Is disordered eating behavior more prevalent in adolescents with early-onset type 1 diabetes than in their representative peers?

The use and misuse of the SCOFF screening measure over two decades: a systematic literature review

PURPOSE

The SCOFF questionnaire was designed as a simple, memorable screening tool to raise suspicion that a person might have an eating disorder. It is over 20 years since the creation of the SCOFF, during which time it has been widely used. Considering this, we wish to review the use of the SCOFF in peer-reviewed scientific journals, and to assess whether it is being used appropriately in the manner in which it was originally devised and tested.

METHODS

The Preferred Reporting Items for a Systematic Review and Meta-analysis (PRISMA) guidelines were followed, and all search strategies and methods were determined before the onset of the study. PubMed and Wiley Online Library were searched using the terms SCOFF and eating. Two reviewers were involved in the reviewing process. Criteria for appropriate use of the SCOFF were formalised with the tool's original authors.

RESULTS

180 articles were included in the final review. 48 articles had used the SCOFF appropriately, 117 articles inappropriately and 15 articles had been mixed in the appropriateness of their use.

CONCLUSION

This systematic review highlights the inappropriate use of the SCOFF in diverse languages and settings. When used correctly the SCOFF has made a significant contribution to the understanding of eating disorders and its simplicity has been applauded and led to widespread use. However in over two-thirds of studies, the use of the SCOFF was inappropriate and the paper highlights how and in what way it was misused, Guidelines for the appropriate use of the SCOFF are stated. Future validation and avenues of research are suggested.

LEVEL OF EVIDENCE

Level I.

Mental Health and Disordered Eating in Athletes

Disordered eating (DE) and eating disorders (EDs) are more prevalent in athletes than non-athletes, and can cause devastating health and performance consequences. Although they can affect any athlete, DE/EDs are more common among women and athletes in lean sports, where there is a perceived competitive advantage to being lean. The sports medicine provider plays a crucial role in screening, diagnosis, and treatment of DE/ED. Treatment should involve a multidisciplinary team with a physician, dietitian, and mental health provider. Preventative efforts should seek to educate athletes and their coaches/support staff and should foster a healthy environment, which deemphasizes weight or body image.

Diabulimia: A Risky Trend Among Adults with Type 1 Diabetes Mellitus

OBJECTIVE

Poor adherence leads to worse glycemic control and increased complications in patients with type 1 diabetes mellitus (T1DM). Diabulimia characterizes patients with T1DM who skip or use less insulin for weight loss purposes. The study objectives were to determine: (1) the prevalence of diabulimia among adult patients with T1DM, (2) compare patients with and without diabulimia, and (3) identify factors that may place individuals at higher risk of diabulimia.

METHODS

A 40-item, web-based survey was administered to 21 T1DM discussion boards, Listservs, and social media outlets. The survey assessed demographics, diabetes management, psychiatric diagnoses, and screened for diabulimia. Individuals who reported intentionally skipping or using less insulin than directed for the purpose of weight loss or to prevent weight gain in the past 12 months were classified as having diabulimia.

RESULTS

Of the 225 participants who completed the survey, 8.9% had diabulimia. Patients with diabulimia had elevated hemoglobin A1C (A1C) levels (8.4% vs 6.9%; P = .014), higher rates of a diabetes-related emergency department visits or hospitalization (30.0% vs 13.2%; P = .042), and higher rates of a major depressive disorder diagnosis (40.0% vs 11.5%; P < .001) than patients without diabulimia. Factors associated with diabulimia included high A1C levels (odds ratio, 1.43; 95% CI [1.08-1.91]; P = .014) and a major depressive disorder diagnosis (odds ratio, 4.87; 95% CI [1.31-18.22]; P = .018).

CONCLUSION

Approximately 1 in 11 adult patients with T1DM screened positive for diabulimia. Higher A1C levels and a diagnosis of major depressive disorder were associated with diabulimia.

The misuse of insulin by males with Type 1 Diabetes Mellitus for weight and/or shape control: a systematic scoping review

Background

Insulin restriction and/or omission in Type 1 Diabetes Mellitus (T1DM) is a risky disordered eating behaviour increasingly reported in the literature. Most existing literature has focused on females with T1DM. Previous research, however, suggests disordered eating behaviours are over-represented in males with T1DM versus males without T1DM. This systematic scoping review sought to summarise the existing literature to contribute to the development of an understanding of males' misuse of insulin for weight and/or shape control.

Methods

A systematic scoping review methodology was used. We searched six electronic databases. Eligible articles were quantitative, qualitative, or mixed methods empirical studies with primary data on the restriction and/or omission of insulin for weight and/or shape control among males, written in English from database inception to December 2021.

Results

A final sample of 56 articles was included (48 quantitative, six qualitative and two mixed methods). Where it was reported to occur, estimates of the behaviour ranged from 5 to 75% in females and 1.4% to 76% in males. In 12 studies examining sex differences, only three reported higher prevalence in females. Understandings about the behavioural context of the behaviour were hampered by lack of qualitative research (n = 4 studies).

Conclusion

Despite common preconceptions, this disordered eating behaviour appears to occur similarly in males and females. The findings shed light on areas for future research, including aetiology in males and the need for longitudinal and qualitative research. Clinical recommendations include being alert to the possibility of this behaviour in males with Type 1 Diabetes Mellitus and the need for health professionals to use open-ended questions to explore current and past deliberate restriction and/or omission of insulin among their patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-022-01151-8.

High prevalence with no gender difference of likely eating disorders in type 1 mellitus diabetes on insulin pump

AIM

The aim of this study was to determine the prevalence of likely eating disorders and insulin misuse in a prospective cohort of adults with type 1 diabetes mellitus (T1DM) treated with insulin pump therapy.

METHODS

This prospective study was held at the participants' home. The participants completed the SCOFF questionnaire as well as a question related to insulin misuse. Information about lifestyle, medical history, insulin pump and Continuous Glucose Monitoring (CGM) data were collected.

RESULTS

The analysis covered 198 participants with a median age of 51 [95% CI 38; 62] years. The prevalence of likely eating disorders was 21.7% (95% CI 16.3; 28.2) in the study population and 20.6% (95% CI 14.3; 28.6) and 24.2% (95% CI 14.6; 37.0) in males and females respectively. The prevalence of insulin misuse was 39.0% (95% CI 30.8; 47.7). There was no significant difference in prevalence between males and females for likely eating disorders and insulin misuse. The analysis of CGM data revealed no factors related to glycaemic control associated with likely eating disorders.

CONCLUSION

The results of this study indicate that the prevalence of likely eating disorders is high even in a middle-aged population with a T1DM and satisfactory glucose control.

Disordered Eating Behaviors and Insulin Restriction in Saudi Adolescents and Young Adults with Type 1 Diabetes

Background and Objectives: The prevalence of disordered eating behaviors (DEBs) in type 1 diabetes (T1D) has been studied globally; however, data from Saudi Arabia and Arab-speaking countries are scarce. This study aimed to measure the prevalence of DEBs and associated clinical characteristics in adolescents and young adults with T1D, and the impact of DEBs on glycemic parameters. Materials and Methods: A total of 265 adolescents and young adults with T1D (aged 12-25 years) were recruited randomly from the registry at the Jazan Endocrinology and Diabetes Center, Saudi Arabia. Participants completed the Diabetes Eating Problem Survey-Revised (DEPS-R) questionnaire. Other measures included hemoglobin A1c (HbA1c) in addition to sociodemographic, anthropometric, and clinical data. Results: The prevalence of DEBs among T1D was 27.2%. Females (32.5%) had a higher proportion of DEBs than males (18.6%) (p = 0.01). About 27% of the participants reported insulin restriction. A history of hospital admission in the previous 6 months due to DKA and frequent hypoglycemia was more frequently reported in T1D participants with DEBs compared to those without (p = 0.03). Participants with DEBs had higher HbA1c and higher BMI compared to those without DEBs. Conclusions: Adolescents and young adults with T1D with disordered eating and insulin restriction have higher glycated hemoglobin, and are at higher risk of DKA. Routine screening for DEBs should be an essential element in diabetes care, especially among highly vulnerable groups.

Disordered eating behaviour and eating disorder among adolescents with type 1 diabetes: An integrative review

BACKGROUND

Type 1 diabetes (DT1) in adolescents brings behavioural changes, altered nutritional habits, and eating disorders.

AIM

To identify and analyze the validated instruments that examine the disordered eating behaviour and eating disorders among adolescents with DT1.

METHODS

An integrative review was accomplished based on the following databases: PubMed, LILACS, CINAHL, Scopus, Web of Science, and Reference Citation Analysis (RCA), including publications in Portuguese, English, or Spanish, without time limit and time published.

RESULTS

The main instruments to evaluate disordered eating behaviour were The Diabetes Eating Problem Survey-Revised, The Diabetes Eating Problem Survey, and the eating attitudes test-26, and for eating disorders the main instruments used were The Bulimic Investigation Test of Edinburgh, The Binge Eating Scale, The Child Eating Disorder Examination, The five questions of the (Sick, Control, One, Fat and Food), and The Mind Youth Questionnaire. These instruments showed an effect in evaluating risks regarding nutritional habits or feeding grievances, with outcomes related to weight control, inadequate use of insulin, and glycaemia unmanageability. We did not identify publication bias.

CONCLUSION

Around the world, the most used scale to study the risk of disordered eating behaviour or eating disorder is The Diabetes Eating Problem Survey-Revised. International researchers use this scale to identify high scores in adolescents with DT1 and a relationship with poorer glycemic control and psychological problems related to body image.

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).

Prevalence of disordered eating behaviors in adolescents with type 1 diabetes: Results of multicenter Italian nationwide study

OBJECTIVE

To assess the prevalence of disordered eating behaviors (DEBs) in a large sample of Italian adolescents with type 1 diabetes and to explore potential demographic, clinical, and psychological differences (understood as emotional and behavioral problems) among adolescents with and without DEBs.

METHOD

Adolescents (11-19 years) with type 1 diabetes completed the Diabetes Eating Problems Survey-revised (DEPS-r) and the Youth Self Report (YSR). Demographic and clinical data were also collected.

RESULTS

Of 690 adolescents with type 1 diabetes (mean age 14.97 ± 1.81, n = 337 girls) assessed in this study, 28.1% (21% boys, 35% girls) were DEPS-r positive (score ≥ 20). Girls had higher DEPS-r total scores (p < .0001, d = .42) than boys, although no age differences were found in mean DEPS-r total scores (p = .961). In both genders, adolescents with DEBs had significantly higher zBMI (p < .0001, d = .52) and HbA1c values (p < .0001, d = .54) and showed more emotional and behavioral problems (both as internalizing and externalizing problems) than those without DEBs (all p < .0001). These differences were largely confirmed in all age groups. Adolescents reporting insulin misuse had higher HbA1c values (p = .001, d = .26), higher DEPS-r mean scores (p < .0001, d = 1.07), and greater psychological problems (all p < .001) than those who did not.

DISCUSSION

DEBs are prevalent among adolescents with type 1 diabetes, and those with eating problems showed adverse clinical and psychological conditions. Routine screening for DEBs and of general psychological condition should be a fundamental part of diabetes care, especially during adolescence.

PUBLIC SIGNIFICANCE STATEMENT

This nationwide study indicated that DEBs are common in adolescents with T1D, and those suffering from them show poorer clinical conditions and higher emotional and behavioral problems. As such, it offers important contributions for those working with EDs and in the T1D field, as it provides a deeper understanding of the co-occurring DEBs-emotional/behavioral problems in youths with T1D and highlights the importance of continuous monitoring of their psychological condition by a multidisciplinary team.

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.

Eating Problems in Youths with Type 1 Diabetes During and After Lockdown in Italy: An 8-Month Follow-Up Study

Eighty-five youths with T1D and 176 controls aged 8–19 years were asked to complete online questionnaires (ChEAT and EAT-26) measuring disordered eating behaviors (DEBs) during (baseline) and after (8-month follow-up) the lockdown. DEB symptoms in all participants (especially younger than 13 years), glycemic control, and zBMI were found unchanged from baseline to follow-up (all p > .05). After 8 months, the ChEAT/EAT-26 critical score frequency decreased significantly in controls (p = .004), as was the score for the ChEAT/EAT-26’s Oral Control subscale in both groups (T1D: p = .005; controls: p = .01). Participants with T1D, especially those older than 13 years, had higher ChEAT/EAT-26 Dieting scores (p = .037) and lower ChEAT/EAT-26 Oral Control scores (p = .046) than controls. Unchanged DEB symptoms suggest that the COVID-19 restrictions did not significantly affect participants’ eating behaviors and that a general adaptation to the challenges of lockdown and other pandemic containment measures occurred in both T1D and control participants.

Effectiveness of medical nutrition therapy in adolescents with type 1 diabetes: a systematic review

BACKGROUND

Medical nutrition therapy (MNT) has an integral role in overall diabetes management. During adolescence, consideration of physiological and psychosocial changes is essential for implementing an optimal diabetes treatment.

OBJECTIVES

Our aim was to identify, summarize, and interpret the published literature about MNT in adolescents with type 1 diabetes.

METHODS

The Medline (PubMed) and EMBASE databases were searched from January 1959 to December 2021. The inclusion criteria were interventional studies with MNT in adolescents with type 1 diabetes with a disease duration over 1 year, including the following outcomes: dietary intake and daily eating patterns (assessed with validated tools, two or more 24 h dietary recall or 3-day dietary records), the diabetes self-management education and support (DSMES), glycemic control, lipid profile and body mass index (BMI). The exclusion criteria were studies without a control group (except for pre-post studies), the lack of randomization and those studies that assessed only a single nutrient, food or meal consumption, as well as reviews, and in-vitro/in-vivo studies. The risk of bias assessment was performed using the Cochrane risk-of-bias tool for randomized trials. A narrative synthesis was performed to present the results. The quality of evidence was assessed with the GRADE guidance.

RESULTS

From a total of 5377 records, 12 intervention studies (9 RCT and 3 pre-post intervention studies) were included. The data were assessed in order to perform a meta-analysis; however, the studies were too heterogeneous. The studies showed conflicting results about the effectiveness of MNT on dietary pattern, DSMES, glycemic control, lipid profile and BMI.

CONCLUSIONS

Clinical research studies on the effectiveness of MNT in adolescents with type 1 diabetes are scarce. The limited number of studies with a high risk of bias precludes establishing robust conclusions on this issue. Further research is warranted.

Caring for individuals with Type 1 Diabetes Mellitus who restrict and omit insulin for weight control: Evidence-based guidance for healthcare professionals

PURPOSE

Evidence-based guidance is needed to inform care for individuals with Type 1 Diabetes Mellitus who deliberately restrict and omit insulin for weight control. Consensus on the best treatment approach for these individuals is currently lacking, and standard eating disorder treatment protocols are ineffective. This article focuses on how healthcare professionals can provide meaningful care to this population.

METHODS

Qualitative research studies were synthesised in a meta-aggregative meta-synthesis. We identified key themes related to individuals' understanding and experience, physical and psychological impacts, support and treatment-related needs and experiences. These themes guided the development of implications for practice.

RESULTS

Individuals engaging in insulin misuse wanted healthcare professionals to demonstrate more empathy, validate their experiences, have increased knowledge about their illness and develop more specialist pathways.

CONCLUSIONS

The findings have widespread interdisciplinary implications for health professionals working with individuals with Type 1 Diabetes Mellitus. Evidence-informed implications for practice are provided and may provide useful guidance concerning the prevention and treatment of this unique behaviour.

Disordered eating and eating disorders among women seeking fertility treatment: A systematic review

The purpose of this systematic review is to evaluate the prevalence of disordered eating and eating disorders among women seeking fertility treatment.Observational studies were searched in Ovid MEDLINE, Web of Science, Embase, and PsycInfo. Studies published prior to September 2020 when the search was conducted were considered. Inclusion criteria included (1) original and empirical research, (2) published in a peer-reviewed journal, and (3) reported on disordered eating among women seeking fertility treatment in the sample or reported on prevalence of eating disorders among women seeking fertility treatment in the sample. Independent screening of abstracts was conducted by two authors (LH and AH). Ten studies met the inclusion criteria. Sample size, study location, measures, and results for each study in this review were reported.Among women pursuing fertility treatment, rates of current eating disorders ranged from 0.5 to 16.7%, while past eating disorder prevalence rates ranged from 1.4 to 27.5%. Current anorexia nervosa or bulimia nervosa was reported by up to 2% and 10.3% of women, respectively, while history of anorexia nervosa or bulimia nervosa was reported by up to 8.5% and 3.3% of women, respectively. Binge eating disorder or other eating disorders were reported by up to 18.5% and 9.1% of women, respectively. Disordered eating pathology was endorsed by 1.6 to 48% of women seeking fertility treatment. Endorsement of pathological eating attitudes was generally higher among women seeking fertility treatment with current or past eating disorders as compared to community samples, with the exception of dietary restraint. Rates of current and past eating disorders are higher among women seeking fertility treatment than in the general population. Providers treating women with infertility should be cognizant of these prevalence rates and consider screening for eating pathology in their patients as this may contribute to their likelihood of successful conception and/or subsequent pregnancy outcomes.

Insulin Restriction or Omission in Type 1 Diabetes Mellitus: A Meta-synthesis of Individuals' Experiences of Diabulimia

OBJECTIVE

Unique to individuals with insulin-dependent diabetes mellitus (IDDM) is a disordered eating behaviour whereby insulin is deliberately restricted or omitted. Despite growing research in this area, experiential perspectives of individuals remain understudied. Therefore, the purpose of this meta-synthesis was to explore the experiences of individuals with Type 1 Diabetes Mellitus (T1DM) by identifying, analysing and synthesising existing knowledge concerning their misuse of insulin for weight control.

DESIGN

Meta-aggregative techniques were employed to generate synthesised findings related to individuals' understanding and experience, physical and psychological impacts, support and treatment-related needs and experiences, noted in twelve studies.

RESULTS

A multifaceted relationship with the unique disordered eating behaviour, beyond weight control was identified. Many individuals experienced a wide range of diabetes-related complications from insulin restriction and omission alongside increased distress, loss of control and feelings of regret, guilt, and shame later in life. Almost all individuals valued peer support from those who shared a 'diabulimic' identity; peer support appeared more conducive to recovery than support from friends, family and formal support services, which were not uniformly supportive.

CONCLUSIONS

This meta-synthesis revealed valuable information from individuals with diabulimia which has widespread interdisciplinary implications and may provide useful guidance concerning the prevention and treatment of this unique behaviour. The results highlight the need for empathic, collaborative care, and proactive prevention and early intervention. Furthermore, the findings highlight the value of peer support in recovery, the need for increased knowledge among family and friends, training among multidisciplinary teams and support services, and crucially the development of evidence-based treatments informed by the behaviour as a unique distinct construct.

Obsessed with Healthy Eating: A Systematic Review of Observational Studies Assessing Orthorexia Nervosa in Patients with Diabetes Mellitus

Orthorexia nervosa (ON) is an unspecified feeding or eating disorder (USFED) characterized by an exaggerated, unhealthy obsession with healthy eating. Τypical eating disorders (EDs) and USFEDs are common among patients with diabetes mellitus (DM), which complicates metabolic control and disease outcomes. The present systematic review summarizes the evidence on the prevalence of ON symptomatology among patients with DM. PubMed, Web of Science, Scopus, and grey literature were searched, and relevant observational studies were screened using the Rayyan software. The quality of the studies was assessed using the appraisal tool for cross-sectional studies (AXIS) and the Newcastle-Ottawa scale (NOS). Out of 4642 studies, 6 fulfilled the predefined criteria and were included in the qualitative synthesis. Most studies relied on the ORTO-15 or its adaptations to identify ON among patients with DM. No apparent sex or age differences exist regarding the prevalence of ON symptoms. None of the studies compared the prevalence of ON in patients with type 1 and type 2 DM. Most of the research was of average to good methodological quality. In conclusion, patients with DM often exhibit ON tendencies, although research is still limited regarding the etiology or mechanistic drivers behind ON and the characteristics of patients with a dual ON-DM diagnosis.

Sex-Related Differences in Cardiovascular Disease Risk Profile in Children and Adolescents with Type 1 Diabetes

Cardiovascular disease (CVD) is the primary cause of higher and earlier morbidity and mortality in people with type 1 diabetes (T1D) compared to people without diabetes. In addition, women with T1D are at an even higher relative risk for CVD than men. However, the underlying pathophysiology is not well understood. Atherosclerotic changes are known to progress early in life among people with T1D, yet it is less clear when excess CVD risk begins in females with T1D. This review explores the prevalence of classical CVD risk factors (such as glycemic control, hypertension, dyslipidemia, obesity, albuminuria, smoking, diet, physical inactivity), as well as of novel biomarkers (such as chronic inflammation), in children and adolescents with T1D with particular regard to sex-related differences in risk profile. We also summarize gaps where further research and clearer clinical guidance are needed to better address this issue. Considering that girls with T1D might have a more adverse CVD risk profile than boys, the early identification of and sex-specific intervention in T1D would have the potential to reduce later CVD morbidity and excess mortality in females with T1D. To conclude, based on an extensive review of the existing literature, we found a clear difference between boys and girls with T1D in the presence of individual CVD risk factors as well as in overall CVD risk profiles; the girls were on the whole more impacted.

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.

Diabetes technologies in people with type 1 diabetes mellitus and disordered eating: A systematic review on continuous subcutaneous insulin infusion, continuous glucose monitoring and automated insulin delivery

AIMS

In this systematic review, we aimed (1) to identify and describe research investigating the use of advanced diabetes technologies (continuous subcutaneous insulin infusion, CSII; continuous glucose monitoring, CGM; automated insulin delivery, AID) in people with type 1 diabetes (T1DM) and disordered eating and (2) to discuss potential (dis)advantages of diabetes technology use in this population, derived from previous research.

METHODS

We conducted a systematic literature search in two electronic databases for English articles published between 2000 and 2020 addressing eating disorders and/or dysfunctional eating behaviours and diabetes technology use in children, adolescents and adults with T1DM (PROSPERO ID CRD42020160244).

RESULTS

Of 70 publications initially identified, 17 were included. Overall, evidence on the use of diabetes technologies in people with T1DM and disordered eating is scarce. The majority of the studies reports findings on CSII in people with T1DM and dysfunctional eating behaviours or eating disorders. Findings predominantly stem from observational data and are, in most cases, secondary findings of the respective studies. Providing the greatest flexibility in diabetes management, CSII may have benefits in disordered eating. CGM data may complement the diagnostic process of disordered eating with a physiological indicator of insulin restriction (i.e. time spent in hyperglycaemia).

CONCLUSIONS

Results on possible (dis)advantages of diabetes technology use in people with T1DM and disordered eating are based on observational data, small pilot trials and anecdotical evidence from case reports. Prospective data from larger samples are needed to reliably determine potential effects of diabetes technology on disordered eating in T1DM.

Disordered Eating Behaviors Among Italian Adolescents with Type 1 Diabetes: Exploring Relationships with Parents' Eating Disorder Symptoms, Externalizing and Internalizing Behaviors, and Body Image Problems

The purpose of this study is to examine associations of disordered eating behaviors (DEBs) with body image problems, parents' eating disorder symptoms, and emotional and behavioral problems among adolescents with type 1 diabetes (T1D). 200 adolescents (M age = 15.24 ± 1.45 years) with T1D completed a self-report measure of DEBs and body ideal internalization, and their parents completed self-report measures of parents' eating problems and child's psychological symptoms. Seventy-three (36.5%) adolescents were DEPS-r-positive (scores ≥ 20), with higher rates among girls (χ² = 9.034, p = .003). Adolescents with T1D and DEBs reported lower SES, worse metabolic control, higher zBMI (p < .001), more eating disorder symptoms, more body image problems, and more emotional and behavioral problems than adolescents with T1D but no DEBs (all p < .05). Parents of adolescents with DEBs showed higher levels of bulimia (p = .028) than parents of adolescents without DEBs. In both genders, pressure to conform to societal norms about body image (p < .01) and externalization symptoms (p < .05) emerged as significant predictors of DEBs. Findings suggest that adolescents with T1D and DEBs showed an alarming psychological condition, with higher level of body image and more emotional and behavioral problems.

Disordered eating behaviors in youths with type 1 diabetes during COVID-19 lockdown: an exploratory study

BACKGROUND

Recent research indicates that patients with type 1 diabetes (T1D) are at higher risk for disordered eating behaviors (DEBs) than their peers without diabetes. The present study aimed to explore the prevalence of DEBs in a sample of Italian children and adolescents with T1D and in matched-pair healthy controls during the COVID-19 lockdown.

METHODS

In a cross-sectional study, 138 children and adolescents with T1D (aged 8.01-19.11 years, 65 boys) attending a Southern Italian diabetic service and 276 age- and gender-matched healthy peers voluntarily completed an online survey about eating behaviors (ChEAT and EAT-26), anthropometric characteristics, and clinical characteristics.

RESULTS

8.69% (N = 12) of participants with T1D and 13.4% (N = 37) of controls had ChEAT/EAT-26 scores indicating presence of DEBs, with no differences between patients-whether children (total ChEAT score F(1, 157) = .104, p = .748) or adolescents (total EAT-26 score F(1, 255) = .135, p = .731)-and healthy peers. zBMI values were lower than those measured in the latest diabetes visit (p < .0001), while HbA1c values remained unchanged (p = .110). In both groups, adolescents had lower Oral Control scores than children (T1D: F(1, 138) = 20.411, p < .0001, η2 = .132, controls: F(1, 276) = 18.271, p < .0001, η2 = .063); additionally, gender (female) and age were found to be significant predictors of several ChEAT/EAT-26 scores.

CONCLUSIONS

This exploratory study suggested that children and adolescents with T1D did not experience more DEB symptoms during the COVID-19 lockdown compared to healthy controls. Results revealed DEBs as more of a female adolescent developmental issue rather than a result of the challenges of living with a chronic illness under quarantine measures. Possible effects of parental pressure on their children's eating behaviors in the context of home confinement and of using a non-diabetes-specific measure to assess DEBs are discussed.

Eating disorders in adolescents with type 1 diabetes mellitus

PURPOSE OF REVIEW

Eating disorders represent one of the most common psychiatric disorders in adolescents with type 1 diabetes mellitus (T1DM), with a prevalence twice as high as in individuals without diabetes. The increased risk for acute and long-term medical complications and a three-fold mortality rate with this dual condition makes it extremely important to screen adolescents for eating disorders as soon as possible.

RECENT FINDINGS

A number of 13 surveys in the last two years focussed on prevalence rates of disordered eating and associations with sociodemographic, eating disorder-specific and diabetes-related factors in this population. Variations in study design, sample size, age range, sex, instruments to assess eating disorders and outcome make comparisons difficult. Healthcare professionals report challenges in detecting and treating adolescents with this dual condition because of a lack of validated screening tools, guidelines, and integration across specialist care. Studies on psychological treatments for the comorbidity of eating disorders and T1DM are scarce, especially for adolescents.

SUMMARY

The development and evaluation of psychological treatments for adolescents with eating disorders and T1DM are urgently needed.

Psychische Komorbiditäten bei Jugendlichen und jungen Erwachsenen mit Typ-1-Diabetes

Jugendliche und junge Erwachsene mit Typ-1-Diabetes sind häufig von komorbiden psychischen Störungen betroffen. Dabei zeigt die Studienlage zur Verbreitung ein heterogenes und inkonsistentes Bild. Diagnose und Behandlung der somatopsychischen Begleiterkrankungen beeinflussen den Behandlungs- und Krankheitsverlauf sowie die Lebensqualität der Betroffenen. Trotzdem wird dies in der klinischen Praxis selten frühzeitig berücksichtigt. Das multizentrische Verbundprojekt COACH verfolgt das Ziel, die Erkennung und Behandlung psychischer Komorbidität für diese Zielgruppe in der bundesweiten Routineversorgung zu optimieren.

Diabetes and eating disorders: an exploration of 'Diabulimia'

Background

‘Diabulimia’ is the term given to the deliberate administration of insufficient insulin for the purpose of weight loss. Although Diabulimia can be life-threatening and prevalence rates in diabetes are high, there is a lack of research for how to effectively support people with the condition. This exploratory study aimed to provide much-needed information to healthcare professionals and guide the focus for future research.

Methods

Forty-five individuals with Type 1 diabetes mellitus (T1DM) and a history of insulin misuse completed an online questionnaire. This included an assessment of their eating disorder psychopathology with the Eating Disorder Examination Questionnaire (EDE-Q) and 16 open-ended questions exploring their experience of Diabulimia. The responses to the open-ended questions were analysed using thematic analysis.

Results

The average global EDE-Q score was 3.96 (1.21), which is consistent with eating disorder populations. Common themes identified were concerns about weight, difficulty coping with diabetes, past trauma, and the importance of relationships. Experiences with health professionals were overwhelmingly negative. Most participants had experienced serious medical intervention due to Diabulimia and were fully aware of the consequences of insulin restriction.

Conclusions

Overall, individuals believed that a greater awareness of Diabulimia and more training for healthcare professionals is needed. While education on insulin misuse may be a necessary first step in treatment, psychological support is crucial. To deliver effective treatment, clinicians should be aware of the specific issues facing those with Diabulimia. The current study identified themes that clinicians may find useful to consider.

Body Image Problems and Disordered Eating Behaviors in Italian Adolescents With and Without Type 1 Diabetes: An Examination With a Gender-Specific Body Image Measure

Objective

To examine body image problems and their associations with disordered eating behavior in adolescents with type 1 diabetes and well-matched healthy peers.

Methods

Using a cross-sectional design, 183 adolescents with type 1 diabetes (13.02–18.05 years) were recruited from diabetes centers in southern Italy and compared to healthy peers matched for age and gender. Participants completed self-report measures of disordered eating behaviors (DEPS-r and EDI-3RF) and a gender-specific body image problem questionnaire (SATAQ-4R). Socio-demographic and clinical data (zBMI, HbA1c, and disease duration) were also collected. Hierarchical multiple linear regression analyses were computed to determine the relative importance of diabetes variables and body image problems on participants’ disordered eating behaviors after controlling for demographic variables.

Results

Adolescents with type 1 diabetes showed diabetes-specific eating problems in 37.7% of cases and had more eating problem symptoms (assessed as drive for thinness and bulimia) than healthy peers. Male adolescents with type 1 diabetes did not display more body image problems (p > 0.05); females with type 1 diabetes compared to females in the control group were found to be more pressured by family (p = 0.025) but less by media (p = 0.022) to improve their appearance and attain a thin body. zBMI and body image problems contributed to a significant increase in disordered eating behavior risk both in male and female adolescents with diabetes and in healthy peers (zBMI 0.213 < β < 0.426, p < 0.05; body image 0.243 < β < 0.572, p < 0.05). None of the variables analyzed were found to significantly predict male bulimic symptoms (all β < 0.296, p > 0.05).

Conclusion

Since in adolescence type 1 diabetes and insulin therapy may increase the risk of weight gain and promote focus and attention on the body and thus contribute to the development of body image problems and disordered eating behaviors, continuity of medical, nutritional, and psychological care is needed.

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.

Screening and identification of disordered eating in people with type 1 diabetes: A systematic review

People with Type 1 diabetes (T1D) have been shown to be an at-risk group for the development of disordered eating behaviours, however, the validity of tools used to assess disordered eating behaviours in T1D is unclear. This review aimed to identify tools used to screen or identify disordered eating behaviours and eating disorders in people with T1D, and evaluate the validity and reliability of these tools. A systematic search strategy was conducted to October 2019 according to the PRISMA guidelines. The search strategy retrieved 2714 articles, with 100 articles describing 90 studies included in the review. Studies were predominantly conducted in adolescent females in clinical settings. Forty-eight individual tools were used across retrieved studies. Overall, the quality of tools reported in included articles was poor, with high risk of bias due to the use of non-validated tools (n = 44 articles) and few studies comparing to the reference standard (n = 10 articles) of a diagnostic interview. This review shows that a variety of tools have been used to screen and identify disordered eating behaviours and eating disorders in people with T1D. Future research including comparison to a gold standard diagnostic interview is warranted to further evaluate the validity and reliability of available tools.

An Examination of Sex Differences in a Disease-Specific Model of Disordered Eating Behaviors in Type 1 Diabetes

OBJECTIVE

Preliminary evidence supports the integration of type 1 diabetes (T1D) disease-specific factors into eating disorder risk models. The current study explored whether cross-sectional associations among constructs included in the modified dual pathway model of eating disorder risk for individuals with T1D are similar across sex among adolescents and young adults with T1D.

METHODS

Original study participants were recruited from the T1D Exchange Clinic Network, a U.S. registry of individuals with T1D. Online surveys included measures of general eating disorder risk factors, hypothesized T1D-specific risk factors, and a T1D-specific eating disorder questionnaire. The current study is a secondary analysis with the adolescents (13-17 years; n = 307; 46.9% female) and young adults (18-25 years; n = 313; 62.6% female) from the original sample. In the absence of strong measurement invariance for all measures of interest, sex-specific path models were estimated among the adolescent and young adult cohorts.

RESULTS

Only two paths emerged as significant in the female, but not male, adolescent model. In the young adult cohort, all significant paths were the same across sex.

CONCLUSIONS

Both general and T1D-specific risk factors are associated with disordered eating behaviors in the T1D population. Patterns of associations were similar across male and female youth with T1D, suggesting that sex-specific prevention approaches to disordered eating behaviors among T1D youth may not be warranted.

Carbohydrate Intake in the Context of Exercise in People with Type 1 Diabetes

Although the benefits of regular exercise on cardiovascular risk factors are well established for people with type 1 diabetes (T1D), glycemic control remains a challenge during exercise. Carbohydrate consumption to fuel the exercise bout and/or for hypoglycemia prevention is an important cornerstone to maintain performance and avoid hypoglycemia. The main strategies pertinent to carbohydrate supplementation in the context of exercise cover three aspects: the amount of carbohydrates ingested (i.e., quantity in relation to demands to fuel exercise and avoid hypoglycemia), the timing of the intake (before, during and after the exercise, as well as circadian factors), and the quality of the carbohydrates (encompassing differing carbohydrate types, as well as the context within a meal and the associated macronutrients). The aim of this review is to comprehensively summarize the literature on carbohydrate intake in the context of exercise in people with T1D.

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.

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.

Course, risk factors, and adverse outcomes of disordered eating in pregnancy

OBJECTIVE

Although eating disorders in pregnancy have been studied extensively, little research attention has been given to disordered eating. The objectives of the present study were to determine the prevalence and levels of disordered eating in the perinatal period, and to identify risk factors and adverse outcomes of disordered eating during pregnancy.

METHOD

A prospective longitudinal design with a quantitative approach was adopted. A consecutive sample of 1,470 Chinese pregnant women from hospitals in Hong Kong was assessed using standardized instruments at five time points from the first trimester to 6 months postpartum.

RESULTS

The levels of disordered eating changed significantly across trimesters. Higher levels of disordered eating in pregnancy were significantly associated with higher levels of disordered eating at 6 weeks and 6 months postpartum, greater anxiety and depressive symptoms, lower 1-min Apgar scores, and abnormal birth weight.

DISCUSSION

The present study pointed to the need for more research and clinical attention to antenatal disordered eating given that it is associated with anxiety, depression, postpartum disordered eating and obstetric outcomes.

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.

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.

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.

Disordered eating and insulin restriction in type 1 diabetes: A systematic review and testable model

AIM

To provide an overview of the existing literature pertaining to insulin restriction as a disordered eating behaviour in individuals with type 1 diabetes and present a novel maintenance model: The Transdiagnostic Model of Disordered Eating in Type 1 Diabetes.

METHOD

A systematic review was conducted of the current literature relevant to insulin restriction and/or omission in the context of disordered eating in type 1 diabetes. A new maintenance model was then developed by incorporating diabetes-specific factors into existing eating disorder models.

RESULTS

Type 1 diabetes may complicate the development and maintenance of disordered eating behaviour. Diabetes-specific circumstances, including disease diagnosis, insulin management, insulin restriction, and diabetes-related complications, contribute to the maintenance of disordered eating cognitions and behaviours.

DISCUSSION

The proposed model offers a comprehensive representation of insulin restriction as a disordered eating behaviour in type 1 diabetes. Future research should test the model to further understand the mechanisms underlying disordered eating in type 1 diabetes and inform treatments for this at-risk population.

Are children with chronic illnesses requiring dietary therapy at risk for disordered eating or eating disorders? A systematic review

OBJECTIVE

Pediatric chronic illnesses (CI) can affect a child's mental health. Chronic illnesses with treatment regimens that specify a therapeutic diet may place the child at increased risk for disordered eating and specific eating disorders (ED). The aim of this review is to examine the relation between diet-treated CI and disordered eating and to determine the order of onset to infer directionality. Diet-treated CI is hypothesized to precede and to be associated with disordered eating.

METHOD

A comprehensive search of empirical articles that examine the relation between diet-treated CI (diabetes, cystic fibrosis, celiac disease, gastrointestinal disorders, and inflammatory bowel diseases) and disordered eating was conducted in Medline and PsycINFO using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A table of the sample's characteristics, ED measures, major pertinent findings, and the onset of CI in relation to ED were provided.

RESULTS

Diet-treated CI was associated with disordered eating and ED. Diet-treated CI had onset prior to disordered eating in most studies, except for inflammatory bowel diseases. Disordered eating and unhealthy weight management practices put children at risk for poor medical outcomes.

DISCUSSION

Interventions for diet-treated CI require a focus on diet and weight, but may increase the risk for disordered eating. Future research is needed to elucidate the mechanisms that transform standard treatment practices into pathological eating, including characteristics and behaviors of the child, parents/care providers, family, and treatment providers.

Understanding antagonism and synergism: A qualitative assessment of weight management in youth with Type 1 diabetes mellitus

Aims

No current clinical guidelines focus on weight management in youth with type 1 diabetes mellitus (T1DM). Our aim was to characterize the patient-perceived experience and barriers to weight management in youth with T1DM.

Methods

Participants were recruited from the University of North Carolina (n = 16, 56% female, 60% White, 50% insulin pump users, mean age 14.8 years, mean HbA1c 8.5% (69 mmol/mol)) and the University of Colorado (n = 18, 50% female, 80% white, 53% pump users, mean age 15.3 years, mean HbA1c 9.3% (78 mmol/mol)). Focus groups were stratified by sex and weight status (BMI cutoff = 25). Discussions were guided by a standardized set of questions, audio-taped, transcribed, and analyzed thematically using inductive qualitative methods.

Results

Youth with T1DM expressed four interrelated themes of antagonism between type 1 diabetes and weight management: dysregulated appetite, disruption of blood glucose levels associated with changing diet/exercise, hypoglycemia as a barrier to weight loss, and the overwhelming nature of dual management of weight and glycemic control, and two interrelated themes of synergism: improvement in shared, underlying heath behaviors and exercise as a tool for weight and glycemic control. Variation in emphasis of specific thematic elements was greatest across sex. Youth identified five major components of a weight management program for T1DM: intensified glucose management, healthy diet with known carbohydrate content, exercise, individualization and flexibility, and psychosocial and peer support.

Conclusions

There is critical need for personalized, T1DM-specific weight recommendations to overcome disease-specific barriers to weight management in the context of T1DM.

Disordered eating behaviour in young adults with type 1 diabetes mellitus

BACKGROUND

The combination of eating disorders and diabetes is associated with increased risk of morbidity and mortality. The aim of this study is to compare the prevalence of disordered eating behaviour (DEB) in young adults with type 1 diabetes mellitus to a sample of non-diabetic controls, and to examine the relationship of DEB to glycaemic control.

METHODS

The Eating Disorder Examination Questionnaire (EDE-Q) was administered to 51 individuals aged 18-30 years attending an outpatient diabetic clinic in a large university teaching hospital. Glycaemic control was assessed by the glycosylated haemoglobin (HbA1c). The control group comprised a consecutive sample of 236 male and female students aged 18-30 years attending a university primary health care service.

RESULTS

The mean global EDE-Q score for the diabetes group was 0.82 ± 1.1 (mean ± SD) and the mean for the control group was 1.4 ± 1.3 (mean ± SD). The diabetes group was significantly more likely to have a lower global EDE-Q score compared to the control group. There was no association between the global EDE-Q score of the diabetes group and HbA1c level.

CONCLUSIONS

We did not find increased levels of disordered eating behavior (DEB) in young adults with type 1 diabetes mellitus compared to a non-diabetic control sample.

Disordered Eating Behaviors in Emerging Adults With Type 1 Diabetes: A Common Problem for Both Men and Women

INTRODUCTION

Emerging adults (EA) with disordered eating behaviors (DEBs) and Type 1 diabetes (T1D) are at increased risk for severe complications of T1D, and these behaviors have been reported in EA women with T1D. Few studies, though, have included men. This study assessed the prevalence of DEB in both EA men and women with T1D.

METHODS

DEB was measured with the diabetes-specific Diabetes Eating Problem Survey-Revised (DEPS-R); scores of 20 or greater indicate need for further evaluation for DEB.

RESULTS

A total of 27 women and 33 men (age range = 21 ± 2.5 years) completed the DEPS-R; 27% of women and 18% of men had scores of 20 or greater (p = .23). Hemoglobin A1c level was significantly higher in subjects with elevated DEPS-R scores (10.4 ± 2.1% vs. 7.8 ± 1.3%; p < .001), and DEPS-R scores correlated with increased body mass index values (r = 0.27, p < .05).

DISCUSSION

Clinicians should assess for DEB in both male and female emerging adults with T1D, especially overweight patients with poor glycemic control.

Disordered eating and insulin restriction in youths receiving intensified insulin treatment: Results from a nationwide population-based study

OBJECTIVE

This Germany-wide population-based study sought to estimate the prevalence of disordered eating and insulin restriction (IR) among 819 youths aged 11-21 years with early-onset type 1 diabetes (T1D) and a disease duration of at least 10 years.

METHODS

All respondents answered the five-item SCOFF screening questionnaire for eating disorders (EDs) and reported on the frequency of IR and clinical outcomes. Screening for disordered eating was positive when more than two SCOFF items were answered affirmatively. Frequent IR was defined as IR occurring more than five times per week.

RESULTS

A total of 28.2%/9.2% of the female/male patients were SCOFF-positive without IR and 4.2%/5.3% reported frequent IR but were SCOFF-negative; 2.7%/1.9% screened positive for both disordered eating and IR. Patients with disordered eating, frequent IR, or both showed significantly worse glycemic control and partly more inpatient-treated diabetic ketoacidoses than patients who screened negative.

DISCUSSION

Approximately one in three female and one in six male patients with early-onset long-duration T1D reported disordered eating and/or frequent IR. Because of their association with worse outcomes, both disordered eating and IR should be considered in T1D care irrespective of sex, age at onset, and diabetes duration.

Medical Complications of Anorexia Nervosa and Bulimia

Anorexia nervosa and bulimia nervosa are serious psychiatric illnesses related to disordered eating and distorted body images. They both have significant medical complications associated with the weight loss and malnutrition of anorexia nervosa, as well as from the purging behaviors that characterize bulimia nervosa. No body system is spared from the adverse sequelae of these illnesses, especially as anorexia nervosa and bulimia nervosa become more severe and chronic. We review the medical complications that are associated with anorexia nervosa and bulimia nervosa, as well as the treatment for the complications. We also discuss the epidemiology and psychiatric comorbidities of these eating disorders.

Psychometric properties of the German version of the Diabetes Eating Problem Survey-Revised: additional benefit of disease-specific screening in adolescents with Type 1 diabetes

AIM

To examine the psychometric properties of the German version of the abbreviated 16-item Diabetes Eating Problem Survey-Revised in a sample of young people with Type 1 diabetes.

METHODS

A total of 246 young people, aged 11-19 years, with Type 1 diabetes from six pediatric diabetes centres in Germany were assessed using the Diabetes Eating Problem Survey-Revised. In addition, they underwent screening with two generic tools as well as the WHO five-question well-being index. A clinician's report was also obtained.

RESULTS

The Diabetes Eating Problem Survey-Revised was found to have good internal consistency (Cronbach's α = 0.84). The Diabetes Eating Problem Survey-Revised scores significantly correlated with those provided by the non-specific screening tools (r = 0.37, P ≤ 0.000 and r = 0.50, P ≤ 0.000 for boys and r = 0.62, P ≤ 0.000 and r = 0.79, P ≤ 0.000 for girls), indicating convergent validity. The mean (sd) total of the scores was 12.0 (9.6). Criterion validity was confirmed against HbA1c value, BMI standard deviation score and expert (clinician) report. Of the boys included in the study, 11 scored higher than the threshold score on the Diabetes Eating Problem Survey-Revised, of whom only three (27%) were classified as 'suspected to have a disordered eating behaviour' by their clinicians.

CONCLUSIONS

The Diabetes Eating Problem Survey-Revised delivered more specific information than generic screening instruments and identified more young people with eating disorders than did clinician report, especially regarding the detection of boys at risk. The results of this study support the utility of the German version of the Diabetes Eating Problem Survey-Revised to identify eating disorders in young people with Type 1 diabetes at an early stage. (German Clinical Trials Registry no.: DRKS00004699).

Symptoms of Eating Disorders and Depression in Emerging Adults with Early-Onset, Long-Duration Type 1 Diabetes and Their Association with Metabolic Control

Background

This study analyzed the prevalence of and association between symptoms of eating disorders and depression in female and male emerging adults with early-onset, long-duration type 1 diabetes and investigated how these symptoms are associated with metabolic control.

Methods

In a nationwide population-based survey, 211 type 1 diabetes patients aged 18-21 years completed standardized questionnaires, including the SCOFF questionnaire for eating disorder symptoms and the Patient Health Questionnaire (PHQ-9) for symptoms of depression and severity of depressive symptoms (PHQ-9 score). Multiple linear and logistic regression models were used to analyze the association between eating disorder and depressive symptoms and their associations with HbA1c.

Results

A total of 30.2% of the women and 9.5% of the men were screening positive for eating disorders. The mean PHQ-9 score (standard deviation) was 5.3 (4.4) among women and 3.9 (3.6) among men. Screening positive for an eating disorder was associated with more severe depressive symptoms among women (β_women 3.8, p<0.001). However, neither eating disorder symptoms nor severity of depressive symptoms were associated with HbA1c among women, while HbA1c increased with the severity of depressive symptoms among men (β_men 0.14, p=0.006).

Conclusions

Because of the high prevalence of eating disorder and depressive symptoms, their interrelationship, and their associations with metabolic control, particularly among men, regular mental health screening is recommended for young adults with type 1 diabetes.