"I Haven't Told Anyone but You": Experiences and Biopsychosocial Support Needs of People With Type 2 Diabetes and Binge Eating

Up to 25% of people with type 2 diabetes (T2D) may binge eat which is almost 10 times as many as in the general population. Binge eating is associated with depression, anxiety, and social isolation. Moreover, binge eating may increase the risk of obesity and high blood glucose levels, both of which can accelerate the onset of complications to diabetes and death in people with T2D. Still, little is known about the experiences, needs, and preferences of people with T2D and binge eating that can inform and develop current and future treatment efforts. The aim of the study was therefore to gain in-depth insights into the experiences and biopsychosocial support needs of women and men with T2D and binge eating. Twenty semi-structured individual interviews (65% with females) were conducted and analyzed according to the methodology of Interpretive Description. Four themes were identified: (a) T2D and binge eating: Feeling trapped in a vicious circle; (b) Unwanted outcasts: Responding to continuous criticism; (c) Biomedical relief: Blaming and adjusting the body; and, (d) Silent struggles: Wanting to cease the secrecy. Pertinent to all themes were the guilt, shame, and worries about developing complications that the participants experienced when binge eating despite having T2D. Although binge eating triggered emotional distress, binge eating was at the same time a way of coping with such distress. Implications for treatment and future research are discussed, including the need to systematically assess and address binge eating in routine T2D care.

A Short-Form Measure of Diabetes Distress Among Adults With Type 1 Diabetes for Use in Clinical Practice: Development and Validation of the T1-DDS-7

OBJECTIVE

Valid and reliable diabetes distress assessment is essential for identifying adults with elevated levels of concern and to guide targeted support. However, assessing diabetes distress must also be feasible in time-limited settings. We aimed to identify a short-form measure of the 28-item Type 1 Diabetes Distress Scale (T1-DDS-28) representing seven sources of type 1 diabetes distress that would be convenient for use in clinical practice.

RESEARCH DESIGN AND METHODS

Based on the evaluation of influence and importance by 14 experts in diabetes care and research, we identified the best-performing item within each of seven sources of diabetes distress included in the T1-DDS-28. To further validate the proposed short-form measure, we used survey data from 2,016 adults living with type 1 diabetes. Validity was examined by exploratory factor analysis, Cronbach's α, test-retest reliability analysis, and correlations with other psychosocial measures.

RESULTS

We identified a short-form measure of the T1-DDS-28 consisting of seven items, each representing a source of diabetes distress. These items showed satisfactory reliability (factor loadings > 0.45; α = 0.82; test-retest correlation, r = 0.90) and validity (correlation with T1-DDS-28, r = 0.95; area under the curve = 0.91; sensitivity 93%; specificity 89%) when combined in the short-form scale (T1-DDS-7).

CONCLUSIONS

We propose the T1-DDS-7 as a valid and reliable measure for routine screening of diabetes distress among adults with type 1 diabetes. In case of elevated levels of diabetes distress, we recommend that a full-scale assessment and open dialogue follow the short-form measure before determining further treatment.

Validation of the type 1 diabetes distress scale (T1-DDS) in a large Danish cohort: Content validation and psychometric properties

Aim

To validate the Type 1 Diabetes Distress Scale (T1-DDS) in a large sample of adults with Type 1 diabetes (T1D) from diabetes clinics in Denmark.

Methods

Altogether 40 adults with T1D were interviewed to explore the content of T1-DDS in a Danish setting and to validate the translation of the T1-DDS into Danish. Subsequently, a survey including T1-DDS, the Problem Areas In Diabetes scale (PAID-20), fear of hypoglycemia, social support, and diabetes duration was answered by 2201 people with T1D. Other person characteristics were collected from the National Patient Register. HbA1c was obtained from the Clinical Laboratory Information System. Data distribution, internal consistency, convergent and construct validity, factor structure, three weeks retest, and cut-points were explored.

Results

Interview data supported the relevance of all T1-DDS items for the assessment of diabetes distress among adults with T1D. The T1-DDS showed good content and acceptable construct validity, and the ability to detect high diabetes distress levels. A high correlation between T1-DDS and PAID-20 (rho = 0.91) was found. The retest scores showed a good reliability (all rho ≥0.68) with the highest variability in the Friends/Family Distress and Physician Distress subscales and the lowest variability in the Powerlessness and Eating Distress subscales of the T1-DDS. Qualitative findings pointed out relevant concerns of people with T1D, which were not included in the T1-DDS.

Conclusion

The study supports the use of the Danish T1-DDS, but also highlights that existing diabetes distress questionnaires including T1-DDS do not cover all potential diabetes stressors and worries.

Playing With Peers: Exploring Peer Support Mechanisms of a Type 2 Diabetes-Specific Board Game

In this study, we explored specific mechanisms of a board game developed to facilitate peer support among people with Type 2 diabetes attending group-based diabetes education. The game was tested with 76 people with Type 2 diabetes who participated in focus groups after the game. Data from observations of audio-recorded games and focus groups were analyzed using Interpretive Description. Six mechanisms facilitating peer support among people with Type 2 diabetes were identified: (a) entering a safe space of normality created by emotional in-game mirroring; (b) mutual in-game acknowledgment of out-of-game efforts; (c) forming relationships through in-game humor; (d) health care professionals using game rules to support group dialogues of interest to people with Type 2 diabetes; (e) being inspired by in-game exchange of tips and tricks; and (f) co-players guiding each other during the game. Peer support was inhibited by the mechanism of game rules obstructing group dialogues.

Patient use of a self-monitoring app during eating disorder treatment: Naturalistic longitudinal cohort study

OBJECTIVE

To explore patients' use of the self-monitoring app Recovery Record during 26 weeks of naturalistic eating disorder treatment.

METHODS

Selected patient characteristics at baseline were explored as predictors of app use using linear regression. Patients were grouped according to diagnosis (anorexia versus bulimia), and mixed-effects analyses were used to explore differences in app use between diagnoses across four time periods (weeks 1-4; weeks 5-8; weeks 9-12; weeks 13-26).

RESULTS

Eighty-four patients were included of which 41 had anorexia and 43 had bulimia. The total number of logs varied greatly (mean (SD): 592 (628.50)), and patient app activity almost ceased at week 13. Increasing age and no previous eating disorder treatment predicted increased app activity (p = .007; p = .039, respectively). Patients with anorexia logged over four times more often than patients with bulimia in the last time period (median (CI): 4.27 (1.28;14.31); p = .018). Time predicted declining app use (all p ≤ .007).

CONCLUSION

Future research on long-term app engagement should investigate associations between patients' app use and changes in their eating disorder symptom severity over time.

Testing an analogue game to promote peer support and person-centredness in education for people with diabetes: A realist evaluation

Aim

To explore the outcomes of testing an analogue game to incorporate person‐centredness and peer dialogues in group‐based diabetes education targeting people with diabetes.

Design

Realist evaluation using quantitative and qualitative methods to explore context, mechanisms and outcomes of the intervention.

Methods

In March–July 2019, the game was tested among 76 people with type 2 diabetes and 17 professionals in 19 settings across nine Danish municipalities. Data consisted of game tests, interviews and questionnaires. Data were analysed using systematic text condensation and descriptive statistics.

Results

Outcomes of using the game were as follows: (a) a playful atmosphere; (b) active engagement; c) reflections on diabetes‐specific experiences; (d) focused dialogues; (e) professionals gaining insight into the needs of participants; and (f) professionals experiencing peer dialogue as important to incorporate into education. Questionnaire responses showed that 92% people with diabetes and 94% professionals found that the game incorporated person‐centredness and peer dialogues into education.

Grasping the weight cut-off for anorexia nervosa in children and adolescents

OBJECTIVE

The Diagnostic and Statistical Manual of Mental Disorders 5 suggests the 5th age-adjusted body mass index (BMI) percentile as the numeric cut-off for anorexia nervosa (AN) in children and adolescents. We aimed to investigate the degree to which the 5th age-adjusted percentile as the numeric cut-off for AN in youths reflects the clinical population of patients accepted for treatment.

METHOD

From a specialized eating disorder clinic, 305 patients with AN below 18 years of age were grouped according to age-adjusted BMI percentiles [below the 5th (low), above the 10th (high), and between the 5th and the 10th (medium)]. The distribution of eating disorder diagnoses and severity measured by the Eating Disorder Examination was compared.

RESULTS

Full-syndrome anorexia nervosa (F.50.0) was found in 182 (59.5%) patients and atypical anorexia nervosa (F.50.1) in 123 patients (40.5%). The number of patients in the low, medium, and high BMI percentile groups was 189 (62.0%), 34 (11.1%), and 82 (26.9%), respectively. Patients in the low BMI group differed from patients in the medium BMI group by a lower frequency of vomiting. The high BMI group presented with more weight and shape concern than the lower BMI group. Age was not a confounder of these associations.

DISCUSSION

We question the applicability of the 5th BMI percentile as a substantiated cut-off for the weight criterion in anorexia nervosa in youths and argue that the cut-off should not be ascribed great clinical importance as this may hinder early detection of illness and initiation of treatment.

Patient Experiences Using a Self-Monitoring App in Eating Disorder Treatment: Qualitative Study

Background

The Recovery Record smartphone app is a self-monitoring tool for individuals recovering from an eating disorder. Unlike traditional pen-and-paper meal diaries, which are often used in eating disorder treatment, the app holds novel features, such as meal reminders, affirmations, and patient-clinician in-app linkage, the latter allowing for clinicians to continuously monitor patients' app data.

Objective

To explore patients' experiences with using Recovery Record as part of outpatient eating disorder treatment.

Methods

A total of 41 patients from a Danish eating disorder treatment facility were included in the study. All 41 patients participated in participant observations of individual or group treatment sessions, and 26 were interviewed about their experiences with using the app in treatment. The data material was generated and analyzed concurrently, applying the inductive methodology of Interpretive Description.

Results

The patients' experiences with Recovery Record depended on its app features, the impact of these features on patients, and their specific app usage. This patient-app interaction affected and was affected by changeable contexts making patients' experiences dynamic. The patient-app interaction affected patients' placement of specific Recovery Record app features along a continuum from supportive to obstructive of individual everyday life activities including the eating disorder treatment. As an example, some patients found it supportive being notified by their clinician when their logs had been monitored as it gave them a sense of relatedness. Contrarily, other patients felt under surveillance, which was obstructive, as it made them feel uneasy or even dismissing the app.

Conclusions

Some patients experienced the app and its features as mostly supportive of their everyday life and the eating disorder treatment, while others experienced it primarily as obstructive. When applying apps in eating disorder treatment, we therefore recommend that patients and clinicians collaborate to determine how the app in question best fits the capacities, preferences, and treatment needs of the individual patient. Thus, we encourage patients and clinicians to discuss how specific features of the applied app affect the individual patient to increase the use of supportive features, while limiting the use of obstructive ones.

Clinicians' perspective on an app for patient self-monitoring in eating disorder treatment

OBJECTIVE

The Recovery Record smartphone app is a self-monitoring tool for individuals recovering from eating disorders. Oppositely to traditional pen-and-paper meal diaries, the app allows for in-app patient-clinician linkage enabling clinicians to access patient app data anytime. The aim of our study was to explore the interdisciplinary clinical perspective on Recovery Record and its impact on treatment.

METHOD

Thirty-one clinicians from a Danish eating disorder treatment facility participated in field studies and 23 of these in interviews. Data were generated and analyzed concurrently applying the inductive methodology of Interpretive Description.

RESULTS

We found two overarching themes: "Access to app data between treatment sessions", and "The patient-clinician relationship". Sub-themes associated with the former were "Online obligations" in relation to the added workload of continuously monitoring patient app data, and "Prepared or prejudiced" relating to advantages and disadvantages of using patient app data as preparation for treatment sessions. Sub-themes pertaining to the latter were "Expectation discrepancy" in relation to patients' and clinicians' divergent expectations for app usage, and "Pacified patients" regarding the clinicians' experience that the app potentially compromised the patient initiative in treatment sessions.

DISCUSSION

Recovery Record induced new and affected pre-existing treatment and work conditions for clinicians. Clinicians were preoccupied with challenges associated with the app, for example, an added work load and potential harm to the patient-clinician collaboration. Thus, prior to adopting the app, we encourage clinicians and managements to discuss the objectives, advantages and disadvantages of adopting the app, and outline specific guidelines for patient and clinician app usage.

Vitamin D, parathyroid hormone, and bone mineral content of lumbar spine and femur in primary biliary cirrhosis

In order to elucidate the pathogenesis and degree of osteopoenia in primary biliary cirrhosis (PBC) we conducted a cross-sectional study of 47 non-selected female patients with biopsy-proven PBC. Bone mineral content (BMC) of the lumbar spine, femoral neck and femoral shaft was determined using dual photon absorptiometry. Compared to healthy females of corresponding decades the PBC patients exhibited significantly decreased mean BMC-values in lumbar spine (88%, P less than 0.05) and femoral neck (92%, P less than 0.05) but not in femoral shaft (96%, NS). Bone mineral content was not significantly associated with duration of liver disease, impairment of liver function (serum concentrations of albumin, clotting factors II + VII + X, bilirubin, alkaline phosphatase galactose elimination capacity or histology), variables reflecting calcium homeostasis (serum concentrations of ionized calcium, parathyroid hormone, vitamin D binding protein, 25-hydroxy vitamin D3 and 1,25-dihydroxy vitamin D3) or previous treatment with glucocorticosteroids. In view of our negative findings we suggest that future studies in this field should focus on physical activity and female sex hormones as determinants for the prevention of osteopoenia in females with primary biliary cirrhosis.

Low serum free T3 concentrations in postobese patients previously treated with very-low-calorie diet

Thirteen postobese patients with stable body weights were studied and compared with obese patients and normal subjects. Six had previously been treated with a very-low-calorie diet (VLCD) whereas seven had been treated with gastroplasty (GP). The median observation time of post-obesity was 20 months for GP patients, but significantly (P less than 0.001) shorter by 2 months in VLCD patients. The median serum concentration of free triiodothyronine (T3) was significantly (P less than 0.005) reduced in the postobese VLCD patients (3.4 pmol/l) but normal in postobese GP patients (4.2 pmol/l) and obese patients (4.5 pmol/l). The serum level of total T3 was correspondingly lowered in the postobese VLCD patients. Also the postobese GP patients had a small, but significant (P less than 0.01) reduction in the median serum concentration of total T3 suggesting a slight decrease in the binding capacity. The serum levels of thyroxine-binding globulin and thyroxine-binding prealbumin were normal in both postobese and obese patients. Furthermore, the serum levels of thyroxine were normal showing that the postobese patients were euthyroid. The study shows that serum concentrations of T3 are not associated with body weights and low serum concentration may be seen in postobese patients after VLCD.

Serum free triiodothyronine in obesity

Serum concentrations of free triiodothyronine (T3) and total T3 were measured in 25 grossly obese patients with constant body weight and no dietary restrictions. The results were compared with serum free T3 and total T3 in 55 non-obese volunteers matched in sex and age. Median serum concentration of free T3 (4.5 pmol/l) and total T3 (1.80 nmol/l) in the obese patients were not significantly (P greater than 0.10) different from free T3 (4.6 pmol/l) and total T3 (1.84 nmol/l) in the normal persons. The risk of type II error (P beta) for overlooking a possible, true difference between obese and normal persons were estimated. If there is a difference in the mean value of free T3 then it is less than 0.5 pmol/l (P beta less than 0.05), corresponding to 12 per cent of the mean value of free T3 in the normal persons. If there is a difference in the mean value of total T3 then it is less than 0.21 nmol/l (P beta less than 0.01) corresponding to 11 per cent of the mean value of total T3 in the normal persons. The caloric and carbohydrate intakes were estimated in 17 of the obese patients and showed no significant correlations with serum free or total T3. The study indicates that the thyroid function per se is normal in obesity and adapts to increasing body weight by enhanced production of thyroid hormones and thereby sustaining a normal serum concentration of free T3.

Endocrine effects of lithium: II. 'Primary' hyperparathyroidism

Ninety-six manic-depressive patients were studied during long-term lithium treatment. Highly significant elevations were observed respecting the levels of serum immunoreactive parathyroid hormone (P less than 0.001) as well as the protein-corrected levels of serum calcium (P less than 0.001) and serum magnesium (P less than 0.001), thus indicating a state of 'primary' hyperparathyroidism. The patients as a group had normophosphataemia and normophosphatasia supporting the impression of a rather mild state of biochemical hyperparathyroidism.

Parathyroid hormone and calcitonin in serum of patients with mammary carcinoma

Immunoreactive parathyroid hormone and calcitonin in serum were measured in 34 normocalcemic patients with mammary carcinoma. The mean value of parathyroid hormone was significantly higher in 26 patients with bone metastases than in 8 patients without (p less than 0.025). One patient with bone metastases had slightly raised calcitonin in serum. No difference as to parathyroid hormone values between the groups of previously irradiated and non-irradiated patients was found. A possible explanation of the normocalcemic hyperparathyroidism is presented.