Eating Disorders and Disordered Eating in Type 1 Diabetes: Prevalence, Screening, and Treatment Options

Risk of Disordered Eating Behaviors in Adolescents with Type 1 Diabetes

OBJECTIVE

Management of type 1 diabetes (T1D) may be difficult for adolescents, who often fail to meet glycemic targets. Adolescents are also at an increased risk for negative affect (i.e., anxiety, depressive symptoms) and are prone to disordered eating behaviors (DEB). This study hypothesized that negative affect would be associated with DEB, self-management, and glycemic control, but that this would be moderated by negative urgency (the urge to engage in impulsive behaviors in response to negative affect), such that this relationship would be significant only for those with higher negative urgency.

METHODS

The Eating in Adolescents with T1D Study recruited 100 caregiver-adolescent dyads (55% male youth, 48% Caucasian) to complete questionnaires reporting on the adolescent's negative affect, negative urgency, DEB, and diabetes management. Glycemic control 3-4 months following survey completion was extracted from the medical record.

RESULTS

A total of 61% of adolescents reported elevated symptoms of anxiety or depression and 25% reported elevated disordered eating symptoms. A total of 81% of adolescents had an A1c level above recommended targets. Negative affect was associated with DEB, suboptimal T1D self-management, and suboptimal glycemic outcomes, moderated by higher levels of negative urgency. Negative affect was associated directly with suboptimal self-management and glycemic control, but not DEB, at all levels of negative urgency.

CONCLUSIONS

Adolescents reported high levels of negative affect, DEB, and suboptimal glycemic control. Interventions that target negative affect and negative urgency in adolescents with T1D are needed in order to reduce the risk for DEB and negative diabetes health outcomes.

Hyperlactatemia in diabetic ketoacidosis is common and can be prolonged: lactate time-series from 25 intensive care admissions

Hyperlactatemia is a documented complication of diabetic ketoacidosis (DKA). Lactate responses during DKA treatment have not been studied and were the focus of this investigation. Blood gas and electrolyte data from 25 DKA admissions to ICU were sequenced over 24 h from the first Emergency Department sample. Hyperlactatemia (> 2 mmol/L) was present in 22 of 25 DKA presentations [mean concentration = 3.2 mmol/L]. In 18 time-series (72%), all concentrations normalized in ≤ 2.6 h (aggregate decay t¹/₂ = 2.29 h). In the remaining 7 (28%), hyperlactatemia persisted > 12 h. These were females (P = 0.04) with relative anemia (hemoglobin concentrations 131 v 155 g/L; P = 0.004) and lower nadir glucose concentrations (5.2 v 8.0 mmol/L, P = 0.003). Their aggregate glucose decay curve commenced higher (42 mmol/L v 29 mmol/L), descending towards a lower asymptote (8 mmol/L v 11 mmol/L). Tonicity decay showed similar disparities. There was equivalent resolution of metabolic acidosis and similar lengths of stay in both groups. Hyperlactatemia is common in DKA. Resolution is often rapid, but high lactates can persist. Females with high glucose concentrations corrected aggressively are more at risk. Limiting initial hyperglycemia correction to ≥ 11 mmol/L may benefit.

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.

Exploring emotional dysregulation characteristics and comorbid psychiatric disorders in type 1 diabetic children with disordered eating behavior risk

OBJECTIVE

To investigate emotional dysregulation and psychiatric comorbidities associated with DEB-risk in children with type 1 diabetes mellitus (T1DM).

METHODS

A total of 75 children with T1DM aged between 8 and 19 were evaluated by K-SADS-PL to assess psychiatric diagnosis. DEB-risk was evaluated via Diabetes Eating Problem Survey-Revised (DEPS-R). Besides, all participants completed the Childhood Depression Inventory (CDI), Difficulties in Emotion Regulation Scale (DERS), and The State-Trait Anxiety Inventory (STAI).

RESULTS

DEPS-R-positive (≥20) was detected in 28% of the participants. The only diagnostic difference was a significantly higher frequency of ED in DEPS-R-positive than DEPS-R-negative (OR = 8.5, CI = 1.94-37.1, p = .004). DEPS-R-positive cases had significantly higher scores of the CDI, STAI, DERS, and the subscales of Goals, Impulse, and Strategies of DERS (CDI U = 266.500, p = .001; STAI U = 288.500,p = .001; DERS U = 229.000, p = .001, Goals U = 283.500, p = .008, Impulse U = 274.000, p = .005, Strategies U = 281.500, p = .007). In stepwise linear regression analysis, STAI-state and DERS scores significantly determined DEB-risk (STAI: β = 0.363, t(60) = 2.33, p = .02, DERS: β = 0.240, t(60) = 4.14, p < .001).

CONCLUSION

This cross-sectional study showed that DEPS-R-positive cases have an 8.5-fold increased risk for ED. DEPS-R-positive ones have difficulties in regulating their emotions and they are incapable of accessing emotion regulation strategies, engaging in goal-directed behavior while under difficult emotions, and impulse control. It can be beneficial for child psychiatrists to screen first for ED in DEPS-R-positive cases who are referred by child endocrinologist. They should also take into consideration anxiety levels and problems in emotion dysregulation in the DEPS-R-positive cases.

Causative factors of eating problems among adolescents with type 1 diabetes mellitus: A qualitative study

Adolescents with type 1 diabetes mellitus are prone to have eating problems. This study aimed to determine factors of eating problems among this population in University Malaya Medical Centre. Fifteen adolescents who scored more than 20 marks in the Diabetes Eating Problem Survey - Revised questionnaire were invited for an in-depth interview. Questions were asked based on their questionnaire's response. The interview sessions were recorded, transcribed verbatim, and thematic analysis was used. Five main themes emerged: pressure, physiological factor, psychological factor, patient's low compliances to insulin intake and food control and fear. Early referral to child psychologist would prevent it from developing.

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.

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.

Parental assessment of disordered eating behaviors in their children with type 1 diabetes: A controlled study

OBJECTIVE

The purpose of this research is to examine the presence of disordered eating behaviors (DEBs) in youths with type 1 diabetes (T1D) according to their parents' evaluations. The roles of demographic and diabetes-related variables were also analyzed.

METHODS

In 54 patients with T1D (aged 10.07-15.08) and in 54 age- and gender-matched healthy controls, DEBs were assessed using a parent-report standardized measure. BMI was calculated from height and weight. Glycemic control was assessed based on the most recent glycosylated hemoglobin value (HbA1c). The association of demographic and clinical factors with DEBs was evaluated through correlation and linear regression analyses.

RESULTS

DEBs were observed more frequently in participants with T1D (33.3%) than in controls (11%) (χ² = 6.501, p = .04). The clinical sample obtained a higher score than controls in PEBEQ total score (t(106) = 2.464, p = .01), as well as in the Exaggerated interest in food (t(106) = 2.723, p = .008) and Rejection/disinterest in food subscales (t(106) = 2.216, p = .01). No gender differences were observed. In participants with T1D, but not in controls, PEBEQ total score was positively correlated with age (r = 0.203, p = .04), HbA1c (r = 0.335, p = .01), and zBMI (r = 0.298, p = .002); HbA1c (standardized beta =0.284, p = .04) was found to uniquely predict the PEBEQ total score.

CONCLUSION

Parents' evaluations may contribute to prompt detection of DEBs, which is crucial in developing appropriate strategies for timely intervention, especially during adolescence.

Factors Associated with Insulin Nonadherence in Type 1 Diabetes Mellitus Patients in Mexico

<b><i>Background:</i></b> Lack of adherence to insulin therapy is common among patients with type 1 diabetes. Factors associated with insulin omission in adult persons with type 1 diabetes in Latin America have not been studied in detail. <b><i>Objectives:</i></b> To investigate factors associated with insulin nonadherence including the presence of psychological disorders (disordered eating behaviors and depression) in adult patients with type 1 diabetes. <b><i>Methods:</i></b> Cross-sectional study including 104 consecutive adults (≥18 years old) attending a tertiary care center in Mexico City. Adherence to insulin therapy was measured with a specific item in a questionnaire. Sociodemographic data and factors related to insulin omission, including validated questionnaires to evaluate disordered eating behavior and depression, were collected and compared between the nonadherent and adherent groups with parametric or nonparametric statistical tests, as appropriate. <b><i>Results:</i></b> We classified 51 (49.1%) patients as nonadherent and 53 (50.9%) as adherent. Adherent subjects reported that they planned their activities around insulin application more often than the nonadherent subjects did (43.4 vs. 23.5%, <i>p</i> = 0.032). In a logistic regression model, fear of hypoglycemia (OR = 11.39) and economic reasons (OR = 6.02) were independently associated with insulin adherence. Presence of disordered eating behavior was identified in 14.4% of subjects, the majority belonging to the nonadherent group. <b><i>Conclusions:</i></b> Only 50% of the patients with type 1 diabetes were adherent. The principal factors associated with nonadherence were economic reasons and fear of hypoglycemia.

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.

Disordered eating behaviors in adolescents with type 1 diabetes: A cross-sectional population-based study in Italy

OBJECTIVE

To evaluate the association of clinical, metabolic and socioeconomic factors with disordered eating behaviors (DEB) among adolescents with type 1 diabetes screened using the Diabetes Eating Problem Survey-Revised (DEPS-R).

METHODS

A cross-sectional, population-based study involved 163 adolescents with type 1 diabetes, aged 11-20 years, recruited from the registry for type 1 diabetes of Marche Region, Italy, who completed the DEPS-R (response rate 74.4%). Clinical characteristics, lipid profile, HbA_1c , family profile of education and occupation were evaluated. The Italian version of DEPS-R was validated, and the prevalence of DEB estimated. The association of demographic, socioeconomic, and clinical factors with DEB was evaluated by multiple correspondence analysis and multiple logistic regression.

RESULTS

The prevalence of DEPS-R-positive (score ≥20) was 27% (95% CI 17-38) in boys and 42% (95% CI 31-53) in girls. A clinical profile of DEPS-R-positive was identified: overweight, little time spent in physical activity, low socioeconomic status, poor metabolic control, skipping insulin injections. Furthermore, the probability of DEPS-R-positive increased 63% for every added unit of HbA_1c , 36% for every added number of insulin injections skipped in a week and decreased about 20% for every added hour/week spent in physical activity. Overweight youth were six times more likely to be DEPS-R-positive.

DISCUSSION

A specific clinical profile of DEPS-R-positive was identified. A multidisciplinary clinical approach aimed to normalize eating behaviors and enhance self-esteem should be used to prevent the onset of these behaviors, and continuous educational programs are needed to promote healthy behaviors and lifestyles.

Executive function is associated with diabetes-specific disordered eating in young adults with type 1 diabetes

OBJECTIVES

Disordered eating behavior in young adults with type 1 diabetes is overrepresented and associated with significant negative health consequences. Thus, determining the key correlates of these behaviors is essential. The aim of the present study was to determine the association between executive function and disordered eating in young adults with type 1 diabetes, relative to a control group without diabetes.

METHODS

74 young adults with type 1 diabetes and 201 demographically similar control participants completed an online survey containing the Eating Disorders Examination Questionnaire (EDE-Q), Diabetes Eating Problems Survey- Revised (DEPS-R), Behavior Rating Inventory of Executive Function- Adult version, Depression Anxiety and Stress Scales, and 3 subscales of the Family Environment Scale (independence, control, and cohesion).

RESULTS

Hierarchical multiple regressions showed that lower executive function was associated with significantly greater disordered eating (as measured by the DEPS-R) over and above psychological and family functioning in the type 1 diabetes group (ΔR² = 0.056, β = 0.366, p = .031). The same relationship was not found when disordered eating was measured by the EDE-Q in either the diabetes group (ΔR² = 0.049, β = 0.342, p = .054), or the control group (ΔR² = 0.010, β = 0.136, p = .100).

CONCLUSIONS

Executive function may play a greater role in the development and/or maintenance of disordered eating in groups with type 1 diabetes relative to those without. This relationship may contribute to the over-representation of eating problems in this clinical group, and may represent a target for prevention or intervention.

Can having a sibling with type 1 diabetes cause disordered eating behaviors?

Background Adolescents with type 1 diabetes mellitus (T1DM) are at an increased risk of eating disturbances. The aim of this study was to evaluate whether the risk of a disordered eating behavior (DEB) also applies to the well sibling sharing the same environment. Methods Well siblings were included if they were 10-18 years old, had a sibling with a T1DM diagnosis for at least 6 months and lived with the sibling during the illness. The control group was comprised of healthy participants recruited from the outpatient clinic with no family history of T1DM. Participants completed a four-part questionnaire concerning their eating behaviors that was developed by the study team. This survey aimed to evaluate the dietary habits and eating patterns. All participants completed the Eating Attitudes Test-26 (EAT-26) and a 24-h food dietary recall. Any participant with a high EAT-26 score or that seemed to be at risk according to the questionnaire was re-evaluated. Results Eight cases (33.3%) in the well sibling group had either a total and/or subgroup pathological score. Three of them were found to have DEB and one case was diagnosed with anorexia nervosa (AN). In the control group, five cases (17.2%) had either a total and/or subgroup pathological score. Three of these cases were found to have DEB, no cases were diagnosed with an eating disorder. There were no statistically significant differences in the EAT-26 scores between the groups. Conclusions Although a direct relationship was not observed, the probability of having a pathologic EAT-26 score was higher in the group with a sibling with T1DM.

Changes in body image and onset of disordered eating behaviors in youth with type 1 diabetes over a five-year longitudinal follow-up

OBJECTIVE

To examine changes over a five-year period in body image accuracy and dissatisfaction, as well as relationships with disordered eating behaviors (DEBs), in young patients with type 1 diabetes.

METHODS

Of 81 children (42 male, 39 female) with type 1 diabetes first assessed at ages 5.1-10.06 years, 67 (83%) were re-enrolled and interviewed as adolescents (aged 10.07-15.08 years) at follow-up. DEBs were assessed using a parent-report standardized measure. Height and weight were determined, and BMI was calculated. Glycemic control was assessed by glycated hemoglobin.

RESULTS

BMI increased from childhood to adolescence. The general tendency towards body size underestimation (i.e., perceiving the body to be smaller than it is) and dissatisfaction, already described at baseline, was found unchanged at follow-up, revealing continuing attitude towards body image problems. Body-size perception accuracy, degree of body-size dissatisfaction, and HbA1c did not increase significantly over five years, but the presence of DEBs was observed. Degree of body dissatisfaction was found to be a significant predictor for DEBs (standardized beta = 0.272, p < 0.05).

CONCLUSION

Body image problems persisted over the five-year study period and were found associated with higher levels of DEBs. Identification of such body image characteristics may be useful in developing strategies for intervention early in the course of illness.

Increased prevalence of disordered eating in the dual diagnosis of type 1 diabetes mellitus and celiac disease

BACKGROUND

Disordered eating behaviors (DEBs) may lead to full blown eating disorders. Both type 1 diabetes mellitus (T1DM) and celiac disease (CD) have been linked to DEBs.

OBJECTIVE

To compare the presence of DEBs between adolescents and young adults with a dual diagnosis of T1DM and CD, and individuals with only one of the diagnoses.

METHODS

Individuals with a dual diagnosis of T1DM and CD ("T1DM + CD group" n = 39), with a diagnosis of T1DM only ("T1DM group" n = 97) and with a diagnosis of CD only ("CD group" n = 267) filled the Eating Attitude Test-26 (EAT-26) questionnaire. Those with T1DM completed in addition to the Diabetes Eating Problem Survey-Revised (DEPS-R).

RESULTS

The study population comprised of 403 individuals, of whom 65% were females. There were no statistically significant differences among the groups in distribution of sex, age, hemoglobin A1c (HbA1c) levels, age of disease diagnosis and duration. The prevalence of DEBs in the T1DM + CD group was 3-fold higher (26.0%) than in the T1DM (8.2%) and CD (8.2%) groups (P = .003). This trend was observed for both females and males. Multivariate analysis demonstrated that the T1DM + CD group had an increased risk for DEBs (odds ratio, OR: 4.7, 95% confidence interval, CI: 1.9-11.2, P = .001) after adjustment for age, sex, and body mass index. Additionally, being female, older and overweight increased the risk for DEBs. HbA1c values were not associated with an increased DEBs rate.

CONCLUSIONS

Individuals with the dual diagnoses of T1DM and CD have an increased likelihood to develop DEBs compared to those with only one of these diagnoses.

Disordered Eating Behaviors Are Not Increased by an Intervention to Improve Diet Quality but Are Associated With Poorer Glycemic Control Among Youth With Type 1 Diabetes

OBJECTIVE

This study examines whether participation in an 18-month behavioral intervention shown previously to improve overall diet quality inadvertently increases disordered eating behaviors (DEBs) in youth with type 1 diabetes and investigates the association of DEB with multiple measures of glycemic control and variability.

RESEARCH DESIGN AND METHODS

Participants reported DEB and diabetes management at baseline and 6, 12, and 18 months; masked continuous glucose monitoring, HbA_1c, and 1,5-anhydroglucitol (1,5-AG) were obtained concurrently. Linear mixed models estimated the intervention effect on DEB, the association of DEB with diabetes adherence and measures of glycemic control and variability, and whether DEB modified glycemic trajectories.

RESULTS

There was no intervention effect on DEB (P = 0.84). DEB was associated with higher HbA_1c (P = 0.001), mean sensor glucose (P = 0.001), and percent sensor glucose values >180 mg/dL (P = <0.001); with lower 1,5-AG (P = 0.01); and with worse diabetes adherence (P = 0.03). DEB was not associated with percent sensor glucose values <70 mg/dL or any measures of glycemic variability. There was a significant DEB × time interaction effect for mean sensor glucose (P = 0.05) and percent sensor glucose values >180 mg/dL (P = 0.04). Participants reporting less DEB had a developmentally expected deterioration in glycemic control throughout the study. Participants reporting more DEB had poor glycemic control at baseline that remained poor throughout the study.

CONCLUSIONS

Findings show a potential to improve diet quality without increasing DEB and indicate an association of DEB with persistent hyperglycemia but not hypoglycemia or glycemic variability.

Gender differences in disordered eating behaviors and body dissatisfaction among adolescents with type 1 diabetes: Results from diabetes MILES youth-Australia

OBJECTIVE

To examine gender differences in disordered eating behaviors (DEB) and body dissatisfaction in adolescents with type 1 diabetes. While evidence shows that female youth with type 1 diabetes are more prone to DEB compared to their peers without diabetes, little is known about male adolescents.

METHOD

In a national online survey, adolescents (13-19 years) with type 1 diabetes for ≥1 year completed the Diabetes Eating Problem Survey-Revised (DEPS-R), and the Body Mass Index Silhouette Matching Test (BMI-SMT) and items on binge eating and insulin omission.

RESULTS

About 477 adolescents (mean age 16 years; 62% females) completed the DEPS-R and 431 the BMI-SMT. The DEPS-R total score was higher for females than males, with scores for females increasing with age. BMI, HbA_1c , insulin omission, and binge-eating frequency were associated moderately with DEPS-R for both genders. On the BMI-SMT, 88% of females wanted to be thinner. Of the males, 76% reported body dissatisfaction; however, only 43% expressed a desire for thinness with the remainder desiring a larger body size. DEPS-R was positively associated with the discrepancy between perceived actual and ideal body size for both genders.

DISCUSSION

A large proportion of adolescents with type 1 diabetes, particularly females reported engaging in DEB. Similarly, high rates of body dissatisfaction were reported, though ideal body shape preferences differed by gender. Given the high levels of self-reported DEB and gender-based patterns of body dissatisfaction, future research needs to examine the effectiveness of routine screening of DEB and consider implementation of stepped care approaches.

Eating Disorders and Disordered Eating Symptoms in Adolescents with Type 1 Diabetes

Eating problems in adolescents with type 1 diabetes (T1D) can be divided into two groups. The first includes the diagnosed eating disorders (EDs), i.e., diseases specifically identified by defined signs and symptoms for which a degree of severity has been established, such as anorexia nervosa, bulimia nervosa, binge-eating disorder, pica, and rumination. The second is the group of disordered eating symptoms (DES), which include behaviors such as dieting for weight loss, binge eating, self-induced vomiting, excessive exercise, and laxative or diuretic use; these behaviors cannot be categorized as complete diseases, and, although apparently mild, they must be closely evaluated because they can evolve into true EDs. In this review, present knowledge about the clinical relevance of EDs and DES and the possible preventive and therapeutic measures used to reduce their impact on the course of T1D will be discussed. As adolescents with diabetes are at higher risk of eating disturbances and consequently for higher rates of disease complications, care providers should pay attention to clinical warning signs that raise suspicion of disturbed eating to refer these patients early to an expert in nutrition and mental health disorders. To ensure the best care for adolescents with T1D, diabetes teams should be multidisciplinary and include a pediatric diabetologist, a skilled nurse, a dietician, and a psychologist.

Biopsychosocial Aspects of Weight Management in Type 1 Diabetes: a Review and Next Steps

PURPOSE OF REVIEW

This review aims to summarize the type 1 diabetes (T1D) and weight literature with an emphasis on barriers associated with weight management, the unique T1D-specific factors that impact weight loss success, maladaptive and adaptive strategies for weight loss, and interventions to promote weight loss.

RECENT FINDINGS

Weight gain is associated with intensive insulin therapy. Overweight and obese weight status in individuals with T1D is higher than the general population and prevalence is rising. A variety of demographic (e.g., female sex), clinical (e.g., greater insulin needs), environmental (e.g., skipping meals), and psychosocial (e.g., depression, stress) factors are associated with overweight/obese weight status in T1D. Fear of hypoglycemia is a significant barrier to engagement in physical activity. Studies evaluating adaptive weight loss strategies in people with T1D are limited. There is a growing literature highlighting the prevalence and seriousness of overweight and obesity among both youth and adults with T1D. There is an urgent need to develop evidence-based weight management guidelines and interventions that address the unique concerns of individuals with T1D and that concurrently address glycemic control.

Assessment of eating disorders with the diabetes eating problems survey - revised (DEPS-R) in a representative sample of insulin-treated diabetic patients: a validation study in Italy

BACKGROUND

The purpose of the study was to evaluate in a sample of insulin-treated diabetic patients, with type 1 or type 2 diabetes, the psychometric characteristics of the Italian version of the DEPS-R scale, a diabetes-specific self-report questionnaire used to analyze disordered eating behaviors.

METHODS

The study was performed on 211 consecutive insulin-treated diabetic patients attending two specialist centers. Lifetime prevalence of eating disorders (EDs) according to DSM-IV and DSM-5 criteria were assessed by means of the Module H of the Structured Clinical Interview for DSM IV Axis I Disorder and the Module H modified, according to DSM-5 criteria. The following questionnaires were administered: DEPS-R and the Eating Disorder Inventory - 3 (EDI-3). Test/retest reproducibility was assessed on a subgroup of 70 patients. The factorial structure, internal consistency, test-retest reliability and concurrent validity of DEPS-R were assessed.

RESULTS

Overall, 21.8% of the sample met criteria for at least one DSM-5 diagnosis of ED. A "clinical risk" of ED was observed in 13.3% of the sample. Females displayed higher scores at DEPS-R, a higher percentage of at least one diagnosis of ED and a higher clinical risk for ED. A high level of reproducibility and homogeneity of the scale were revealed. A significant correlation was detected between DEPS-R and the 3 ED risk scales of EDI-3.

CONCLUSIONS

The data confirmed the overall reliability and validity of the scale. In view of the significance and implications of EDs in diabetic patients, it should be conducted a more extensive investigation of the phenomenon by means of evaluation instruments of demonstrated validity and reliability.

I Should but I Can't: Controlled Motivation and Self-Efficacy Are Related to Disordered Eating Behaviors in Adolescents With Type 1 Diabetes

PURPOSE

Among adolescents with type 1 diabetes, disordered eating behaviors (DEBs) are more prevalent and have more serious health implications than in adolescents without diabetes, necessitating identification of modifiable correlates of DEB in this population. This study hypothesized that (1) autonomous motivation and (2) controlled motivation for healthy eating (i.e., eating healthfully because it is important to oneself vs. important to others, respectively) are associated with DEB among adolescents with type 1 diabetes. The third hypothesis was that baseline healthy eating self-efficacy moderates these associations.

METHODS

Adolescents with type 1 diabetes (n = 90; 13-16 years) participating in a behavioral nutrition intervention efficacy trial reported DEB, controlled and autonomous motivation, and self-efficacy at baseline, 6, 12, and 18 months. Linear-mixed models estimated associations of controlled and autonomous motivation with DEB, adjusting for treatment group, body mass index, socioeconomic status, age, and gender. Separate models investigated the interaction of self-efficacy with each motivation type.

RESULTS

Controlled motivation was positively associated with DEB (B = 2.18 ± .33, p < .001); the association was stronger for those with lower self-efficacy (B = 3.33 ± .55, p < .001) than those with higher self-efficacy (B = 1.36 ± .36, p < .001). Autonomous motivation was not associated with DEB (B = -.70 ± .43, p = .11).

CONCLUSIONS

Findings identify controlled motivation for healthy eating as a novel correlate of DEB among adolescents with type 1 diabetes and show that self-efficacy can modify this association. Motivation and self-efficacy for healthy eating represent potential intervention targets to reduce DEB in adolescents with type 1 diabetes.

Eating disorders in persons with type 1 diabetes: A focus group investigation of early eating disorder risk

Through focus groups, we examined the development and maintenance of an eating disorder in 16 females with type 1 diabetes and an eating disorder. The quotes and qualitative data summaries provide rich insights into understanding why those with type 1 diabetes are at increased risk for eating disorders. Content analyses revealed five themes pertinent to the dual diagnosis (feeling different, difficulty with control/coping, body image, feelings, and quality of life) of which four themes were relevant to eating disorder development. Findings support early identification of those at risk and inform interventions to mitigate development of an eating disorder.

Development and validation of the Screen for Early Eating Disorder Signs (SEEDS) in persons with type 1 diabetes

This study's objective was to develop and validate an instrument to identify those at risk of developing an eating disorder (ED) in persons with type 1 diabetes. The Screen for Early Eating Disorder Signs (SEEDS) instrument was developed using a multi-phase process including focus groups, cognitive interviews, and mailed questionnaires. Factor analysis revealed 20 items across three factors (Body Image, Feelings, Quality of Life) demonstrating strong psychometric properties. Scoring guidelines and interpretation are provided. SEEDS is a brief (20-item; 2-5 minutes to complete), self-administered, screen designed for use in clinical practice or research to identify or confirm suspicions of ED risk and does not include weight-control behavior items.

Long-term impact of childhood-onset type 1 diabetes on social life, quality of life and sexuality

AIM

This study describes the socio-professional outcomes, health-related quality of life (HRQOL) and sexuality of adults with childhood-onset type 1 diabetes (T1D).

METHODS

The study participants (n=388), recruited from a nationwide registry (age: 28.5 ± 3.1 years; T1D duration: 17.0 ± 2.7 years), completed a questionnaire (198 items); the results were compared with the French general population using standardized incidence ratios (SIRs) and Z scores matched for age, gender and period with/without education levels and patterns of family life. Linear regression models also investigated correlates of SF-36 Physical (PCS) and Mental Composite Scores (MCS).

RESULTS

Compared with the French general population, education levels of people with T1D were similar, with 68.6% having at least a high-school diploma or higher (SIR: 1.06, 95% CI: 0.93; 1.20), as were also their patterns of family life. Unemployment was higher in T1D women (15.3%, SIR: 1.50, 1.00; 2.05), but not in T1D men (8.6%, SIR: 0.96, 0.51; 1.57). Social discrimination was more common (SIR: 5.64, 4.64; 6.62), and frequency of daily alcohol consumption was higher (SIR: men, 3.34, 2.38; 4.54; women, 6.53, 4.57; 12.99). PCS and MCS were decreased moderately (mean ± SD: 52.0 ± 7.5; mean Z score: -0.2, 95% CI: -0.3; -0.1) and substantially (mean ± SD: 42.1 ± 12.4; mean Z score: -0.7, -0.8; -0.6), respectively. Fatigue and abandoning sports were predictive of a lower HRQOL. Both men and women were more frequently dissatisfied with their sex life. Prevalence of sexual problems was higher in women (SIR for: dysorgasmia, 1.91, 1.21-2.88; decreased/loss of desire: 2.11, 1.35-3.08), but similar in men. Participants with T1D-related complications had preserved social outcomes, but altered HRQOL.

CONCLUSION

Young adults with T1D have satisfactory social participation. However, their higher alcohol consumption, lower MCS and frequent dissatisfaction with sexuality suggest a heavy impact of the disease on morale, especially in women. Improving the everyday well-being of these young adults represents a key challenge for diabetes healthcare.

Testing an integrated model of eating disorders in paediatric type 1 diabetes mellitus

BACKGROUND

Eating disorders in young people with type 1 diabetes mellitus confer additional health risks beyond those conferred by the disease itself. Risk factors for developing eating disorders are poorly understood.

OBJECTIVE

The current study aimed to examine risk factors for eating disturbance in young people with type 1 diabetes mellitus. Both diabetes specific risk factors, such as body mass index (BMI), glycaemic control and diabetes-related conflict, and also more general risk factors such as dysfunctional perfectionism and low self-esteem were assessed.

METHODS

Fifty young people aged 14-16 and their primary caregiver were asked to complete interviews and questionnaires about their eating attitudes and behaviours, dysfunctional perfectionism, self-esteem, family conflict, and general mental health symptoms. Recent weight and height and glycaemic control were extracted from the medical file.

RESULTS

Different factors distinguished those young people who displayed eating disorder attitudes from those who did not (higher BMI-z, poorer glycaemic control, and lower self-esteem) and those young people who displayed eating disorder behaviour from those who did not (lower self-esteem and higher diabetes-related family conflict).

CONCLUSIONS

The results of the current study suggest that there might be different factors associated with eating disorders (ED) attitudes and ED behaviours, but that food/eating-related factors, family factors, and intra-personal factors are all important. Furthermore there are some gender differences in the presence of ED attitudes and behaviours and preliminary evidence that higher body mass indexes (BMIs) impact on girls more than they do on boys.

A review of adolescent adherence in type 1 diabetes and the untapped potential of diabetes providers to improve outcomes

Only 21 % of adolescents with type 1 diabetes (T1D) meet glycemic goals set forth by the American Diabetes Association. Adherence to therapy is a particular concern in this population, and the association between poor adherence and worsening glycemic control indicates that there is a critical need to improve adherence to therapy in adolescents with T1D. In this article, we review barriers to adherence in adolescents with T1D and discuss interventions aimed at improving adherence to therapy and glycemic control. Interventions include technology-based applications, family-based therapies, motivational interviewing, and others. Notably, less than 10 % of the interventions reviewed are provider-led, clinic-based interventions, and few have focused on regimen-related aspects of adherence. This article also outlines the importance of provider communication and the role of providers in facilitating adherence behaviors in adolescents with T1D. Finally, we suggest future directions of research to improve adherence to therapy in adolescents with T1D.

Topical review: a comprehensive risk model for disordered eating in youth with type 1 diabetes

OBJECTIVES

Provide an updated literature review on prevalence, measurement, and correlates of disordered eating in youth with Type 1 diabetes (T1D), present a novel theoretical risk model (i.e., The Modified Dual Pathway Model) for disordered eating in youth with T1D incorporating psychosocial and physiological risk factors, and discuss clinical implications.

METHODS

Literature review of prevalence, correlates, risk factors, and outcomes of disordered eating behavior (DEB) in youth with T1D.

RESULTS

Insulin treatment, subsequent weight gain, and disruptions to hunger and satiety regulation are hypothesized disease-related mechanisms through which the treatment of T1D may increase vulnerability to development of behavior characterized as DEB. The Modified Dual Pathway Model integrates these factors with a validated psychosocial risk (body dissatisfaction, depression, and abstinence violation) model for DEB in nondiabetic youth.

CONCLUSIONS

The Modified Dual Pathway model of DEB in youth with T1D is a comprehensive representation of both psychosocial and T1D-related risk factors with the potential to inform future interventions for this population.

If it does not significantly change HbA1c levels why should we waste time on it? A plea for the prioritization of psychological well-being in people with diabetes

Despite improvements in pharmacological treatments and methods of care and care delivery, the burden of living with diabetes remains an ongoing challenge, as many people with diabetes are at increased risk of mental health disorders, psychological disturbances and functional problems associated with living with diabetes. Person-centred collaborative care that also meets the psychological needs of the individual is not available to many people with diabetes. The present article examines the role of psychological factors in the onset of diabetes and in relation to living with diabetes. It is argued that the pursuit of psychological well-being is worthy of individual attention in the care of people with diabetes and should not be contingent upon attainment of somatic indices of health. The barriers to attaining this goal are examined, including the costs of treating (or not treating) psychological problems in people with diabetes. Recommendations on how to improve diabetes care are offered, including psychological interventions that are both evidence-based and cost-effective.

Eating behavior and BMI in adolescent survivors of brain tumor and acute lymphoblastic leukemia

OBJECTIVES

Elevated body mass index (BMI) has been reported in pediatric cancer survivors. It is unclear whether this is related to altered energy intake (via disordered eating), decreased energy expenditure (via limited exercise), or treatment-related direct/indirect changes. The aims of this study are to describe the occurrence of overweight and obesity, exercise frequency, and the extent of disordered eating patterns in this sample of survivors, and to examine relationships among BMI, eating patterns, exercise frequency, and demographic and disease and treatment-related variables to identify those survivors most at risk for overweight/obesity.

METHODS

This cross-sectional study recruited 98 cancer survivors (50 acute lymphoblastic leukemia [ALL], 48 brain tumor [BT]), aged 12 to 17 years and ≥12 months posttreatment from a large pediatric oncology hospital. Survivors completed health behavior measures assessing disordered eating patterns and physical activity. Clinical variables were obtained through medical record review. Univariate analyses were conducted to make comparisons on health behaviors by diagnosis, gender, treatment history, and BMI category.

RESULTS

Fifty-two percent of ALL survivors and 41.7% of BT survivors were classified as overweight/obese. Overweight/obesity status was associated with higher cognitive restraint (odds ratio = 1.0; 95% confidence interval = 1.0-1.1). Only 12% of ALL survivors and 8.3% of BT survivors met Centers for Disease Control and Prevention guidelines for physical activity. Males reported more physical activity, t(96) = 2.2, P < .05.

CONCLUSIONS

Overweight/obese survivors may attempt to purposefully restrict their food intake and rely less on physiological cues to regulate consumption. Survivors should be screened at follow-up for weight-related concerns.