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.

The role of diabetes distress in Diabulimia

IMPORTANCE

Diabulimia is a disordered eating behavior in which a person with type 1 diabetes withholds insulin injections to lose weight. It is thought that the psychosocial stress of managing this chronic disease, which is termed diabetes distress, may contribute to developing diabulimia.

OBJECTIVE

This paper explores links between diabetes distress and diabulimia and their relevance to the diagnosis and treatment of diabulimia by assessing whether people with diabulimia report measurable evidence of diabetes distress.

EVIDENCE REVIEW

We evaluated studies examining the qualitative experiences of people with disordered eating behaviors in the setting of type 1 diabetes for themes of diabetes distress by identifying aspects of the patients' stories that matched the criteria in the Diabetes Distress Scale. Selected studies recorded primary data, analyzed qualitative data, examined lived experiences of individuals with diabulimia, and were made available in English-language peer-reviewed journals between January 1, 2000 and August 31, 2022. Exclusion criteria included partial articles, editorials, reviews, and abstracts along with studies of patients with type 2 diabetes.

FINDINGS

Over forty individual participants across twelve studies were found to have aspects of their experiences that met one or more criteria from the Diabetes Distress Scale. Participants reported experiences that matched criteria items from each of the seven subscales of the Diabetes Distress Scale. Participants in the twelve studies included 185 individuals with type 1 diabetes experiencing diabulimia, including 164 females (88.6%), 20 males (10.8%), and 1 non-reported gender (0.54%).

CONCLUSION

We believe this discovery warrants further research probing the prevalence of diabetes distress among people with diabulimia as well as other links between the two conditions. We advocate for a diabetes distress-informed approach to diabulimia treatment and for diabetes distress screening in every patient with type 1 diabetes.

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

OBJECTIVE

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

DESIGN

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

RESULTS

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

CONCLUSIONS

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

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

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

Causative factors of eating problems among adolescents with type 1 diabetes mellitus: A qualitative study

Adolescents with type 1 diabetes mellitus are prone to have eating problems. This study aimed to determine factors of eating problems among this population in University Malaya Medical Centre. Fifteen adolescents who scored more than 20 marks in the Diabetes Eating Problem Survey - Revised questionnaire were invited for an in-depth interview. Questions were asked based on their questionnaire's response. The interview sessions were recorded, transcribed verbatim, and thematic analysis was used. Five main themes emerged: pressure, physiological factor, psychological factor, patient's low compliances to insulin intake and food control and fear. Early referral to child psychologist would prevent it from developing.

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

OBJECTIVE

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

RESEARCH DESIGN AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level III, case-control study.

Can having a sibling with type 1 diabetes cause disordered eating behaviors?

Background Adolescents with type 1 diabetes mellitus (T1DM) are at an increased risk of eating disturbances. The aim of this study was to evaluate whether the risk of a disordered eating behavior (DEB) also applies to the well sibling sharing the same environment. Methods Well siblings were included if they were 10-18 years old, had a sibling with a T1DM diagnosis for at least 6 months and lived with the sibling during the illness. The control group was comprised of healthy participants recruited from the outpatient clinic with no family history of T1DM. Participants completed a four-part questionnaire concerning their eating behaviors that was developed by the study team. This survey aimed to evaluate the dietary habits and eating patterns. All participants completed the Eating Attitudes Test-26 (EAT-26) and a 24-h food dietary recall. Any participant with a high EAT-26 score or that seemed to be at risk according to the questionnaire was re-evaluated. Results Eight cases (33.3%) in the well sibling group had either a total and/or subgroup pathological score. Three of them were found to have DEB and one case was diagnosed with anorexia nervosa (AN). In the control group, five cases (17.2%) had either a total and/or subgroup pathological score. Three of these cases were found to have DEB, no cases were diagnosed with an eating disorder. There were no statistically significant differences in the EAT-26 scores between the groups. Conclusions Although a direct relationship was not observed, the probability of having a pathologic EAT-26 score was higher in the group with a sibling with T1DM.

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.

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.

Teachers’ self-perception of their dietary behavior and needs to teach healthy eating habits in the school

Through focus groups, we explored 22 third- to fifth-grade teachers’ perceptions about their eating habits, including barriers and facilitators to healthy eating. It also explored teachers’ thoughts about how to teach students healthy eating habits. The information was transcribed and treated using the content analysis technique. Results were evaluated using the concept of majority and minority group and presented in a sequential way: teachers’ perceptions about eating habits, barriers to healthy eating, teacher’s culinary habits, abilities to teach students healthy eating habits through Information and Communication Technologies, and cooking activities. Teachers’ eating habits were poor, with lack of time, money, and will to improve. They had culinary habits skills and the desire to instruct and guide their students in eating healthier food. They need a program with Information and Communication Technologies and cooking workshops to apply in the classroom.