in the general population to establish the presence of ED and DEB in patients with diabetes. Questionnaires include but are not limited to the Eating Attitudes Test (EAT) 40 (Garner 1979) and EAT-26 (Garner 1982), Eating Disorder Inventory (EDI-3) (Garner 2004), the Bulimia Test - Revised (BULIT-R) (Thelen 1991), and the Eating Disorder Examination (EDE) (Cooper 1989), which is conducted in interview format. Evaluation tools include items about attitudes and behaviors that are embedded in the diabetes treatment regimen. For example BULIT-R items (“Do you feel you have control over the amount of food you consume?” and “I eat a lot of food when I’m not even hungry.”) could refer to the diabetes care regimen (the former by prescription of dietary restraint and the latter by a prescribed meal plan), carbohydrate to insulin ratio, and/or treatment for low blood glucose. Diabetes care providers identified more than twenty questions on the EDI-3 that could be answered in the context of treatment and endorsed independent of weight concerns (Young-Hyman 2010). When questionnaires standardized in healthy populations are used, scores may be elevated in patients with both T1D and T2D, due to the overlap in items which are diagnostic of disordered eating attitudes and DEB and prescribed as part of diabetes treatment (Daneman 1998). When questionnaires or interview techniques standardized in the nondiabetic population are used, it is recommended that questions be modified to address intent of behaviors, including insulin manipulation (Criego 2009). Some studies have expanded the EDE and SCID interview format to include such questions (Peveler 2005).
Two questionnaire exceptions were found: the Diabetes Eating Problems Survey (DEPS), created by Antisdel, Laffel, and Anderson (2001) and refined by Markowitz et al. (2010), and the AHEAD (Assessing Health and Eating among Adolescents with Diabetes) survey (Neumark-Sztainer 2002a). Both include questions regarding the adjustment of insulin specifically for the purposes of weight reduction, and both couch questions in terms of diabetes care and issues related to glycemic control and weight gain due to treatment (Antisdel 2001, Neumark-Sztainer 2002a). However, neither questionnaire has been validated in a clinical population with an independent diagnosis of ED. Findings from a study validating a questionnaire that assesses hunger and satiety in the context of diabetic care, the Diabetes Treatment and Satiety Scale (DTSS-20), suggest that patients with T1D routinely experience contradictory clinical situations (regarding blood glucose levels, usual MNT, and insulin dosing) during which they feel full, hungry, and/or out of control of food intake (Young-Hyman 2011a). It is speculated that the lack of appropriate hunger and satiety cues is related to hormonal dysregulation. (See section regarding physiologic dysregulation of appetite.)
To establish diagnosis of ED or document subclinical DEB, thorough evaluation in the diabetes population should include assessment of adjustment to illness, overall psychological status, weight and shape concerns, specific questions regarding maladaptive use of the insulin or medication regimen to lose weight, and reliability of proprioceptive cues regarding hunger and satiety in the context of blood glucose levels (Young-Hyman 2010).
Limitations of Current Research Findings
Gaps in research regarding the association of DEB and diabetes include: 1) assessment of DEB in the context of adherence to medical regimen and adjustment to illness; 2) understanding the contribution of insulin and medication dosing to feelings of hunger and satiety; 3) dietary prescriptions/medical nutrition therapy as potential sources of information/attitudes leading to feelings of loss of control over food intake; 4) need for appropriate comparison groups such as healthy-weight matched individuals seeking to prevent weight gain or weight loss, minority comparison groups, and other chronic disease groups with conditions affecting weight/metabolism; 5) incomplete psychological characterization of samples; 6) discrimination of preexisting/evolving psychopathology associated with noncompliance; and 7) the need to use diabetes-specific assessment tools.
Prior studies of the prevalence of DEB in individuals with diabetes have not systematically addressed issues of regimen intensity, responsibility taking for regimen decisions, expectations of health care providers for glycemic and weight outcomes, and eating cognitions associated with medical care. The contributions of diabetes treatment knowledge or regimen adherence to the prevalence or endorsement of DEB are not established. Very few studies were found to have monitored patients from the time of diagnosis to establish the relationships or chronology between psychological symptomatology (depression in particular), DEB, weight gain, or regimen adjustment to prevent weight gain. Studies in adult women have not taken into account use of hormones for birth control or hormone replacement therapy (HRT), which can cause excess weight gain and increase appetite (Abrams 1992, Gallo 2004, Gallo 2006). Last, no studies to date have simultaneously assessed physiologic markers of hormones and incretins contributing to dysregulation of hunger and satiety and symptoms of DEB in the context of diabetes care.
Recommendations for Screening and Care
DEB is accepted as a serious and potentially life-threatening comorbidity of diabetes, despite controversy about diagnosis and prevalence. No published randomized controlled intervention trials of treatment of DEB or ED with diabetes cohorts could be found. Therefore screening recommendations are derived from the extant literature, and treatment recommendations are adapted from DEB interventions with healthy populations (Kelly 2005, Goebel-Fabbri 2009).
If DEB is suspected, screening should be implemented as follows:
1. Use diabetes-specific measurement tools to distinguish between behavior that indicates regimen adherence versus DEB to control weight, independent of glycemic control goals (Goebel-Fabbri 2009, Young-Hyman 2011a).
2. Evaluate overall psychological adjustment to establish whether behaviors indicate DEB, psychiatric morbidity, and/or poor adjustment to the diagnosis and requirements of treatment regimen (noncompliance). Patients with known psychiatric morbidity should be screened for DEB when unexplained poor glycemic control, weight gain, and/or weight loss occurs (Kelly 2005).
3. Evaluate insulin and other medication dosing/amount and episodes of hypoglycemia as potential causes for lack of satiety and/or loss of control over food intake. Evaluate accuracy of internal cues indicating need for food or treatment (with medication) in the context of blood glucose level (Goebel-Fabbri 2009).
4. Evaluate potential contributions of dietary prescription and information (MNT) to attitudes and behaviors regarding food intake, including food preoccupation and self-evaluation of actual or subjective dietary restraint and binging (ADA 2007).
5. Assess patients’ expectations for achieving good glycemic control: at what cost to psychosocial adjustment, quality of life, eating behaviors, and weight.
If screening indicates DEB, formal evaluation and care should be implemented:
1. Refer for psychological/psychiatric evaluation. Once ED/DEB is established by questionnaire/interview, referral for treatment to a mental health professional familiar with the medical management of diabetes and treatment of DEB should be made (ADA 2007).
2. When treatment for DEB is begun, the treating professional as well as key individuals in the patient’s social support network in treatment (parents for children and teens, partners or close family/community members for adults) should be incorporated into the diabetes management team (Criego 2009).
3. Depending on severity of symptoms, medications (antidepressant and antianxiety) and hospitalization should be considered.
4. Routine monitoring of DEB symptoms at medical management visits is also an integral part of the ongoing treatment process so that appropriate adjustments to the diabetes care regimen can be made (ADA 2007, Criego 2009). Careful evaluation of the contribution of prescribed diabetes care behaviors, knowledge, intent of behavior, and glycemic and weight goals should be conducted. Incorporation of diabetes treatment personnel into the DEB treatment plan helps to ensure that the prescription for regimen behaviors can be adjusted as needed (Goebel-Fabbri 2009).
