Comorbidity of diabetes mellitus and eating disorders: a follow-up study

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Diabetes and disordered eating behaviours in a community-based sample of Australian adolescents

BACKGROUND

People with diabetes have been shown to be at risk for disordered eating compared to their non-diabetic peers. However, the majority of studies have been conducted in relatively small samples drawn from clinical diabetes settings or registries. Community-based samples are required to better understand disordered eating behaviours in this population. In a large community-based population sample of Australian adolescents, this study aimed to (1) investigate disordered eating behaviours in adolescents reporting a diagnosis of diabetes compared to their non-diabetic peers and (2) test associations between disordered eating behaviours and insulin restriction.

METHODS

Secondary school students (n = 4854; mean (SD) age 14.4 (1.6) years; 47% boys) completed an online survey, including self-reported presence of diabetes, demographics, weight status, substance use, insulin restriction and disordered eating behaviours. Clinically meaningful cut-offs for disordered eating behaviours were generated for analysis.

RESULTS

Disordered eating behaviours, specifically self-induced vomiting (diabetes 19.2%, no diabetes 3.3%; p <  0.001), laxative use (diabetes 15.4%, no diabetes 2.1%; p <  0.001), use of cigarettes (diabetes 26.9%, no diabetes 4.3%; p <  0.001) and other drugs (diabetes 28.9%, no diabetes 4.0%; p <  0.001), cleanse/detox (diabetes 30.8%, no diabetes 10.5%; p <  0.001) and extreme weight loss diets (diabetes 13.5%, no diabetes 4.7%; p <  0.003) were higher in those reporting a diagnosis of diabetes. In addition, 17% of those with diabetes reported frequent insulin restriction (≥ once per week), and insulin restriction was associated with more frequent disordered eating behaviours.

CONCLUSION

There was a high rate of disordered eating behaviours in adolescents with diabetes compared to their peers without diabetes. The findings of this study may have the potential to inform future health promotion, prevention, and early intervention approaches for those with comorbid diabetes and disordered eating behaviours. Future longitudinal studies are required to evaluate disordered eating behaviours in those with diabetes over time in community-based samples.

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

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

Does binge-eating matter for glycemic control in type 2 diabetes patients?

BACKGROUND

Eating behavior is an important aspect related to type 2 diabetes mellitus (T2DM) treatment and may have an impact on glycemic control. Previous reports showed elevated prevalence of eating disordered behaviors, especially binge eating disorder in clinical samples of type 2 diabetes patients. However, results regarding the impact of an eating disorder on the glycemic and clinical control of T2DM is inconsistent. The purpose of this study was to assess the impact of a comorbid eating disorder on glycemic control (GC) in a group of patients with T2DM.

METHODS

Eating behaviors of 70 consecutive patients with T2DM were assessed using a Structured Clinical Interview for DSM-IV and the Binge Eating Scale. The GC was examined with fasting blood glucose (FBG) and glycated hemoglobin (A1c) levels. In addition, secondary clinical variables were assessed, including body mass index (BMI) and lipids. Chi-square and Student's T tests were used to compare clinical and psychopathological characteristics of patients with and without an ED. In order to evaluate the relationship between GC and eating disorder (ED) a linear regression analysis was performed, controlling for BMI. A significance level of 5% was adopted.

RESULTS

Seventy-seven percent of the sample (n = 54) were female and 50% were obese. Fourteen patients exhibited an ED, mostly binge eating disorder (BED). In a regression analysis, both FBG (beta coefficient = 47.4 (22.3); p = 0.037) and A1c (beta coefficient = 1.12 (0.57); p = 0.05) were predicted by the presence of an ED. However, the presence of an ED lost its impact on glycemic control outcomes after the addition of the BMI in the models.

CONCLUSIONS

Eating psychopathology is frequently observed in patients with T2DM. Among individuals with T2DM, co-morbid ED is associated with a poorer glycemic control in the presence of a higher BMI. The presence of an eating disordered behavior in patients with T2DM seems to have clinical relevance in the usual care of patients with diabetes. Therefore, we recommend eating psychopathology should be routinely assessed in T2DM patients.

Eating disoders in type 2 diabetic people: Brief review

BACKGROUND

Relationship between type 1 diabetes and Eating disorders is well-known, less information exists on the relationship between type 2 diabetes (T2DM) people and eating disorders.

AIM

Review information on the prevalence and impact of type 2 diabetes and eating disorders comorbidity.

METHODS

Search in Medline and PubMed relevant articles on the aforementioned co-morbidity. Review includes articles on epidemiological, clinical and therapeutics aspects.

CONCLUSIONS

Disordered eating behaviours may affect around 40% of T2DM people, being the predominant clinical forms: Eating Disorders Non otherwise specified (EDNOS), Night Eating Syndrome (NES) and Binge Eating Disorder (BED), however, population-based estimates of T2DM and ED comorbidity are mandatory to determine the prevalence of ED in T2DM people. The association between both entities has a consequence which is an impairment of metabolic control, associated to increase risk of vascular complications and difficult body weight loss, basis of T2DM treatment.

Psychological conditions in adults with diabetes

Type 1 (T1D) and Type 2 diabetes (T2D) represent a demanding set of biopsychosocial challenges for patients and their families, whether the age of disease onset occurs in childhood, adolescence, or adulthood. Psychological conditions, defined as syndromes, disorders, and diabetes-specific psychological issues affect a larger proportion of individuals with T1D and T2D compared to the general population. In this review, we summarize the prevalence, impact and psychological treatments associated with the primary categories of psychological conditions that affect adults with T1D and T2D: depressive symptoms and syndromes, anxiety disorders, eating behaviors and disorders and serious mental illness. The implications of the literature for psychologists are discussed, and priorities for future research to advance the science of psychological conditions for adults with T1D and T2D are identified. (PsycINFO Database Record

Medical comorbidity and medical complications associated with binge-eating disorder

OBJECTIVE

The purpose of this review is to provide an overview of possible medical complications of binge-eating disorder (BED).

METHOD

Literature on BED, both in obese and nonobese patients, was reviewed.

RESULTS

A growing literature suggests that BED independently may increase the likelihood of developing components of the metabolic syndrome, and that LOC eating in children may contribute to weight gain and metabolic disturbances. Limited evidence suggests that other organ systems may be affected by BED as well.

DISCUSSION

Additional prospective studies are needed. Although the results of the available studies are not definitive and provide somewhat mixed results, there does appear to be a clear suggestion of an increased risk for the development of components of the metabolic syndrome in adults and children.

Psychological and Personality Predictors of Weight Loss and Comorbid Metabolic Changes After Bariatric Surgery

Bariatric surgery (BS) has proven to be the most effective treatment for weight loss and for improving comorbidities in severe obesity. A comprehensive psychological assessment prior to surgery is proposed to prepare patients for a successful post-surgical outcome. Therefore, the main aim of the present study was to assess psychological and personality predictors of BS outcome. The sample comprised 139 severely obese patients who underwent BS. Assessment measures included the Eating Disorders Inventory-2, the Symptom Checklist-Revised and the Temperament and Character Inventory-Revised. Our results show that favourable BS outcome, after 2 years follow up, was associated with younger age, less depression, moderate anxiety symptoms and high cooperativeness levels. Likewise, metabolic improvements were found to be linked to younger age and certain psychopathological factors. In conclusion, our findings suggest that age, baseline body mass index, psychopathological indexes and personality traits predict successful BS outcome.

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.

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.

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.

Addressing diabetes and depression in the school setting; the role of school nurses

What Can School Nurses Do to Address Diabetes and Depression in the School Setting? 1. Remember that depression and diabetes are common comorbidities. If you see signs of depression, remember to obtain the appropriate consent and approvals for students under the age of 18 before screening. 2. Remember that depression can interfere with self-management skills and may make diabetes worse--so connect students to community resources to help them reduce the risk of complications. 3. Remember that depression and risk-taking behaviors are common in adolescents with diabetes. Have educational materials ready and available to help students in need.

Eating disorders in adolescents with type 2 and type 1 diabetes

Diabetes is associated with increased risk for eating disorders; with different types of eating disorders associating with different types of diabetes. Binge eating disorders show increased prevalence among individuals with type 2 diabetes (T2DM). Intentional omission of insulin for the purpose of inducing weight loss presents among individuals with type 1 (T1DM). Similarly, some individuals with T2DM intentionally omit oral hypoglycemic drugs, resulting in poor glycemic control, and weight loss. Common dominators for the development of eating disorders in T1DM and T2DM are female gender, increased body weight, body dissatisfaction, a history of dieting, and a history of depression. Patients tend to deny the existence of the problem. Clinical signs that should raise suspicion are: poor glycemic control, missed clinical appointments, recurrent episodes of diabetes ketoacidosis, recurrent hypoglycemia secondary to intentional overdose, poor self-esteem, and dietary manipulation. Eating disorders are associated with poorer glycemic control, and therefore increased risk of diabetes associated comorbidities.

Prosocial effects of oxytocin and clinical evidence for its therapeutic potential

There has been unprecedented interest in the prosocial effects of the neuropeptide oxytocin in humans over the last decade. A range of studies has demonstrated correlations between basal oxytocin levels and the strength of social and bonding behaviors both in healthy individuals and in those suffering from psychiatric disorders. Mounting evidence suggests associations between polymorphisms in the oxytocin receptor gene and prosocial behaviors and there may also be important epigenetic effects. Many studies have now reported a plethora of prosocial effects of intranasal application of oxytocin, including the domains of trust, generosity, socially reinforced learning, and emotional empathy. The main focus of this review will be to summarize human preclinical work and particularly the rapidly growing number of clinical studies which have identified important links between oxytocin and a wide range of psychiatric disorders, and have now started to directly assess its therapeutic potential.

Epidemiology and correlates of weight worry in the multinational Diabetes Attitudes, Wishes and Needs study

OBJECTIVE

This study examined the epidemiology of worry about weight among adults with diabetes and whether this weight worry was associated with worse quality of life and diabetes self-management.

RESEARCH DESIGN AND METHODS

Participants were 5088 adults with type 1 or type 2 diabetes from the multi-national DAWN study. Random samples of approximately 500 were obtained from each of 11 countries/regions in Asia, Australia, Europe, and North America. All measures were self-reported data obtained during structured interviews. High weight worry was represented by the highest level of agreement with the statement 'I feel very anxious about my weight.'

RESULTS

One-quarter (25.1%) of respondents reported high weight worry. Using multivariate logistic regression to assess independent relationships, high weight worry was significantly (p < 0.05) more common among respondents who were women, less educated, had type 2 diabetes and more comorbidities, were diagnosed more recently and reported weight gain with diabetes. Using multivariate logistic regression to control for confounding factors, high weight worry was significantly (p < 0.05) associated with most of the adverse outcomes examined, including lower self-rated health, poorer reported regimen adherence and diabetes control, more diabetes-related distress, poorer psychological well-being, and more psychological treatment.

LIMITATIONS

The cross-sectional, correlational analysis could not assess causal relationships among patient reported outcomes, and the study did not include objective outcome measures.

CONCLUSIONS

High weight worry was common among adults with diabetes and associated with several adverse outcomes, including multiple indicators of diabetes-related distress, poor physical and psychological well-being, and regimen non-adherence. These findings suggest that healthcare providers should assess and address weight worry among their patients with diabetes.

Human cerebral neuropathology of Type 2 diabetes mellitus

The cerebral neuropathology of Type 2 diabetes (CNDM2) has not been positively defined. This review includes a description of CNDM2 research from before the 'Pubmed Era'. Recent neuroimaging studies have focused on cerebrovascular and white matter pathology. These and prior studies about cerebrovascular histopathology in diabetes are reviewed. Evidence is also described for and against the link between CNDM2 and Alzheimer's disease pathogenesis. To study this matter directly, we evaluated data from University of Kentucky Alzheimer's Disease Center (UK ADC) patients recruited while non-demented and followed longitudinally. Of patients who had come to autopsy (N = 234), 139 met inclusion criteria. These patients provided the basis for comparing the prevalence of pathological and clinical indices between well-characterized cases with (N = 50) or without (N = 89) the premortem diagnosis of diabetes. In diabetics, cerebrovascular pathology was more frequent and Alzheimer-type pathology was less frequent than in non-diabetics. Finally, a series of photomicrographs demonstrates histopathological features (including clinical-radiographical correlation) observed in brains of persons that died after a history of diabetes. These preliminary, correlative, and descriptive studies may help develop new hypotheses about CNDM2. We conclude that more work should be performed on human material in the context of CNDM2.

The Relationship between Negative Communication and Body Image Dissatisfaction in Adolescent Females with Type 1 Diabetes Mellitus

Maladaptive eating attitudes and behaviors are common in adolescent females with Type 1 Diabetes Mellitus (T1DM). This research assessed potential pathways through which individual and familial factors relate to treatment adherence and glycemic control. Seventy-five females with T1DM (aged 11—17 years) and their mothers completed questionnaires regarding communication, diabetes management, and eating attitudes and behaviors. Hierarchical regression analyses found that body image dissatisfaction moderates the relationship between negative communication and maladaptive eating attitudes and behaviors. Treatment adherence mediates the relationship between maladaptive eating attitudes and behaviors and glycemic control. None of the participants endorsed omitting insulin for the purposes of weight management. This study highlights the need to address familial and individual factors along with treatment adherence within this population.

The duration of severe insulin omission is the factor most closely associated with the microvascular complications of Type 1 diabetic females with clinical eating disorders

OBJECTIVE

To investigate which features of eating disorders are associated with retinopathy and nephropathy in Type 1 diabetic females with clinical eating disorders.

METHOD

Participants were 109 Type 1 diabetic females with clinical eating disorders diagnosed by the structured clinical interview for DSM-IV (bulimia nervosa [n = 70], binge-eating disorder [n = 28], anorexia nervosa [n = 7], and eating disorder not otherwise specified [n = 4]). Retinopathy and nephropathy were screened and demographic, medical, and eating disorder related factors were investigated. To identify the factors associated with each complication, logistic regression analysis was done.

RESULTS

Duration of severe insulin omission and duration of Type 1 diabetes were significantly associated with retinopathy (odds ratios = 1.35 and 1.23, respectively) and nephropathy (odds ratio = 1.35 and 1.21, respectively) in multivariate regression analyses.

CONCLUSION

Of the various problematic behavioral factors related to eating disorders, the duration of severe insulin omission was the factor most closely associated with the retinopathy and nephropathy of Type 1 diabetic females with clinical eating disorders by multivariate analysis. This finding may help patients who deliberately omit insulin become aware of medical risk of insulin omission.

Weight-related concerns and behaviors in children and adolescents with type 1 diabetes

Children and adolescents with type 1 diabetes are at risk for disordered eating and unhealthy weight-control practices. This study describes (a) participants' weight perception and weight satisfaction, (b) participants' scores on the Diabetes Eating Problem Survey (DEPS), (c) prevalence of weight-control behaviors, and (d) association of DEPS and weight-control behaviors with race, gender, age, body mass index (BMI), hemoglobin A1c (HbA1c), weight satisfaction, and weight perception. TheAHEAD survey was completed by 295 participants to determine weight satisfaction, weight perception, and weight-control behaviors. Height, weight, and HbA1c were obtained from clinic charts. Older females with higher BMI and elevated HbA1c used significantly more weight-control behaviors. Weight dissatisfaction and heavy weight perception were associated with significantly more unhealthy weight-control practices. Prevention programs should be directed toward the preteen female. Older female teens presenting with higher BMI, elevated HbA1c, weight dissatisfaction, and heavy weight perception should be formally assessed for unhealthy weight-control behaviors. J Am Psychiatr Nurses Assoc, 2008; 13(6), 376-385. DOI: 10.1177/1078390307310154.

Eating behavior among type 2 diabetic patients: a poorly recognized aspect in a poorly controlled disease

Nutrition intervention is an integral part of type 2 diabetes care. Dietary management entails a series of eating behavior changes regarding meal planning, food selection, food preparation, dining out, portion control, as well as appropriate responses to eating challenges. Diabetic patients encounter several difficulties in complying with the dietary regime. They exhibit restrictive eating behaviors, they express feelings of dietary deprivation, and rigid dietary control is perceived as the only way to a proper diet and weight management. However, pressure to conform to nutritional recommendations may render diabetics more prone to dietary under-reporting. Binge eating, restraint and body dissatisfaction frequently occur among these patients. Health professionals, therefore, need to take into account these difficulties in their collaboration with the patients in order to improve the effectiveness of nutrition intervention.

Disturbed eating attitudes, coping styles, and subjective quality of life in adolescents with Type 1 diabetes

OBJECTIVES

To evaluate coping styles and quality of life in youth with Type 1 diabetes with and without eating disorders and to identify relationships between these variables in each group.

METHODS

Adolescents were evaluated for eating disorders with a two-stage diagnostic procedure. Adolescents with and without eating disorders then provided data on coping styles and on subjective well-being.

RESULTS

Adolescents with Type 1 diabetes and disordered eating behavior reported more often blaming themselves and resorting to wishful thinking and poorer physical and psychosocial quality of life than do adolescents with Type 1 diabetes without disordered eating behavior. Specific coping strategies were also positively linked with quality of life and metabolic control.

CONCLUSIONS

Eating disorders and disordered eating behavior in adolescents with Type 1 diabetes seem to be associated with certain negative and avoidant coping strategies and with impeded physical and bio-psychosocial well-being.

Position of the American Dietetic Association and Dietitians of Canada: Nutrition and Women’s Health

It is the position of the American Dietetic Association (ADA) and Dietitians of Canada (DC) that women have specific nutritional needs and vulnerabilities and, as such, are at unique risk for various nutrition-related diseases and conditions. Therefore, the ADA and the DC strongly support research, health promotion activities, health services, and advocacy efforts that will enable women to adopt desirable nutrition practices for optimal health. Women are at risk for numerous chronic diseases and conditions that affect the duration and quality of their lives. Although women's health-related issues are multifaceted, nutrition has been shown to influence significantly the risk of chronic disease and to assist in maintaining optimal health status. Dietetics professionals strongly support research, health promotion activities, health services, and advocacy efforts that will enable women to adopt desirable nutrition practices for optimal health.

The implementation of nutritional advice for people with diabetes

These consensus-based recommendations emphasize the practical implementation of nutritional advice for people with diabetes, and describe the provision of services required to provide the information. Important changes from previous recommendations include greater flexibility in the proportions of energy derived from carbohydrate and monounsaturated fat, further liberalization in the consumption of sucrose, more active promotion of foods with a low glycaemic index, and greater emphasis on the provision of nutritional advice in the context of wider lifestyle changes, particularly physical activity. Monounsaturated fats are now promoted as the main source of dietary fat because of their lower susceptibility to lipid peroxidation and consequent lower atherogenic potential. Consumption of sucrose for patients who are not overweight can be increased up to 10% of daily energy provided that this is eaten in the context of a healthy diet and distributed throughout the day [corrected]. Evidence is presented for the effectiveness of advice provided by trained dieticians. The increasing evidence for the importance of good metabolic control and the growing requirement for measures to prevent Type 2 diabetes in an increasingly obese population will require major expansion of dietetic services if the standards in National Service Frameworks are to be successfully implemented.

An integrated inpatient therapy for type 1 diabetic females with bulimia nervosa: a 3-year follow-up study

OBJECTIVE

To describe an "integrated inpatient therapy" for type 1 diabetic patients with recurrent binge eating and to assess its effectiveness for females with bulimia nervosa (BN).

METHODS

At the first visit to our outpatient clinic for treatment of an eating disorder and diabetes, type 1 diabetic females with BN underwent single session "outpatient counseling." All patients then returned to the referring physician for further treatment and observation. None of the BN patients had the minimum expected 1% fall in HbA1c and all were therefore encouraged to undergo our "integrated inpatient therapy." However, only patients accepting inpatient treatment on their own volition were admitted. An "INPATIENT" group (n=9) consisted of those who underwent inpatient therapy and had a 3-year follow-up period after discharge. The clinical course was assessed by the HbA1c and BMI course and by comparison of psychological/behavioral factors between baseline and follow-up. For reference, the clinical course of a "NON-INPATIENT" group (n=10), who did not have the inpatient therapy for at least 2 years after first visit, was also assessed.

RESULTS

The "INPATIENTs" had significantly lower HbA1c; lower psychological test scores related to eating disorder psychopathology, depressiveness, and anxiety-proneness; a reduced frequency and amount of binge eating; and fewer patients exhibited purging behaviors at follow-up than at first visit. At follow-up, seven (78%) "INPATIENTs" no longer fulfilled any criterion for clinical or subclinical eating disorders. The "NON-INPATIENTs" had no significant improvement.

CONCLUSION

The findings give interesting insights into the possibilities of "integrated inpatient therapy" as an effective treatment for type 1 diabetic females with BN.

Comorbidity of diabetes mellitus and eating disorders: a follow-up study

OBJECTIVE

There is increasing evidence that the coexistence of diabetes and eating disorders (ED) leads to poor glycemic control and an increased risk of long-term complications.

METHODS

In a questionnaire- and interview-based study, a sample of 36 out of originally 38 (94.7%) diabetic patients with an ED (type-1: n=13, type-2: n=23) was assessed after a period of about 2 years in order to determine the course of EDs, body mass index (BMI), glycemic control, and psychiatric symptomatology.

RESULTS

Five patients (13.9%) of the total sample showed full remission for at least 12 consecutive weeks. Twenty-two patients (61.6%) showed no change in the diagnosis of the ED. Four patients (11.1%) shifted from subclinical to clinical EDs and five patients (13.9%) vice versa. Of the eight patients who went on to psychotherapy, only one patient (12.5%) showed full remission. Emotional distress of type-2 diabetics was considerably higher compared to type-1 diabetics, which was rather low at baseline. Except interpersonal distrust as one ED-related variable, no significant change of any psychological variable could be observed in the type-1 diabetic sample during follow-up. Of the 13 type-1 diabetic patients with an ED, five patients deliberately omitted insulin in order to lose weight. These patients showed a more serious psychopathology with regard to each measured psychological variable, a higher BMI, and worse metabolic control compared to those without insulin omission. Type-2 diabetics showed a significant increase in drive for thinness and body dissatisfaction. No considerable change could be observed with regard to BMI, glycemic control, and depressive and global psychiatric symptomatology in either diabetic subsample during follow-up.

CONCLUSION

EDs tended to persist over time with a considerable shift within the different types of EDs. Insulin-purging in type-1 diabetics was associated with enhanced psychopathology, higher BMI, and worse metabolic control. Both mean body mass and ED-related symptoms such as "drive for thinness" and "body dissatisfaction" increased in the average obese type-2 diabetic sample, illustrating the vicious circle of low self-esteem, enhanced restraint eating, and binge eating in weight control measures.