Eating disorders in females with type 1 diabetes: an update of a meta-analysis

Association Between Type 1 Diabetes Mellitus and Eating Disorders: A Systematic Review and Meta-Analysis

BACKGROUND

Previous meta-analyses have shown mixed results regarding the association between eating disorders (EDs) and type 1 diabetes mellitus (T1DM). Our paper aimed to analyse different EDs and disordered eating behaviours that may be practiced by patients with T1DM.

METHODS

A literature search of PubMed, Scopus and Web of Science was conducted on 17 January 2023, using the key terms "T1DM," "Eating Disorders" and "Bulimia." Only observational controlled studies were included. The Revman software (version 5.4) was used for the analysis.

RESULTS

T1DM was associated with increased risk of ED compared with nondiabetic individuals (RR = 2.47, 95% CI = 1.84-3.32, p-value < 0.00001), especially bulimia nervosa (RR = 2.80, 95% CI = 1.18-6.65, p-value = 0.02) and binge eating (RR = 1.53, 95% CI = 1.18-1.98, p-value = 0.001). Our analysis has shown that increased risk of ED among T1DM persisted regardless of the questionnaire used to diagnose ED; DM-validated questionnaires (RR = 2.80, 95% CI = 1.91-4.12, p-value < 0.00001) and generic questionnaires (RR = 2.03, 95% CI = 1.27-3.23, p-value = 0.003). Prevalence of insulin omission/misuse was 10.3%; diabetic females demonstrated a significantly higher risk of insulin omission and insulin misuse than diabetic males.

CONCLUSION

Our study establishes a significant and clear connection between EDs and T1DM, particularly bulimia and binge eating, with T1DM. Moreover, female diabetics are at higher risk of insulin misuse/omission. Early proactive screening is essential and tailored; comprehensive interventions combining diabetes and ED components are recommended for this population, with referral to a specialised psychiatrist.

A pilot study of a virtually delivered dissonance-based eating disorder prevention program for young women with type 1 diabetes: within-subject changes over 6-month follow-up

INTRODUCTION

In an uncontrolled study, we previously demonstrated the feasibility and preliminary efficacy of our virtual diabetes-specific version (Diabetes Body Project) of the eating disorder (ED) prevention program the Body Project. The aim of the current study was to evaluate further this program for women with type 1 diabetes (T1D) by assessing within-subject changes in outcomes from pretest over 6-month follow-up.

METHODS

Young women with T1D aged 16-35 years were invited to participate in Diabetes Body Project groups. A total of 35 participants were allocated to five Diabetes Body Project groups (six meetings over 6 weeks). Primary outcome measures included ED risk factors and symptoms, and secondary outcomes included three T1D-specific constructs previously found to be associated with ED pathology: glycemic control as measured by HbA1c level, diabetes distress, and illness perceptions.

RESULTS

Within-subject reductions, with medium-to-large effect sizes, were observed for the primary (ED pathology, body dissatisfaction, thin-ideal internalization, and appearance ideals and pressures) and secondary outcomes (within-condition Cohen's ds ranged from .34 to 1.70).

CONCLUSION

The virtual Diabetes Body Project appears to be a promising intervention worthy of more rigorous evaluation. A randomized controlled trial with at least a 1-year follow-up is warranted to determine its efficacy compared to a control condition.

Prevalence and risk factors of disordered eating behavior in youth with hypertension disorders

BACKGROUND

Adolescents with certain health conditions requiring lifestyle management, such as diabetes mellitus, have higher disordered eating behavior (DEB) risk than the general adolescent population, but DEB is underdiagnosed and can lead to adverse health consequences. In youth with other conditions requiring lifestyle counseling such as hypertension (HTN), DEB prevalence and associated risk factors are unknown. We hypothesized that youth with HTN disorders would have higher DEB prevalence than the general adolescent population, and that obesity, chronic kidney disease (CKD), and less specialized lifestyle counseling would be associated with higher DEB risk.

METHODS

Prospective cross-sectional study of youth aged 11-18 years with HTN disorders. We excluded patients with diabetes mellitus, kidney failure or transplantation, or gastrostomy tube dependence. We collected data via surveys and electronic health record abstraction. We administered the validated SCOFF DEB screening questionnaire. We compared DEB prevalence using a one-sample z-test of proportions (p0 = 0.1) and estimated DEB risk by obesity, CKD, and lifestyle counseling source using multivariable generalized linear models.

RESULTS

Of 74 participants, 59% identified as male, 22% as Black or African American, and 36% as Hispanic or Latino; 58% had obesity and 26% had CKD. DEB prevalence was 28% (95% CI 18-39%, p < 0.001). CKD was associated with higher DEB prevalence (adjusted RR 2.17, 95% CL 1.09 to 4.32), but obesity and lifestyle counseling source were not.

CONCLUSIONS

DEB prevalence is higher in youth with HTN disorders and comparable to other conditions requiring lifestyle counseling. Youth with HTN disorders may benefit from DEB screening. A higher resolution version of the Graphical abstract is available as Supplementary information.

Eating Disorders and Diabetes: Facing the Dual Challenge

Eating disorders and diabetes mellitus are distinct yet closely linked health conditions, presenting distinct challenges in terms of care and management. Eating disorders encompass a spectrum of mental health disorders characterized by abnormal eating behaviors and disruptions in weight regulation. Research indicates that individuals with diabetes might be at an elevated risk of developing eating disorders. The necessity to adhere to specific dietary guidelines, monitor blood sugar levels vigilantly, and manage drug administration can collectively contribute to the emergence of detrimental attitudes toward food and body image. On the other hand, incorrect eating behaviors such as binge eating and purging can disrupt blood sugar control, significantly impacting the development and management of diabetes. This intricate relationship emphasizes the crucial necessity for a comprehensive understanding and specialized care to effectively address the dual challenges faced by individuals dealing with both diabetes and eating disorders. This paper represents the inaugural comprehensive review delving into the intricate connection between eating disorders and diabetes, thereby illuminating previously under-researched areas. The insights gleaned from this review may contribute to developing integrated interventions that aim to improve the overall well-being and quality of life for individuals grappling with the complexities of eating disorders and diabetes.

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.

Patients' perspectives on screening for disordered eating among adolescents with type 1 diabetes

PURPOSE

People with type 1 diabetes have an increased risk of disordered eating (DE) and eating disorders (ED). Screening is recommended however little is known about patients' perspectives on screening questionnaires. This paper reports qualitative analyses of patients' perspectives on the questionnaire Diabetes Eating Problem Survey Revised (DEPS-R), including acceptability, attitudes, and cognitive understanding.

RESEARCH DESIGN AND METHODS

15 adolescents with type 1 diabetes between 11 and 18 years, were interviewed. A semi-structured format and a qualitative Interpretive Descriptive (ID) methodology was chosen.

RESULTS

The analyses identified four themes: (1) The Questionnaire, (2) Reframing Diabetes Visits, (3) This is (not) for me, and (4) Out in the Open. The DEPS-R was completed with-in 5-10 min. with no technical difficulties. The questionnaire altered the diabetes visit for some, creating a new dialog, and time for self-reflection. Adolescents appreciated the direct approach in the questionnaire, and showed willingness to complete the questionnaire, when presented to them by a health care professional (HCP). One item in the DEPS-R proved difficult to understand for some participants.

CONCLUSION

The study highlights DEPS-R as a clinically relevant screening questionnaire. Completing DEPS-R prior to a consultation opens the door to a consultation that invites the adolescent to address matters of eating behavior. Our findings suggest that systematic screening of DE/ED using the DEPS-R is both accepted and welcomed by adolescents with type 1 diabetes. Future research should focus on a potential update of selected items in DEPS-R.

LEVEL OF EVIDENCE

V - qualitative study.

Associations between diabetic retinopathy, mortality, disease, and mental health: an umbrella review of observational meta-analyses

BACKGROUND

Diabetic retinopathy is a complication of diabetes affecting the eyes and can lead to blindless if left untreated. Several significant risk factors have been reported for DR, of which several can be classified as some form of disease. Furthermore, several systematic reviews have reported associations between several types of mortality and DR. Numerous meta-analyses have pooled the data on these factors, however, a systematic evaluation of these meta-analytic relationships is lacking. In this study, therefore, we performed an umbrella review of systematic reviews of meta-analyses for mortality, diseases and DR, grading the credibility of evidence.

METHODS

A comprehensive database search for observational meta-analyses was conducted from inception until 29/04/2022 against pre-published inclusion criteria. For each meta-analytic outcome, a random-effects meta-analysis was re-conducted, stratifying by study design (and type of DR where possible) of included studies. Several statistical variables, including publication bias, heterogeneity, excess significance bias, and prediction intervals were used to grade the credibility of significant evidence from I to IV, using the recommendations from the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria.

RESULTS

Of the 1,834 initial results, 11 systematic reviews with meta-analyses were included covering 16 independent outcomes (total participants = 299,655; median participants per outcome: 7,266; median individual studies per outcome = 5). Overall, 10/16 outcomes (62.5%) yielded significant results, most of which were graded as 'highly suggestive' (Grade II) evidence. DR was associated with all-cause and cardio-vascular mortality, obstructive sleep apnoea, depression eating disorders, and several forms of cognitive impairment.

CONCLUSIONS

Results show highly suggestive evidence for associations between health outcomes and/or conditions and DR. Public health professionals and practitioners should note these findings when developing and/or reviewing public health polices.

Food-Related Quality of Life in Children and Adolescents With Crohn's Disease

BACKGROUND

Food-related quality of life (FRQoL) encompasses the psychosocial elements of eating and drinking. The FRQoL of children and adolescents with inflammatory bowel disease has not yet been assessed. This study aimed to evaluate the utility of the validated FR-Qol-29 instrument in children with Crohn's disease (CD).

METHODS

Children diagnosed with CD, a shared home environment healthy sibling, and healthy control subjects 6 to 17 years of age were recruited to this single-center, prospective, cross-sectional study. Children or their parent or guardian completed the FR-QoL-29 instrument. Internal consistency was assessed by completing Cronbach's α. Construct validity was established by correlating the CD FR-QoL-29 sum scores with the Physician Global Assessment and Pediatric Crohn Disease Activity Index scores. The discriminant validity was analyzed using a 1-way analysis of variance, and a Spearman's correlation coefficient test was completed to identify any correlations associated with FRQoL.

RESULTS

Sixty children or their parent or guardian completed the FR-QoL-29 instrument (10 children in each subgroup). The internal consistency was excellent (Cronbach's α = 0.938). The mean FR-QoL-29 sum scores were 94.3 ± 27.6 for CD, 107.6 ± 20 for siblings, and 113.7 ± 13.8 for control subjects (P = .005). Those with higher disease activity had worse FRQoL (Physician Global Assessment P = .021 and Pediatric Crohn Disease Activity Index P = .004). Inflammatory bowel disease FR-QoL-29 sum scores correlated with weight (P = .027), height (P = .035), body mass index (P = .023), and age (P = .015).

CONCLUSIONS

FRQoL is impaired in children with CD. Healthy siblings also have poorer FRQoL than control subjects. Several clinical factors are associated with poorer FRQoL in children with CD including age and level of nutritional risk (weight, height, and body mass index). Further research is required validate these findings and to develop strategies for the prevention or treatment of impaired FRQoL in children with CD.

Pathological eating behaviours and risk of retinopathy in diabetes: a systematic review and meta-analysis

Background

Diabetes mellitus can cause several long-term macrovascular and microvascular complications including nephropathy, neuropathy, and retinopathy (DR). Several studies have reported positive associations between eating pathologies and DR; however, these studies have not been aggregated and sub-grouped into type of pathological eating behaviour, and the differences in risk according to type of eating behaviour is unknown. The aim of this review, therefore, was to aggregate risks of DR in populations with and without pathological eating behaviours, stratified according to eating behaviour.

Methods

A systematic review and meta-analysis was conducted. Major databases and grey literature were search from inception until 1/6/2021. Studies reporting the prevalence of pathological eating behaviours (against a control group with no pathological eating behaviours) in diabetic people with and without DR were included. Odds ratios were calculated from primary data.

Results

Seven studies with eight independent outcomes with a total of 1162 participants were included. The odds ratio of DR in the total pooled analysis was 2.94 (95%CI 1.86-4.64; p = <0.001; I2 = 29.59). Two types of eating behaviour yielded enough data for sub-group analysis. Eating disorder not otherwise specified yielded an odds ratio of 2.73 (95%CI 1.81-4.10; p = <0.001; I2 = 0.00), and binge eating disorder yielded an non-significant odds ratio of 0.92 (95%CI 0.31-2.77; p = 0.887;I2 = 0.00).

Discussion

The likelihood of DR increases almost three times in the presence of pathological eating behaviours. More studies are required to confirm this in clinical populations stratified by eating disorder. Practitioners working with people with diabetes should closely monitor eating behaviours to preclude this risk.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-022-00980-x.

Neurodevelopmental Disorders, Glycemic Control, and Diabetic Complications in Type 1 Diabetes: a Nationwide Cohort Study

CONTEXT

Neurodevelopmental disorders are more prevalent in childhood-onset type 1 diabetes than in the general population, and the symptoms may limit the individual's ability for diabetes management.

OBJECTIVE

This study investigated whether comorbid neurodevelopmental disorders are associated with long-term glycemic control and risk of diabetic complications.

METHODS

This population-based cohort study used longitudinally collected data from Swedish registers. We identified 11 326 individuals born during 1973-2013, diagnosed with type 1 diabetes during 1990-2013 (median onset age: 9.6 years). Among them, 764 had a comorbid neurodevelopmental disorder, including attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder, and intellectual disability. We used multinomial logistic regression to calculate odds ratios (ORs) of having poor glycemic control (assessed by glycated hemoglobin [HbA1c]) and Cox regression to estimate hazard ratios (HRs) of nephropathy and retinopathy.

RESULTS

The median follow-up was 7.5 years (interquartile range [IQR] 3.9, 11.2). Having any neurodevelopmental disorder (ORadjusted 1.51 [95% CI 1.13, 2.03]), or ADHD (ORadjusted 2.31 [95% CI 1.54, 3.45]) was associated with poor glycemic control (mean HbA1c > 8.5%). Increased risk of diabetic complications was observed in patients with comorbid neurodevelopmental disorders (HRadjusted 1.72 [95% CI 1.21, 2.44] for nephropathy, HRadjusted 1.18 [95% CI 1.00, 1.40] for retinopathy) and patients with ADHD (HRadjusted 1.90 [95% CI 1.20, 3.00] for nephropathy, HRadjusted 1.33 [95% CI 1.07, 1.66] for retinopathy). Patients with intellectual disability have a particularly higher risk of nephropathy (HRadjusted 2.64 [95% CI 1.30, 5.37]).

CONCLUSION

Comorbid neurodevelopmental disorders, primarily ADHD and intellectual disability, were associated with poor glycemic control and a higher risk of diabetic complications in childhood-onset type 1 diabetes.

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.

The Welsh Eating Disorder Service Review 2018, Scottish Eating Disorder Service Review 2021 and recommendations of best practice in comorbid eating disorders and diabetes

BACKGROUND

Diabetes and eating disorders are frequently comorbid. This particular comorbidity is not only often poorly recognised, but is difficult to treat and has a high mortality.

METHOD

In this article, we will briefly review the relationship between diabetes and eating disorders. We will review the current NICE and other guidance and reports concerning both diabetes and eating disorders in the United Kingdom. We will then describe the recommendations of the 2018 Welsh Government Eating Disorder Service Review and the 2021 the Scottish Government Eating Disorder Service Review regarding diabetes and eating disorders, which will lead to service change.

CONCLUSIONS

We conclude that this is a relatively underdeveloped but important area where there needs to be further service development and more collaboration between diabetes and eating disorder services.

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.

Association and Familial Coaggregation of Type 1 Diabetes and Eating Disorders: A Register-Based Cohort Study in Denmark and Sweden

OBJECTIVE

To ascertain the association and coaggregation of eating disorders and childhood-onset type 1 diabetes in families.

RESEARCH DESIGN AND METHODS

Using population samples from national registers in Sweden (n = 2,517,277) and Demark (n = 1,825,920), we investigated the within-individual association between type 1 diabetes and eating disorders and their familial coaggregation among full siblings, half siblings, full cousins, and half cousins. On the basis of clinical diagnoses, we classified eating disorders into any eating disorder (AED), anorexia nervosa (AN) and atypical AN, and other eating disorder (OED). Associations were determined with hazard ratios (HRs) with 95% CIs from Cox regressions.

RESULTS

Swedish and Danish individuals with a type 1 diabetes diagnosis had a greater risk of receiving an eating disorder diagnosis (HR [95% CI] Sweden: AED 2.02 [1.80-2.27], AN 1.63 [1.36-1.96], OED 2.34 [2.07-2.63]; Denmark: AED 2.19 [1.84-2.61], AN 1.78 [1.36-2.33], OED 2.65 [2.20-3.21]). We also meta-analyzed the results: AED 2.07 (1.88-2.28), AN 1.68 (1.44-1.95), OED 2.44 (2.17-2.72). There was an increased risk of receiving an eating disorder diagnosis in full siblings in the Swedish cohort (AED 1.25 [1.07-1.46], AN 1.28 [1.04-1.57], OED 1.28 [1.07-1.52]); these results were nonsignificant in the Danish cohort.

CONCLUSIONS

Patients with type 1 diabetes are at a higher risk of subsequent eating disorders; however, there is conflicting support for the relationship between having a sibling with type 1 diabetes and an eating disorder diagnosis. Diabetes health care teams should be vigilant about disordered eating behaviors in children and adolescents with type 1 diabetes.

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

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

Disturbed Eating Behaviors in Youth with Type 1 Diabetes: An Exploratory Study about Challenges in Diagnosis

Background: Disordered eating behaviors (DEBs), including diagnosable eating disorders, are quite common and can interfere with optimal type 1 diabetes (T1DM) management. We explored DEBs prevalence in youth with T1DM, proposing news diagnostic subscales, to represent the clinical dimensions associated with feeding and eating disorders (ED); Methods: additionally to SCOFF questionnaire and Diabetes Eating Problem Survey–Revised (DEPS-R), four subscales combined from the original DEPS-R questionnaire were administered to 40 youths with T1DM (15.0 ± 2.6); Results: females showed higher scores than males in DEPS-R original factor 2 (“preoccupations with thinness/weight”, p = 0.024) and in DEPS-R proposed “restriction” factor (p = 0.009). SCOFF scores was correlated with original DEPS-R factors 1 (“maladaptive eating habits”) and 2 (p < 0.001) and with the newly proposed DEPS-R factors: restriction, disinhibition, compensatory behaviors, diabetes management (all p < 0.02). Diabetes management was the only factor related to glycated hemoglobin level (p = 0.006). Patients with high DEPS-R score (≥20) scored higher than patients with low (<20) DEPS-R score in DEPS-R original factors 1 (p < 0.001) and 2 (p = 0.002) as well as in the proposed factors including restriction, disinhibition, diabetes management (all p < 0.02); Conclusions: the complicated nature of DEBs calls for the development target specific questionnaires to be used as screening tools to detect cases of DEBs and exclude non cases. Early recognition of DEBs in adolescents with T1DM is essential for effective prevention and successful treatment.

The impact of psychological aspects, age, and BMI on eating disorder psychopathology among adult males and females with type 1 diabetes

This study investigated correlates of eating disorder (ED) psychopathology among adults with type 1 diabetes (T1D). A total of 282 males (n = 112) and females (n = 170) with T1D (18–79 years) participated. Overall, psychological aspects (i.e. illness perceptions, coping strategies, insulin beliefs, anxiety, and depression) were associated with ED psychopathology. Associations were generally stronger among females than males. In a regression model, age, BMI, personal control, and anxiety explained 51% of the variance in ED psychopathology among females, whereas BMI, personal control, and anxiety explained 47% of the variance among males. Greater clinical awareness of health psychological aspects may contribute to reduce the risk of developing ED.

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.

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.

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

OBJECTIVE

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

RESEARCH DESIGN AND METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

RESEARCH DESIGN AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Medical and Psychological Considerations for Carbohydrate-Restricted Diets in Youth With Type 1 Diabetes

PURPOSE OF REVIEW

Given the challenges achieving recommended glycemic targets in youth with type 1 diabetes (T1D), providers may consider recommending carbohydrate-restricted diets (CRDs) to optimize glycemic control. The goal of the present review is to describe relevant literature on the potential medical and psychosocial benefits and risks of CRDs in youth with T1D.

RECENT FINDINGS

Limited data exist on the effects of CRDs in pediatric populations. Findings from studies with youth and adults are mixed; some indicate that CRDs may be associated with desirable medical outcomes, such as improved glycemic control and reduced HbA1c, which may contribute to positive psychological outcomes such as reduced diabetes distress and depressive symptoms. Others suggest that CRDs may also be associated with detrimental outcomes, including mineral deficiencies and suboptimal growth, and dietary restriction has been linked to greater diabetes distress, disordered eating, and diabetes management. More research is needed to evaluate benefits and risks of CRDs in youth. Providers should exercise caution when discussing CRDs with youth and families, particularly when considering CRDs for youth at elevated risk for eating disordered behavior.

Disturbed eating, illness perceptions, and coping among adults with type 1 diabetes on intensified insulin treatment, and their associations with metabolic control

This study investigated associations between psychological aspects and metabolic control among adults with type 1 diabetes ( n = 282). Linear regression analyses demonstrated that the illness perception personal control and the coping strategy seeking emotional social support explained 23.2 percent of the variance in hemoglobin A1c among females ( β = 0.40, p < 0.001 and β = −0.22, p < 0.01, respectively). Among males, only personal control remained significant, explaining 13.9 percent of the variance in hemoglobin A1c ( β = 0.37, p < 0.001). The associations between psychological correlates and hemoglobin A1c indicate that addressing such aspects clinically may facilitate metabolic control, thereby potentially contributing to reduce the risk of complications.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Gender differences in diabetes self-care in adults with type 1 diabetes: Findings from the T1D Exchange clinic registry

AIMS

To evaluate gender differences in diabetes self-care components including glycemic, blood pressure and lipid control, utilization of diabetes technologies and acute diabetes complications in adults with type 1 diabetes.

METHODS

A total of 9,481 participants >18 years were included in the analysis, 53% were female. Variables of interest included glycemic control measured by HbA1c, systolic/diastolic blood pressures, presence of dyslipidemia, insulin delivery modality, and rates of acute complications.

RESULTS

Glycemic control was similar in women and men (mean HbA1c in both groups: 8.1% ± 1.6% (64 ± 16 mmol/mol), (p = 0.54). More women used insulin pump therapy (66% vs. 59%, p < 0.001) but use of sensor technology was similar (p < = 0.42). Women had higher rates of diabetic ketoacidosis (DKA) (5% vs. 3%, p < 0.001) and eating disorders (1.7% vs. 0.1%, p < 0.001). Severe hypoglycemia rates were not different between men and women (p = 0.42). Smoking (6% vs 4%, p < 0.001), systolic (125 ± 14.2 vs. 121 ± 14.4, p < 0.001) and diastolic blood pressure (73.3 ± 9.5 vs. 72.2 ± 9.3, p < 0.001) and rate of dyslipidemia (28% vs. 23%, p < 0.001) were higher in men.

CONCLUSION

While glycemic control in type 1 diabetes was similar regardless of gender, rates of DKA and eating disorders were higher in women while rates of smoking, hypertension and dyslipidemia were higher in men.

Prevalence of disturbed eating behavior and associated symptoms of anxiety and depression among adult males and females with type 1 diabetes

BACKGROUND

The increased prevalence of disturbed eating behaviors (DEB), depression, and anxiety in type 1 diabetes (T1D) is generally well established; however the majority of existing research to date has focused on female adolescents and young adults. Data on males and older females is scarce. The aim of this study was to assess prevalence of DEB and symptoms of depression and anxiety among adult males and females with type 1 diabetes, to investigate differences between individuals scoring below and above the cut-off on psychopathology, and to examine patterns of eating disorder psychopathology by age and weight.

METHODS

A total of 282 adults with type 1 diabetes aged 18-79 years participated in the study. Measures included the Diabetes Eating Problem Survey - Revised (DEPS-R), the Hospital Anxiety and Depression Scale (HADS), and clinical data from the Norwegian Quality Improvement of Laboratory Examinations (NOKLUS) system.

RESULTS

A total of 20.3% of the whole sample (13.3% among males and 24.8% among females) scored above the DEPS-R cut-off score for DEB. As for depression and anxiety, the prevalence in the whole sample was 6.2% and 19.0%, respectively. The prevalence was generally higher in females than males across all psychopathology measures. HbA1c was significantly associated with the DEPS-R total score (p < .01) among females, but not with depression and anxiety. Mean DEPS-R score decreased with increasing age, and when our previous reported data from children and adolescents are included, a peak prevalence in DEB in adolescence and young adult age is demonstrated.

CONCLUSIONS

The results of this study point to the need for increased awareness of psychological comorbidity among adults with type 1 diabetes, in particular young adult females. Screening is recommended to secure early detection and subsequent intervention for these individuals.

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.

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.

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.

Translation and validation of the Diabetes Eating Problem Survey to screen eating disorders in patients with type-1 diabetes mellitus

INTRODUCTION

The treatment of type-1 diabetes mellitus (T1DM) requires changes in patients' eating habits and lifestyles which could lead to the development of an eating disorder (ED). An early detection of these disorders in subjects with T1DM is necessary. However, there is no specific questionnaire concerning the presence of an ED in these patients.

OBJECTIVES

To translate and validate for the Spanish population a specific questionnaire aimed at detecting the risk of onset of an ED on a sample of subjects with T1DM. To analyze its agreement with its shortened version and with the gold standard tool, EAT-26.

MATERIAL AND METHODS

Cross-sectional study. The study population consisted of 112 adults with T1DM. The EAT-26 tool and DEPS-R questionnaire were used to detect subjects at risk for developing ED. In addition, several characteristics such as weight, height, BMI, age and age of onset were assessed by means of self-administered questionnaires, in order to study their correlation with test scoring.

RESULTS

Structural properties of the tests were evaluated through methodological procedures aimed at calculating reliability and validity. The translated and adapted version had a high consistency in both its complete and summarized version (α=0,821).The test-retest also yielded consistent results (intraclass correlation coefficient 95.8% for EPAD and 92.3% for EPAD-R). The factor analysis yielded 5 factors: 1) Eating attitudes; 2) Bulimic behavior; 3) Weight control; 4) Avoidance, and 5) Restriction.

CONCLUSIONS

We have developed a questionnaire in Spanish capable of identifying the risk of onset of a specific ED in patients with T1DM. The EPAD-R questionnaire detected 10% more cases and different ones than those detected by the EAT-26 test. It is necessary to use specific screening tools to correctly identify eating disorders in patients with T1DM.

Complexity in eating disorders: a case for simple or complex formulation and treatment?

Eating disorders are commonly regarded as complex psychiatric conditions, although this perception might be a product of the high levels of physical and psychological co-morbidity that are present in many such cases, rather than being about complexity in the eating disorderper se. This paper will consider the reasons that eating disorders are seen as complex, and whether or not that perceived complexity should be seen as a genuine reason to deviate from existing evidence-based cognitive behavioural therapy (CBT) protocols. Case examples will be used to illustrate how complex presentations can require clinicians to work skilfully with relatively simple formulations to achieve the best outcome, rather than using unnecessarily complex formulations and treatments. The importance of clear supervision is also stressed, as it can play a role in clinicians’ perception of the need for a complex or simple formulation, it can support the clinician in developing a collaborative, focused and efficient formulation, and it can keep the clinician on track with an evidence-based CBT approach.

Metabolic Control and Illness Perceptions in Adolescents with Type 1 Diabetes

BACKGROUND

Disturbed eating behavior and psychosocial variables have been found to influence metabolic control, but little is known about how these variables interact or how they influence metabolic control, separately and combined.

OBJECTIVE

To explore associations between metabolic control (measured by HbA1c) and eating disorder psychopathology, coping strategies, illness perceptions, and insulin beliefs in adolescents with type 1 diabetes.

METHODS

A total of 105 patients (41.9% males) with type 1 diabetes (12-20 years) were interviewed with the Child Eating Disorder Examination. In addition, self-report psychosocial questionnaires were completed. Clinical data, including HbA1c, was obtained from the Norwegian Childhood Diabetes Registry.

RESULTS

Significant gender differences were demonstrated. Among females, HbA1c correlated significantly with eating restriction (.29, p < .05), the illness perception dimensions consequences, personal control, coherence, and concern (ranging from .33 to .48), and the coping strategy ventilating negative feelings (-.26, p < .05). Illness perception personal control contributed significantly to HbA1c in a regression model, explaining 23% of the variance among females (β .48, p < .001). None of the variables were significantly associated with HbA1c among males.

CONCLUSIONS

Illness perceptions appear to be important contributors to metabolic control in females, but not males, with type 1 diabetes.

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).

Adolescents with Type 1 Diabetes--The Impact of Gender, Age, and Health-Related Functioning on Eating Disorder Psychopathology

Objective

To investigate correlates of eating disorder psychopathology in adolescent males and females with type 1 diabetes.

Method

A total of 105 adolescents with type 1 diabetes (42% males), aged 12–20 years, were recruited from the Norwegian Childhood Diabetes Registry in this population-based study. All participants were interviewed with the Child Eating Disorder Examination. Additionally, the Brief Illness Perception Questionnaire, the Adolescent Coping Orientation for Problem Experiences and the Beliefs about Medicines Questionnaire were administered to assess health-related functioning. Clinical data were obtained from the Norwegian Childhood Diabetes Registry.

Results

Significant gender differences were demonstrated in the pattern of correlates of eating disorder pathology. Among females, eating disorder psychopathology was significantly associated with body mass index adjusted for age and gender, age, insulin restriction, coping, illness perceptions, and perceptions of insulin concern. In a regression model, age, illness perceptions, and insulin restriction remained significantly associated with eating disorder psychopathology, explaining 48% of the variance. None of the variables were associated with eating disorder psychopathology among males.

Discussion

Greater clinical awareness of illness perceptions, attitudes toward insulin, and insulin restriction may potentially decrease the risk of developing eating disorders among female adolescents with type 1 diabetes, and the subsequent increased morbidity and mortality associated with comorbid type 1 diabetes and eating disorders.

Momentary Predictors of Insulin Restriction Among Adults With Type 1 Diabetes and Eating Disorder Symptomatology

OBJECTIVE

Individuals with type 1 diabetes who restrict insulin to control weight are at high risk for diabetes-related complications and premature death. However, little is known about this behavior or how to effectively intervene. The aim of the current study was to identify predictors of insulin restriction in the natural environment that might inform new treatment directions.

RESEARCH DESIGN AND METHODS

Eighty-three adults with type 1 diabetes and a range of eating disorder symptomatology completed 3 days of ecological momentary assessment. Participants reported emotions, eating, and insulin dosing throughout the day using their cellular telephone. Linear mixed models were used to estimate the effects of heightened negative affect (e.g., anxiety) before eating and characteristics of the eating episode (e.g., eating a large amount of food) on the risk of insulin restriction.

RESULTS

Individuals who reported greater-than-average negative affect (general negative affect and negative affect specifically about diabetes) during the study period were more likely to restrict insulin. Momentary increases in anxiety/nervousness and guilt/disgust with self before eating (relative to an individual's typical level) further increased the odds of restricting insulin at the upcoming meal. Insulin restriction was more likely when individuals reported that they broke a dietary rule (e.g., "no desserts").

CONCLUSIONS

Results suggest that insulin restriction might be decreased by helping patients with type 1 diabetes respond effectively to heightened negative affect (e.g., anxiety, guilt) and encouraging patients to take a less rigid, punitive approach to diabetes management.

Eating Disorders in Girls and Women With Type 1 Diabetes: A Longitudinal Study of Prevalence, Onset, Remission, and Recurrence

OBJECTIVE

Girls and women with type 1 diabetes are at increased risk for developing eating disorders (EDs), and these disorders are associated with serious diabetes-related medical complications. This study describes the longitudinal course of disturbed eating behavior (DEB) and EDs in a cohort with type 1 diabetes.

RESEARCH DESIGN AND METHODS

A total of 126 girls with type 1 diabetes receiving care for diabetes at The Hospital for Sick Children in Toronto participated in a series of seven interview-based assessments of ED behavior and psychopathology over a 14-year period, beginning in late childhood. Survival analysis was used.

RESULTS

Mean age was 11.8 ± 1.5 years at time 1 and 23.7 ± 2.1 years at time 7. At time 7, 32.4% (23/71) met the criteria for a current ED, and an additional 8.5% (6/71) had a subthreshold ED. Mean age at ED onset (full syndrome or below the threshold) was 22.6 years (95% CI 21.6-23.5), and the cumulative probability of onset was 60% by age 25 years. The average time between onset of ED and subsequent ED remission was 4.3 years (95% CI 3.1-5.5), and the cumulative probability of remission was 79% by 6 years after onset. The average time between remission of ED and subsequent recurrence was 6.5 years (95% CI 4.4-8.6), and the cumulative probability of recurrence was 53% by 6 years after remission.

CONCLUSIONS

In this longitudinal study, EDs were common and persistent, and new onset of ED was documented well into adulthood. Further research regarding prevention and treatment for this vulnerable group is urgently needed.

Eating disorders in individuals with type 1 diabetes: case series and day hospital treatment outcome

Women with type 1 diabetes are at high risk for eating disorders (ED), a combination that can increase medical complications and mortality. As little is known about treatment response in this population, clinical presentation and treatment outcome in an extended case series were assessed. A chart review at the Eating Disorders Day Hospital Program at Toronto General Hospital identified a total of 100 individuals with type 1 diabetes assessed 1990-2012. Of 37 who attended day hospital, most experienced improvement in ED symptoms, but only 18.8% had a good immediate treatment outcome, while 43.8% had an intermediate outcome and 37.5% had a poor outcome (meeting diagnostic criteria at discharge). This is poorer than program outcomes in individuals without diabetes (χ(2)  = 12.2, df = 2; p = 0.002). Factors influencing treatment engagement and outcome must be further studied and used to improve treatment results in this high-risk group.

A comparison of clinical characteristics between adolescent males and females with eating disorders

BACKGROUND

Eating disorders (ED) are serious disorders that have a negative impact on both the psychological and the physiological well-being of the afflicted. Despite the fact that ED affect both genders, males are often underrepresented in research and when included the sample sizes are often too small for separate analyses. Consequently we have an unclear and sometimes contradictory picture of the clinical characteristics of males with ED. The aim of the present study was to improve our understanding of the clinical features of adolescent males with eating disorders.

METHODS

We compared age at presentation, weight at presentation, history of significantly different premorbid weight and psychiatric (Attention Deficit Hyperactivity Disorder (ADHD)) and somatic comorbidity (celiac disease and diabetes) of 58 males to 606 females seeking medical care for eating disorders at the Children's Hospital in Uppsala, Sweden during the years 1999-2012. As all boys were diagnosed with either AN or Other Specified Feeding or Eating Disorder (OSFED) atypical AN, the age and weight comparisons were limited to those girls fulfilling the diagnostic criteria for AN or OSFED atypical AN.

RESULTS

There was no significant difference in age at presentation. Differences in weight at presentation and premorbid weight history were mixed. A significantly higher percentage of males had a history of a BMI greater than two standard deviations above the mean for their corresponding age group. As well, there was a higher prevalence of ADHD among the males whereas celiac disease and diabetes only was found among the females.

CONCLUSIONS

A better understanding of the clinical characteristics of males with ED at presentation should improve our ability to identify males with ED and thereby aid in tailoring the best treatment alternatives.

Multidisciplinary residential treatment of type 1 diabetes mellitus and co-occurring eating disorders

Research on treatment for diabetes and co-occurring eating disorders is sparse. We examined outcomes from multidisciplinary residential treatment for women with type 1 diabetes and eating disorders and the impact of treatment duration on outcomes. Participants were 29 women with type 1 diabetes and eating disorders receiving residential treatment. Repeated measures analyses of variance examined changes in blood glucose and psychological symptoms over treatment. Analyses were repeated to include treatment by duration interactions. Treatment produced significant reductions in blood glucose, eating disorder symptoms, and psychological concerns. Longer treatment duration was associated with greater improvements in psychological symptoms.

Disinhibited eating and weight-related insulin mismanagement among individuals with type 1 diabetes

OBJECTIVE

Withholding insulin for weight control is a dangerous practice among individuals with type 1 diabetes; yet little is known about the factors associated with this behavior. Studies of nondiabetic individuals with weight concerns suggest that eating in a disinhibited manner (e.g., binge eating) predicts the use of maladaptive compensatory strategies (e.g., self-induced vomiting). The purpose of this study was to test whether individuals with type 1 diabetes are less restrained in their eating when they think their blood glucose (BG) is low and whether this contributes to insulin omission for weight control purposes and subsequently higher hemoglobin A1c (HbA1c).

METHODS

Two-hundred and seventy-six individuals with type 1 diabetes completed an online survey of eating behaviors, insulin dosing and most recent HbA1c. We used structural equation modeling to test the hypothesis that disinhibited eating when blood sugar is thought to be low predicts weight-related insulin mismanagement, and this, in turn, predicts higher HbA1c.

RESULTS

The majority of participants endorsed some degree of disinhibition when they think their blood glucose is low (e.g., eating foods they do not typically allow) and corresponding negative affect (e.g., guilt/shame). The frequency of disinhibited eating was positively associated with weight-related insulin mismanagement. Controlling for age, sex, education, and insulin pump use, the model explained 31.3% of the variance in weight-related insulin mismanagement and 16.8% of the variance in HbA1c.

CONCLUSION

Addressing antecedents to disinhibited eating that are unique to type 1 diabetes (e.g., perceived BG level) and associated guilt or shame may reduce weight-related insulin omission.

The evaluation of body image in children with type 1 diabetes: A case-control study

This study evaluated the body image perception in children with type 1 diabetes in order to identify symptoms of disordered eating behaviours early. Children with type 1 diabetes and controls showed underestimation and dissatisfaction with body size. The patients, especially girls, were more accurate in their perception of body size than the control group. The study sheds light on some of the underlying factors that may contribute to the development of disordered eating behaviours in adolescence. The causes of the differences of perception of body size are discussed.

Primary care of female adolescents with type 1 diabetes mellitus and disordered eating

AIM

To identify the role of the nurse practitioner in caring for female adolescents with type 1 diabetes mellitus at risk for disordered eating behaviour and to formulate clinical recommendations for nurse practitioners in the primary care setting.

BACKGROUND

Transition into adulthood can be difficult for female adolescents with type 1 diabetes mellitus. Challenges associated with management of this illness may place adolescent females at an increased risk for disordered eating.

DESIGN

Discussion paper.

DATA SOURCES

Sourced literature from 1991-2013, located through CINAHL, Health Source, Proquest, PubMed, PsychInfo, Web of Science and Medline databases.

IMPLICATIONS FOR NURSING

Nurses involved in the primary care of female adolescents with type 1 diabetes mellitus need to be aware of the increased risk for disordered eating behaviours and develop the competencies to care for both the adolescent and her family to reduce the serious consequences of these behaviours.

CONCLUSION

Awareness and acquisition of the skills required to intervene will enable nurse practitioners to recognize clients at risk for disordered eating, gain appreciation of the motivation of female adolescents with type 1 diabetes mellitus towards disordered eating behaviours and give optimal opportunity for education, counselling and recovery. Future direction for research includes exploration of the experiences of adolescents with type 1 diabetes mellitus; early interventions in the primary care setting; effective educational, preventative or supportive services for adolescents with this illness and their families; and outcomes to emerging technologies for insulin therapy on disordered eating occurrence.