Disordered eating and body dissatisfaction in adolescents with type 1 diabetes and a population-based comparison sample: comparative prevalence and clinical implications

Perceived comfort with weight, body shape and eating pattern of young adults with type 1 diabetes and associations with clinical and psychological parameters in a clinical setting

BACKGROUND

Higher prevalence of disordered eating in young adults with type 1 diabetes (T1D) culminates in higher levels of morbidity and mortality. In addition to validated questionnaires for diabetes distress, depression/anxiety symptoms and emotional well-being, the Diabetes Psychosocial Assessment Tool (DPAT) includes three questions about comfort with weight, body shape and eating pattern (WSE), which were derived from literature and multidisciplinary team consensus. Recognising individuals with low comfort with WSE, is the first step towards identifying those who may be at risk of developing eating disorders.

AIMS

Observe comfort with WSE, in young adults with T1D, and its associations with demographic/clinical characteristics and psychological parameters.

METHODS

276 young adults, aged 15-26, who attended routine clinical care at a Young Adult Diabetes Clinic, completed the DPAT. The WSE questions were scored on a 5-point Likert scale (1 indicating lowest comfort). Linear regression analysed differences in comfort with weight and eating pattern by demographic and psychological parameters.

RESULTS

1 in 3 young adults (29%) reported low comfort with WSE (scores 1 or 2). In females, 40%, 41% and 35% had low comfort with weight, shape and eating patterns respectively, in comparison to males in whom it was 18.5%, 16% and 21.5%. Females reported lower comfort with weight and eating pattern (mean 2.9 and 3.0 respectively) than Males (mean 3.7 and 3.6 respectively), each p < 0.001. Lower comfort with weight (p < 0.001) and eating pattern (p = 0.001) was associated with higher body mass index (BMI). Young adults with low comfort with weight and eating pattern experienced elevated diabetes distress and depressive/anxiety symptoms (each p < 0.001), also when adjusted for sex and BMI.

CONCLUSIONS

The study has shown that low comfort with WSE is common among young adults with T1D. Adding these questions into routine care, can allow for easy and early identification of low comfort, initiation of a therapeutic dialogue and implementation of focused management strategies.

Comparative Analysis of Body Image Dissatisfaction, Depression, and Health-Related Quality of Life in Adults with Type 1 Diabetes: A Case-Control Study

(1) Objective: This case-control study investigated body image dissatisfaction, depression, and health-related quality of life (HRQoL) in adults with type 1 diabetes. (2) Methods: A total of 35 adults with diabetes and an equal number of age- and gender-matched controls were included. Assessment tools used were the Body Image Disturbance Questionnaire (BIDQ), the Hospital Anxiety and Depression Scale (HADS), and the RAND 36-Item Health Survey. Both quantitative and qualitative data were analyzed. (3) Results: Body image dissatisfaction did not differ significantly between the groups. However, adults with diabetes reported higher levels of depression (p = 0.002) and lower scores for physical health (p = 0.015) and general health (p < 0.001) on the HRQoL measure. Qualitative analysis identified common themes related to physical disturbance, effect on activities, and psychosocial concerns. (4) Conclusions: Despite similar body image dissatisfaction, adults with type 1 diabetes exhibited increased depression and reduced HRQoL. These findings emphasize the need to integrate psychological well-being into type 1 diabetes management. They also support further research into the impact of body image dissatisfaction in T1D and potential interventions to address it.

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.

Disordered eating behaviours and eating disorders in adults with type 1 diabetes (DEBBI): rational and design of an observational longitudinal online study

INTRODUCTION

Disordered eating behaviours (DEB) and eating disorders (ED) are among the most common mental health comorbidities of type 1 diabetes. However, research on diabetes-specific risk and protective factors is limited. To this end, comprehensive characterisations of DEB and ED in type 1 diabetes, as well as longitudinal research on the course of DEB and ED, are needed to gain more insight. The 'Disordered eating behaviours and eating disorders in diabetes type I' (DEBBI) study aims to describe DEB/ED and their correlates in people with type 1 diabetes, to identify key diabetes-specific, psychosocial risk and protective factors, and to describe the course of DEB over time.

METHODS AND ANALYSIS

The DEBBI study is a longitudinal online survey with follow-up assessments after 6, 12 and 18 months, targeted at adults who have been diagnosed with type 1 diabetes for at least 12 months. The survey covers data on diabetes diagnosis and self-management (eg, diabetes treatment and complications), lifestyle (eg, eating habits, physical activity), psychosocial well-being (eg, anxiety, depressive symptoms) and demographic and medical information. It includes validated instruments and self-generated items. One key aspect of the data analysis will be latent profile analyses to determine latent subtypes of DEB manifestation in people with type 1 diabetes and their courses over time, including data on the clinical picture and symptoms, behaviours and diabetes-specific complications.

ETHICS AND DISSEMINATION

The study protocol was approved by the Ethics Committee of the State Medical Chamber of Rhineland-Palatine, Germany (ID 2021-16040). Participants give informed written consent before starting the survey. The DEBBI study will provide more clarity in the so far inconsistent empirical evidence base and will help to inform research on prevention and intervention strategies that are tailored to diabetes-specific needs.

TRIAL REGISTRATION NUMBER

The study is registered with DRKS German Clinical Trials Register (DRKS00028833).

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

OBJECTIVE

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

METHOD

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

RESULTS

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

DISCUSSION

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

PUBLIC SIGNIFICANCE STATEMENT

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

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Eating disorders in adolescents with type 1 diabetes mellitus

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

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

Objective

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

Methods

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

Results

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

Conclusion

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

Gestörtes Essverhalten und psychosoziale Versorgungssituation junger Menschen mit Typ 1 Diabetes

Einleitung Gestörtes Essverhalten oder klinisch relevante Essstörungen in Verbindung mit Typ 1 Diabetes haben schwerwiegende Folgen für die Qualität der Stoffwechseleinstellung und die langfristige gesundheitliche Prognose Betroffener. Eine frühzeitige Diagnose und qualifizierte therapeutische Interventionen können bereits bei gestörtem Essverhalten dazu beitragen, vorzeitige mikrovaskuläre Schädigungen zu vermeiden. In dieser Studie wurden für eine Gruppe junger Menschen mit Typ 1 Diabetes, die an einem 4-tägigen Camp teilnahmen, die Prävalenz essgestörten Verhaltens und die spezifische psychosoziale Versorgungssituation untersucht.

Material und Methoden Während eines bundesweit ausgeschriebenen Diabetescamps für junge Menschen (16–29 Jahre) beantworteten die Teilnehmenden Fragen zu ihrer aktuellen Diabetesbehandlung, zu diabetesspezifischen Belastungen (PAID-5) sowie zur psychosozialen Versorgung im Rahmen der ambulanten Langzeittherapie. Symptome gestörten Essverhaltens wurden mit einem diabetesspezifischen Screeningfragebogen, dem Diabetes Eating Problem Survey-Revised (DEPS-R), erhoben. Eine lineare multiple Regression wurde berechnet, um Prädiktoren gestörten Essverhaltens zu identifizieren.

Ergebnisse An der Umfrage beteiligten sich 308 junge Menschen mit Typ 1 Diabetes (Alter 21,4±3,4 Jahre; 73% weiblich; Diabetesdauer 10,2±5,9 Jahre; 74% in internistischer Behandlung). Bei 28,2% der Befragten ergaben sich Hinweise auf ein gestörtes Essverhalten (17% der Männer, 32% der Frauen). Teilnehmende mit einem auffälligen Summenwert im DEPS-R wurden nur zu 7% entsprechend psychologisch betreut. Das HbA1c, der BMI, die diabetesspezifischen Belastungen, das Alter, die Diabetesdauer sowie das Geschlecht erwiesen sich als signifikante Prädiktoren für das Ausmaß gestörten Essverhaltens.

Diskussion Unter den Teilnehmenden eines Diabetescamps für junge Menschen zeigten sich bei über einem Viertel Hinweise auf ein gestörtes Essverhalten. Insgesamt waren davon junge Frauen häufiger betroffen, weitere relevante Risikofaktoren waren ein erhöhter BMI, ein höheres HbA1c und stärkere diabetesspezifische Belastungen. Nur ein sehr geringer Anteil der jungen Menschen mit Typ 1 Diabetes und gestörtem Essverhalten erhielt psychologische Unterstützung.

Schlussfolgerung In der ambulanten diabetologischen Versorgung sollten diabetesspezifische Screeninginstrumente und/oder gezielte Screeningfragen insbesondere bei jungen Frauen regelmäßig eingesetzt und die Ergebnisse mit den Betroffenen im Hinblick auf eine weiterführende Behandlung besprochen werden.

The Impact of Externally Worn Diabetes Technology on Sexual Behavior and Activity, Body Image, and Anxiety in Type 1 Diabetes

BACKGROUND

We aimed to explore the impact of externally worn diabetes technologies on sexual behavior and activity, body image, and anxiety in adopters and nonadopters of these devices.

METHODS

People with type 1 diabetes aged 16-60 years living in Western Australia were invited to complete an online survey.

RESULTS

Of the 289 respondents (mean age 34.3 years), 45% used continuous subcutaneous insulin infusion (CSII) and 35% used continuous glucose monitoring (CGM). Approximately half of CSII users stated that the pump interferes with sex. Of these, 75% disconnect their pump during sexual activity to avoid this issue. Comfort during sex influenced the location of the CSII insertion site in 22% of respondents, with the abdomen being preferred. One in four non-CSII users cited sex-related concerns as a factor for not adopting the technology. CGM interfered with sexual activity in 20% of users, but did not commonly affect CGM placement (only 18%). Sexual activity was reported as a factor for not adopting the technology in 10% of non-CGM users. No differences in body dissatisfaction (P = .514) or anxiety (P = .304) between CSII and non-CSII users were observed. No differences in sexual activity and behavior between technology users and nontechnology users were observed.

CONCLUSION

Wearable technologies impact upon sexual activity and this influences the decision to adopt the technology. Despite this, technology users are similar in terms of sexual behavior, anxiety, and body image compared to nontechnology users. Where appropriate, these data can be used to identify potential concerns, address strategies to mitigate them, and inform people with diabetes when considering adopting external technologies.

Protocol for a feasibility study: a brief self-compassion intervention for adolescents with type 1 diabetes and disordered eating

INTRODUCTION

Adolescents with type 1 diabetes are at a higher risk of developing psychiatric disorders, particularly eating disorders, compared with their healthy peers. In turn, this increases the risk for sub-optimal glycaemic control and life-threatening diabetes-related complications. Despite these increased risks, standard diabetes care does not routinely provide psychological support to help prevent or reduce mental health risks. There is an urgent need to develop 'clinically usable' psychosocial interventions that are acceptable to patients and can be realistically integrated into clinical care. This study aims to examine the feasibility and acceptability of a brief self-compassion intervention for adolescents with type 1 diabetes and disordered eating behaviour.

METHODS AND ANALYSIS

This feasibility study will examine the effectiveness of a brief self-compassion intervention, compared with a waitlist control group. Participants aged 12-16 years will be recruited from three diabetes outpatient clinics in Auckland, New Zealand. The brief self-compassion intervention is adapted from the standardised 'Making Friends with Yourself' intervention and will be delivered in a group format over two sessions. Apart from examining feasibility and acceptability through the flow of participants through the study and qualitative questions, we will assess changes to disordered eating behaviour (primary outcome), self-care behaviours, diabetes-related distress, self-compassion, stress and glycaemic control (secondary outcomes). Such data will be used to calculate the required sample size for a fully powered randomised controlled trial.

ETHICS AND DISSEMINATION

This trial has received ethics approval from the Health and Disability Ethics Committee (research project number A+8467). Study results will be disseminated through peer-reviewed journals and conferences.

TRIAL REGISTRATION NUMBER

ANZCTR (12619000541101).

Examination of Psychosocial and Physiological Risk for Bulimic Symptoms in Youth With Type 1 Diabetes Transitioning to an Insulin Pump: A Pilot Study

Objectives

This study tested hypotheses drawn from a risk model positing that psychosocial risk plus disease-related and treatment factors contribute to bulimic symptoms in youth with type 1 diabetes (T1D) transitioning to an insulin pump. The goal of this study was to examine whether disease-related factors, particularly disease- and treatment-based disruption in hunger and satiety, contribute to report of bulimic symptoms in youth with T1D after accounting for psychosocial risk factors.

Methods

43 youth (ages 10-17, 54% female) with established T1D were recruited before transition from multiple daily injections to insulin-pump therapy from three tertiary pediatric diabetes centers. Participants completed measures of bulimic symptoms, depressive symptoms dietary restraint, and the Diabetes Treatment and Satiety Scale, a diabetes-specific questionnaire assessing hunger and satiety cues and eating behavior in response to blood glucose levels and treatment.

Results

Hierarchical multiple regression was used to assess contributions of psychosocial and disease-based risk to report of bulimic symptoms. After assessing the contributions of body mass index, body image dissatisfaction, and dietary restraint, a significant 2-way interaction emerged between depression and diabetes-related uncontrollable hunger related to bulimic symptoms (β = 1.82, p < .01).

Conclusions

In addition to psychosocial risk, disease- and treatment-based hunger and satiety dysregulation appear to be important factors contributing to report of bulimic symptoms in youth with T1D. These preliminary findings have significant treatment implications for bulimic symptoms in youth with T1D.

Assessing the clinical utility of the diabetes eating problem survey-revised (DEPS-R) in adolescents with type 1 diabetes

OBJECTIVE

Eating disorders are prevalent among adolescents with type 1 diabetes (T1D). We examined the clinical utility of the Diabetes Eating Problem Survey-Revised (DEPS-R), a brief self-report questionnaire developed for patients with T1D, to identify at-risk adolescents. We aimed to determine whether a positive DEPS-R screen was predictive of a formal diagnosis of an eating disorder as per the DSM-V. In addition, we assessed whether other variables including psychosocial characteristics and diabetes conflict were associated with an abnormal DEPS-R screen.

METHODS

Cross-sectional study of 116 T1D adolescents aged 12-17 years. All participants completed the DEPS-R screening; both participants and parents completed a questionnaire addressing psychosocial characteristics/conflict around diabetes management. Clinical variables were obtained from participant charts. Differences were examined between positive and negative DEPS-R groups. Adolescents who screened positive were offered a referral to a specialized eating disorder team for further assessment.

RESULTS

From 116 participants (mean age ± SD = 14.6 years ± 1.56), 21% (24/116) scored positive for DEPS-R More females than males had abnormal DEPS-R (75% vs 25%, P = 0.001). Those with positive DEPS-R score had higher HbA1c% (mean = 9.3 ± 1.3 vs 8.3 ± 1.2, P = 0.001). Positive DEPS-R group had higher conflict score for diabetes management in both parents' and children's assessments (both ps < 0.001). In regression analysis, being female (OR males = 0.07, 95%CI: 0.010-0.46, P = 0.006), older (OR = 2.01, 95%CI: 1.16-3.48, P = 0.040) and > child-reported conflict (OR = 1.78, 95%CI: 1.02-3.11, P = 0.044) were predictors of an abnormal DEPS-R score.

CONCLUSION

The DEPS-R score is a useful clinical tool for identifying T1D adolescents at risk for disordered eating behaviour, but has a low positive predictive value (PPV) for identifying adolescents who meet diagnostic criteria for an eating disorder. Female gender, suboptimal diabetes control and increased conflict in diabetes management are associated with an abnormal DEPS-R score.

Bidirectional relationship between eating disorders and autoimmune diseases

BACKGROUND

Immune system dysfunction may be associated with eating disorders (ED) and could have implications for detection, risk assessment, and treatment of both autoimmune diseases and EDs. However, questions regarding the nature of the relationship between these two disease entities remain. We evaluated the strength of associations for the bidirectional relationships between EDs and autoimmune diseases.

METHODS

In this nationwide population-based study, Swedish registers were linked to establish a cohort of more than 2.5 million individuals born in Sweden between January 1, 1979 and December 31, 2005 and followed up until December 2013. Cox proportional hazard regression models were used to investigate: (a) subsequent risk of EDs in individuals with autoimmune diseases; and (b) subsequent risk of autoimmune diseases in individuals with EDs.

RESULTS

We observed a strong, bidirectional relationship between the two illness classes indicating that diagnosis in one illness class increased the risk of the other. In women, the diagnoses of autoimmune disease increased subsequent hazards of anorexia nervosa (AN), bulimia nervosa (BN), and other eating disorders (OED). Similarly, AN, BN, and OED increased subsequent hazards of autoimmune diseases.Gastrointestinal-related autoimmune diseases such as, celiac disease and Crohn's disease showed a bidirectional relationship with AN and OED. Psoriasis showed a bidirectional relationship with OED. The previous occurence of type 1 diabetes increased the risk for AN, BN, and OED. In men, we did not observe a bidirectional pattern, but prior autoimmune arthritis increased the risk for OED.

CONCLUSIONS

The interactions between EDs and autoimmune diseases support the previously reported associations. The bidirectional risk pattern observed in women suggests either a shared mechanism or a third mediating variable contributing to the association of these illnesses.

Worse Metabolic Control and Dynamics of Weight Status in Adolescent Girls Point to Eating Disorders in the First Years after Manifestation of Type 1 Diabetes Mellitus: Findings from the Diabetes Patienten Verlaufsdokumentation Registry

OBJECTIVE

To assess indications of eating disorders in girls with type 1 diabetes mellitus (T1DM).

STUDY DESIGN

In total 31 556 girls aged >6 months and <23 years of age with T1DM from the Diabetes Patienten Verlaufsdokumentation (DPV) cohort were analyzed including 155 (0.49%) girls with anorexia nervosa, 85 (0.27%) girls with bulimia nervosa, 45 (0.14%) girls with binge eating disorder, and 229 (0.73%) girls with eating disorders not otherwise specified. Patient characteristics, weight changes, numbers of patients with severe hypoglycemia and diabetic ketoacidosis (DKA), changes of glycosylated hemoglobin A1c (HbA1c) levels, use of pumps, and prevalence of celiac disease and autoimmune thyroiditis were compared between girls with and without eating disorders. Multiple logistic regression analyses were performed.

RESULTS

Eating disorders were significantly associated with late pubertal age, nonusage of pumps, no migration background, increased HbA1c levels, increased frequencies of DKA and severe hypoglycemia, and celiac disease were not related to eating disorders. Significant differences in HbA1c levels, prevalence of DKA and severe hypoglycemia between girls with and without eating disorders were already detectable in the first years after onset of T1DM. A decrease of body mass index (BMI)-SDS increased the risk for comorbid anorexia nervosa (7.1-fold [95% CI 3.6-14.3] compared with stable BMI-SDS, 6.9-fold [95%CI 3.4-14.1] compared with increase of BMI-SDS).

CONCLUSIONS

Poor metabolic control and increased rates of DKA and severe hypoglycemia in the first years after manifestation of T1DM can be hints for eating disorders in girls with T1DM, and weight loss is specific for anorexia nervosa. These clinical features should lead to screening for eating disorders especially at a late pubertal age.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Association of insulin-manipulation and psychiatric disorders: A systematic epidemiological evaluation of adolescents with type 1 diabetes in Austria

BACKGROUND/OBJECTIVE

The aim of this study was to systematically assess the association of insulin-manipulation (intentional under- and/or overdosing of insulin), psychiatric comorbidity and diabetes complications.

METHODS

Two diagnostic interviews (Diabetes-Self-Management-Patient-Interview and Children's-Diagnostic-Interview for Psychiatric Disorders) were conducted with 241 patients (age 10-22) with type 1 diabetes (T1D) from 21 randomly selected Austrian diabetes care centers. Medical data was derived from medical records.

RESULTS

Psychiatric comorbidity was found in nearly half of the patients with insulin-manipulation (46.3%) compared to a rate of 17.5% in patients, adherent to the prescribed insulin therapy. Depression (18.3% vs 4.9%), specific phobia (21.1% vs 2.9%), social phobia (7.0% vs 0%), and eating disorders (12.7% vs 1.9%) were elevated in patients with insulin-manipulation. Females (37.7%) were more often diagnosed (P = 0.001) with psychiatric disorders than males (18.4%). In females, the percentage of psychiatric comorbidity significantly increased with the level of non-adherence to insulin therapy. Insulin-manipulation had an effect of +0.89% in HbA1c (P = <0.001) compared to patients adherent to insulin therapy, while there was no association of psychiatric comorbidity with metabolic control (HbA1c 8.16% vs 8.12% [65.68 vs 65.25 mmol/mol]). Ketoacidosis, severe hypoglycemia, and frequency of outpatient visits in a diabetes center were highest in patients with insulin-manipulation.

CONCLUSIONS

This is the first study using a systematic approach to assess the prevalence of psychiatric disorders in patients who do or do not manipulate insulin in terms of intentional under- and/or overdosing. Internalizing psychiatric disorders were associated with insulin-manipulation, especially in female patients and insulin-manipulation was associated with deteriorated metabolic control and diabetes complications.

Sociodemographic associations of longitudinal adiposity in youth with type 1 diabetes

Excess adiposity is common in youth with type 1 diabetes, yet little is known about the sociodemographic factors that predict longitudinal trajectories of body fat. We analyzed data from 363 females and 379 males with type 1 diabetes over ~9 years of follow-up (mean baseline age 12.8 ± 2.3 years in females, 13.2 ± 2.4 years in males). Estimated body fat percentage (eBFP) was calculated with validated sex- and race/ethnicity-specific equations. Group-based modeling identified three eBFP trajectories for each sex. All female trajectories showed gradual increases, while male trajectories showed gradual decreases (<5% in eBFP) that plateaued around 7 years of diabetes duration. Female trajectories showed differences in baseline eBFP: Group F1 (38.0%), mean eBFP 27.8 ± 3.0%: Group F2 (47.9%), mean eBFP 33.9 ± 3.0%: and Group F3 (14.1%), mean eBFP 41.7 ± 4.1%. Male trajectories also showed differences in baseline eBFP: Group M1 (57.2%), mean eBFP 22.0 ± 3.0%: Group M2 (30.9%), mean eBFP 33.9 ± 3.0%: and Group M3 (12.9%), mean eBFP 36.1 ± 3.7%. In multinomial models, adjusted for clinical factors (eg, insulin regimen, insulin dose, and hemoglobin A1c), females who reported a single-parent household (adjusted odds ratio [aOR] = 3.34, 95% confidence interval [CI]: 1.49, 7.47), parental education of less than a college degree (aOR = 3.79, 95% CI: 1.60, 9.60), and a lack of private health insurance (aOR = 3.74, 95% CI: 1.45, 9.60), and a household income of less than $75 000 per year (aOR = 3.13, 95% CI: 1.27, 7.70) were approximately three to four times more likely to be in the highest eBFP trajectory group relative to the lowest eBFP trajectory group. Males who reported a household income of <$75 000/year were almost twice as likely to be in the Group M3 than the Group M1 in the unadjusted model only (aOR = 1.79, 95% CI: 0.91, 4.01 vs unadjusted OR: 2.48, 95% CI: 1.22, 5.06). Lower socioeconomic status may be associated with excess body fat throughout adolescence in type 1 diabetes, particularly among females.

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.

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

AIM

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

METHOD

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

RESULTS

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

DISCUSSION

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

METHOD

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

RESULTS

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

DISCUSSION

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

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.

Diabetes, eating disorders and body image in young adults: an exploratory study about "diabulimia"

PURPOSE

The purpose of this study was to compare disordered eating (DE) and body image dissatisfaction (BID) among young adults with type 1 diabetes and their peers without diabetes, to investigate the consequences of diabetes for food, body image and weight in individuals with diabetes and to identify the behavior of insulin omission as a weight loss strategy.

METHODS

Fifty-five young adults with diabetes and 73 without diabetes (ages 18-30) completed self-report questionnaires to evaluate their behaviors, attitudes and feelings related to eating disorders and their perceptions about body image. The participants with diabetes were asked to answer a questionnaire with open and closed questions developed specifically for this study.

RESULTS

No significant differences between participants with and without diabetes in relation to BID and DE were found. The results demonstrated several changes resulting from diabetes in terms of food, body image and weight that interfere with the day-to-day life of individuals with diabetes; 7.3% of these participants reported insulin omission as a weight loss strategy.

CONCLUSIONS

This study emphasizes the importance of research on DE in the population with diabetes and their prevention, screening and treatment. In particular, it is essential to give more attention to insulin omission as a compensatory behavior that is inappropriate and harmful to health.

LEVEL OF EVIDENCE

Level III, case-control analytic study.

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.

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

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

Patient Characteristics Associated with Differences in Admission Frequency for Diabetic Ketoacidosis in United States Children's Hospitals

OBJECTIVES

To determine across and within hospital differences in the predictors of 365-day admission frequency for diabetic ketoacidosis (DKA) in children at US children's hospitals.

STUDY DESIGN

Multicenter retrospective cohort analysis of 12,449 children 2-18 years of age with a diagnosis of DKA in 42 US children's hospitals between 2004 and 2012. The main outcome of interest was the maximum number of DKA admissions experienced by each child within any 365-day interval during a 5-year follow-up period. The association between patient characteristics and the maximum number of DKA admissions within a 365-day interval was examined across and within hospitals.

RESULTS

In the sample, 28.3% of patients admitted for DKA experienced at least 1 additional DKA admission within the following 365 days. Across hospitals, patient characteristics associated with increasing DKA admission frequency were public insurance (OR 1.97, 95% CI 1.71-2.26), non-Hispanic black race (OR 2.40, 95% CI 2.02-2.85), age ≥ 12 (OR 1.98, 95% CI 1.7-2.32), female sex (OR 1.41, 95% CI 1.29-1.55), and mental health comorbidity (OR 1.36, 95% CI 1.13-1.62). Within hospitals, non-Hispanic black race was associated with higher odds of 365-day admission in 59% of hospitals, and public insurance was associated with higher odds in 56% of hospitals. Older age, female sex, and mental health comorbidity were associated with higher odds of 365-day admission in 42%, 29%, and 15% of hospitals, respectively.

CONCLUSIONS

Across children's hospitals, certain patient characteristics are associated with more frequent DKA admissions. However, these factors are not associated with increased DKA admission frequency for all hospitals.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

DISCUSSION

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

Psychological correlates of eating disorder symptoms and body image in adolescents with type 1 diabetes

OBJECTIVE

To examine eating disorder symptoms and body image in adolescents with type 1 diabetes and to investigate the associations among social support, self-esteem, health locus of control, eating disorder symptoms and body image.

METHODS

Forty-six adolescents with type 1 diabetes and 27 healthy comparison adolescents completed questionnaires.

RESULTS

No significant differences were identified in eating disorder symptoms and body image between adolescents with type 1 diabetes and healthy comparison adolescents. Regression analyses were completed with the full sample of adolescents with type 1 diabetes and healthy comparison adolescents. Higher levels of social support and being male were associated with a more positive body image, less body dissatisfaction and a lower drive for thinness. A belief by the adolescents that parents or healthcare providers (i.e. external powerful others locus of control) were in control of their health was associated with a more positive body image and less body dissatisfaction. Higher self-esteem was associated with a greater drive for thinness and a higher level of body dissatisfaction.

CONCLUSIONS

Social support, health locus of control and self-esteem appear to be important correlates of eating disorder symptoms and body image in adolescents with diabetes and their typically developing peers.

Eating disorders in adolescents with type 1 diabetes: Challenges in diagnosis and treatment

Eating disorders (ED) are characterized by a persistent disturbance of eating that impairs health or psychosocial functioning. They are associated with increased rates of medical complications and mortality. Insulin omission is a unique purging behavior available to individuals with type 1 diabetes mellitus (T1DM). The standard treatment regimen for T1DM requires a major focus on food and eating patterns. Moreover, intensive insulin therapy is associated with increasing body weight. These factors, combined with the psychological burden of chronic disease management and depression, may contribute to ED. The comorbidity of ED in T1DM patients is associated with poorer glycemic control and consequently higher rates of diabetes complications. Early recognition and adequate treatment of ED in T1DM is essential.

Clinical characteristics and outcome of 467 patients with a clinically recognized eating disorder identified among 52,215 patients with type 1 diabetes: a multicenter german/austrian study

OBJECTIVE

To compare clinical characteristics and outcome of type 1 diabetes mellitus (T1DM) between patients with and without a clinically recognized eating disorder (ED).

RESEARCH DESIGN AND METHODS

A total of 52,215 T1DM patients aged 8 to <30 years from the prospective diabetes data acquisition system DPV were analyzed. A total of 467 patients had an additional diagnosis of ED according to DSM-IV criteria (anorexia nervosa [AN], n = 141 [female: 94.3%]; bulimia nervosa [BN], n = 62 [90.3%]; and EDs not otherwise specified, including binge-eating disorder [EDNOS], n = 264 [74.2%]). Groups were compared using multivariable regression. Cox proportional hazard ratios were calculated for the association between ED and retinopathy.

RESULTS

After adjustment for age, sex, and duration of diabetes, patients with ED revealed higher HbA1c (no ED vs. AN, BN, or EDNOS, respectively: 8.29 ± 0.01% [67.1 ± 0.1 mmol/mol] vs. 8.61 ± 0.15% [70.6 ± 1.6 mmol/mol], 9.11 ± 0.23% [76.1 ± 2.5 mmol/mol], or 9.00 ± 0.11% [74.9 ± 1.2 mmol/mol]) and a higher rate of pathological insulin injection sites (48.4 vs. 64.3, 64.1, or 62.1%). Furthermore, ketoacidosis (5.7 ± 0.1 vs. 12.1 ± 2.1, 18.0 ± 4.1, or 12.9 ± 1.6 events per 100 person-years) and hospitalization (54.9 ± 0.3 vs. 89.3 ± 6.0, 132.0 ± 12.7, or 91.0 ± 4.4 per 100 person-years) were more common, and duration of hospital stay was longer (4.81 ± 0.01 vs. 11.31 ± 0.21, 18.05 ± 0.48, or 8.44 ± 0.13 days per year). All P values were <0.05. Patients with BN and EDNOS had a 2.5-fold (95% CI 1.3-4.8) and a 1.4-fold (0.8-2.3) higher risk for retinopathy, whereas AN patients had no increased risk (0.9 [95% CI 0.4-2.3]).

CONCLUSIONS

Diabetes health care professionals should be aware of comorbid EDs in pediatric/young-adult T1DM patients. An ED diagnosis is associated with worse metabolic control and higher rates of diabetes complications.

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.

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

OBJECTIVE

Despite modern therapeutic regimens, youths with Type 1 diabetes may be at increased risk of mental and behavioral disorders. In this study, the prevalence of disordered eating behavior (DEB) in intensely treated children and adolescents with early-onset Type 1 diabetes and peers from the general population was compared.

METHOD

Data from 629 patients from a population-based, nationwide survey (54.1% male, mean age 15.3 years) with early-onset Type 1 diabetes of at least 10 years duration were compared with data from 6,813 participants of the German KiGGS study (51.3% male, mean age 14.6 years). The generic SCOFF questionnaire was used as screening instrument to identify participants with symptoms of DEB. Both groups were compared with multivariable regression analysis adjusting for sociodemographic covariates.

RESULTS

31.2% of the female and 11.7% of the male diabetic patients and 28.9% of the females and 15.2% of the males in the comparison group were SCOFF-positive (SCOFF score ≥2; p > .05). The odds for symptoms of eating disorders were 3.7% higher in female and 4.3% lower in male patients with diabetes than in the comparison group, but the differences were not significant. 20.5% of the female and 18.5% of the male diabetic patients reported insulin restriction at least three times per week.

DISCUSSION

Children and adolescents with early-onset Type 1 diabetes of long duration do not seem to be more frequently SCOFF-positive than peers. However, as insulin restriction is practiced in a substantial portion of patients, attention for insulin restriction in diabetes care is essential.

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.

Risk behaviors for eating disorder in adolescents and adults with type 1 diabetes

OBJECTIVE

To evaluate the frequency of risk behaviors for eating disorder (ED) in patients with type 1 diabetes (T1D) and their association with gender, nutritional status, variables related to T1D, and body satisfaction.

METHOD

189 individuals with T1D (12-56 years old) answered the Bulimic Investigation Test (BITE), the Eating Attitude Test (EAT), the Binge Eating Scale (BES), Stunkard's Figure Rating Scale, and questions regarding control of T1D. Association between ED risk behaviors and the selected variables was assessed with the chi-square test and Student's t-test; factors that influenced the risk of ED were identified by means of logistic regression.

RESULTS

Of the patients with T1D, 58.7% were at risk of ED (45, 40, and 16% according to the EAT, BITE and BES, respectively). There were significant differences between groups with and without risk for ED related to BMI (p = 0.009), gender (p = 0.001), insulin omission (p = 0.003), use of the carbohydrate counting method (p = 0.019), and body dissatisfaction (p = 0.001). The risk of ED was nine times higher in patients who reduced or omitted insulin (p = 0.036).

CONCLUSIONS

Patients with T1D demonstrated a high frequency of body dissatisfaction and ED risk behaviors; the omission or reduction of insulin was an important risk factor.

Relationships of neophobia and pickiness with dietary variety, dietary quality and diabetes management adherence in youth with type 1 diabetes

BACKGROUND/OBJECTIVES

Neophobia, pickiness and diet variety are associated with diet quality and health outcomes in young children. Limited research has examined these associations among youth with type 1 diabetes (T1D), a population at risk for poor health outcomes when dietary quality is inadequate.

SUBJECTS/METHODS

Youth (n=252, age 13.2 ± 2.8 years, 92% white, diabetes duration 6.3 ± 3.4 years) with T1D and their parents completed 3-day youth diet records; parents completed questionnaires regarding youth neophobia, pickiness and diabetes management adherence. Medical records provided biomedical data. Dietary quality indicators included Nutrient-Rich Foods Index 9.3 (NRF9.3), Healthy Eating Index-2005 (HEI-2005), Whole Plant Food Density (WPFD) and key single nutrients. Dietary variety was operationalized as a count of 20 recommended food groups consumed. Relationships of dietary quality and diabetes management adherence with neophobia, pickiness and dietary variety as independent variables were examined using multiple linear regression analyses adjusted for total energy intake, age, height and weight.

RESULTS

In multiple linear regression analyses, NRF9.3 and HEI-2005 were each inversely associated with neophobia and pickiness, and positively associated with dietary variety. WPF and potassium were each positively associated and saturated fat was inversely associated with dietary variety. However, in models simultaneously including neophobia, pickiness and dietary variety as independent correlates of dietary quality, only relationships with dietary variety remained significant. Diabetes management adherence was negatively associated with both neophobia and pickiness and positively associated with dietary variety.

CONCLUSIONS

Findings suggest that increasing dietary variety may contribute toward improved dietary quality among youth with T1D, despite potentially adverse influences of neophobia and pickiness.

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.

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

This review is focused on the prevalence of eating disorders and disordered eating behaviors in individuals with type 1 diabetes. Recent research indicates higher prevalence rates of eating disorders among people with type 1 diabetes compared with their peers without diabetes. Eating disorders and disordered eating behaviors-especially insulin omission-are associated with poorer glycemic control and serious risk for increased morbidity and mortality. Screening should begin in pre-adolescence and continue through early adulthood, as many disordered eating behaviors begin during the transition to adolescence and may persist for years. Available screening tools and treatment options are reviewed. Given the complexity of diabetes management in combination with eating disorder treatment, it is imperative to screen early and often, in order to identify those most vulnerable and begin appropriate treatment in a timely manner.

Determining the influence of type 1 diabetes on two common eating disorder questionnaires

PURPOSE

This research evaluated the level of influence that having type 1 diabetes (T1DM) has on responses to questions about food choices, eating concerns, dietary restraint, and others that are included on two widely used, validated eating disorder (ED) questionnaires and examined responses to these two questionnaires from patients with T1DM and an eating disorder (ED-T1DM) and an ED-no-diabetes.

METHOD

An expert panel rated each item on the Eating Disorders Examination Questionnaire (EDE-Q) and Eating Disorders Inventory, version 3 (EDI-3) regarding T1DM level of influence on item interpretation. These questionnaires were completed by 2 matched samples (ED-T1DM, n = 48 and ED-no-diabetes, n = 96); responses were compared between the samples with particular attention to items of high T1DM influence.

RESULTS

The expert panel identified that 50% (19/38) of the items on the EDE-Q and 6.6% (6/91) on the EDI-3 could be highly influenced by having T1DM. Before Bonferroni correction, the 2 groups responded statistically different on 9 out of 38 items on the EDE-Q and 27 out of 91 items on the EDI-3; generally responses were healthier for those with ED-T1DM than ED-no-diabetes. Of these items, on the EDE-Q, 5 were rated high T1DM influence and on the EDI-3, 3 were rated high.

CONCLUSION

Having T1DM influences responses on ED questionnaires developed for the general population. This influence may be greater when questionnaires focus on eating, weight, and shape and result in misinterpretation of total and subscale scores by even well-trained clinicians. A careful review of individual item responses by the treatment team is warranted.

Eating problems in adolescents with Type 1 diabetes: a systematic review with meta-analysis

AIMS

We report a systematic review to determine (1) prevalence of eating problems compared with peers and (2) the association between eating problems and glycaemic control in young adults with Type 1 diabetes.

METHOD

  We conducted a systematic literature search via electronic databases and meta-analysis. Cohen's d (the mean difference score between Type 1 diabetes and comparison groups) was calculated for 13 studies that met inclusion criteria.

RESULTS

  Eating problems [both disordered eating behaviour (39.3 and 32.5%; d = 0.52, 95% CI 0.10-0.94) and eating disorders (7.0 and 2.8%; d = 0.46, 95% CI 0.10-0.81)] were more common in adolescents with Type 1 diabetes compared with peers and both were associated with poorer glycaemic control (d = 0.40, 95% CI 0.17-0.64). In restricted analyses involving measures adapted for diabetes, associations between eating problems and poorer glycaemic control remained (d = 0.54, 95% CI 0.32-0.76). Disordered eating behaviour (51.8 and 48.1%; d = 0.06, 95% CI -0.05 to 0.21) and eating disorders (6.4 and 3.0%; d = 0.43, 95% CI -0.06 to 0.91) were more common in adolescents with Type 1 diabetes compared with peers, but differences were non-significant.

CONCLUSIONS

  Eating problems are common among this age group. Future work in populations with Type 1 diabetes should develop sensitive measures of eating problems and interventions, and establish predictors of eating problems. Screening in clinics is recommended.

Mental health issues in adolescents and young adults with type 1 diabetes: prevalence and impact on glycemic control

Mental health comorbidities can negatively affect disease management in adolescents with chronic illnesses. This study sought to determine the prevalence and impact of mental health issues in a population of adolescents and young adults with type 1 diabetes. A cross-sectional study of 150 patients aged 11 to 25 years with type 1 diabetes from an urban, academic diabetes center was conducted. Participants completed 3 validated mental health disorder screening instruments: Beck's Depression Inventory, the Screen for Child Anxiety Related Emotional Disorders-41 anxiety screen, and the Eating Disorder Screen for Primary Care. More than a third screened positive: 11.3% for depression, 21.3% for anxiety, and 20.7% for disordered eating (14.7% had ≥2 positive screens). Patients with a positive screen had twice the odds of having poor glycemic control as those without, as measured by HgbA1c. This study supports screening for mental health issues in adolescents and young adults with type 1 diabetes.