Eating disorders in adolescents with type 2 and type 1 diabetes

Mind Matters: Mental Health and Diabetes Management

CONTEXT

Managing diabetes is an intensive, lifelong responsibility that significantly impacts a person's mental health and diabetes outcomes such as glycemic stability and complications. This mini-review examines the research leading to this conclusion as well as the implications for screening and treatment of mental health issues in people with diabetes within an interdisciplinary care model.

EVIDENCE ACQUISITION

We searched the literature for the past 10 years, including original articles, reviews, and meta-analyses from PubMed and OVID using the search terms diabetes and mental health.

EVIDENCE SYNTHESIS

Diabetes is a lifelong burden, and people with the disease grapple with intensive management, financial burden, fear of hypoglycemia, chronic hyperglycemia complications, and diabetes stigma. These stressors have a debilitating emotional impact, making it difficult to carry out diabetes care tasks, which in turn is associated with poorer short-term glycemic stability and greater mental health symptoms. Psychological syndromes related to a diabetes diagnosis, management, or coping with the disease include major depressive disorder, diabetes distress, anxiety, and eating disorders. Providers managing people with diabetes can leverage 4 validated screening instruments to assess for these syndromes. The main psychological interventions studied to treat these mental health conditions include cognitive behavioral therapy, cognitive conceptualization, dialectical behavioral therapy, relational therapy, and psychoeducation.

CONCLUSION

It is pertinent to address the mental health of people with diabetes as rates of psychological syndromes are significantly higher than among those without diabetes. Interdisciplinary care involving endocrinologists, mental health providers, diabetes educators, and medical nutritionists could improve diabetes self-care and glycemic control.

ISPAD Clinical Practice Consensus Guidelines 2024: Type 2 Diabetes in Children and Adolescents

Youth-onset type 2 diabetes (T2D) results from genetic, environmental, and metabolic causes that differ among individuals and populations. This chapter builds on the 2022 ISPAD guidelines and summarizes recent advances in the management of T2D in children and adolescents. Updates include diagnostic algorithm for youth with new onset T2D, algorithms and tables for treatment, management, and assessment of comorbidities and complications and recommendations on recently approved pharmacologic therapies for the treatment of youth-onset T2D and management strategies. Youth-onset type 2 diabetes (T2D) results from genetic, environmental, and metabolic causes that differ among individuals and populations. This chapter builds on the 2022 ISPAD guidelines and summarizes recent advances in the management of T2D in children and adolescents. Updates include diagnostic algorithm for youth with new onset T2D, algorithms and tables for treatment, management, and assessment of comorbidities and complications and recommendations on recently approved pharmacologic therapies for the treatment of youth-onset T2D and management strategies.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Adolescents with Type 2 Diabetes: Overcoming Barriers to Effective Weight Management

The prevalence of type 2 diabetes (T2DM) among children and adolescents has remarkably increased in the last two decades, particularly among ethnic minorities. Management of T2DM is challenging in the adolescent population due to a constellation of factors, including biological, socioeconomic, cultural, and psychological barriers. Weight reduction is an essential component in management of T2DM as weight loss is associated with improvement in insulin sensitivity and glycemic status. A family centered and culturally appropriate approach offered by a multidisciplinary team is crucial to address the biological, psychosocial, cultural, and financial barriers to weight management in youth with T2DM. Lifestyle interventions and pharmacotherapy have shown modest efficacy in achieving weight reduction in adolescents with T2DM. Bariatric surgery is associated with excellent weight reduction and remission of T2DM in youth. Emerging therapies for weight reduction in youth include digital technologies, newer GLP-1 agonists and endoscopic procedures.

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.

Prevalence, associations and health outcomes of binge eating in adults with type 1 or type 2 diabetes: Results from Diabetes MILES - The Netherlands

AIMS

To examine the prevalence and health risks of binge eating in people with diabetes.

METHODS

Self-report data were analysed from a subsample (n = 582 type 1 diabetes/735 type 2 diabetes) of Diabetes MILES - the Netherlands, an online survey. Prevalence of binge eating was compared across diabetes type and treatment and between participants with and without binges for eating styles, diabetes treatment and outcomes, weight, BMI and psychological comorbidity. Associations between binge eating, HbA_1c , BMI, diabetes distress were assessed using hierarchical linear regression analyses.

RESULTS

23% (n = 308) of participants reported eating binges, with 16% at least monthly, and 6% at least weekly. Prevalence and frequency of binges did not differ across diabetes type or treatment. People reporting binges scored higher on dietary restraint, emotional and external eating and reported higher weight and BMI than those without binges. Only people with type 1 diabetes and eating binges had a higher HbA_1c . Hierarchical regression analyses demonstrated that binge eating was independently associated with higher HbA_1c (β = 0.12, p=0.001), BMI (β = 0.13, p < 0.001) but not with diabetes distress.

CONCLUSIONS

This study found binge eating to be associated with eating styles, BMI and HbA_1c . However, our cross-sectional data do not allow for conclusions on causality. Future studies could further examine the directions of these associations and their clinical implications.

ISPAD Clinical Practice Consensus Guidelines 2022: Type 2 diabetes in children and adolescents

Since the 2018 ISPAD guidelines on this topic, follow-up of large cohorts from around the globe have continued informing the current incidence and prevalence of co-morbidities and complications in young adults with youth-onset type 2 diabetes (T2D). This chapter focuses on the risk factors, diagnosis and presentation of youth-onset T2D, the initial and subsequent management of youth-onset T2D, and management of co-morbidities and complications. We include key updates from the observational phase of the multi-center Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) clinical trial, the SEARCH for Diabetes in Youth (SEARCH) study and new data from the Restoring Insulin Secretion (RISE) study, a head-to-head comparison of youth onset vs adult-onset T2D. We also include an expanded section on risk factors associated with T2D, algorithms and tables for treatment, management, and assessment of co-morbidities and complications, and sections on recently approved pharmacologic therapies for the treatment of youth-onset T2D, social determinants of health, and settings of care given COVID-19 pandemic.

Reconsidering a role for attachment in eating disorder management in the context of paediatric diabetes

We suggest a reconsideration of the role of 'attachment orientation' in the context of eating disorders and paediatric diabetes. Attachment orientation is a psychological construct that describes a relatively stable set of expectations and behaviours an individual relies upon in managing relationships. There is considerable evidence of an association between attachment orientation and the development and maintenance of disordered eating in individuals without diabetes, though evidence is more scant in populations with diabetes. We discuss the underpinning theory and critically examine the existing literature for the relationship between attachment orientation and disordered eating in paediatric diabetes. Finally, we draw on adjacent literatures to highlight potential future directions for research should this area be revisited. Overall, we contextualise our discussion in terms of patient-centred, holistic care that addresses the mind and body (i.e., our discussion of attachment orientation assumes a psycho-biological approach).

Dietary intake on days with and without hypoglycemia in youth with type 1 diabetes: The Flexible Lifestyle Empowering Change trial

OBJECTIVE

To address a common perception that hypoglycemia is associated with increased dietary intake, we examined calorie and carbohydrate consumption on days with and without hypoglycemia among adolescents with type 1 diabetes (T1D).

METHODS

Days (N = 274) with 24-hour dietary recalls and continuous glucose monitoring were available for 122 adolescents with T1D in the Flexible Lifestyle Empowering Change trial (age 13-16 years, diabetes duration >1 year, hemoglobin A1c 8%-13%). Days with no hypoglycemia, clinical hypoglycemia (54-69 mg/dL) or clinically serious hypoglycemia (<54 mg/dL) were further split into night (12-5:59 am) and day (6 am-11:59 pm). Mixed models tested whether intake of calories or carbohydrates was greater on days with than without hypoglycemia.

RESULTS

Fifty-nine percent, 23% and 18% of days had no hypoglycemia, clinical hypoglycemia and clinically serious hypoglycemia, respectively. Intake of calories and carbohydrates was not statistically significantly different on days with clinical hypoglycemia (57.2 kcal [95% CI -126.7, 241.5]; 12.6 g carbohydrate [95% CI -12.7, 38.0]) or clinically serious hypoglycemia (-74.0 kcal [95% CI -285.9, 137.9]; (-7.8 g carbohydrate [95% CI -36.8, 21.1]), compared to days without hypoglycemia. Differences by day and night were not statistically significant.

CONCLUSIONS

Among adolescents with T1D, daily intake of calories and carbohydrates did not differ on days with and without hypoglycemia. It is possible that hypoglycemic episodes caused by undereating relative to insulin dosing, followed by overeating, leading to a net neutral difference. Given the post-hoc nature of these analyses, larger studies should be designed to prospectively test the hypoglycemia-diet relationship.

Cognitive Behavioral Therapy and Mindfulness-Based Cognitive Therapy in Children and Adolescents with Type 2 Diabetes

PURPOSE OF REVIEW

Among adults with type 2 diabetes (T2D), cognitive behavioral therapy (CBT), acceptance and commitment therapy, and mindfulness interventions have demonstrated improvement in depression, anxiety, and glycemic control. We assessed whether these treatment modalities have shown usefulness in adolescents with T2D or at risk for T2D.

RECENT FINDINGS

Data are limited on the use of the abovementioned therapeutic interventions and include only adolescent girls at risk for T2D. CBT was as useful as health education sessions. At 1 year, greater decreases in depression, insulin resistance, and BMI were observed in girls randomized to mindfulness compared with CBT groups. Given the positive outcome of mindfulness intervention in adults and in adolescent girls at risk for T2D, future studies should involve males at risk for T2D, and adolescents diagnosed with T2D. Longer interventions and booster meetings for maintenance should be studied.

Depression in Youth-Onset Type 2 Diabetes

PURPOSE OF REVIEW

The current review summarizes extant knowledge regarding the prevalence of depression in youth-onset type 2 diabetes (T2D) and how depression might impact glycemic control through stress-related behavioral and physiological mechanisms. The current review also discusses depression intervention studies in adult-onset T2D, as there are no such studies in youth-onset T2D, and provides recommendations for clinical research.

RECENT FINDINGS

The prevalence of elevated depression symptoms in youth-onset T2D is approximately 20%. Some studies suggest depression may negatively impact glycemic control through inadequate medication adherence and disordered eating, but there is a dearth of studies investigating associations with depression and physical activity/sedentary time, sleep, and stress-related physiological mechanisms. In adult-onset T2D, evidence-based behavioral interventions tailored to address diabetes-related issues have shown positive effects for depression and glycemic control. Future research is needed to characterize the epidemiology of depression in youth-onset T2D and test interventions to improve depression, glycemic control, and health outcomes in this specific pediatric population.

Diabetes and Humor: A Preliminary Investigation

Diabetes can take a tremendous toll on physical and psychological health. Given the growing evidence of the benefits of humor, this study examined the association between diabetes and humor. The sample consisted of 249 participants: 72.3% with type 1 diabetes, 70.3% female, 89.5% Caucasian, and 70.9% college educated. Participants completed the Humor Styles Questionnaire (HSQ) and were compared with HSQ norms. On the affiliative humor scale, the diabetes group did not differ from the norm (P >0.05), nor did those with type 1 diabetes (P >0.05). Scores of those with type 2 diabetes were lower than the norm (P <0.05). On the self-enhancing humor scale, the diabetes group did not differ from the norm (P >0.05), nor did the subgroups with type 1 diabetes (P >0.05) or type 2 diabetes (P >0.05). The diabetes group was lower than the norm on aggressive humor (P <0.01), as were the subgroups with type 1 diabetes (P <0.01) and type 2 diabetes (P <0.05). The diabetes group was higher than the norm on self-defeating humor (P <0.01), as were the subgroups with type 1 diabetes (P <0.01) and type 2 diabetes (P <0.01). Results suggest that people with either type of diabetes are more inclined toward self-enhancing humor, are less inclined toward aggressive humor, and score higher on self-defeating humor, and those with type 1 diabetes are also inclined toward affiliative humor. Results are discussed relative to the sample being comprised of individuals with good glycemic control (mean A1C 7.06 ± 1.39%). This study offers a preliminary comparison of humor among people with diabetes versus those in a healthy norm group without diabetes.

Extreme Risk-Taking Behaviors in Patients With Eating Disorders

BACKGROUND

Patients with eating disorders (EDs) engage in different self-inflicted at-risk behaviors, including suicide, attempted suicide and non-suicidal self-injury. Our aim was to describe the occurrence and underlying motivations of non-suicidal extreme risk-taking behaviors in patients with EDs.

METHODS

Four cases from different treatment centers in Israel were analyzed.

RESULTS

All patients were females hospitalized in inpatient settings because of long lasting anorexia nervosa (AN) with either binge/purge or purging episodes (AN-B/P/AN-P), including in most cases both self-induced voting and laxative abuse. Case [1] was an adolescent also diagnosed with type 1 diabetes mellitus. She abused insulin, both omission and overdose, was highly suicidal, and suffered from comorbid oppositional behavior, depression and anxiety. Case [2] was a 24-years old woman, transitioning from restricting to AN with vomiting and laxative use during inpatient treatment. She was also diagnosed with attention deficit hyperactivity disorder, depression, anxiety, and suicidal thoughts. In hospital, she developed excessive water consumption, leading to very low urine concentrations and sodium levels, and one episode of loss of consciousness. Case [3] was in her late thirties, demonstrating particularly massive laxative abuse. She also suffered from alcohol addiction, sexual trauma, and one attempted suicide. During hospitalization she developed laxative-abuse-related rectal prolapse that was successfully operated. Nonetheless, after operation she resumed laxative abuse. Case [4] was a 23-year old pregnant women with highly active AN-B/P during pregnancy. She was hospitalized at 23 weeks of gestation following abdominal pressure. She only partly complied with inpatient treatment, discharged herself against medical advice after 5 weeks, and gave birth at week 34.

DISCUSSION

All cases were females with long-standing B/P type AN, often with multiple purging behaviors, other impulsive and non-impulsive comorbidities, and many environmental vulnerabilities. Different motivations were found for these extreme behaviors in addition to ED-related factors, mostly not related to suicide. The severity of the medical and psychological condition required multimodal medical and psychological inpatient interventions. The patients mostly did not comply with their treatment, showing considerable indifference to their grave medical condition.

Dysglycemia among youth with type 1 diabetes and suboptimal glycemic control in the Flexible Lifestyle Empowering Change trial

OBJECTIVE

To examine the prevalence and correlates of non-severe hypoglycemia among adolescents with type 1 diabetes and suboptimal glycemic control, an understudied topic in this group.

METHODS

Seven days of blinded continuous glucose monitor data were analyzed in 233 adolescents at baseline of the Flexible Lifestyle Empowering Change trial (13-16 years, type 1 diabetes duration >1 year, and hemoglobin A1c [HbA1c] 8-13% [64-119 mmol]). Incidence of clinical hypoglycemia (54-69 mg/dL) and clinically serious hypoglycemia (<54 mg/dL) was defined as number of episodes ≥15 minutes. Logistic regression modeling was used to determine the correlates of long duration of hypoglycemia, categorized by median split among those who experienced hypoglycemia.

RESULTS

The sample was 76.1% non-Hispanic white, 49.8% female, age = 14.9 ± 1.1 years, diabetes duration = 6.4 ± 3.7 years, and HbA1c = 9.6 ± 1.2% (81 ± 13 mmol/mol). Over 7 days, 79.4% of youth experienced ≥1 hypoglycemic episodes of <70 mg/dL, and 55.4% of youth experienced ≥1 hypoglycemic episodes of <54 mg/dL. Among all adolescents, the median duration of clinical hypoglycemia and clinically serious hypoglycemia was 21.9 (range 0-250.2) and 4.3 (range 0-209.7) minutes/day, respectively. Long duration of clinical hypoglycemia (range 1.8-17.4% time overall) and clinically serious hypoglycemia (range 1.2-14.6% time overall) was associated with older age and decreasing HbA1c. Long duration of clinically serious hypoglycemia also was associated with insulin pump use.

CONCLUSIONS

Almost 80% of adolescents with elevated HbA1c had an episode of clinical hypoglycemia, and >50% had clinically serious hypoglycemia in a week. Increased education alongside access to emerging diabetes technologies may help to prevent hypoglycemia while improving glycemic control.

Dietary patterns as a red flag for higher risk of eating disorders among female teenagers with and without type I diabetes mellitus : Adolescents with type I diabetes mellitus are a risk factor for eating disorders: a case-control study

BACKGROUND

Female adolescents with type I diabetes mellitus (TIDM) have an increased risk of developing eating disorders (ED) due to the dietary recommendations.

OBJECTIVE

Investigate the association between dietary intake and increased risk of ED.

METHODS

Case-control study with 50 T1DM female adolescents (11-16 years) and 100 healthy peers (CG). Measures included food frequency questionnaire (FFQ-PP), Child-EDE.12, economic and anthropometric data.

RESULTS

Comparing female adolescents with T1DM vs CG, the first had higher intake of: bread, cereal, rice, and pasta (29.7 vs 23.8%, p = 0.001), vegetables (6.5 vs 2.8%, p < 0.001), milk yogurt and cheese (9.9 vs 7.6%, p = 0.032), fat, and oils (8.2 vs 5.9%, p = 0.003), besides higher fiber intake (19.2 vs 14.7%, p = 0.006) and lower consumption of sweets (13.6 vs 30.7%, p < 0.001). No differences on ED psychopathology (Child-EDE subscales and global score) were found between groups. In unadjusted association between the ED psychopathology and dietary intake, a diet rich in fiber was significantly associated with both the global and eating concern scores. Among CG, increased intake of meat, poultry, fish, and eggs and decreased bread, cereal, rice, and pasta consumption were significantly associated with higher ED psychopathology. When BMI and age are adjusted, the association between fiber intake and ED psychopathology is no longer significant among diabetic participants; however, in the CG, this association remains.

CONCLUSIONS

The study suggests that an association between dietary intake and ED psychopathology might exist in female adolescents with and without TIDM and that careful evaluation of the dietary profile and risk of developing an ED should be considered in clinical practice.

LEVEL OF EVIDENCE

Level III, case-control study.

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

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

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.

Reliability and Validity of the Diabetes Eating Problem Survey in Turkish Children and Adolescents with Type 1 Diabetes Mellitus

OBJECTIVE

The aim of this study was to show the reliability and validity of a Turkish version of Diabetes Eating Problem Survey-Revised (DEPS-R) in children and adolescents with type 1 diabetes mellitus.

METHODS

A total of 200 children and adolescents with type 1 diabetes, ages 9-18 years, completed the DEPS-R Turkish version. In addition to tests of validity, confirmatory factor analysis was conducted to investigate the factor structure of the 16-item Turkish version of DEPS-R.

RESULTS

The Turkish version of DEPS-R demonstrated satisfactory Cronbach's ∝ (0.847) and was significantly correlated with age (r=0.194; p<0.01), hemoglobin A1c levels (r=0.303; p<0.01), and body mass index-standard deviation score (r=0.412; p<0.01) indicating criterion validity. Median DEPS-R scores of Turkish version for the total samples, females, and males were 11.0, 11.5, and 10.5, respectively.

CONCLUSION

Disturbed eating behaviors and insulin restriction were associated with poor metabolic control. A short, self-administered diabetes-specific screening tool for disordered eating behavior can be used routinely in the clinical care of adolescents with type 1 diabetes. The Turkish version of DEPS-R is a valid screening tool for disordered eating behaviors in type 1 diabetes and it is potentially important to early detect disordered eating behaviors.

Behavioural implications of traditional treatment and closed-loop automated insulin delivery systems in Type 1 diabetes: applying a cognitive restraint theory framework

As the prevalence of obesity in Type 1 diabetes rises, the effects of emerging therapy options should be considered in the context of both weight and glycaemic control outcomes. Artificial pancreas device systems will 'close the loop' between blood glucose monitoring and automated insulin delivery and may transform day-to-day dietary management for people with Type 1 diabetes in multiple ways. In the present review, we draw directly from cognitive restraint theory to consider unintended impacts that closed-loop systems may have on ingestive behaviour and food intake. We provide a brief overview of dietary restraint theory and its relation to weight status in the general population, discuss the role of restraint in traditional Type 1 diabetes treatment, and lastly, use this restraint framework to discuss the possible behavioural implications and opportunities of closed-loop systems in the treatment of Type 1 diabetes. We hypothesize that adopting closed-loop systems will lift the diligence and restriction that characterizes Type 1 diabetes today, thus requiring a transition from a restrained eating behaviour to a non-restrained eating behaviour. Furthermore, we suggest this transition be leveraged as an opportunity to teach people lifelong eating behaviour to promote healthy weight status by incorporating education and cognitive reappraisal. Our aim was to use a transdisciplinary approach to highlight critical aspects of the emerging closed-loop technologies relating to eating behaviour and weight effects and to promote discussion of strategies to optimize long-term health in Type 1 diabetes via two key outcomes: glycaemic control and weight management.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Appraisal of clinical practice guidelines for management of paediatric type 2 diabetes mellitus using the AGREE II instrument: a systematic review protocol

BACKGROUND

The prevalence of type 2 diabetes mellitus (T2DM) in children and adolescents is increasing. This has spurred the development and publication of clinical practice guidelines (CPGs) for the management of paediatric T2DM. Given the long-term complications of T2DM, optimal management is important to prevent or delay these complications. However, the quality of published CPGs has not yet been empirically evaluated. Our objective is to systematically appraise all published CPGs for the management of T2DM in children and adolescents.

METHODS

We will identify all published CPGs that address T2DM in children and adolescents through MEDLINE, Embase, CINAHL, Trip, and the National Guideline Clearinghouse and will screen diabetes and paediatric societies and associations' websites. Search records will be screened in duplicate for inclusion. Grey literature will be covered by systematically searching publications of all relevant diabetes societies and associations and other health organizations for CPGs that meet our inclusion criteria. CPGs deemed eligible for inclusion will be retrieved. Quality assessment will be conducted using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool by a team of four appraisers. Scaled scores of the AGREE II will be used to gauge the overall quality of CPGs.

DISCUSSION

The results of this review will be disseminated through presentations at local, national, and international conferences and publication in a peer-reviewed journal. The results of this review can help improve the reporting of future guidelines, inform decisions of policy-makers to endorse CPGs, and affect the choice of guideline use in clinical practice.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016034187.

Eating-Disordered Behaviour in Adolescents with Type 1 Diabetes

OBJECTIVES

To evaluate dysfunctional eating behaviour, self-esteem, social physique anxiety and quality of life in adolescents with type 1 diabetes who have differing desired weights and to evaluate the predictors of dysfunctional eating behaviour in these adolescents, with a focus on personal and psychological variables.

METHODS

We evaluated 79 adolescents with type 1 diabetes (mean age of 15.71 years) of both sexes (58.2% females) using the Eating Disorders Examination Questionnaire (EDE-Q), the Rosenberg Self-Esteem Scale (RSES), the Social Physique Anxiety Scale (SPAS-R) and the Diabetes Quality of Life (DQoL) measure.

RESULTS

Of the adolescents, 44 with type 1 diabetes reported the desire to maintain or increase their current weight, and 35 reported the desire to reduce their current weight. The participants with the desire to weigh less were mainly females who exercised regularly and demonstrated more frequent binge eating and purging. Additionally, this group exhibited an increased frequency of eating disturbances, such as restraint and eating, weight and shape concerns. Moreover, this group demonstrated increased social physique anxiety and decreased diabetes quality of life in relation to the impact of diabetes, worries about diabetes and satisfaction with life. Finally, predictors of eating disturbances included the desire for lower weight, higher social physique anxiety and lower diabetes-related quality of life.

CONCLUSIONS

The desire for a lower weight in adolescents with type 1 diabetes may increase problems related to eating behaviour and general quality of life.

Highly increased risk of type 2 diabetes in patients with binge eating disorder and bulimia nervosa

OBJECTIVE

We aimed to examine the prevalence and incidence of type 2 diabetes (T2D) in a large patient cohort treated for binge eating disorder (BED), bulimia nervosa (BN), and anorexia nervosa.

METHOD

Patients (N = 2,342) treated at the Eating Disorder Unit of Helsinki University Central Hospital over the period up to 16 years were compared with matched general population controls (N = 9,368) in three stages: before entering to the treatment for an eating disorder, after the entrance until the end of the study period, and combined any time before, during, and after the treatment. The study population was linked with the oral TSD medication data of 17 years from The Medical Reimbursement Register. Data were analyzed using conditional and Poisson regression models.

RESULTS

Before entering to the treatment for eating disorders, the risk of T2D was substantially increased in patients compared with controls (OR 6.6, 95% CI 4.0-10.7). At the end of the study period, the lifetime prevalence of T2D was 5.2% among patients, 1.7% among controls (OR 3.4, 95% CI 2.6-4.4), and in male patients, it was significantly higher compared with females. Of those treated for BED, every third had T2D by the end of the study period (OR 12.9, 95% CI 7.4-22.5), whereas the same was true for 4.4% of those with BN (OR 2.4, 95% CI 1.7-3.5).

DISCUSSION

Our findings provide strong support for the association between T2D and clinically significant binge eating. Disturbed glucose metabolism may contribute to the onset and maintenance of BED and BN.

Mindfulness and eating behavior in adolescent girls at risk for type 2 diabetes

OBJECTIVE

The purpose of this investigation was to examine the relationship of dispositional mindfulness to binge eating and associated eating attitudes and behaviors among adolescent girls at risk for type 2 diabetes (T2D).

METHODS

Participants were 114 overweight or obese adolescents enrolled in a study of girls with a family history of T2D and mild depressive symptoms. Adolescent self-reports of mindfulness, eating in the absence of hunger, and depressive symptoms were collected. An interview was administered to determine presence of binge eating episodes and a behavioral task was used to assess the reinforcing value of food relative to other nonsnack food rewards. Body composition was assessed using dual-energy X-ray absorptiometry.

RESULTS

In analyses accounting for race, percent body fat, lean mass, height, age, and depressive symptoms, dispositional mindfulness was associated with a lower odds of binge eating (p = .002). Controlling for the same potential confounds, mindfulness was also inversely associated with eating concern, eating in the absence of hunger in response to fatigue/boredom, and higher food reinforcement relative to physical activity (all p < .05).

DISCUSSION

In girls with a family history of T2D, independent of body composition and depressive symptoms, intraindividual differences in mindfulness are related to binge eating and associated attitudes and behaviors that may confer risk for obesity and metabolic problems. Further research is needed to determine the extent to which mindfulness plays a role in the etiology and/or maintenance of disinhibited eating in adolescents at risk for T2D.

Correlation of binge eating disorder with level of depression and glycemic control in type 2 diabetes mellitus patients

OBJECTIVE

It is reported that eating disorders and depression are more common in patients with type 2 diabetes mellitus (T2DM). In this study, we aimed to determine the prevalence of binge eating disorder (BED) in T2DM patients and examine the correlation of BED with level of depression and glycemic control.

METHOD

One hundred fifty-two T2DM patients aged between 18 and 75 years (81 females, 71 males) were evaluated via a Structured Clinical Interview for DSM-IV Axis I Disorder, Clinical Version in terms of eating disorders. Disordered eating attitudes were determined using the Eating Attitudes Test (EAT) and level of depression was determined using the Beck Depression Scale. Patients who have BED and patients who do not were compared in terms of age, gender, body mass index, glycosylated hemoglobin (HbA1c) levels, depression and EAT scores.

RESULTS

Eight of the patients included in the study (5.26%) were diagnosed with BED. In patients diagnosed with BED, depression and EAT scores were significantly high (P<.05). A positive correlation was found between EAT scores and depression scores (r = +0.196, P<.05). No significant difference was found in HbA1c levels between patients with BED and those without (P<.05).

CONCLUSIONS

T2DM patients should be examined in terms of the presence of BED and disordered eating attitudes. Psychiatric treatments should be organized for patients diagnosed with BED by taking into consideration comorbid depression.

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

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

Cardiovascular complications of type 2 diabetes in youth

The prevalence of type 2 diabetes mellitus (T2DM) in youth has increased dramatically over the past decades. The literature also suggests that the progression from an impaired glucose tolerance state to established T2DM is more rapid in youth, compared to adults. The presence of significant cardiovascular complications in youth with T2DM, including cardiac, macrovascular, and microvascular remodeling, is another major issue in this younger cohort and poses a significant threat to the healthcare system. However, this issue is only now emerging as a major public health concern, with few data to support optimal treatment targets and strategies to reduce cardiovascular disease (CVD) risk in youth with T2DM. Accordingly, the purpose of this minireview is to better understand the cardiovascular complications in youth with T2DM. We briefly describe the pathophysiology from youth studies, including oxidative stress, inflammation, renin-angiotensin aldosterone system, and epigenetics, which link T2DM and CVD. We also describe the literature concerning the early signs of CVD in youth and potential treatment options to reduce cardiovascular risk.

Early onset type 2 diabetes: risk factors, clinical impact and management

Early onset type 2 diabetes mellitus (T2DM) is increasingly prevalent with a significant impact on the individual, healthcare service delivery and planning. The individuals are likely to be obese, lead a sedentary lifestyle, have a strong family history of T2DM, be of black and minority ethnic (BME) origin and come from a less affluent socioeconomic group. They have a heightened risk of developing microvascular and macrovascular complications, often at an earlier stage and with greater frequency than seen in type 1 diabetes. As such, early and aggressive risk factor management is warranted. Early onset T2DM is complex and impacts on service delivery with a need for multidisciplinary care of complications and comorbidities', in addition to adequate educational and psychological support. This review on the impact of early onset T2DM provides the latest insights into this emerging epidemic.

Double jeopardy. Addressing diabetes and eating disorders among adolescents in the school setting

Eating disorders are more common in youth with diabetes, especially females, and not only interfere with diabetes management but can increase the risk for diabetes-related complications. School nurses may be the first to recognize eating disorders among students with diabetes. They are an integral part of a multidisciplinary team, connecting students and families to both health care and community resources, ensuring that mental, physical, and social needs are addressed.

Eating disorders in children and adolescents: state of the art review

Despite their high prevalence, associated morbidity and mortality, and available treatment options, eating disorders (EDs) continue to be underdiagnosed by pediatric professionals. Many adolescents go untreated, do not recover, or reach only partial recovery. Higher rates of EDs are seen now in younger children, boys, and minority groups; EDs are increasingly recognized in patients with previous histories of obesity. Medical complications are common in both full and subthreshold EDs and affect every organ system. No single cause of EDs has emerged, although neurobiological and genetic predispositions are emerging as important. Recent treatment paradigms acknowledge that they are not caused by families or chosen by patients. EDs present differently in pediatric populations, and providers should have a high index of suspicion using new Diagnostic and Statistical Manual, 5th edition diagnostic criteria because early intervention can affect prognosis. Outpatient family-based treatment focused on weight restoration, reducing blame, and empowering caregivers has emerged as particularly effective; cognitive behavioral therapy, individual therapy, and higher levels of care may also be appropriate. Pharmacotherapy is useful in specific contexts. Full weight restoration is critical, often involves high-calorie diets, and must allow for continued growth and development; weight maintenance is typically inappropriate in pediatric populations. Physical, nutritional, behavioral, and psychological health are all metrics of a full recovery, and pediatric EDs have a good prognosis with appropriate care. ED prevention efforts should work toward aligning with families and understanding the impact of antiobesity efforts. Primary care providers can be key players in treatment success.

Treatment outcome of patients with comorbid type 1 diabetes and eating disorders

BACKGROUND

Co-morbidity between Type 1 Diabetes Mellitus (T1DM) and eating disorders (ED) has been previously described; however the effect of this illness on the outcomes for conventional ED treatments has not been previously investigated. This study aims to compare clinical, psychopathological and personality features between two samples of ED individuals: those with comorbid T1DM and those without (No-DM); and to identify differences in treatment outcomes between the groups.

METHODS

This study compares treatment outcome, dropouts, ED psychopathology and personality characteristics for 20 individuals with ED and T1DM and 20 ED patients without diabetes, matched for diagnostic and treatment type.

RESULTS

The study found higher dropout rates from therapy in individuals with T1DM and worse treatment outcome in spite of having no significant differences in eating disorder psychopathology, although individuals with T1DM report misusing insulin.

CONCLUSIONS

The low levels of motivation to change, and insulin abuse in T1DM patients, may suggest that treatment for patients with ED and T1DM should consider the individual's personality and role of insulin abuse when determining the appropriate intervention.

Detecting intentional insulin omission for weight loss in girls with type 1 diabetes mellitus

OBJECTIVE

Intentional insulin omission is a unique inappropriate compensatory behavior that occurs in patients with type 1 diabetes mellitus, mostly in females, who omit or restrict their required insulin doses in order to lose weight. Diagnosis of this underlying disorder is difficult. We aimed to use clinical and laboratory criteria to create an algorithm to assist in the detection of intentional insulin omission.

METHOD

The distribution of HbA1c levels from 287 (181 females) patients with type 1 diabetes were used as reference. Data from 26 patients with type 1 diabetes and intentional insulin omission were analysed. The Weka (Waikato Environment for Knowledge Analysis) machine learning software, decision tree classifier with 10-fold cross validation was used to developed prediction models. Model performance was assessed by cross-validation in a further 43 patients.

RESULTS

Adolescents with intentional insulin omission were discriminated by: female sex, HbA1c>9.2%, more than 20% of HbA1c measurements above the 90th percentile, the mean of 3 highest delta HbA1c z-scores>1.28, current age and age at diagnosis. The models developed showed good discrimination (sensitivity and specificity 0.88 and 0.74, respectively). The external test dataset revealed good performance of the model with a sensitivity and specificity of 1.00 and 0.97, respectively.

DISCUSSION

Using data mining methods we developed a clinical prediction model to determine an individual's probability of intentionally omitting insulin. This model provides a decision support system for the detection of intentional insulin omission for weight loss in adolescent females with type 1 diabetes mellitus.