Perspective from Ann Goebel-Fabbri, PhD
Disclosures: One of the authors reports he was a co-founder and former head of research and development at mySugr GmbH. He left the position in 2018, with no stock retained after acquisition by Roche Diagnostics in 2017. The other authors report no relevant financial disclosures.
December 08, 2020
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Hyperglycemia in type 1 diabetes more prevalent among women with disordered eating

Perspective from Ann Goebel-Fabbri, PhD
Disclosures: One of the authors reports he was a co-founder and former head of research and development at mySugr GmbH. He left the position in 2018, with no stock retained after acquisition by Roche Diagnostics in 2017. The other authors report no relevant financial disclosures.
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Women with disordered eating and type 1 diabetes experience more negative emotions and spend more time in hyperglycemia than those without disordered eating, according to a study published in Diabetic Medicine.

“People with type 1 diabetes and disordered eating spend four times longer in level 2 hyperglycemia (> 13.9 mmol/L [ 250 mg/dL]) with an associated higher frequency of negative emotions and physical symptoms, and had higher glucose variability,” Marietta Stadler, MD, a National Institute for Health Research (NIHR) clinician scientist at King’s College London, and colleagues wrote. “Disordered eating thrives in secrecy and behaviors are often hidden and unknown to the health care providers. Characterization of glycemic changes could serve as a surrogate marker for early identification of this condition.”

Participants in the disordered eating group spent more time in level 2 hyperglycemia than those in the control cohort.

Researchers conducted a case-control study using a mixed-methods approach. The study population was split into a group of 13 women with disordered eating and type 1 diabetes and a control group of 10 women who had type 1 diabetes without disordered eating. Participants wore a blinded continuous glucose monitor for 1 week and reported activity in a diabetes diary through a smartphone application (mySugr, Roche). They were encouraged to record details about each meal, such as carbohydrate intake or insulin dose taken. Participants were also asked to record emotions and behaviors about the meal, such as skipping insulin, binge eating or feeling guilty about eating. Self-reported insulin doses, glucose measurements and exercise were also included in the diary. Participants used their own capillary glucose meters for testing and were asked to test before meals and at bedtime.

A clinical psychologist with expertise in eating disorders conducted semi-structured interviews with each individual to inform a revised theoretical model of disordered eating as part of a substudy. All participants completed the Diabetes Eating Problem Survey-Revised, Diabetes Distress Screening Scale, Patient Health Questionnaire-9 and the Yale Food Addiction Scale. A higher score on each survey indicated more disordered eating, diabetes distress, depression and food addiction.

Hyperglycemia higher with disordered eating

Baseline characteristics were similar in the disordered eating and control groups. The disordered eating group had a higher prevalence of recreation drug use than controls (38.5% vs. 10%). The disordered eating cohort also had a higher mean HbA1c and higher scores on the diabetes distress, depression and the diabetes eating problem surveys.

The disorder eating group had a mean serum glucose of greater than 10 mmol/L (180 mg/dL) for 49.8% of the study period, whereas the control cohort spent 25.6% of time above range (P = .036). When examining level 2 hyperglycemia (serum glucose > 13.9 mmol/L, or 250 mg/dL), the disorder eating group was above range 21.3% of the time vs. 5% for the control group (P = .015). The disordered eating cohort also had fewer capillary glucose readings per day than controls (4.5 vs. 6.3; P = .03) and a higher capillary glucose standard deviation (4.7 mmol/L vs. 3 mmol/L; P = .018).

Negative emotions and disordered eating

Both groups used the diabetes diary for a median of 6 days, but the disordered eating cohort had fewer median entries per day than women in the control group (5.5 vs. 8.3; P = .03). The disordered eating group had a median of two negative emotions per week (95% CI, 1-6), whereas those in the control cohort had a median of zero negative emotions (9% CI, 0-1; P = .03).

The negative emotions linked to high blood glucose could be the result of various thought processes; a feeling of guilt for omitting/restricting insulin, anxiety about the risk of diabetes-specific complications or a sense of failure despite attempts at maintaining glucose within the target range,” the researchers wrote.

Those with disordered eating also had more physical symptoms than individuals without disordered eating with glucose of 10 mmol/L (180 mg/dL) or greater (7 vs. 2.5; P = .49) and glucose of 15 mmol/L (270 mg/dL) or higher (4 vs. 0; P = .021).

“Diagnosis of type 1 diabetes is a significant disruption to the life of a person, demanding large behavioral changes,” the researchers wrote. “The early adaptive strategies that a person employs has a substantial impact on their future diabetes self-care and psychological well-being. It appears that inappropriate diabetes self-care behaviors are a key factor in the development of disordered eating in type 1 diabetes. This calls for early psychological support to foster realistic expectations in people with newly diagnosed type 1 diabetes paired with the early introduction of essential skills and knowledge for flexible insulin dosing for normal eating, to avoid large glucose fluxes.”