Disordered eating behavior in individuals with diabetes: importance of context, evaluation, and classification

Age-based challenges to type 1 diabetes management in the pediatric population

Type 1 diabetes is rising in the pediatric population, affecting approximately 1.2 million children and adolescents globally. Its complex pathogenesis involves the interaction between genetic predisposition and environmental factors, leading to T cell-mediated destruction of insulin-producing pancreatic beta-cells. This destruction results in insulin insufficiency and hyperglycemia. Hence, managing type 1 diabetes requires a comprehensive approach that includes various aspects such as blood glucose monitoring, insulin therapy, carbohydrate counting, caloric intake monitoring, considering family habits and food preferences, planning daily schedules, and incorporating physical activity. Children with type 1 diabetes encounter age-specific challenges in disease management that may exacerbate the risk of metabolic complications and adverse health outcomes. These risk factors may be neurological, physiological, behavioral, psychological, or social, complicate management and necessitate tailored approaches for effective care. Regardless of the age group, primary caregivers have a high responsibility to maintain optimal glycemic control, including monitoring diet, daily activity, and administering insulin. By reviewing research on the challenges faced by pediatric patients with type 1 diabetes, we summarized key insights aimed at developing targeted interventions and support systems that enhance diabetes management and improve health outcomes in this vulnerable population.

Reliability and validity of a parent-reported screening tool for disordered eating in children and young people with type 1 diabetes

BACKGROUND

There is a high prevalence and complex overlap between type 1 diabetes (T1D) and disordered eating. However, screening for disordered eating in children and young people (CYP) with T1D is not routinely conducted, with reluctance reported by both professionals and parents. This study aimed to validate a parent-reported version of a validated disordered eating screening tool for CYP with T1D (the Diabetes Eating Problems Survey-Revised; DEPS-R).

METHODS

The existing DEPS-R was adapted for parental use. Eighty-nine parents of CYP with T1D aged 11-14 years completed the parent-reported DEPS-R and other questionnaires related to demographics, child eating behaviours and parental well-being. CYP of parents were invited to participate, with 51 CYP completing the validated CYP-reported DEPS-R for comparison.

RESULTS

The parent-reported DEPS-R demonstrated good internal consistency (Cronbach's α = 0.89). Moderate to good inter-rater reliability was found between the parent-reported DEPS-R and CYP-reported DEPS-R (ICC 0.746, 95% CI = 0.554-0.855, p < 0.001), indicating good convergent validity. Construct validity with hypothesised variables, including specific eating behaviours, diabetes-related distress, well-being, CYP BMI, gender and parental worry about CYP disordered eating, suggested validity of the measure. However, some hypothesised variables did not significantly correlate with the parent-reported DEPS-R as expected.

CONCLUSIONS

The parent-reported DEPS-R has demonstrated good reliability and validity, and it may provide clinical benefit by increasing screening and early detection of disordered eating in CYP with T1D. Whilst novel and providing stepped increase in our knowledge, these findings would benefit from further validation (e.g. in a larger sample and responsiveness).

5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Correlates of disordered eating and insulin restriction behavior and its association with psychological health in Taiwanese youths with diabetes mellitus

BACKGROUND

Adolescents and young adults (AYAs) with diabetes mellitus (DM) are prone to eating disorders that may worsen metabolic control. This study investigated the clinical and behavioral correlates of disordered eating and insulin restriction (DE/IR) behavior and its association with psychological health among AYAs with DM.

METHODS

We enrolled patients with DM aged 10-30 years receiving insulin treatment in a tertiary medical center from 2019 to 2021. After obtaining informed consent, we assessed various visit-to-visit HbA1c measures indicating glycemic control, DE/IR behavior using the modified SCOFF questionnaire, weight-control practices (e.g., self-medication, induced vomiting, and over-exercising), and anxious and depressive symptoms using the Hospital Anxiety and Depression Scale. Correlation and hierarchical regression analyses were applied to understand the clinical and behavioral correlates of DE/IR behavior and its association with anxiety and depression.

RESULTS

Among the 110 patients with type 1 and type 2 DM recruited, we found 17.6% restricting insulin use and 6.3% self-medicating for weight control (higher in type 2 DM than type 1 DM). Hierarchical regression analyses showed HbA1c standard deviation (odds ratio = 2.18, [95% confidence interval 1.07-4.42]), body image (1.83, [1.05-3.20]), and dieting (4.74, [1.70-13.23]) associated with DE/IR behavior. Moreover, DE/IR behavior was further associated with anxiety (1.17 [1.08-1.27]) and depression (1.12 [1.03-1.22]).

CONCLUSION

DE/IR behavior is not uncommon among AYAs with DM, particularly those with type 2 DM, and may be associated with anxiety and depressive symptoms. In addition, HbA1c variability is correlated with DE/IR behavior, and the clinical implications need further exploration.

Behavioral approaches to nutrition and eating patterns for managing type 2 diabetes: A review

Nutritional interventions are a key component of type 2 diabetes management; making health-supporting changes in eating patterns can improve postprandial glycemic excursions and lower HbA1c to reduce diabetes-related morbidity and mortality. Research around implementing calorie-restricted and/or low-carbohydrate diets is plentiful, though the ability to sustain physiologic and behavioral changes for longer than 12 months is a concern. An understanding of intervention goals and adherence is needed to apply this research to patient care and translate expectations to real-world living contexts. Diverse dietary patterns including a Mediterranean eating pattern, vegetarian or plant-based eating pattern, or others that emphasize high-quality carbohydrates (e.g., whole grains), vegetables, whole fruits, legumes, and fish can support achievement of glycemic targets. Counseling strategies like motivational interviewing can be used to build eating competence. These approaches prioritize collaborative decision-making with the goal of increasing patient empowerment and self-efficacy. Strategies for incorporating these tools and frameworks in a clinical setting are highlighted. Providing ongoing diabetes and nutrition education, paired with appropriate support to address the challenges in implementing and sustaining behavior changes, is warranted. Further, social determinants of health including environmental context, education, socioeconomic status, access to healthcare, and experiences of systemic stigma (e.g., racism or weight bias) can interfere with individuals' diabetes self-care and nutrition behaviors. Providing medical nutrition therapy and tailoring nutrition interventions to individual needs and circumstances can be an important way physicians, dietitians, and diabetes providers can support individuals with type 2 diabetes.

Implementation of Psychosocial Screening into Diabetes Clinics: Experience from the Type 1 Diabetes Exchange Quality Improvement Network

PURPOSE OF REVIEW

Although advances in diabetes technology and pharmacology have significantly and positively impacted diabetes management and health outcomes for some, diabetes care remains burdensome and can be challenging to balance with other life priorities. The purpose of this article is to review the rationale for assessment of psychosocial domains in diabetes care settings and strategies for the implementation of psychosocial screening into routine practice. Survey data from the Type 1 Diabetes Exchange Quality Improvement Network is highlighted.

RECENT FINDINGS

Implementation of psychosocial screening requires identifying the population; selecting validated tools to assess target domains; determining frequency of screening and mode of survey delivery; and scoring, interpreting, documenting, and facilitating referrals such that these processes are part of clinical workflows. Recognizing the influence of psychosocial factors for people with diabetes (PWD), professional society guidelines for comprehensive diabetes care recommend the integration of psychosocial screening into routine care.

5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

[Mental disorders and diabetes mellitus (Update 2023)]

Psychiatric disorders and psychological problems are common in patients with diabetes mellitus. There is a twofold increase in depression which is associated with suboptimal glycemic control and increased morbidity and mortality. Other psychiatric disorders with a higher incidence of diabetes are cognitive impairment, dementia, disturbed eating behavior, anxiety disorders, schizophrenia, bipolar disorders and borderline personality disorder. The coincidence of mental disorders and diabetes has unfavorable influences on metabolic control and micro- and macroangiopathic complications. Improvement of therapeutic outcome is a challenge in the modern health care system. The intentions behind this position paper are to rise awareness of this special set of problems, to intensify cooperation between involved health care providers and to reduce incidence of diabetes mellitus as well as morbidity and mortality from diabetes in this patient group.

Prevalence, associations and health outcomes of binge eating in adults with type 1 or type 2 diabetes: Results from Diabetes MILES - The Netherlands

AIMS

To examine the prevalence and health risks of binge eating in people with diabetes.

METHODS

Self-report data were analysed from a subsample (n = 582 type 1 diabetes/735 type 2 diabetes) of Diabetes MILES - the Netherlands, an online survey. Prevalence of binge eating was compared across diabetes type and treatment and between participants with and without binges for eating styles, diabetes treatment and outcomes, weight, BMI and psychological comorbidity. Associations between binge eating, HbA_1c , BMI, diabetes distress were assessed using hierarchical linear regression analyses.

RESULTS

23% (n = 308) of participants reported eating binges, with 16% at least monthly, and 6% at least weekly. Prevalence and frequency of binges did not differ across diabetes type or treatment. People reporting binges scored higher on dietary restraint, emotional and external eating and reported higher weight and BMI than those without binges. Only people with type 1 diabetes and eating binges had a higher HbA_1c . Hierarchical regression analyses demonstrated that binge eating was independently associated with higher HbA_1c (β = 0.12, p=0.001), BMI (β = 0.13, p < 0.001) but not with diabetes distress.

CONCLUSIONS

This study found binge eating to be associated with eating styles, BMI and HbA_1c . However, our cross-sectional data do not allow for conclusions on causality. Future studies could further examine the directions of these associations and their clinical implications.

Classification of Type 2 Diabetes Incidence Risk and the Health Behavior of the 30-50-Year-Old Korean Adults: Latent Class Analysis

This study aimed to categorize the risk of type 2 diabetes mellitus development (T2DD) in the 30-50-year-old (3050) Korean adults and establish a baseline framework of customized management to prevent the progression to diabetes. A total of 9515 participants were enrolled in the Korea National Health and Nutrition Examination Survey (KNHANES) 2016-2019. Latent class analysis (LCA) was performed based on the health behaviors that were obtained from the secondary data source and were considered to affect T2DD. The major results were compared by latent class, multinomial regression analysis was performed, and the predicted risk of T2DD was evaluated using a self-assessment tool for Korean adults. Data analysis was performed using SPSS (ver. 25.0) and Mplus (ver. 8.6). The latent classes were divided into four categories: negative abdominal obesity and high-risk health behavior (Class A) (28.2%), negative abdominal obesity and low-risk health behavior (Class B) (37.1%), positive abdominal obesity and high-risk health behavior (Class C) (10.7%), and positive abdominal obesity and low-risk health behavior (Class D) (23.9%). The predicted risk scores for T2DD were 6.27 (Class C), 4.50 (Class D), 3.58 (Class A), and 2.16 (Class B), with a higher score indicating a worse state. Significant differences were observed in the predicted risk of T2DD between the latent classes, and abdominal obesity increased the risk. When managing the 30s-50s Korean generation physical activity and abdominal obesity control are strongly recommended.

Managing type 2 diabetes or prediabetes and binge eating disorder: a qualitative study of patients' perceptions and lived experiences

BACKGROUND

The overlap in prevalence between type 2 diabetes and binge eating disorder is substantial, with adverse physical and mental health consequences. Little is known about patients' efforts at managing these two conditions simultaneously. The research objective was to explore patients' experiences managing co-existing type 2 diabetes or prediabetes and binge eating disorder.

METHODS

This is a qualitative descriptive study using semi-structured interviews. Participants included 21 women with type 2 diabetes or prediabetes (90% non-Hispanic White; mean age 49 ± 14.8 years, mean BMI 43.8 ± 8.4; 48% with type 2 diabetes and mean HbA1c was 8.4%). Interviews were analyzed using thematic analysis and NVivo software.

RESULTS

Qualitative analysis revealed that participants reported binge episodes frequently started in childhood or adolescence and went undiagnosed for decades; notably, they recalled that diabetes diagnosis preceded the binge eating disorder diagnosis. They also described trying to lose weight throughout their lives and how feelings of deprivation, shame, and failure exacerbated binge eating. Participants further reported how binge eating made diabetes self-care and outcomes worse. Finally, participants observed that when binge eating disorder treatment and diabetes management were synergistically integrated, they experienced improvements in both binge eating and glycemic outcomes. This integration included reframing negative thoughts surrounding binge eating disorder and diabetes self-management and increasing their understanding of how the two disorders were inter-related.

CONCLUSION

Findings highlight the importance of increasing healthcare providers' awareness of and screening for binge eating disorder in the treatment of diabetes and inform specific integrated interventions that address both diagnoses. From this study where we interviewed 21 women with binge eating disorder (BED) and type 2 diabetes/prediabetes, we learned how binge eating impacted diabetes management and how diabetes impacted BED. Most participants reported receiving the diabetes diagnosis before being diagnosed with BED despite the earlier onset of binge eating, pointing to the need for BED screening. Participants described trying to lose weight throughout their lives and reported feelings of failure and shame, which made binge eating worse. Binge eating made diabetes management harder, but when diabetes and BED treatment were aligned, participants experienced improvements in binge symptoms and diabetes outcomes.

Randomised controlled trial of a web-based low carbohydrate diet intervention for adults with type 2 diabetes: the T2Diet study protocol

INTRODUCTION

Type 2 diabetes (T2D) management frequently involves a multidisciplinary care team. However, standard care for patients with T2D is the central role of the general practice physician, and consists of routine appointments to monitor glycaemic status and overall health. Dietary modification is an essential component of T2D management. Evidence suggests that a low carbohydrate diet (LCD) provides better clinical outcomes for people with T2D compared with other diets. However, providing dietary support in face-to-face settings is challenged by issues of availability and accessibility. Provided in conjunction with standard care, digital interventions can help bridge this gap. The objective of this paper is to describe the protocol of a randomised controlled trial (RCT) of a web-based intervention that will evaluate the effectiveness of standard care plus web-based LCD intervention when compared with standard care only.

METHODS AND ANALYSIS

In a two-arm parallel RCT, 100 adults with non-insulin-dependent T2D aged between 40 and 89 years will be randomised to either a theoretically informed 16-week automated web-based LCD intervention plus standard care or standard care only. LCD recommendations emphasise consuming nutrient-dense whole foods and encourage a daily carbohydrate goal of 50-100 g, with an objective of achieving 10% to <26% carbohydrates from total energy intake. Assessments will take place at baseline and 16 weeks. The primary outcome will be haemoglobin A1c. Additional data collected will include dietary intake, self-efficacy, weight and height, anti-diabetes medication and dosages, and diabetes-related comorbidities. Process evaluation will consist of a mixed-methods assessment of website engagement metrics, user experience and participants' perspectives.

ETHICS AND DISSEMINATION

All study procedures have been approved by the Deakin University Human Research Ethics Committee (2020-349). Study findings will be disseminated widely through public, professional and academic presentation and publication.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12621000096853).

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.

An Article in Two Parts: My Dinners With Richard and Addressing Diabetes Disparities in Hispanic Populations

Editor's note: This article was adapted from the address Dr. Marrero delivered as the recipient of the American Diabetes Association's Richard R. Rubin Award for 2021. This award recognizes a behavioral researcher who has made outstanding, innovative contributions to the study and understanding of the behavioral aspects of diabetes in diverse populations. Dr. Marrero delivered the address in June 2021 at the Association's virtual 81st Scientific Sessions. A webcast of this speech is available for viewing at https://bit.ly/3HIkOpz.

5. Facilitating Behavior Change and Well-being to Improve Health Outcomes: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Disordered Eating among People with Schizophrenia Spectrum Disorders: A Systematic Review

Disordered eating, or abnormal eating behaviours that do not meet the criteria for an independent eating disorder, have been reported among people with schizophrenia. We aimed to systemati-cally review literature on disordered eating among people with schizophrenia spectrum disorder (SSD). Seven databases were systematically searched for studies that described the prevalence and correlates of disordered eating among patients with SSD from January 1984 to 15 February 2021. Qualitative analysis was performed using the National Institutes of Health scales. Of 5504 records identified, 31 studies involving 471,159 subjects were included in the systematic review. The ma-jority of studies (17) rated fair on qualitative analysis and included more men, and participants in their 30s and 40s, on antipsychotics. The commonest limitations include lack of sample size or power calculations, poor sample description, not using valid tools, or not adjusting for con-founders. The reported rates were 4.4% to 45% for binge eating, 16.1% to 64%, for food craving, 27% to 60.6% for food addiction, and 4% to 30% for night eating. Positive associations were re-ported for binge eating with antipsychotic use and female gender, between food craving and weight gain, between food addiction and increased dietary intake, and between disordered eating and female gender, mood and psychotic symptoms. Reported rates for disordered eating among people with SSD are higher than those in the general population. We will discuss the clinical, treatment and research implications of our findings.

Obsessed with Healthy Eating: A Systematic Review of Observational Studies Assessing Orthorexia Nervosa in Patients with Diabetes Mellitus

Orthorexia nervosa (ON) is an unspecified feeding or eating disorder (USFED) characterized by an exaggerated, unhealthy obsession with healthy eating. Τypical eating disorders (EDs) and USFEDs are common among patients with diabetes mellitus (DM), which complicates metabolic control and disease outcomes. The present systematic review summarizes the evidence on the prevalence of ON symptomatology among patients with DM. PubMed, Web of Science, Scopus, and grey literature were searched, and relevant observational studies were screened using the Rayyan software. The quality of the studies was assessed using the appraisal tool for cross-sectional studies (AXIS) and the Newcastle-Ottawa scale (NOS). Out of 4642 studies, 6 fulfilled the predefined criteria and were included in the qualitative synthesis. Most studies relied on the ORTO-15 or its adaptations to identify ON among patients with DM. No apparent sex or age differences exist regarding the prevalence of ON symptoms. None of the studies compared the prevalence of ON in patients with type 1 and type 2 DM. Most of the research was of average to good methodological quality. In conclusion, patients with DM often exhibit ON tendencies, although research is still limited regarding the etiology or mechanistic drivers behind ON and the characteristics of patients with a dual ON-DM diagnosis.

Dual Action Gels Containing DsiRNA Loaded Gold Nanoparticles: Augmenting Diabetic Wound Healing by Promoting Angiogenesis and Inhibiting Infection

Hyperglycemia induces the prostaglandin transporter (PGT) gene overexpression, leading to poor vascularization and wound healing. Dicer substrate small interfering RNA (DsiRNA) and gold nanoparticles (AuNPs) co-loaded into PF127 gel was developed to overcome the disturbance and infections. The AuNPs were biosynthesized using cold and hot water extracts of Lignosus rhinocerotis (abbreviated CLRE and HLRE, respectively). The wound healing efficacy of a PF127 gel containing DsiRNA-AuNPs-CLRE and -HLRE (assigned as F2 and F3, respectively) was evaluated in a diabetes-induced Wistar rat model. The F2 (DC) and F3 (DH) treated groups revealed a faster wound closure (92.67 ± 3.4% and 85.1 ± 7.3%, respectively) than the positive control (commercial gel, DTI)(74.9 ± 13.3%). DH and DC groups presented an increased blood vessel density, along with decreased inflammatory cells. In comparison to positive control, higher prostaglandin E₂ (PGE₂) (495 ±79 and 50 ±121 pg/mL, for DC and DH group, respectively), vascular endothelial growth factor (VEGF) (49 ±15 and 38 ±3 pg/mL, for DC and DH group, respectively) and VEGF-A levels were detected in both groups (DC and DH), indicating the effectiveness of DsiRNA in enhancing PGE₂ production and vascularization. On evaluating microbiomes adhered to the wound areas, Gram-positive bacteria Staphylococcus and Corynebacterium, as well as Gram-negative Pseudomonas, Rodentibacter, and Acinetobacter, were found to be sensitive to the gel. Collectively, the gel was confirmed as a promising dressing for diabetic wound therapy, warranting further studies for clinical use.

Psychiatric illness, emotional distress, glycemic control and chronic complications in type 1 diabetes subjects

Objective

To assess the prevalence of psychiatric disorders in patients with type 1 diabetes mellitus (T1D) and to compare patients with and without psychiatric disorder.

Methods

We made a cross-sectional study including patients with T1D assisted in the outpatient clinics of the Brazilian National Health System. To assess depression and anxiety, we used the PHQ-9 questionnaire and the DSM-5th edition criteria, respectively. B-PAID evaluated the level of emotional distress associated with diabetes; EAT-26, eating disorders; SCI-R, adherence to the proposed clinical treatment.

Results

We analyzed 166 patients aged 33 (22-45.2) years, 53.6% female. The prevalence of depression and anxiety was 20.5% and 40.4%, respectively. HbA1c was worse in the depressed (9.0% vs. 8.4%, p = 0.008), in the anxious ones (9.0% vs. 8.3%, p = 0.012) and in the patients with high levels of B-PAID (8.8 % vs. 8.3 %, p = 0.009). There was no difference in the prevalence of complications related to diabetes.

Conclusion

The prevalence of psychiatric disorders and emotional distress related to diabetes was high in our population of T1D patients, and depression and high levels of B-PAID were associated with the worse glycemic control.

Diabetes technologies in people with type 1 diabetes mellitus and disordered eating: A systematic review on continuous subcutaneous insulin infusion, continuous glucose monitoring and automated insulin delivery

AIMS

In this systematic review, we aimed (1) to identify and describe research investigating the use of advanced diabetes technologies (continuous subcutaneous insulin infusion, CSII; continuous glucose monitoring, CGM; automated insulin delivery, AID) in people with type 1 diabetes (T1DM) and disordered eating and (2) to discuss potential (dis)advantages of diabetes technology use in this population, derived from previous research.

METHODS

We conducted a systematic literature search in two electronic databases for English articles published between 2000 and 2020 addressing eating disorders and/or dysfunctional eating behaviours and diabetes technology use in children, adolescents and adults with T1DM (PROSPERO ID CRD42020160244).

RESULTS

Of 70 publications initially identified, 17 were included. Overall, evidence on the use of diabetes technologies in people with T1DM and disordered eating is scarce. The majority of the studies reports findings on CSII in people with T1DM and dysfunctional eating behaviours or eating disorders. Findings predominantly stem from observational data and are, in most cases, secondary findings of the respective studies. Providing the greatest flexibility in diabetes management, CSII may have benefits in disordered eating. CGM data may complement the diagnostic process of disordered eating with a physiological indicator of insulin restriction (i.e. time spent in hyperglycaemia).

CONCLUSIONS

Results on possible (dis)advantages of diabetes technology use in people with T1DM and disordered eating are based on observational data, small pilot trials and anecdotical evidence from case reports. Prospective data from larger samples are needed to reliably determine potential effects of diabetes technology on disordered eating in T1DM.

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

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

Ecological momentary assessment for health behaviors and contextual factors in persons with diabetes: A systematic review

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.

The Role of Disordered Eating in Type 2 Diabetes: A Pilot Study

Rates of type 2 diabetes mellitus continue to rise around the world, largely due to lifestyle factors such as poor diet, overeating, and lack of physical activity. Diet and eating is often the most challenging aspect of management and, when disordered, has been associated with increased risk for diabetes-related complications. Thus, there is a clear need for accessible and evidence-based interventions that address the complex lifestyle behaviors that influence diabetes management. The current study sought to assess the efficacy and acceptability of a pilot lifestyle intervention for women with type 2 diabetes and disordered eating. The intervention followed a cognitive behavioral therapy guided-self-help (CBTgsh) model and included several pillars of lifestyle medicine, including: diet, exercise, stress, and relationships. Ten women completed the 12-week intervention that provided social support, encouraged physical activity, and addressed eating behaviors and cognitions. Results indicate the lifestyle intervention was a feasible treatment for disordered eating behaviors among women with type 2 diabetes and was also associated with improved diabetes-related quality of life. The intervention was also acceptable to participants who reported satisfaction with the program. The current CBTgsh lifestyle intervention is a promising treatment option to reduce disordered eating and improve diabetes management.

Binge-Eating Disorder and Type 2 Diabetes: A Review

OBJECTIVE

To familiarize health care providers with diagnosis and treatment of binge-eating disorder (BED), a common comorbidity of type 2 diabetes (T2DM).

METHODS

Literature review of binge eating and T2DM. Key words used in search include BED, T2DM, obesity, and treatment.

RESULTS

The prevalence of BED in patients with T2DM appears to be much higher than the 2% to 3.5% prevalence seen in the general population. Studies suggest that up to 20% of patients with T2DM have an underlying eating disorder, the most common of which is binge eating. BED is probably underdiagnosed, even though there are multiple simple tools that providers can use to improve screening for the disorder. Though the relationship between BED and hemoglobin A1c control can vary, it appears that binge-eating behaviors can worsen metabolic markers, including glycemic control. Various medications used by patients with diabetes have been associated with new-onset BED, and treatment may be as simple as removing or replacing such agents. Several medications have been found to significantly reduce binge-eating frequency, and potentially, weight. Patients with BED generally benefit from psychotherapy, including cognitive behavioral therapy.

CONCLUSION

BED, only recently added to the International Classification of Disease-10 diagnostic list, is very common in patients with obesity and T2DM. The diagnosis is important to establish, as treatment or referral for treatment, could potentially improve many of the comorbidities and metrics of T2DM.

5. Facilitating Behavior Change and Well-being to Improve Health Outcomes: Standards of Medical Care in Diabetes-2021

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Disturbed Eating Behaviors in Youth with Type 1 Diabetes: An Exploratory Study about Challenges in Diagnosis

Background: Disordered eating behaviors (DEBs), including diagnosable eating disorders, are quite common and can interfere with optimal type 1 diabetes (T1DM) management. We explored DEBs prevalence in youth with T1DM, proposing news diagnostic subscales, to represent the clinical dimensions associated with feeding and eating disorders (ED); Methods: additionally to SCOFF questionnaire and Diabetes Eating Problem Survey–Revised (DEPS-R), four subscales combined from the original DEPS-R questionnaire were administered to 40 youths with T1DM (15.0 ± 2.6); Results: females showed higher scores than males in DEPS-R original factor 2 (“preoccupations with thinness/weight”, p = 0.024) and in DEPS-R proposed “restriction” factor (p = 0.009). SCOFF scores was correlated with original DEPS-R factors 1 (“maladaptive eating habits”) and 2 (p < 0.001) and with the newly proposed DEPS-R factors: restriction, disinhibition, compensatory behaviors, diabetes management (all p < 0.02). Diabetes management was the only factor related to glycated hemoglobin level (p = 0.006). Patients with high DEPS-R score (≥20) scored higher than patients with low (<20) DEPS-R score in DEPS-R original factors 1 (p < 0.001) and 2 (p = 0.002) as well as in the proposed factors including restriction, disinhibition, diabetes management (all p < 0.02); Conclusions: the complicated nature of DEBs calls for the development target specific questionnaires to be used as screening tools to detect cases of DEBs and exclude non cases. Early recognition of DEBs in adolescents with T1DM is essential for effective prevention and successful treatment.

Eating disorders in adolescents with type 1 diabetes mellitus

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

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

Objective

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

Methods

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

Results

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

Conclusion

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

High prevalence of disordered eating behavior in Danish children and adolescents with type 1 diabetes

OBJECTIVE

A higher prevalence of disordered eating behavior (DEB) has been demonstrated in children and adolescents with type 1 diabetes (T1D) compared to healthy aged-matched peers. DEB is associated with higher HbA1c levels and increased risk of developing complications to T1D. The aim of this study was to determine the prevalence of DEB in a Danish cohort of children and adolescents with T1D aged 11 to 19 years and to characterize them regarding metabolic control and relevant clinical data.

RESEARCH DESIGN AND METHODS

In a cross-sectional study, we determined the prevalence of DEB using the revised Diabetes Eating Problem Survey (DEPS-R) questionnaire. HbA1c and relevant clinical data were obtained at the time they filled in the questionnaire.

RESULTS

Hundred and ninety-two children and adolescents (46% girls) aged 11 to 19 years with T1D were included from the pediatric diabetes outpatient clinic. A total of 40 participants (21%) had DEB. The prevalence was higher among girls compared with boys (34.1% vs 8.9%) and those who had DEB were older (16.7 vs 15.0 years, P < .001), had longer duration of T1D (7.5 vs 4.9 years, P < .001), higher BMI Z-scores (1.2 vs 0.3, P < .001), higher HbA1c (72.8 (8.8%) vs 62.0 (7.8%) mmol/mol, P < .001), higher total cholesterol (4.6 mmol/L vs 4.2 mmol/L, P = .0048), and LDL (2.7 vs 2.3, P = .001) compared with those with no signs of DEB.

CONCLUSION

As in other countries, the prevalence of DEB is high in Danish adolescents with T1D. Early detection of DEB is essential to prevent short- and long-term complications to T1D.

Clinical features of the diabetes eating problem survey-revised Turkish version in children and adolescent with type 1 diabetes

Objectives We aim to delineate clinical characteristics that place individuals with type 1 diabetes (T1DM) at risk of developing eating problems by using Turkish version of diabetes eating problem survey-revised (DEPS-R). Methods The patients aged 9-18 years with T1DM who came to the pediatric endocrine outpatient clinic for control between February and December 2019 completed Turkish version of DEPS-R. Clinical and laboratory findings were obtained from patient files. Cases with a questionnaire score ≥20 were considered to be at risk for eating disorders (ED). Parents were informed when the results of the screening were positive, and were offered to child psychiatrist. Results The median scores obtained with the Turkish version of DEPS-R for the total sample, for females and males were 15, 16, and 13 respectively. The score was significantly higher among females compared to males (p<0.001). DEPS-R score positive group had higher age (mean [SD]=14.6 [2.7], p=0.009), BMI (mean [SD]=21.4 [3.2], p<0.001), HbA1c % (mean [SD]=9.37[2.3], p<0.001) and year of diabetes duration (mean [SD]=5.5 [3.6], p<0.001) compared to the negative group. Conclusions Early recognition and adequate treatment of ED in T1DM is essential. DEPS-R is sensitive in identifying young people with ED.

Diabetes Self-Management Decrements Mediate the Relation of Stressful Life Events and Hemoglobin A1c-Differences by Race/Ethnicity in Adolescents

PURPOSE

The aim of the study was to establish whether suboptimal self-management explains the relationship between stressful life events and hemoglobin A1c (HbA_1c) in adolescents with type 1 diabetes and whether these relationships differ across race/ethnicity.

METHODS

Participants were 6,368 adolescents enrolled in the U.S. T1D Exchange registry. The outcome, HbA_1c, was chart-based; predictors and covariates were self-reported. Moderated mediation was tested using Mplus, adjusting for gender, age, insulin treatment modality, and socioeconomic status.

RESULTS

Higher frequency of missed insulin doses and lower frequency of daily self-monitoring of blood glucose partially explained the relationship between past-year stressful life events and higher HbA_1c. Mediation by self-monitoring of blood glucose was detected for those who identified as white non-Hispanic and Hispanic, but not for those who identified as African American.

CONCLUSIONS

In adolescents, there is some evidence for a behavioral mechanism in the stressor-HbA_1c relationship. African American youth may be more resilient against some detrimental behavioral effects of stressors.

Psychological correlates of disordered eating in youth with type 1 diabetes: Results from diabetes MILES Youth-Australia

BACKGROUND

This study examined the relationship between disordered eating (DE), body dissatisfaction (BD), and psychological variables; and identified correlates of DE in youth with type 1 diabetes.

METHODS

Data were from the Diabetes Management and Impact for Long-Term Empowerment and Success Youth Study-Australia, an online survey assessing the psychosocial impact of type 1 diabetes. Adolescents (N = 477; mean age 16 ± 2 years) with type 1 diabetes for at least 1 year, completed the Diabetes Eating Problem Survey-Revised, measures of BD, quality of life, well-being, depressive and anxiety symptoms, diabetes distress, and resilience.

RESULTS

DE correlated positively (moderate-large) with depressive and anxiety symptoms, diabetes distress, and BD; and negatively (moderate-large) with well-being, quality of life, and resilience. In contrast, BD correlated (moderately) with all psychological variables in females only. In the stepwise regression, high diabetes distress and BD were the strongest predictors of DE. While the magnitude of BD was almost five times higher in females, the level of DE risk across genders did not differ when BD was added into the model, which overall explained 71% of the variance.

CONCLUSIONS

This study explored potential risk and protective factors associated with DE. The novel finding that diabetes distress is a strong indicator of DE provides preliminary support for its inclusion into future risk models and potential target for intervention. Longitudinal studies are required to map how these factors predict changes over time with greater emphasis needed into understanding the gender-specific risks associated with BD, particularly during more difficult developmental phases, such as adolescence to young adulthood.

The cognitive and psychological effects of living with type 1 diabetes: a narrative review

Across the lifespan, type 1 diabetes mellitus has a profound (neuro)psychological impact. In young people, type 1 diabetes can interfere with psychosocial development and hamper school performance. In adulthood, it can interfere with work life, relationships and parenting. A substantial minority of adults with type 1 diabetes experience coping difficulties and high diabetes-related distress. In youth and adulthood, type 1 diabetes is related to mild cognitive decrements as well as affective disorders, such as depression and anxiety. There is limited literature available that explores the interaction between cognitive and psychological comorbidity and underlying mechanisms. The aims of the present narrative review were to summarize the current state of the literature regarding both cognitive and psychological comorbidities in type 1 diabetes across the lifespan, and to explore potential links between the two domains of interest to make suggestions for future research and clinical practice.

25 Years of psychological research investigating disordered eating in people with diabetes: what have we learnt?

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.

Exploring emotional dysregulation characteristics and comorbid psychiatric disorders in type 1 diabetic children with disordered eating behavior risk

OBJECTIVE

To investigate emotional dysregulation and psychiatric comorbidities associated with DEB-risk in children with type 1 diabetes mellitus (T1DM).

METHODS

A total of 75 children with T1DM aged between 8 and 19 were evaluated by K-SADS-PL to assess psychiatric diagnosis. DEB-risk was evaluated via Diabetes Eating Problem Survey-Revised (DEPS-R). Besides, all participants completed the Childhood Depression Inventory (CDI), Difficulties in Emotion Regulation Scale (DERS), and The State-Trait Anxiety Inventory (STAI).

RESULTS

DEPS-R-positive (≥20) was detected in 28% of the participants. The only diagnostic difference was a significantly higher frequency of ED in DEPS-R-positive than DEPS-R-negative (OR = 8.5, CI = 1.94-37.1, p = .004). DEPS-R-positive cases had significantly higher scores of the CDI, STAI, DERS, and the subscales of Goals, Impulse, and Strategies of DERS (CDI U = 266.500, p = .001; STAI U = 288.500,p = .001; DERS U = 229.000, p = .001, Goals U = 283.500, p = .008, Impulse U = 274.000, p = .005, Strategies U = 281.500, p = .007). In stepwise linear regression analysis, STAI-state and DERS scores significantly determined DEB-risk (STAI: β = 0.363, t(60) = 2.33, p = .02, DERS: β = 0.240, t(60) = 4.14, p < .001).

CONCLUSION

This cross-sectional study showed that DEPS-R-positive cases have an 8.5-fold increased risk for ED. DEPS-R-positive ones have difficulties in regulating their emotions and they are incapable of accessing emotion regulation strategies, engaging in goal-directed behavior while under difficult emotions, and impulse control. It can be beneficial for child psychiatrists to screen first for ED in DEPS-R-positive cases who are referred by child endocrinologist. They should also take into consideration anxiety levels and problems in emotion dysregulation in the DEPS-R-positive cases.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

TRIAL REGISTRATION NUMBER

ANZCTR (12619000541101).

5. Facilitating Behavior Change and Well-being to Improve Health Outcomes: Standards of Medical Care in Diabetes-2020

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

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

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

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

Objectives

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

Methods

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

Results

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

Conclusions

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

[Mental disorders and diabetes mellitus (Update 2019)]

Psychiatric disorders and psychological problems are common in patients with diabetes mellitus. There is a twofold increase in depression which is associated with suboptimal glycemic control and increased morbidity and mortality. Other psychiatric disorders with a higher incidence of diabetes mellitus are cognitive impairment, dementia, disturbed eating behavior, anxiety disorders, schizophrenia, bipolar disorders and borderline personality disorder. The coincidence of mental disorders and diabetes mellitus has unfavorable influences on metabolic control and micro- and macroangiopathic complications. Improvement of therapeutic outcome is a challenge in the modern health care system. The intentions behind this position paper are to rise awareness of this special set of problems, to intensify cooperation between involved health care providers and to reduce incidence of diabetes mellitus as well as morbidity and mortality from diabetes in this patient group.

Dysfunctional eating in type 2 diabetes mellitus: A multicenter Italian study of socio-demographic and clinical associations

BACKGROUND AND AIMS

Dysfunctional eating might impact on the management and metabolic control of type 2 diabetes (T2DM), modifying adherence to healthy diet and food choices.

METHODS AND RESULTS

In a multicenter study, we assessed the prevalence of dysfunctional eating in 895 adult outpatients with T2DM (51% males, median age 67, median BMI 30.3 kg/m²). Socio-demographic and clinical characteristics were recorded; dysfunctional eating was tested by validated questionnaires (Eating Attitude Test-EAT-26, Binge Eating Scale-BES; Night Eating Questionnaire-NEQ); food intake and adherence to Mediterranean diet were also measured (in-house developed questionnaire and Mediterranean Diet Score-MDS). Obesity was present in 52% of cases (10% obesity class III), with higher rates in women; 22% had HbA1c ≥ 8%. The EAT-26 was positive in 19.6% of women vs. 10.2% of men; BES scores outside the normal range were recorded in 9.4% of women and 4.4% of men, with 3.0% and 1.5% suggestive of binge eating disorder, respectively. Night eating (NEQ) was only present in 3.2% of women and 0.4% of men. Critical EAT and BES values were associated with higher BMI, and all NEQ + ve cases, but one, were clustered among BES + ve individuals. Calorie intake increased with BES, NEQ, and BMI, and decreased with age and with higher adherence to Mediterranean diet. In multivariable logistic regression analysis, female sex, and younger age were associated with increase risk of dysfunctional eating.

CONCLUSION

Dysfunctional eating is present across the whole spectrum of T2DM and significantly impacts on adherence to dietary restriction and food choices.

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

OBJECTIVE

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

RESEARCH DESIGN AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Bidirectional relationship between eating disorders and autoimmune diseases

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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