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

Prevalence of eating disorder symptoms in people with insulin-dependent-diabetes: A systematic review and meta-analysis

AIMS

To examine the prevalence of eating disorder symptoms (EDS) in 16 years and older individuals with insulin-dependent diabetes including both clinical and subclinical eating disorder symptoms.

METHODS

We searched PubMed, Embase, Scopus, PsycINFO, and CINAHL databases to discover studies reporting prevalence of eating disorder symptoms in patients with insulin-dependent diabetes (both type 1 and type 2). We performed a meta-analysis to estimate the pooled prevalence of eating disorder symptoms and an independent meta-analysis to estimate the prevalence of insulin omission.

RESULTS

A total of 45 studies were included in the meta-analysis of eating disorder symptoms. Diabetes Eating Problem Survey (DEPS-R) was the most frequently used screening tool (in 43 % of studies, n = 20). The pooled prevalence of eating disorder symptoms was 24 % (95 % CI 0.21-0.28), whereas in studies using DEPS-R, it was slightly higher, 27 % (95 % CI 0.24-0.31), with the prevalence ratio (PR) of 1.1. The prevalence differed between screening tools (χ2 = 85.83, df = 8, p < .0001). The sex distribution was associated with the observed prevalences; in studies with a higher female prevalence (>58 %), the pooled eating disorder symptom prevalence was higher [30 % (95 % CI 0.26-0.34) vs. 18 % (95 % Cl 0.14-0.22), PR 1.7]. The prevalence of insulin omission was 21 % (95 % CI 0.13-0.33).

CONCLUSIONS

Eating disorder symptoms and insulin omission are common in patients with insulin-dependent diabetes regardless of age. DEPS-R is the most used screening tool. Studies with a higher proportion of female participants report higher prevalence rates.

The role of diabetes distress in Diabulimia

IMPORTANCE

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

OBJECTIVE

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

EVIDENCE REVIEW

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

FINDINGS

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

CONCLUSION

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

A scoping review exploring the role of the dietitian in the identification and management of eating disorders and disordered eating in adolescents and adults with type 1 diabetes mellitus

BACKGROUND

Eating disorder diagnoses and disordered eating behaviours are more prevalent in people living with Type 1 Diabetes Mellitus, in particular in adolescents. The role of the dietitian in this setting is not clearly outlined in the literature.

AIM

This scoping review aims to outline the available information for the role of the dietitian in identifying and managing eating disorders in adolescents and adults with co-occurring Type 1 Diabetes Mellitus (T1DM) in a clinical setting.

METHODS

The Johanna Briggs Institute was utilised to guide this scoping review and to develop a search strategy for relevant databases. Relevant organisations and societies websites and professional magazines were reviewed as part of the grey literature search.

RESULTS

38 peer reviewed journal articles, 5 professional articles, 5 book chapters and 11 clinical guidelines were included in this scoping review. Roles for the dietitian in identification, prevention and screening for eating disorders in Type 1 Diabetes Mellitus were identified and outlined in a visual workflow. The role of the dietitian in the management of eating disorder in both the outpatient/community and inpatient setting and as core member of the multidisciplinary team was detailed in the literature.

CONCLUSION

This scoping review mapped the available information in the current literature on the role of the dietitian in the identification and management of eating disorders and disordered eating in adolescents and adults with a dual diagnosis of T1DM. The reviewed literature suggests there is a strong reliance on expert opinion and practice to inform the role of the dietitian. Further research is required in order to ensure more robust evidence-based practice in this area.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A thematic analysis of YouTube comments on a television documentary titled 'Diabulimia: The World's most dangerous eating disorder'

AIM

Omitting insulin for fear of weight gain is a type of disordered eating (also labelled as diabulimia) common in type 1 diabetes (T1D) and is associated with a worse biomedical prognosis but is not a formally recognised condition. This research explored the public's opinion of diabulimia as a condition as presented in a television documentary.

METHODS

We conducted a coding reliability thematic analysis using NVivo software of the original comments to a YouTube documentary 'Diabulimia: The World's Most Dangerous Eating Disorder' between 24 September 2017 and 16 June 2020.

RESULTS

Of 1424 original comments, 1264 were eligible and uploaded into NVivo 12. The commenters were people with T1D, family and friends, health care professionals, and the wider public who collectively had questions, personal stories and/or opinions. Three main themes were discerned: lack of awareness of diabulimia as a condition; the importance of support; diabulimia as a psychiatric condition in the diabetes setting.

CONCLUSION

This analysis of social media comments found that there is a lack of awareness of diabulimia amongst patients, their families and friends, and healthcare professionals and that there were many commenters who had the experience of disordered eating with T1D. This study has reported on themes that suggest there may be an eating disorder specifically in people with T1D and that further work is needed to understand the diagnostic criteria for diabulimia in order to develop effective treatments.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Investigating Service Users' Perspectives of Eating Disorder Services: A Meta-Synthesis

Objective

Despite a number of qualitative studies published from the perspective of eating disorder (ED) service users, there has been no attempt to exclusively synthesize their views to gain a fuller understanding of their ED service experiences. It is important to understand this perspective, since previous research highlights the difficulties ED healthcare professionals report when working with this client group.

Method

A systematic search of the literature was conducted to identify qualitative studies focusing on experiences of ED services from the perspective of service users. Twenty‐two studies met the inclusion criteria and underwent a quality appraisal check using the Critical Appraisal Skills Programme (CASP) tool for qualitative research. These were then synthesized using a meta‐synthesis approach.

Results

Four overarching themes were generated: “Treatment: Focus on physical vs. psychological symptoms”; “Service Environment: The role of control within services”; “Staff: Experiences with staff and the value of rapport”; and “Peer Influence: Camaraderie vs. comparison.” Service users expressed a desire for more psychological input to tackle underlying difficulties relating to their ED. A complex relationship with feelings of control was described, with some feeling over‐controlled by service providers, while others retrospectively recognized the need for control to be taken away. Staff values, knowledge and trust played a significant role in treatment and recovery. Peers with an ED were described to be a valuable source of understanding and empathy, but some found peer influence to perpetuate comparison and competitiveness.

Discussion

The results portray some of the conflicts and complexities that service users encounter in ED services. A running thread throughout is the perceived importance of adopting an individualized approach within these services.

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

OBJECTIVE

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

DESIGN

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

RESULTS

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

CONCLUSIONS

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

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

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

Piloting an Intervention to Improve Outcomes in Young Adults Living With Type 1 Diabetes: The Experience of the D1 Now Support Worker

Introduction

D1 Now is a novel intervention which aims to support self-management and clinic engagement and improve outcomes in young adults (18-25 years) living with type 1 diabetes in Ireland. It has been developed using a systematic, theoretical, user-centred approach. The specific role of the Support Worker, one of three components of the D1 Now intervention, was developed to provide continuity and build relationships between young adults and their diabetes team.

Methods

A Support Worker - an Occupational Therapist, who had a background in youth mental health - was hired as part of the D1 Now pilot randomised controlled trial and was based in one intervention site to join the existing diabetes team.

Discussion

The Support Worker aimed to provide an accessible and consistent point of contact for young adults, facilitated conversations about distress, and encouraged graded goal setting and collaborative problem solving. The role afforded her with a unique window into the lived experiences of young adults with type 1 diabetes where she observed the ongoing negotiation of life and living alongside diabetes care and management. The prevalence of diabetes distress was high in the study cohort with particular challenges associated with ‘all or nothing’ thinking patterns as well as disordered eating behaviours. The Support Worker also played an advocacy role in supporting the diabetes team’s awareness of young adults’ needs and explored current barriers to care. Preliminary findings from the D1 Now pilot have identified that the role of the Support Worker was viewed positively from the perspective of young adults with type 1 diabetes.

Multidisciplinary healthcare teams' challenges and strategies in supporting people with type 1 diabetes to recover from disordered eating

AIM

To examine the challenges healthcare teams face when treating people with type 1 diabetes and disordered eating and the strategies these teams have developed to facilitate effective treatment.

METHODS

Four semi-structured focus groups were conducted including two tertiary diabetes specialist teams and three tertiary eating disorders specialist teams between July and December 2018. Thematic analysis of the transcripts followed a six-phase process.

RESULTS

Twenty-nine experienced healthcare professionals (16 diabetes and 13 eating disorder specialists, 16±12 years' professional experience) were interviewed. The challenges identified in treating people with type 1 diabetes and disordered eating included subthemes the 'challenges specific to the healthcare professional' (feeling not competent enough and perceived emotional burden), 'challenges pertaining to patient factors' (e.g. difficulties with engaging in therapy) and 'challenges created by the healthcare system' (time pressure and staff shortage). Healthcare professionals expressed the need for a consensus on diagnosis and the definition of disordered eating in type 1 diabetes, as well as the need for training and educational resources specific to type 1 diabetes and disordered eating. Healthcare professionals gave practical examples of strategies of communication for better patient engagement and felt that multidisciplinary working in joint clinics with the other specialty were facilitators for recovery from disordered eating.

CONCLUSIONS

Healthcare professionals require multidisciplinary team support when treating people with type 1 diabetes and to improve their own competencies. The development of effective screening and assessment tools, educational resources and training for healthcare professionals, and developing multidisciplinary treatment pathways will be key to improving outcomes for their service users with type 1 diabetes and disordered eating.

The role of parental support for emerging adults with type 1 diabetes: A scoping review

BACKGROUND

Emerging adults with type 1 diabetes often have poor diabetes self-care and pose a considerable therapeutic challenge. They simultaneously handle a life phase characterized by instability, identity exploration, and transitions and manage a chronic illness that demands structure, self-discipline, and repeated health care contacts. Relation to parents is often ambivalent but typically remains the most stable social support, so parental support could potentially be helpful for diabetes self-care and wellbeing.

METHOD

This scoping review aimed to identify, summarize and analyze empirical studies (for instance interview studies, questionnaire studies and intervention studies) exploring parental support for emerging adults with type 1 diabetes. Studies were identified in PsycInfo, PubMed, Scopus, and Google Scholar. Data were extracted by one author and checked by another. Study results were synthesized by a convergent mixed methods approach and qualitative thematic analysis.

RESULTS

We included 26 studies (2829 participants), 16 interview studies, 10 questionnaire studies, and no intervention studies. Five overarching themes were identified: self-care and glycemic control, diabetes-related emotional wellbeing, support characteristics, ambivalence and harms, and core support providers. Parents tended to contribute positively to diabetes self-care, glycemic control, and psychological wellbeing. However, emerging adults did not want to be too dependent on their parents and family, and family could also act unsupportively; when absent, disinterested in diabetes or controlling.

CONCLUSION

This review underlines that parental support still plays a role for diabetes self-care and wellbeing in emerging adults with type 1 diabetes. Age-appropriate parental support therefore seems a promising path to investigate further.

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.

The lived experience of working with people with eating disorders: A meta-ethnography

OBJECTIVE

Working with people with eating disorders (EDs) is known to elicit strong emotional reactions, and the therapeutic alliance has been shown to affect outcomes with this clinical population. As a consequence, it is important to understand healthcare professionals' (HCPs') experiences of working with this client group.

METHOD

A meta-synthesis was conducted of qualitative research on HCPs' lived experiences of working with people with EDs. The results from the identified studies were analyzed using Noblit and Hare's meta-ethnographic method. Data were synthesized using reciprocal translation, and a line of argument was developed.

RESULTS

Thirty-seven studies met the inclusion criteria. Reciprocal translation resulted in a key concept: "Coping with caring without curing." This was underpinned by the following third-order concepts: (a) "The dissonance and discomfort of being a helper struggling to help," (b) "Defending against the dissonance," and (c) "Accepting the dissonance to provide safe and compassionate care." These concepts were used to develop a line-of-argument synthesis, which was expressed as a new model for understanding HCPs' experiences of working with people who have an ED.

DISCUSSION

Although the conflict associated with being a helper struggling to help led some HCPs to avoid and blame people with EDs, others adopted a compassionate stance characterized by humanity, humility, balance, and awareness.

Transforming mental well-being for people with diabetes: research recommendations from Diabetes UK's 2019 Diabetes and Mental Well-Being Workshop

AIMS

To identify key gaps in the research evidence base that could help to improve the mental well-being of people with diabetes, and to provide recommendations to researchers and research funders on how best to address them.

METHODS

A 2-day international research workshop was conducted, bringing together research experts in diabetes and in mental health, people living with diabetes and healthcare professionals.

RESULTS

The following key areas needing increased financial investment in research were identified: understanding the mechanisms underlying depression; understanding the multifactorial impact of social stigma; improving the language used by healthcare professionals; supporting people who find it difficult to engage with their diabetes; supporting significant others; supporting people with diabetes and eating disorders; improving models of care by learning from best practice; the potential benefits of screening and managing diabetes distress in routine diabetes care pathways; primary prevention of mental health issues at the time of diagnosis of diabetes; establishing the effectiveness of diabetes therapies on mood and other mental health issues; and understanding the impact of current diabetes technologies on mental health. Research recommendations as to how to address each of these priority areas were also developed.

CONCLUSIONS

This inaugural position statement outlines recommendations to address the urgent unmet need related to the mental well-being of people living with diabetes, and calls on the research community and funders to develop research programmes and strategies to reduce this need.