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

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

The relationship between diabetic ketoacidosis and suicidal or self-injurious behaviour: A systematic review

Background

It has been suggested that there may be an association between type 1 diabetes (T1DM) and suicide, with one study reporting a rate 11 times that of the general population The aim of this paper was to investigate the association between Diabetic ketoacidosis (DKA: a life-threatening acute complication of T1DM) and suicidal behaviours in people with T1DM.

Methods

We performed a search of the following databases: PubMed, PsychInfo, and Embase for papers which explored the association between suicidal behaviours and self-harm with DKA in T1DM. We excluded case reports and review papers.

Results

Only three papers explored the relationship between DKA and self-harm. One study found an association between DKA and self-harm in a national cohort of people with type 1 diabetes and schizophrenia. The second found a significant increase in psychiatric admissions for self-harm following an episode of DKA. The third study reported that patients with diabetes and a history of self-harm were at elevated risk of a range of diabetes complications including DKA. These findings indicate an association between DKA and self-harm and support the guidelines in recommending a psychosocial assessment where DKA cannot be explained.

Conclusions

This review suggests that DKA is associated with suicidal or self-injurious behaviours. The small number of studies and the seriousness of this issue highlight the importance of further research on this topic, to improve the evidence base for the identification and treatment of risk of suicidal behaviours in people with T1DM.

Eating Disorders and Diabetes: Facing the Dual Challenge

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

Health Professionals' Experiences Supporting People With Type 1 Diabetes Mellitus Who Deliberately Restrict and/or Omit Insulin for Weight, Shape, and/or Appearance: A Meta-synthesis

OBJECTIVES

It has been reported that health professionals currently lack the required empathy, understanding, and knowledge about the deliberate restriction and/or omission of insulin to influence weight and/or shape, which may impact the quality of care provided. We sought to synthesize existing qualitative research pertaining to health professionals' experiences supporting individuals within this unique population.

METHODS

We conducted a meta-synthesis using a meta-aggregative approach. We searched 5 electronic databases. Eligible articles were qualitative or mixed-methods empirical studies with primary data reporting health professionals' experiences supporting people with type 1 diabetes restricting and/or omitting insulin for weight and/or shape control, written in English, from database inception to March 2022.

RESULTS

A final sample of 4 primary studies were included. The analysis indicated that in the absence of standardized screening and diagnostic tools, health professionals found it challenging to decide when behaviour became clinically significant. Health professionals were also challenged by complex perceptions and behaviours relating to their illness management and features of broader health-care systems and organizational factors.

CONCLUSIONS

Our findings have widespread multidisciplinary implications for health professionals and the broader health-care systems in which they work. We provide evidence-based clinical recommendations and suggestions for vital future research.

Eating disorder outcomes: findings from a rapid review of over a decade of research

BACKGROUND

Eating disorders (ED), especially Anorexia Nervosa (AN), are internationally reported to have amongst the highest mortality and suicide rates in mental health. With limited evidence for current pharmacological and/or psychological treatments, there is a grave responsibility within health research to better understand outcomes for people with a lived experience of ED, factors and interventions that may reduce the detrimental impact of illness and to optimise recovery. This paper aims to synthesise the literature on outcomes for people with ED, including rates of remission, recovery and relapse, diagnostic crossover, and mortality.

METHODS

This paper forms part of a Rapid Review series scoping the evidence for the field of ED, conducted to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded and released by the Australian Government. ScienceDirect, PubMed and Ovid/MEDLINE were searched for studies published between 2009 and 2022 in English. High-level evidence such as meta-analyses, large population studies and Randomised Controlled Trials were prioritised through purposive sampling. Data from selected studies relating to outcomes for people with ED were synthesised and are disseminated in the current review.

RESULTS

Of the over 1320 studies included in the Rapid Review, the proportion of articles focused on outcomes in ED was relatively small, under 9%. Most evidence was focused on the diagnostic categories of AN, Bulimia Nervosa and Binge Eating Disorder, with limited outcome studies in other ED diagnostic groups. Factors such as age at presentation, gender, quality of life, the presence of co-occurring psychiatric and/or medical conditions, engagement in treatment and access to relapse prevention programs were associated with outcomes across diagnoses, including mortality rates.

CONCLUSION

Results are difficult to interpret due to inconsistent study definitions of remission, recovery and relapse, lack of longer-term follow-up and the potential for diagnostic crossover. Overall, there is evidence of low rates of remission and high risk of mortality, despite evidence-based treatments, especially for AN. It is strongly recommended that research in long-term outcomes, and the factors that influence better outcomes, using more consistent variables and methodologies, is prioritised for people with ED.

Caring for individuals with Type 1 Diabetes Mellitus who restrict and omit insulin for weight control: Evidence-based guidance for healthcare professionals

PURPOSE

Evidence-based guidance is needed to inform care for individuals with Type 1 Diabetes Mellitus who deliberately restrict and omit insulin for weight control. Consensus on the best treatment approach for these individuals is currently lacking, and standard eating disorder treatment protocols are ineffective. This article focuses on how healthcare professionals can provide meaningful care to this population.

METHODS

Qualitative research studies were synthesised in a meta-aggregative meta-synthesis. We identified key themes related to individuals' understanding and experience, physical and psychological impacts, support and treatment-related needs and experiences. These themes guided the development of implications for practice.

RESULTS

Individuals engaging in insulin misuse wanted healthcare professionals to demonstrate more empathy, validate their experiences, have increased knowledge about their illness and develop more specialist pathways.

CONCLUSIONS

The findings have widespread interdisciplinary implications for health professionals working with individuals with Type 1 Diabetes Mellitus. Evidence-informed implications for practice are provided and may provide useful guidance concerning the prevention and treatment of this unique behaviour.

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.

Prevention and early help for eating disorders in young people with type 1 diabetes

There is building evidence that early intervention is key to improving outcomes in eating disorders, whereas a 'watch and wait' approach that has been commonplace among GPs and other healthcare professionals is now strongly discouraged. Eating disorders occur at approximately twice the rate in individuals with type 1 diabetes compared to the general population. In this group, standard eating disorder treatments have poorer outcomes, and eating disorders result in a particularly high burden of morbidity. Therefore, our first priority must be prevention, with early intervention where disordered eating has already developed. Clinicians working in both eating disorders and diabetes specialist services have highlighted the need for multidisciplinary team collaboration and specific training, as well as improved treatments. We review the current evidence and future directions for prevention, identification and early intervention for eating disorders in children and young people with type 1 diabetes.

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

BACKGROUND

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

METHOD

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

CONCLUSIONS

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

Lifetime Weight Course as a Phenotypic Marker of Severity and Therapeutic Response in Patients with Eating Disorders

The association between lifetime weight fluctuations and clinical characteristics has been widely studied in populations with eating disorders (ED). However, there is a lack of literature examining the potential role of weight course as a transdiagnostic factor in ED so far. Therefore, the aim of this study is to compare ED severity and treatment outcomes among four specific BMI profiles based on BMI-trajectories across the lifespan: (a) persistent obesity (OB-OB; (n = 74)), (b) obesity in the past but currently in a normal weight range (OB-NW; n = 156), (c) normal weight throughout the lifespan (NW-NW; n = 756), and (d) current obesity but previously at normal weight (NW-OB; n = 314). Lifetime obesity is associated with greater general psychopathology and personality traits such as low persistence and self-directedness, and high reward dependence. Additionally, greater extreme weight changes (NW-OB and OB-NW) were associated with higher psychopathology but not with greater ED severity. Higher dropout rates were found in the OB-OB group. These results shed new light on the BMI trajectory as a transdiagnostic feature playing a pivotal role in the severity and treatment outcome in patients with ED.

An open trial of app-assisted acceptance and commitment therapy (iACT) for eating disorders in type 1 diabetes

BACKGROUND

Eating disorders (EDs) among individuals with type 1 diabetes (T1D) increase the risk of early and severe diabetes-related medical complications and premature death. Conventional eating disorder (ED) treatments have been largely ineffective for T1D patients, indicating the need to tailor treatments to this patient population and the unique conditions under which ED symptoms emerge (in the context of a chronic illness with unrelenting demands to control blood glucose, diet and exercise). The current study was a pilot open trial of iACT, a novel intervention for EDs in T1D grounded in Acceptance and Commitment Therapy (ACT). iACT was based on the premise that ED symptoms emerge as individuals attempt to cope with T1D and related emotional distress. iACT taught acceptance and mindfulness as an alternative to maladaptive avoidance and control, and leveraged personal values to increase willingness to engage in T1D management, even when it was upsetting (e.g., after overeating). A tailored mobile application ("app") was used in between sessions to facilitate the application of ACT skills in the moment that individuals are making decisions about their diabetes management.

METHODS

Adults with T1D who met criteria for an ED completed 12 sessions of iACT (with three optional tapering sessions). In addition to examining whether treatment was acceptable and feasible (the primary aim of the study), the study also examined whether iACT was associated with increased psychological flexibility (i.e., the ability to have distressing thoughts/feelings about diabetes while pursuing personally meaningful values), and improvements in ED symptoms, diabetes management and diabetes distress.

RESULTS

Treatment was acceptable to T1D patients with EDs and feasible to implement. Participants reported increased psychological flexibility with diabetes-related thoughts/feelings, and less obstruction and greater progress in pursuing personal values. There were large effects for change in ED symptoms, diabetes self-management and diabetes distress from baseline to end-of-treatment (Cohen's d = .90-1.79). Hemoglobin A1c also improved, but the p-value did not reach statistical significance, p = .08.

CONCLUSIONS

Findings provide preliminary evidence for iACT to improve outcomes for T1D patients with EDs and support further evaluation of this approach in a controlled trial.

TRIAL REGISTRATION

NCT02980627 . Registered 8 July 2016.

Diabetes and eating disorders: an exploration of 'Diabulimia'

Background

‘Diabulimia’ is the term given to the deliberate administration of insufficient insulin for the purpose of weight loss. Although Diabulimia can be life-threatening and prevalence rates in diabetes are high, there is a lack of research for how to effectively support people with the condition. This exploratory study aimed to provide much-needed information to healthcare professionals and guide the focus for future research.

Methods

Forty-five individuals with Type 1 diabetes mellitus (T1DM) and a history of insulin misuse completed an online questionnaire. This included an assessment of their eating disorder psychopathology with the Eating Disorder Examination Questionnaire (EDE-Q) and 16 open-ended questions exploring their experience of Diabulimia. The responses to the open-ended questions were analysed using thematic analysis.

Results

The average global EDE-Q score was 3.96 (1.21), which is consistent with eating disorder populations. Common themes identified were concerns about weight, difficulty coping with diabetes, past trauma, and the importance of relationships. Experiences with health professionals were overwhelmingly negative. Most participants had experienced serious medical intervention due to Diabulimia and were fully aware of the consequences of insulin restriction.

Conclusions

Overall, individuals believed that a greater awareness of Diabulimia and more training for healthcare professionals is needed. While education on insulin misuse may be a necessary first step in treatment, psychological support is crucial. To deliver effective treatment, clinicians should be aware of the specific issues facing those with Diabulimia. The current study identified themes that clinicians may find useful to consider.

Eating Disorders and Diabetes

PURPOSE OF REVIEW

This review describes the characteristics of patients with eating disorders in both type 1 and type 2 diabetes and the principles of their treatment.

RECENT FINDINGS

The combination of type 1 diabetes and an eating disorder is sometimes known as "diabulimia". The hallmark of the condition is that the patient deliberately takes an inadequate amount of insulin in order control their body weight (insulin restriction). Other disordered eating behaviours, such as dietary restriction, self-induced vomiting and binge eating, may also be present but typical anorexia nervosa is rare. There is an increased prevalence of eating disorders in adolescents with type 1 diabetes, which is estimated at 7%. The combination of type 1 diabetes and an eating disorder leads to elevated levels of HbA1c and an increased risk of both acute and chronic complications. Screening is recommended but rarely carried out. Management requires an understanding of the inter-relationships between eating behaviour, mood, blood glucose and insulin administration. Treatment aims to introduce a regular eating pattern and support the patient to increase their insulin dose gradually. Eating disorders also occur in those with type 2 diabetes, where binge eating disorder is the most common diagnosis. Eating disorders are common in both type 1 and type 2 diabetes, with an increased prevalence of complications in type 1. Treatment requires an understanding of both diabetes and eating behaviour.

Is food addiction a predictor of treatment outcome among patients with eating disorder?

OBJECTIVES

The study aimed to examine whether food addiction (FA) was associated with greater severity in both binge eating disorders (BED) and bulimia nervosa and, therefore, to determine if FA was predictive of treatment outcome.

METHOD

Seventy-one adult patients with bulimia nervosa and BED (42 and 29, respectively) participated in the study. FA was assessed by means of the Yale Food Addiction Scale.

RESULTS

The results confirmed a high prevalence of FA in patients with binge disorders (around 87%) and also its association with a greater severity of the disorder (i.e., related to an increased eating psychopathology and greater frequency of binge eating episodes). Although FA did not appear as a predictor of treatment outcome in general terms, when the diagnostic subtypes were considered separately, FA was associated with poor prognosis in the BED group. In this vein, FA appeared as a mediator in the relationship between ED severity and treatment outcome.

DISCUSSIONS

Our findings suggest that FA may act as an indicator of ED severity, and it would be a predictor of treatment outcome in BED but not in BN.

The relationship between attentional bias to food and disordered eating in females with type 1 diabetes

OBJECTIVE

Factors which may render females with type 1 diabetes mellitus (T1DM) vulnerable to disordered eating behavior or difficulties with dietary management require further investigation. Given prior associations observed between food-related attentional biases and eating behavior in groups without diabetes, this study explored the relationships between attentional bias to healthy and unhealthy pictorial food cues and disordered eating in young adult females with and without T1DM, aged 18-40yrs.

METHODS

97 participants (41 with T1DM, 56 without) completed an initial online survey assessing demographic and clinical information, and disordered eating via the Eating Disorders Examination- Questionnaire (EDE-Q). They subsequently attended an in-person session to complete a computer-based visual probe task to assess attentional bias to pictorial food cues.

RESULTS

Analyses of Variance (ANOVAs) adjusting for age and body mass index showed a unique significant relationship in the group with T1DM whereby greater attentional bias scores away from unhealthy foods was associated with greater disordered eating. No relationship was observed in the group without diabetes.

DISCUSSION

This study suggests that early attentional disengagement from food-related cues may be uniquely associated with eating-related outcomes for females with T1DM relative to those without diabetes. This should be further explored in future research with an aim to develop novel strategies for prevention and treatment of disordered eating behavior in this vulnerable group.

Disordered Eating Behaviors in Youth and Young Adults With Type 1 or Type 2 Diabetes Receiving Insulin Therapy: The SEARCH for Diabetes in Youth Study

OBJECTIVE

This study examines the prevalence of disordered eating behaviors (DEB) and its associations with glycemic control, insulin sensitivity (IS), and psychosocial functioning in a large, diverse cohort of youth and young adults with type 1 or type 2 diabetes.

RESEARCH DESIGN AND METHODS

In the SEARCH for Diabetes in Youth study, 2,156 youth and young adults with type 1 diabetes (mean ± SD age 17.7 ± 4.3 years; 50.0% female) and 149 youth and young adults with type 2 diabetes (age 21.8 years ± 3.5; 64.4% female) who were receiving insulin therapy completed the Diabetes Eating Problem Survey-Revised (DEPS-R), a self-reported measure for identifying disordered eating. DEB were defined as a DEPS-R score ≥20. Demographic characteristics, clinical measures, and health behaviors of participants with DEB and those without DEB were compared by using t tests.

RESULTS

DEB were observed in 21.2% of participants with type 1 diabetes and 50.3% of participants with type 2 diabetes. Participants encountered challenges in maintaining a healthy weight while controlling their diabetes. For both types of diabetes, individuals with DEB had a significantly higher BMI z score, lower insulin sensitivity, more depressive symptoms, and poorer quality of life than those without DEB. Diabetic ketoacidosis episodes occurred more frequently in youth with type 1 diabetes with DEB compared to those without DEB.

CONCLUSIONS

These findings highlight that DEB are prevalent among youth and young adults with type 1 and type 2 diabetes and who are receiving insulin therapy, and DEB are associated with poorer clinical outcomes and psychosocial well-being. Heightened awareness and early interventions are needed to address DEB for this at-risk population, as are longitudinal studies evaluating the course of DEB and diabetes outcomes.

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.

Real-time predictors and consequences of binge eating among adults with type 1 diabetes

BACKGROUND

Objective binge eating (OBE) is common among individuals with type 1 diabetes (T1D) and may have negative consequences for glycemic control. Recent studies have suggested that diabetes distress (i.e., emotional distress specific to diabetes and living with the burden of management) is a distinct emotional experience among individuals with diabetes. Preliminary studies have found diabetes distress is associated with eating disorder symptoms and poor glycemic control. The aim of the current study was to examine real-time emotional precursors and consequences of OBE in adults with T1D (i.e., general negative affect, specific emotional states and diabetes distress) using ecological momentary assessment methods. We also explore the impact of OBE on 2-h postprandial glycemic control relative to non-OBE eating episodes.

METHODS

Adults with T1D (N = 83) completed 3-days of ecological momentary assessment assessing mood and eating behavior using a telephone-based survey system. Participants were prompted to rate momentary affect, including level diabetes distress, at random intervals and reported on eating episodes. Participants also wore continuous glucose monitors allowing for ongoing assessment of glycemic control. Multi-level modeling was used to examine between- and within-person effects of momentary increases in emotions prior to eating on the likelihood of OBE and the impact of OBE on postprandial blood glucose. Generalized linear mixed models examined whether change in post-meal affect differed between OBE and non-OBE episodes.

RESULTS

Participants were predominately middle-aged (Mean = 42; SD = 12.43) Caucasian (87%) females (88%) reporting clinically significant eating disorder symptoms (76%). Nearly half of the sample (43%) reported OBE during the 3-day study period. The between-person effect for negative affect was significant (OR = 1.93, p < .05), indicating a 93% increased risk of OBE among individuals with higher negative affect compared to individuals with average negative affect. Between-person effects were also significant for guilt, frustration and diabetes distress (OR = 1.48-1.77, ps < .05). Analyses indicated that mean change in post-meal negative affect was significantly greater for OBE relative to non-OBE episodes (B = 0.44, p < .001). Blood glucose at 120 min postprandial was also higher for OBE than for non-OBE episodes (p = .03).

CONCLUSIONS

Findings indicate that individuals who tend to experience negative affect and diabetes distress before eating are at increased risk of OBE at the upcoming meal. Results also suggest that engaging in binge eating may result in greater subsequent negative affect, including diabetes distress, and lead to elevated postprandial blood glucose levels. These findings add to a growing literature suggesting diabetes distress is related to eating disordered behaviors among individuals with T1D.

Royal College of Psychiatrists Liaison Faculty & Joint British Diabetes Societies (JBDS): guidelines for the management of diabetes in adults and children with psychiatric disorders in inpatient settings

The Royal College of Psychiatrists Liaison Faculty & Joint British Diabetes Societies (JBDS) for Inpatient Care guidelines for the management of diabetes in adults and children with psychiatric disorders in inpatient settings are available in full at: www.diabetes.org.uk/joint-british-diabetes-society and https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group. This article summarizes the guidelines and recommendations. Commissioners are urged to ensure that the needs of people with diabetes and severe mental illness are specifically addressed in contracts with providers of inpatient care, and to avoid financial or other barriers to cross-organizational working and to ensure that patient-structured education is commissioned to meets the complex needs of people with diabetes and severe mental illness. Acute trusts are asked to develop joint pathways with mental health providers and facilitate multidisciplinary working and to screen for mental ill health in those admitted with acute complications of diabetes whose aetiology is unclear or not medically explained. Mental health trusts should create a diabetes register, screen for diabetes, particularly in those prescribed second-generation antipsychotics and ensure that staff are trained in managing and avoiding hypoglycaemia, and the safe use of insulin. Finally, clinical teams should ensure that all staff can access training in diabetes and mental health to support them to care for people with both diabetes and severe mental illness, develop local pathways for joint working and ensure best practice tariff criteria are met for diabetic ketoacidosis and hypoglycaemia, and for children and young people with diabetes.

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.

Eating disorders in people with Type 1 diabetes: experiential perspectives of both clients and healthcare professionals

AIMS

To explore the experiential perspective of people with Type 1 diabetes mellitus and eating disorders and that of the healthcare professionals treating them, and to understand the experience of both sides to inform future development of healthcare services.

METHODS

Participants were recruited from Diabetics with Eating Disorders (a national UK charity), and through professional networks. Nine partially/fully recovered individuals with Type 1 diabetes and eating disorders and eight healthcare professionals participated in semi-structured interviews carried out by medically trained researchers. Data were transcribed and coded using a six-stage framework of thematic analysis.

RESULTS

Four superordinate themes and several subordinate themes emerged from the Type 1 diabetes and eating disorders dataset: (1) perceptions surrounding service provision; (2) reflections on the recovery process; (3) the experiential perspective of living with Type 1 diabetes and an eating disorder; and (4) support mechanisms. Healthcare professional data elicited three superordinate themes and several subordinate themes: (1) service provision; (2) personal insight and reflection of professional role; and (3) challenges of working with dual diagnoses.

CONCLUSION

People with Type 1 diabetes and eating disorders and their healthcare professionals provided insight into healthcare services from the patient and care delivery perspectives. There was general agreement from both groups that a multidisciplinary, collaborative (family inclusive), clinical approach to treatment is important, as well as adequate training opportunities for service providers. These findings may help to inform development strategies for multidisciplinary care approaches to Type 1 diabetes complicated by eating disorders.

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.

Systematic review and meta-analysis of the efficacy of interventions for people with Type 1 diabetes mellitus and disordered eating

AIM

To examine the types of interventions currently available for people with Type 1 diabetes mellitus and their effectiveness.

BACKGROUND

The prevalence of disordered eating in people with Type 1 diabetes mellitus is twice that in their counterparts without diabetes, and is associated with worse biomedical outcomes and greater mortality.

METHODS

Medline, Embase, PsycINFO, the Cochrane Library, PubMed and OpenGrey databases were searched up to August 2016 to identify studies on interventions in people with Type 1 diabetes-associated disordered eating. For the systematic review, intervention components were identified and their effectiveness was examined. For the meta-analysis, the pooled effect sizes of glycaemic control (HbA_1c ) between pre- and post-treatment in treatment and comparison groups were calculated using a random effects model.

RESULTS

Of 91 abstracts reviewed, six studies met the inclusion criteria, of which three had appropriate data for the meta-analysis (n = 118). The pooled effect size was -0.21 95% CI (-0.58 to 0.16; where negative values represent an improvement in HbA_1c levels), indicating no statistically significant improvement in the treatment group compared with comparison group. Inpatient therapy appeared to be the most effective treatment, and this had multiple components including cognitive behavioural therapy, psychoeducation and family therapy.

CONCLUSION

Limited or no improvement in glycaemic control and disordered eating symptoms was observed in people with Type 1 diabetes-associated disordered eating who were receiving currently available interventions. The present review suggests that developing an intensive intervention with a joint focus on both disordered eating and diabetes management is needed for this complex patient group.

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.

Microvascular Complications Associated With Rapid Improvements in Glycemic Control in Diabetes

PURPOSE OF REVIEW

Aggressive glycemic control has become the standard clinical approach to diabetes care. Unintended consequences have included the development of microvascular complications that are related to the rapidity of glycemic improvement.

RECENT FINDINGS

Diabetic neuropathy may develop in up to 10% of individuals secondary to aggressive glycemic control. The neuropathy is predominantly small fiber sensory and autonomic, and the severity of the neuropathy is tied to the change in the glycosylated hemoglobin A1C. Other microvascular complications such as retinopathy and nephropathy are common and may occur in parallel with the neuropathy. Eating disorders are a common comorbid risk factor. Individuals with uncontrolled diabetes for prolonged periods, particularly those with a history of eating disorders involving insulin restriction for calorie purging, are at high risk for developing treatment-induced microvascular complications. Gradual glycemic improvements should be encouraged but future research is needed to optimize treatment and prevention strategies.

Short-Term Treatment Outcomes and Dropout Risk in Men and Women with Eating Disorders

This study compared treatment outcomes between men and women with eating disorders (EDs) and analysed clinical predictors of treatment outcome. Our sample consisted of 131 male and 131 female ED patients who underwent cognitive behavioural therapy treatment. ED severity, personality and psychopathology were assessed using standard instruments. We found that the risk of dropout was higher for men with bulimia nervosa (BN) than for women with BN and that men with BN and other specified feeding and EDs were more likely to obtain full remission in comparison with their female counterparts. Predictive models of treatment outcome indicated that higher scores in novelty seeking were a shared factor associated with higher risk of dropout and not obtaining full remission for both men and women with ED. However, only in men, younger age and lower scores in reward dependence predicted higher dropout. Contrastingly, higher persistence scores were predictors of full remission. This study reinforces the effectiveness of using outpatient cognitive behavioural therapy as treatment as usual for men with ED. Nonetheless, placing greater emphasis on strategies targeting gender-specific issues could enhance outcomes. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

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

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

The importance of social identities in the management of and recovery from 'Diabulimia': A qualitative exploration

INTRODUCTION

A significant barrier to recovery for individuals with co-morbid eating disorders and type 1 diabetes is the way in which group members self-categorise. Nonetheless, identity issues are neglected during the recovery process. The aim of this paper is to explore how group memberships (and the associated identities) both contribute to and hinder recovery in this cohort.

METHOD

Transcripts from five online focus groups with 13 members of an online support group for individuals with 'Diabulimia' were thematically analysed.

RESULTS

Findings suggested that those with whom one shares a recovery identity can be well placed to provide psychological resources necessary for successful recovery although such connections can be damaging if group norms are not managed. Members recognised that other important relationships (including family and friends and health professionals) are also key to recovery; these other group memberships (and the associated identities) can be facilitated through the recovery identity group membership, which allows for external validation of the recovery identity, provides encouragement to disclose the illness to supportive others, and provides information to facilitate positive service interactions.

CONCLUSIONS

While clinical interventions typically focus on eliminating disordered behaviours, we suggest that these should also include strengthening important group memberships that promote recovery.

Orexin and sleep quality in anorexia nervosa: Clinical relevance and influence on treatment outcome

BACKGROUND AND AIMS

Orexins/hypocretins are orexigenic peptides implicated in the regulation of feeding behavior and the sleep/wake cycle. Little is known about the functioning of these peptides in anorexia nervosa (AN). The aims of the current study were to evaluate the extent to which orexin-A might be linked to sleep and treatment outcome in AN.

METHOD

Fasting plasma orexin-A concentrations were measured in 48 females with AN at the start of a day hospital treatment and in 98 normal-eater/healthy-weight controls. The Pittsburgh Sleep Quality Index was administered at the beginning of the treatment as a measure of sleep quality. Other psychopathological variables were evaluated with the Symptom Checklist-Revised (SCL90R) and the Eating Disorder Inventory-2 (EDI). Patients were assessed at the start and end of treatment by means of commonly used diagnostic criteria and clinical questionnaires.

RESULTS

The AN patients presented more sleep disturbances and poorer overall sleep quality than did the healthy controls (p=.026) but there were no global differences between groups in plasma orexin-A concentrations (p=.071). In the AN sample, orexin-A concentrations were associated with greater sleep disturbances (|r|=.30), sleep inefficiency (|r|=.22) and poorer overall sleep (|r|=.22). Structural Equation Modeling (SEM) showed that both elevated orexin-A concentrations and inadequate sleep predicted poorer treatment outcome.

CONCLUSION

Plasma orexin-A concentrations contribute to poor sleep quality in AN, and both of these variables are associated with therapy response.

The medical complications associated with purging

OBJECTIVE

Purging behaviors, including self-induced vomiting, laxative abuse, and diuretic abuse, are present across many of the eating disorders. Here we review the major medical complications of these behaviors.

METHOD

Although we identified over 100 scholarly articles describing medical complications associated with purging, most papers involved case studies or small, uncontrolled samples. Given the limited evidence base, we conducted a qualitative (rather than systematic) review to identify medical complications that have been attributed to purging behaviors.

RESULTS

Medical conditions affecting the teeth, esophagus, gastrointestinal system, kidneys, skin, cardiovascular system, and musculoskeletal system were identified, with self-induced vomiting causing the most medical complications.

DISCUSSION

Purging behavior can be associated with severe medical complications across all body systems. Mental health professionals should refer patients with purging behaviors to medical providers for screening and treatment as needed. The medical work-up for individuals with eating disorders should include a comprehensive metabolic panel, complete blood count, and a full body exam including the teeth to prevent severe complications. Medical providers should screen patients for purging behaviors and associated medical complications, even in the absence of an eating disorder diagnosis, to increase the detection of eating disorders. Recognizing the link between purging and medical complications can aid in identifying potential eating disorders, particularly those that often elude detection such as purging disorder.

Developing a theoretical maintenance model for disordered eating in Type 1 diabetes

BACKGROUND

According to the literature, eating disorders are an increasing problem for more than a quarter of people with Type 1 diabetes and they are associated with accentuated diabetic complications. The clinical outcomes in this group when given standard eating disorder treatments are disappointing. The Medical Research Council guidelines for developing complex interventions suggest that the first step is to develop a theoretical model.

AIM

To review existing literature to build a theoretical maintenance model for disordered eating in people with Type 1 diabetes.

METHOD

The literature in diabetes relating to models of eating disorder (Fairburn's transdiagnostic model and the dual pathway model) and food addiction was examined and assimilated.

RESULTS

The elements common to all eating disorder models include weight/shape concern and problems with mood regulation. The predisposing traits of perfectionism, low self-esteem and low body esteem and the interpersonal difficulties from the transdiagnostic model are also relevant to diabetes. The differences include the use of insulin mismanagement to compensate for breaking eating rules and the consequential wide variations in plasma glucose that may predispose to 'food addiction'. Eating disorder symptoms elicit emotionally driven reactions and behaviours from others close to the individual affected and these are accentuated in the context of diabetes.

CONCLUSION

The next stage is to test the assumptions within the maintenance model with experimental medicine studies to facilitate the development of new technologies aimed at increasing inhibitory processes and moderating environmental triggers.

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

OBJECTIVE

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

RESEARCH DESIGN AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Deconstructing "Atypical" Eating Disorders: an Overview of Emerging Eating Disorder Phenotypes

Recent changes to the diagnostic framework of eating disorders (ED's) in DSM-5 were introduced to reduce the large preponderance of cases falling within the residual and undifferentiated category. However, current reports continue to illustrate overrepresentation of cases in this residual category, suggesting that clinical reality comprises more diverse ED psychopathology than is accounted for in the current diagnostic spectrum. However, with emerging evidence preliminarily delineating several additional distinct phenotypes, we aim to provide a narrative overview of emerging ED phenotypes which (i) are not currently located as a specific diagnostic category in diagnostic criteria for ED's, (ii) centrally feature ED psychopathology, and (iii) have emerging empirical evidence suggesting the distinct nature of the syndrome. A greater awareness of these emerging phenotypes will likely facilitate accurate diagnostic practice and may also serve to facilitate further empirical efforts.

Physical activity in anorexia nervosa: How relevant is it to therapy response?

OBJECTIVE

Elevated physical activity has been observed in some patients with anorexia nervosa (AN) despite their emaciated condition. However, its effects on treatment outcome remain unclear. This study aimed to examine objectively measured physical activity in this clinical population and how it might be related to a partial hospitalization therapy response, after considering potential confounders.

METHOD

The sample comprised 88 AN patients consecutively enrolled in a day hospital treatment program, and 116 healthy-weight controls. All participants were female and a baseline assessment took place using an accelerometer (Actiwatch AW7) to measure physical activity, the Eating Disorders Inventory-2 and the Depression subscale of the Symptom Checklist-Revised. Outcome was evaluated upon the termination of the treatment program by expert clinicians.

RESULTS

Although AN patients and controls did not differ in the average time spent in moderate-to-vigorous physical activity (MVPA) (P=.21), nor daytime physical activity (P=.34), fewer AN patients presented a high physical activity profile compared to the controls (37% vs. 61%, respectively; P=.014). Both lower levels of MVPA and greater eating disorder severity had a direct effect on a poor treatment outcome. Depression symptoms in the patients were associated with lower MVPA, as well as with an older age, a shorter duration of the disorder and greater eating disorder psychopathology.

CONCLUSIONS

There is a notable variation in the physical activity profile of AN patients, characterized by either low or very high patterns. Physical activity is a highly relevant issue in AN that must be taken into account during the treatment process.

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

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

Topical review: a comprehensive risk model for disordered eating in youth with type 1 diabetes

OBJECTIVES

Provide an updated literature review on prevalence, measurement, and correlates of disordered eating in youth with Type 1 diabetes (T1D), present a novel theoretical risk model (i.e., The Modified Dual Pathway Model) for disordered eating in youth with T1D incorporating psychosocial and physiological risk factors, and discuss clinical implications.

METHODS

Literature review of prevalence, correlates, risk factors, and outcomes of disordered eating behavior (DEB) in youth with T1D.

RESULTS

Insulin treatment, subsequent weight gain, and disruptions to hunger and satiety regulation are hypothesized disease-related mechanisms through which the treatment of T1D may increase vulnerability to development of behavior characterized as DEB. The Modified Dual Pathway Model integrates these factors with a validated psychosocial risk (body dissatisfaction, depression, and abstinence violation) model for DEB in nondiabetic youth.

CONCLUSIONS

The Modified Dual Pathway model of DEB in youth with T1D is a comprehensive representation of both psychosocial and T1D-related risk factors with the potential to inform future interventions for this population.

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.