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Merwin RM, Dmitrieva NO, Moskovich AA, Warnick JL, Goebel-Fabbri AE, Topor LS, Darling KE. Profiles of disordered eating behaviour in type 1 diabetes using the DEPS-R and behaviour and glycaemic outcomes in a real-life setting. Diabet Med 2024; 41:e15314. [PMID: 38450859 PMCID: PMC11114251 DOI: 10.1111/dme.15314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 02/06/2024] [Accepted: 02/21/2024] [Indexed: 03/08/2024]
Abstract
AIMS The Diabetes Eating Problems Survey - Revised (DEPS-R) is commonly used to assess disordered eating behaviour (DEB) in individuals with type 1 diabetes and has advantages compared to other measures not specifically tailored to diabetes. A score ≥20 on the DEPS-R is used to indicate clinically significant DEB; however, it does not distinguish between eating disorder (ED) phenotypes necessary to guide treatment decisions, limiting clinical utility. METHODS The current study used latent class analysis to identify distinct person-centred profiles of DEB in adults with type 1 diabetes using the DEPS-R. Analysis of Variance with Games Howell post-hoc comparisons was then conducted to examine the correspondence between the profiles and binge eating, insulin restriction and glycaemic control (HbA1c, mean blood glucose, and percent time spent in hyperglycaemia) during 3 days of assessment in a real-life setting. RESULTS Latent class analysis indicated a 4-class solution, with patterns of item endorsement suggesting the following profiles: Bulimia, Binge Eating, Overeating and Low Pathology. Differences in binge eating, insulin restriction and glycaemic control were observed between profiles during 3 days of at-home assessment. The Bulimia profile was associated with highest HbA1c and 3-day mean blood glucose. CONCLUSIONS There are common patterns of responses on the DEPS-R that appear to reflect different ED phenotypes. Profiles based on the DEPS-R corresponded with behaviour in the real-life setting as expected and were associated with different glycaemic outcomes. Results may have implications for the use of the DEPS-R in research and clinical settings.
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Affiliation(s)
| | - Natalia O. Dmitrieva
- Duke University School of Medicine, USA, Durham, 27710
- Northern Arizona University, USA, Flagstaff, 86011
| | | | - Jennifer L. Warnick
- The Warren Alpert Medical School of Brown University, USA, Providence, 02903
- The Miriam Hospital, USA, Providence, 02906
| | | | - Lisa Swartz Topor
- The Warren Alpert Medical School of Brown University, USA, Providence, 02903
| | - Katherine E. Darling
- The Warren Alpert Medical School of Brown University, USA, Providence, 02903
- The Miriam Hospital, USA, Providence, 02906
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Chad-Friedman E, Clary L, Jhe G. Disordered eating in adolescents with type 1 diabetes: risk factors and screening recommendations. Curr Opin Pediatr 2024:00008480-990000000-00180. [PMID: 38655800 DOI: 10.1097/mop.0000000000001353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
PURPOSE OF REVIEW Adolescents with Type 1 diabetes (T1D) are at significantly greater risk for disordered eating behaviors compared to their peers without T1D. Given that this is a dangerous and potentially lethal combination, this review aims to support pediatric medical providers in increasing competence in identification, assessment, and prevention of disordered eating behaviors in adolescents with T1D. RECENT FINDINGS This review provides an up-to-date synthesis of unique risk factors for disordered eating behaviors in adolescents with T1D, including the daily diabetes management tasks, effects of insulin on weight and hunger, family conflict, and reinforcement from their environment for disordered behaviors. This review recommends two brief screening tools, the Diabetes Eating Problems Survey-Revised (DEPS-R) and Modified SCOFF (mSCOFF), to be used in busy practices; it also provides practical strategies for providersto use with patients in the form of effective, nonjudgmental language. SUMMARY A clear understanding of unique experiences impacting adolescents with T1D may increase use of evidence-based screening tools and identification of disordered eating behaviors among a high-risk population in clinic/practice. In addition, providers' intentional use of nonjudgmental and de-stigmatizing language may lead to more positive interactions for adolescents and willingness to engage in further treatment.
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Affiliation(s)
- Emma Chad-Friedman
- Adolescent and Young Adult Medicine
- Department of Psychiatry and Behavioral Sciences, Boston Children's Hospital
| | - Lauren Clary
- Children's National Hospital
- George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Grace Jhe
- Adolescent and Young Adult Medicine
- Department of Psychiatry and Behavioral Sciences, Boston Children's Hospital
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
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Propper-Lewinsohn T, Elran-Barak R, Gillon-Keren M, Yackobovitch-Gavan M, Liberman A, Phillip M, Shalitin S. Disordered Eating Behaviors Among Adolescents and Young Adults with Type 1 Diabetes Treated with Insulin Pumps and Hybrid Closed-Loop Systems. Diabetes Technol Ther 2024; 26:229-237. [PMID: 38090768 DOI: 10.1089/dia.2023.0500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2024]
Abstract
Background and Aims: Disordered eating behaviors (DEB) are more common among individuals with type 1 diabetes (T1D) compared to those without, and for insulin pump users may be associated with higher hemoglobin A1c (HbA1c). We investigated DEB risk factors among insulin pump-treated individuals with T1D and clinical characteristics of hybrid closed-loop (HCL) systems' users by DEB level. Methods: An observational, cross-sectional study of 167 insulin pump-treated individuals with T1D, 13-21 years of age. Data were obtained from patients' medical charts with additional self-reported questionnaires, including assessment of DEB. Results: DEB were found in 71 (42.5%) individuals, and positively associated with female sex (β = 2.98 [standard error (SE) = 1.31], P = 0.025), body mass index (BMI)-Z-score (β = 2.12 [SE = 0.64], P = 0.001), HbA1c (β = 1.40 [SE = 0.45], P = 0.02), and higher rate of pump discontinuation (β = 4.48 [SE = 1.99], P = 0.026). The use of HCL systems compared to insulin pumps was associated with higher BMI-Z-score (odds ratio [OR]: 3.46 [95% confidence interval, CI: 1.52-7.87], P = 0.003) and tendency to lower HbA1c level (OR: 0.44 [95% CI: 0.18-1.09], P = 0.078) among individuals without DEB, and with lower HbA1c level (OR: 0.29 [95% CI: 0.10-0.83], P = 0.022) and higher socioeconomic status (OR: 1.73 [95% CI: 1.09-2.74], P = 0.020) among individuals with DEB. Conclusions: DEB are common among individuals with T1D treated with insulin pumps and are associated with higher HbA1c levels. Among T1D individuals with DEB, HCL system use is associated with lower HbA1c compared to insulin pump treatment. Our findings highlight the importance of regular screening for DEB and its risk factors to improve pump treatment and diabetes management. Moreover, individuals with DEB using HCL systems may benefit from reduced HbA1c levels.
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Affiliation(s)
- Tamar Propper-Lewinsohn
- The Institute of Endocrinology and Diabetes, Schneider Children's Medical Center, Petah Tikva, Israel
- School of Public Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
| | - Roni Elran-Barak
- School of Public Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
| | - Michal Gillon-Keren
- The Institute of Endocrinology and Diabetes, Schneider Children's Medical Center, Petah Tikva, Israel
- Faculty of Sciences, Kibbutzim College of Education Technology and the Arts, Tel Aviv, Israel
| | - Michal Yackobovitch-Gavan
- The Institute of Endocrinology and Diabetes, Schneider Children's Medical Center, Petah Tikva, Israel
- Department of Epidemiology and Preventive Medicine, School of Public Health, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alon Liberman
- The Institute of Endocrinology and Diabetes, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Moshe Phillip
- The Institute of Endocrinology and Diabetes, Schneider Children's Medical Center, Petah Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shlomit Shalitin
- The Institute of Endocrinology and Diabetes, Schneider Children's Medical Center, Petah Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Muley A, Deshmane A, Mahajan A, Shah J. Eating Disorders: Assessing Its Prevalence and Pattern Among Adults With Type 2 Diabetes. Cureus 2024; 16:e52425. [PMID: 38371141 PMCID: PMC10870338 DOI: 10.7759/cureus.52425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2024] [Indexed: 02/20/2024] Open
Abstract
BACKGROUND Eating disorders (EDs) are severe and multifaceted mental health issues that affect a person's perception of their body weight in relationship with food. Existing evidence shows that EDs significantly affect the physical and emotional health of individuals with Type-2 Diabetes (T2D) and are associated with impaired metabolic control and a high risk of medical complications, including higher mortality rates. However, there is a paucity of research looking into the prevalence of EDs. OBJECTIVE A cross-sectional study was conducted to map the prevalence of EDs and to assess its pattern among adults with T2D from Ahmedabad City, Gujarat, India. METHODOLOGY Two hundred fifty-four T2D individuals aged 30-60 were enrolled in the study. A questionnaire was developed using the Sick, Control, One, Fat, Food (SCOFF) questionnaire and a five-question screening tool intended to identify the possibility of EDs as well as the Eating Disorder Examination-Questionnaire (EDEQ), which is used to identify the pattern of EDs with subscales like Restraint, Eating Concern, Shape Concern, and Weight Concern. Written informed consent was obtained from all participants. Descriptive statistics, Pearson's Correlation, and Logistic Regression analysis were used. A p-value of < 0.05 was considered significant. RESULTS The results revealed that 90 (35%) of the total participants were at a high risk of EDs. Among these, 54 (21% of the total population) were males, and 36 (14% of total participants) were females. There was a mild statistically significant negative correlation between age and exercise with the presence of ED (r = -0.151, p = 0.016 and r = -0.186, p = 0.003, respectively), while education showed a significant positive correlation (r = 0.150, p = 0.017). Males had significantly higher scores for eating concerns than females (19.75±4.88 vs 17.88±5.92; p = 0.008). The logistic regression model revealed that education was a significant predictor of EDs (OD = 1.47, 95% CI 1.00-2.16 and p = 0.04). CONCLUSION The study identified that people with T2D are at risk of EDs, and eating concerns worry them the most. Thus, counseling sessions should focus on identifying the determinants of EDs and educating the patients regarding quality eating. This will have implications in addressing the other morbidities as well as health risks related to BMI; especially obesity as it is more prevalent in the T2D population.
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Affiliation(s)
- Arti Muley
- Nutrition and Dietetics, Symbiosis Institute of Health Sciences, Symbiosis International (Deemed University), Pune, IND
| | - Aditi Deshmane
- Nutrition and Dietetics, Symbiosis Institute of Health Sciences, Symbiosis International (Deemed University), Pune, IND
| | - Anu Mahajan
- Nutrition and Dietetics, Symbiosis Institute of Health Sciences, Symbiosis International (Deemed University), Pune, IND
| | - Jeel Shah
- Nutrition and Dietetics, Symbiosis Institute of Health Sciences, Symbiosis International (Deemed University), Pune, IND
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Poos S, Faerovitch M, Pinto C, Jamalkhani N, Chaudhri F, Khan S, Lo DF, McGowan K, Martin A. The role of diabetes distress in Diabulimia. J Eat Disord 2023; 11:213. [PMID: 38041170 PMCID: PMC10691075 DOI: 10.1186/s40337-023-00924-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 10/31/2023] [Indexed: 12/03/2023] Open
Abstract
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.
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Affiliation(s)
- Stephen Poos
- Stony Brook Southampton Hospital, 240 Meeting House Ln, Southampton, NY, USA
| | - Misha Faerovitch
- School of Medicine and Dentistry, University of Rochester, 601 Elmwood Ave, Rochester, NY, USA
| | - Celeste Pinto
- Rowan-Virtua School of Osteopathic Medicine, 1 Medical Center Dr, Stratford, NJ, USA
| | - Nima Jamalkhani
- Rowan-Virtua School of Osteopathic Medicine, 1 Medical Center Dr, Stratford, NJ, USA
| | - Fahad Chaudhri
- Rowan-Virtua School of Osteopathic Medicine, 1 Medical Center Dr, Stratford, NJ, USA
| | - Satara Khan
- Touro University, 3 Times Sq, New York, NY, USA
| | - David F Lo
- Rowan-Virtua School of Osteopathic Medicine, 1 Medical Center Dr, Stratford, NJ, USA.
| | - Kaitlin McGowan
- Dartmouth Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH, USA
| | - Ashaki Martin
- Ocean University Medical Center, 425 Jack Martin Blvd, Brick, NJ, USA
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Emotional eating and disordered eating behaviors in children and adolescents with type 1 diabetes. Sci Rep 2022; 12:21854. [PMID: 36528643 PMCID: PMC9759523 DOI: 10.1038/s41598-022-26271-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
Disordered eating behaviors (DEB) are more common in adolescents with type 1 diabetes (T1D) than in peers without diabetes. Emotional eating is a risk factor for binge eating in children and adolescents in the general population and is associated with increased intake of high energy-dense foods rich in sugars and fats. The primary objective is to evaluate whether emotional eating is associated with the metabolic control (glycated hemoglobin, plasma lipids and uric acid) in children and adolescents with type 1 diabetes and whether subjects with DEB (DEPS-R ≥ 20) have higher emotional eating than those without DEB. The secondary objective is to evaluate whether emotional eating is associated with the different symptoms of DEB. Emotional eating is positively correlated with HbA1c, total and LDL cholesterol values in children and adolescents with T1D. Subjects with DEB have a higher emotional eating score than subjects without DEB. Disinhibition is the most common disordered eating behavior in children and adolescents with T1D and is associated with a higher emotional eating score. Early identification and treatment of emotional eating could be tools for preventing DEB in people with type 1 diabetes. A total of 212 adolescents with T1D completed two self-administered questionnaires: the Diabetes Eating Problem Survey-Revised (DEPS-R) and the Emotional Eating Scale for Children and Adolescents (EES-C). Demographic (age, sex, duration of the disease), anthropometric (weight, height, BMI, BMI-SDS), therapeutic (type of insulin therapy, daily insulin dose) and metabolic (HbA1c, total cholesterol, HDL, LDL, triglycerides, uric acid) data were taken from the patients' medical records. The presence of other autoimmune diseases was also recorded.
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Presseller EK, Patarinski AGG, Zhang F, Page KA, Srivastava P, Manasse SM, Juarascio AS. Glucose variability: A physiological correlate of eating disorder behaviors among individuals with binge-spectrum eating disorders. Int J Eat Disord 2022; 55:1788-1798. [PMID: 36305323 DOI: 10.1002/eat.23838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 10/12/2022] [Accepted: 10/14/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Elevated glucose variability may be one mechanism that increases risk for significant psychological and physiological health conditions among individuals with binge-spectrum eating disorders (B-EDs), given the impact of eating disorder (ED) behaviors on blood glucose levels. This study aimed to characterize glucose variability among individuals with B-EDs compared with age-matched, sex-matched, and body mass index-matched controls, and investigate the association between frequency of ED behaviors and glucose variability. METHODS Participants were 52 individuals with B-EDs and 22 controls who wore continuous glucose monitors to measure blood glucose levels and completed ecological momentary assessment surveys to measure ED behaviors for 1 week. Independent samples t-tests compared individuals with B-EDs and controls and multiple linear regression models examined the association between ED behaviors and glucose variability. RESULTS Individuals with B-EDs demonstrated numerically higher glucose variability than controls (t = 1.42, p = .08, d = 0.43), although this difference was not statistically significant. When controlling for covariates, frequency of ED behaviors was significantly, positively associated with glucose variability (t = 3.17, p = .003) with medium effect size (f2 = 0.25). Post hoc analyses indicated that binge eating frequency was significantly associated with glucose variability, while episodes of 5+ hours without eating were not. DISCUSSION Glucose variability among individuals with B-EDs appears to be positively associated with engagement in ED behaviors, particularly binge eating. Glucose variability may be an important mechanism by which adverse health outcomes occur at elevated rates in B-EDs and warrants future study. PUBLIC SIGNIFICANCE This study suggests that some individuals with binge ED and bulimia nervosa may experience elevated glucose variability, a physiological symptom that is linked to a number of adverse health consequences. The degree of elevation in glucose variability is positive associated with frequency of eating disorder behaviors, especially binge eating.
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Affiliation(s)
- Emily K Presseller
- Department of Psychological and Brain Sciences, Drexel University, Philadelphia, Pennsylvania, USA.,Center for Weight, Eating, and Lifestyle Sciences, Drexel University, Philadelphia, Pennsylvania, USA
| | | | - Fengqing Zhang
- Department of Psychological and Brain Sciences, Drexel University, Philadelphia, Pennsylvania, USA.,Center for Weight, Eating, and Lifestyle Sciences, Drexel University, Philadelphia, Pennsylvania, USA
| | - Kathleen A Page
- Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Paakhi Srivastava
- Center for Weight, Eating, and Lifestyle Sciences, Drexel University, Philadelphia, Pennsylvania, USA
| | - Stephanie M Manasse
- Center for Weight, Eating, and Lifestyle Sciences, Drexel University, Philadelphia, Pennsylvania, USA
| | - Adrienne S Juarascio
- Department of Psychological and Brain Sciences, Drexel University, Philadelphia, Pennsylvania, USA.,Center for Weight, Eating, and Lifestyle Sciences, Drexel University, Philadelphia, Pennsylvania, USA
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Hermanns N, Ehrmann D, Shapira A, Kulzer B, Schmitt A, Laffel L. Coordination of glucose monitoring, self-care behaviour and mental health: achieving precision monitoring in diabetes. Diabetologia 2022; 65:1883-1894. [PMID: 35380233 PMCID: PMC9522821 DOI: 10.1007/s00125-022-05685-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 01/06/2022] [Indexed: 02/02/2023]
Abstract
Monitoring of glucose plays an essential role in the management of diabetes. However, to fully understand and meaningfully interpret glucose levels, additional information on context is necessary. Important contextual factors include data on behaviours such as eating, exercise, medication-taking and sleep, as well as data on mental health aspects such as stress, affect, diabetes distress and depressive symptoms. This narrative review provides an overview of the current state and future directions of precision monitoring in diabetes. Precision monitoring of glucose has made great progress over the last 5 years with the emergence of continuous glucose monitoring (CGM), automated analysis of new glucose variables and visualisation of CGM data via the ambulatory glucose profile. Interestingly, there has been little progress in the identification of subgroups of people with diabetes based on their glycaemic profile. The integration of behavioural and mental health data could enrich such identification of subgroups to stimulate precision medicine. There are a handful of studies that have used innovative methodology such as ecological momentary assessment to monitor behaviour and mental health in people's everyday life. These studies indicate the importance of the interplay between behaviour, mental health and glucose. However, automated integration and intelligent interpretation of these data sources are currently not available. Automated integration of behaviour, mental health and glucose could lead to the identification of certain subgroups that, for example, show a strong association between mental health and glucose in contrast to subgroups that show independence of mental health and glucose. This could inform precision diagnostics and precision therapeutics. We identified just-in-time adaptive interventions as a potential means by which precision monitoring could lead to precision therapeutics. Just-in-time adaptive interventions consist of micro-interventions that are triggered in people's everyday lives when a certain problem is identified using monitored behaviour, mental health and glucose variables. Thus, these micro-interventions are responsive to real-life circumstances and are adaptive to the specific needs of an individual with diabetes. We conclude that, with current developments in big data analysis, there is a huge potential for precision monitoring in diabetes.
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Affiliation(s)
- Norbert Hermanns
- Research Institute Diabetes Academy Mergentheim (FIDAM), Bad Mergentheim, Germany.
- Department of Clinical Psychology and Psychotherapy, University of Bamberg, Bamberg, Germany.
- German Center for Diabetes Research (DZD), Muenchen-Neuherberg, Germany.
| | - Dominic Ehrmann
- Research Institute Diabetes Academy Mergentheim (FIDAM), Bad Mergentheim, Germany
- Department of Clinical Psychology and Psychotherapy, University of Bamberg, Bamberg, Germany
- German Center for Diabetes Research (DZD), Muenchen-Neuherberg, Germany
| | - Amit Shapira
- Harvard Medical School, Joslin Diabetes Center, Boston, MA, USA
| | - Bernhard Kulzer
- Research Institute Diabetes Academy Mergentheim (FIDAM), Bad Mergentheim, Germany
- Department of Clinical Psychology and Psychotherapy, University of Bamberg, Bamberg, Germany
- German Center for Diabetes Research (DZD), Muenchen-Neuherberg, Germany
| | - Andreas Schmitt
- Research Institute Diabetes Academy Mergentheim (FIDAM), Bad Mergentheim, Germany
- German Center for Diabetes Research (DZD), Muenchen-Neuherberg, Germany
| | - Lori Laffel
- Harvard Medical School, Joslin Diabetes Center, Boston, MA, USA
- Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
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Dietary Risk Factors and Eating Behaviors in Peripheral Arterial Disease (PAD). Int J Mol Sci 2022; 23:ijms231810814. [PMID: 36142725 PMCID: PMC9504787 DOI: 10.3390/ijms231810814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/10/2022] [Accepted: 09/13/2022] [Indexed: 11/17/2022] Open
Abstract
Dietary risk factors play a fundamental role in the prevention and progression of atherosclerosis and PAD (Peripheral Arterial Disease). The impact of nutrition, however, defined as the process of taking in food and using it for growth, metabolism and repair, remains undefined with regard to PAD. This article describes the interplay between nutrition and the development/progression of PAD. We reviewed 688 articles, including key articles, narrative and systematic reviews, meta-analyses and clinical studies. We analyzed the interaction between nutrition and PAD predictors, and subsequently created four descriptive tables to summarize the relationship between PAD, dietary risk factors and outcomes. We comprehensively reviewed the role of well-studied diets (Mediterranean, vegetarian/vegan, low-carbohydrate ketogenic and intermittent fasting diet) and prevalent eating behaviors (emotional and binge eating, night eating and sleeping disorders, anorexia, bulimia, skipping meals, home cooking and fast/ultra-processed food consumption) on the traditional risk factors of PAD. Moreover, we analyzed the interplay between PAD and nutritional status, nutrients, dietary patterns and eating habits. Dietary patterns and eating disorders affect the development and progression of PAD, as well as its disabling complications including major adverse cardiovascular events (MACE) and major adverse limb events (MALE). Nutrition and dietary risk factor modification are important targets to reduce the risk of PAD as well as the subsequent development of MACE and MALE.
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Schneider S, Biggerstaff DL, Barber TM. Helpful or harmful? The impact of the ketogenic diet on eating disorder outcomes in type 1 diabetes mellitus. Expert Rev Endocrinol Metab 2022; 17:319-331. [PMID: 35748612 DOI: 10.1080/17446651.2022.2089112] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/09/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Eating disorders (EDs) are common complications in people with type 1 diabetes (PwT1D), given the rigid focus on food and insulin dose adjustment. Dietary recommendations for T1D match those for the general population, yet many fail to achieve target HbA1c. Evidence suggests that lower carbohydrate meals and thus reduced insulin requirements may decrease inconsistencies in insulin absorption, maintain euglycemia and weight. Dietary restriction is a recognized risk factor for ED development, and Ketogenic Diets (KD) involve restriction of common family-based foods, thus impacting social normality and microbiome diversity. We reviewed the current literature on PwT1D following a KD to understand effects on ED risks. AREAS COVERED Published data from MEDLINE, Embase, and PsycINFO were used. Search terms included: type 1 diabetes mellitus; or insulin dependent diabetes or T1D AND EDs or anorexia or bulimia or disordered eating AND low-carbohydrate diet or carbohydrate restricted diet or low carb diet or ketogenic diet. EXPERT OPINION Research into the effects of KDs on ED outcomes in PwT1D are limited, given the concerns over risks of diabetic ketoacidosis, hypoglycemia, and dyslipidemia. Longer term studies on the participants' experience and motivations of adhering or admonishing the diet are needed.
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Affiliation(s)
- Suzanne Schneider
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Deborah L Biggerstaff
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Thomas M Barber
- Division of Biomedical Sciences, Warwick Medical School, University of Warwick, Coventry, UK
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire, Coventry, UK
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Salah NY, Hashim MA, Abdeen MSE. Disordered eating behaviour in adolescents with type 1 diabetes on continuous subcutaneous insulin infusion; relation to body image, depression and glycemic control. J Eat Disord 2022; 10:46. [PMID: 35379350 PMCID: PMC8981863 DOI: 10.1186/s40337-022-00571-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 03/24/2022] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Disordered eating behaviour (DEB) represents a significant morbidity among people with type-1 diabetes (T1D). Continuous-subcutaneous insulin infusion (CSII) improves glycemic control and psychological wellbeing in those with T1D. However, its relation to DEB remains obscure. OBJECTIVES To compare DEB among adolescents with T1D on CSII versus basal-bolus regimen and correlate it with body image, HbA1C and depression. METHODS Sixty adolescents with T1D (30 on CSII and 30 on basal-bolus regimen), aged 12-17 years were studied focusing on diabetes-duration, insulin therapy, exercise, socioeconomic standard, hypoglycemic attacks/week and family history of psychiatric illness. Anthropometric measures, HbA1C, binge eating scale (BES), body image tool, patient health questionnaire-9 (PHQ9) and the Mini-KID depression scale were assessed. RESULTS Among the studied adolescents with T1D, six had DEB (10%), 14 had poor body-image perception (23.3%), 42 had moderate body-image perception (70%) and 22 had depression (36.7%). Adolescents with T1D on CSII had significantly lower BES (p = 0.022), Mini-KID depression (p = 0.001) and PHQ9 (p = 0.02) than those on basal-bolus regimen. BES was positively correlated to depression (p < 0.001), HbA1C (p = 0.013) and diabetes-duration (p = 0.009) and negatively correlated to body-image (p = 0.003). CONCLUSION DEB is a prevalent comorbidity among adolescents with T1D, with higher frequency in those on basal-bolus regimen than CSII.
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Affiliation(s)
- Nouran Yousef Salah
- Department of Pediatrics, Faculty of Medicine, Ain Shams University, 25 Korash Street, Nasr City, Cairo, Egypt.
| | - Mostafa Ahmad Hashim
- Department of Psychiatry, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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12
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Nam S, Griggs S, Ash GI, Dunton GF, Huang S, Batten J, Parekh N, Whittemore R. Ecological momentary assessment for health behaviors and contextual factors in persons with diabetes: A systematic review. Diabetes Res Clin Pract 2021; 174:108745. [PMID: 33713720 DOI: 10.1016/j.diabres.2021.108745] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 02/13/2021] [Accepted: 03/02/2021] [Indexed: 01/25/2023]
Abstract
AIM The objective of this systematic review was to summarize the ecological momentary assessment (EMA) methodology and associations between EMA-measured psychosocial, contextual factors and diabetes self-management. METHODS The inclusion criteria were: research of EMA and diabetes self-management behaviors such as glucose checks, administration of insulin and eating-and dietary intake behaviors among persons with diabetes. A comprehensive search of several databases was conducted across all dates until July 2020. RESULTS A modified Checklist for Reporting EMA Studies was used to assess the quality of studies. Among the ten included studies, participants were predominantly White adolescents with type 1 diabetes (T1D) and type 2 diabetes was studied in two studies. Time-varying, psychosocial contexts such as negative affect or negative social interaction were associated with missed insulin injection and poor adherence to glucose check. More preceding psychological stress was associated with more calorie intake from snacks or binge eating behaviors. Mornings were the most challenging time of day for adherence to diabetes self-management among adolescents with T1D. Intentional insulin withholding was more common in the afternoon in adults with T1D. CONCLUSIONS EMA has potential clinical utility in the assessment of diabetes self-management and in the development of timely and individualized diabetes interventions.
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Affiliation(s)
- Soohyun Nam
- Yale University, School of Nursing, 400 West Campus Dr. Orange, Connecticut 06477, United States.
| | - Stephanie Griggs
- Frances Payne Bolton School of Nursing, Case Western Reserve University, 9501 Euclid Ave, Cleveland, OH 44106-4904, United States
| | - Garrett I Ash
- Veterans Affairs Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, United States; Yale University, Center for Medical Informatics, 300 George St, New Haven, CT 06511, United States
| | - Genevieve F Dunton
- University of Southern California, Departments of Preventive Medicine and Psychology, 2001 N Soto Street, Los Angeles, CA 90032, United States
| | - Shuyuan Huang
- Yale University, School of Nursing, 400 West Campus Dr. Orange, Connecticut 06477, United States
| | - Janene Batten
- Harvey Cushing/John Hay Whitney Medical Library, Yale University, 333 Cedar St, New Haven, CT 06520-8014, United States
| | - Niyati Parekh
- New York University, School of Global Public Health, 715 Broadway, Room 1220, New York, NY 10003, United States
| | - Robin Whittemore
- Yale University, School of Nursing, 400 West Campus Dr. Orange, Connecticut 06477, United States
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13
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Rama Chandran S, Zaremba N, Harrison A, Choudhary P, Cheah Y, Allan J, Debong F, Reid F, Treasure J, Hopkins D, Ismail K, Stadler M. Disordered eating in women with type 1 diabetes: Continuous glucose monitoring reveals the complex interactions of glycaemia, self-care behaviour and emotion. Diabet Med 2021; 38:e14446. [PMID: 33141942 DOI: 10.1111/dme.14446] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 10/03/2020] [Accepted: 10/28/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVES Glycaemia in people with type 1 diabetes and disordered eating is not well characterised. We explored the glycaemia, self-care behaviour and emotional state of women with type 1 diabetes and disordered eating. RESEARCH DESIGN AND METHODS In all, 13 women with and 10 without disordered eating and type 1 diabetes participated in this case-control study. We used a mixed-methods approach with a 7-day blinded continuous glucose monitoring and real-time record of non-prompted capillary glucose (CG), emotion, activity and physical symptoms on a diabetes diary using a smartphone application (mySugr®). We compared groups using Mann-Whitney U test or Fisher's exact test. We conducted thematic analyses of free-text diary entries (NVivo®) and quantitative analysis of emotion/symptom tags. RESULTS People with type 1 diabetes and disordered eating spent longer time above range in level 2 hyperglycaemia (>13.9 mmol/L, Median [interquartile range]: 21% [16,60] vs 5% [2,17], p = 0.015). They had lower time in range and similar time below range compared to those without disordered eating. The standard deviation of CG was significantly higher in the disordered eating group (4.7 mmol/L [4.5, 6.1] vs 3 [2.8, 3.2], p = 0.018). The median of the percentage of rising sensor glucose trends was three times higher in the disordered eating group. They also had higher negative emotional and physical symptoms associated with high blood glucose (>15 mmol/L). CONCLUSIONS Disordered eating has a significant impact on the glycaemia and emotion of a person with type 1 diabetes.
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Affiliation(s)
- Suresh Rama Chandran
- Department of Diabetes, King's College Hospital, London, UK
- Department of Endocrinology, Singapore General Hospital, Singapore
| | - Natalie Zaremba
- Diabetes Research Group, King's College London, Weston Education Centre, London, UK
| | - Amy Harrison
- Diabetes Research Group, King's College London, Weston Education Centre, London, UK
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Pratik Choudhary
- Department of Diabetes, King's College Hospital, London, UK
- Diabetes Research Group, King's College London, Weston Education Centre, London, UK
| | - Yee Cheah
- Department of Diabetes, King's College Hospital, London, UK
| | - Jacqueline Allan
- Diabetes Research Group, King's College London, Weston Education Centre, London, UK
| | | | - Fiona Reid
- Faculty of Life Sciences and Medicine, Population Health, King's College London, London, UK
| | - Janet Treasure
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - David Hopkins
- Institute of Diabetes Endocrinology and Obesity, King's Health Partners, London, UK
| | - Khalida Ismail
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Marietta Stadler
- Diabetes Research Group, King's College London, Weston Education Centre, London, UK
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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14
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Mikhail ME. Affect Dysregulation in Context: Implications and Future Directions of Experience Sampling Research on Affect Regulation Models of Loss of Control Eating. Front Psychiatry 2021; 12:747854. [PMID: 34646178 PMCID: PMC8502879 DOI: 10.3389/fpsyt.2021.747854] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 09/01/2021] [Indexed: 01/04/2023] Open
Abstract
Loss of control eating is a core, transdiagnostic eating disorder symptom associated with psychological distress, functional impairment, and reduced quality of life. However, the factors that contribute to persistent loss of control eating despite negative consequences are not fully understood. Understanding the mechanisms that maintain loss of control eating is crucial to advance treatments that interrupt these processes. Affect regulation models of loss of control eating hypothesize that negative emotions trigger loss of control eating, and that loss of control eating is negatively reinforced because it temporarily decreases negative affect. Several variations on this basic affect regulation model have been proposed, including theories suggesting that negative affect decreases during loss of control eating rather than afterwards (escape theory), and that loss of control eating replaces one negative emotion with another that is less aversive (trade-off theory). Experience sampling designs that measure negative affect and eating behavior multiple times per day are optimally suited to examining the nuanced predictions of these affect regulation models in people's everyday lives. This paper critically reviews experience sampling studies examining associations between negative affect and loss of control eating, and discusses the implications for different affect regulation models of loss of control eating. The review concludes by proposing an expanded affect-focused model of loss of control eating that incorporates trait-level individual differences and momentary biological and environmental variables to guide future research. Clinical implications and recommendations are discussed.
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Affiliation(s)
- Megan E Mikhail
- Department of Psychology, Michigan State University, East Lansing, MI, United States
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15
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Wisting L, Siegwarth C, Skrivarhaug T, Dahl-Jørgensen K, Rø Ø. The impact of psychological aspects, age, and BMI on eating disorder psychopathology among adult males and females with type 1 diabetes. Health Psychol Open 2020; 7:2055102920975969. [PMID: 33282331 PMCID: PMC7691919 DOI: 10.1177/2055102920975969] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
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.
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Affiliation(s)
- Line Wisting
- Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital, Norway.,Oslo Diabetes Research Centre, Oslo, Norway
| | - Cecilie Siegwarth
- Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital, Norway
| | - Torild Skrivarhaug
- Oslo Diabetes Research Centre, Oslo, Norway.,The Norwegian Diabetes Centre, Oslo, Norway.,Division of Childhood and Adolescent Medicine, University of Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Norway
| | - Knut Dahl-Jørgensen
- Oslo Diabetes Research Centre, Oslo, Norway.,The Norwegian Diabetes Centre, Oslo, Norway.,Division of Childhood and Adolescent Medicine, University of Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Norway
| | - Øyvind Rø
- Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital, Norway.,Institute of Clinical Medicine, Mental Health and Addiction, University of Oslo, Norway
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16
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Broadley MM, Zaremba N, Andrew B, Ismail K, Treasure J, White MJ, Stadler M. 25 Years of psychological research investigating disordered eating in people with diabetes: what have we learnt? Diabet Med 2020; 37:401-408. [PMID: 31797439 DOI: 10.1111/dme.14197] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/28/2019] [Indexed: 12/29/2022]
Abstract
Disordered eating is a serious and under-recognized problem in people with diabetes. This narrative review summarizes the research contributions made by psychological science over the past 25 years to the study of disordered eating in people with type 1 or type 2 diabetes, and identifies gaps and future directions relevant to both healthcare professionals and researchers. Key focus areas of psychological research investigating disordered eating in people with diabetes have been: (1) defining and classifying types of disordered eating; (2) identifying demographic, diabetes-specific and psychosocial correlates of disordered eating, and developing theoretical models of disordered eating in people with type 1 diabetes; (3) identifying the physical and psychosocial consequences of disordered eating; and (4) developing screening measures to identify disordered eating in people with type 1 diabetes. Psychological science has made significant contributions over the past 25 years to our understanding of the nature of this problem and the multiple factors which may interrelate with disordered eating in people with diabetes. Key areas for further attention include: (1) a better definition of disordered eating subtypes in people with type 1 diabetes; (2) characterizing disordered eating in people with type 2 diabetes; and (3) developing multidisciplinary, evidence-based prevention and treatment interventions for comorbid disordered eating and diabetes.
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MESH Headings
- Behavioral Research/history
- Behavioral Research/methods
- Behavioral Research/trends
- Biomedical Research/history
- Biomedical Research/methods
- Biomedical Research/trends
- Diabetes Complications/epidemiology
- Diabetes Complications/etiology
- Diabetes Complications/psychology
- Diabetes Mellitus, Type 1/complications
- Diabetes Mellitus, Type 1/epidemiology
- Diabetes Mellitus, Type 1/metabolism
- Diabetes Mellitus, Type 1/psychology
- Diabetes Mellitus, Type 2/complications
- Diabetes Mellitus, Type 2/epidemiology
- Diabetes Mellitus, Type 2/metabolism
- Diabetes Mellitus, Type 2/psychology
- Feeding and Eating Disorders/complications
- Feeding and Eating Disorders/epidemiology
- Feeding and Eating Disorders/psychology
- History, 20th Century
- History, 21st Century
- Humans
- Psychology/history
- Psychology/methods
- Psychology/trends
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Affiliation(s)
- M M Broadley
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | - N Zaremba
- Diabetes Research Group, Weston Education Centre, King's College London, London, UK
| | - B Andrew
- Queensland University of Technology School of Psychology and Counselling, Kelvin Grove, QLD, Australia
- Institute of Health and Biomedical Innovation, Kelvin Grove, QLD, Australia
| | - K Ismail
- Department of Psychological Medicine, Diabetes Psychology and Psychiatry Research Group, Weston Education Centre, London, UK
| | - J Treasure
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - M J White
- Queensland University of Technology School of Psychology and Counselling, Kelvin Grove, QLD, Australia
- Institute of Health and Biomedical Innovation, Kelvin Grove, QLD, Australia
| | - M Stadler
- Diabetes Research Group, Weston Education Centre, King's College London, London, UK
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Smith LB, Foster N, Bollepalli S, Fitterman-Harris HF, Rancourt D. An Examination of Sex Differences in a Disease-Specific Model of Disordered Eating Behaviors in Type 1 Diabetes. J Pediatr Psychol 2020; 45:91-100. [PMID: 31764987 PMCID: PMC6964220 DOI: 10.1093/jpepsy/jsz090] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 10/04/2019] [Accepted: 10/04/2019] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Preliminary evidence supports the integration of type 1 diabetes (T1D) disease-specific factors into eating disorder risk models. The current study explored whether cross-sectional associations among constructs included in the modified dual pathway model of eating disorder risk for individuals with T1D are similar across sex among adolescents and young adults with T1D. METHODS Original study participants were recruited from the T1D Exchange Clinic Network, a U.S. registry of individuals with T1D. Online surveys included measures of general eating disorder risk factors, hypothesized T1D-specific risk factors, and a T1D-specific eating disorder questionnaire. The current study is a secondary analysis with the adolescents (13-17 years; n = 307; 46.9% female) and young adults (18-25 years; n = 313; 62.6% female) from the original sample. In the absence of strong measurement invariance for all measures of interest, sex-specific path models were estimated among the adolescent and young adult cohorts. RESULTS Only two paths emerged as significant in the female, but not male, adolescent model. In the young adult cohort, all significant paths were the same across sex. CONCLUSIONS Both general and T1D-specific risk factors are associated with disordered eating behaviors in the T1D population. Patterns of associations were similar across male and female youth with T1D, suggesting that sex-specific prevention approaches to disordered eating behaviors among T1D youth may not be warranted.
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Affiliation(s)
- Laura B Smith
- Department of Pediatrics, Diabetes & Endocrinology Center, Morsani College of Medicine, University of South Florida
| | | | - Sureka Bollepalli
- Department of Pediatrics, Diabetes & Endocrinology Center, Morsani College of Medicine, University of South Florida
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18
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Goebel-Fabbri A, Copeland P, Touyz S, Hay P. EDITORIAL: Eating disorders in diabetes: Discussion on issues relevant to type 1 diabetes and an overview of the Journal's special issue. J Eat Disord 2019; 7:27. [PMID: 31360517 PMCID: PMC6637645 DOI: 10.1186/s40337-019-0256-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 06/27/2019] [Indexed: 11/15/2022] Open
Affiliation(s)
| | - Paul Copeland
- 2Endocrine Unit and MGH Weight Center, Massachusetts General Hospital, and Harvard Medical School, Boston, MA USA
| | - Stephen Touyz
- 3School of Psychology, Faculty of Science, the University of Sydney, Camperdown, New South Wales Australia.,4InsideOut Institute, Charles Perkins Centre, University of Sydney, Sydney, Australia
| | - Phillipa Hay
- 5Translational Health Research Institute, School of Medicine, Western Sydney University, Sydney, NSW Australia
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