes is available, there is limited information on the impact of psychological response and unmanaged emotional distresses on overall health. The current review therefore examines the emotional, psychological needs of the patients with diabetes and emphasizes the role of diabetologist, mental health professionals including clinical psychologists to mitigate the problems faced by these patients. Search was performed using a combination of keywords that cover all relevant terminology for diabetes and associated emotional distress. The psychological reactions experienced by the patient upon diagnosis of diabetes have been reviewed in this article with a focus on typical emotional distress at different levels. Identifying and supporting patients with psychosocial problems early in the course of diabetes may promote psychosocial well-being and improve their ability to adjust or take adequate responsibility in diabetes self-management - the utopian state dreamt of by all diabetologists !.