Skip to main content
Download PDF
Download ePub

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

Journal of Eating Disorders volume 11, Article number: 158 (2023) Cite this article

Abstract

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.

Plain English Summary

While young patients with diabetes mellitus (DM) are prone to eating disorders that may worsen metabolic control, early detection and appropriate intervention of comorbid emotional and behavioral symptoms are urged when providing diabetes care to this vulnerable age group. Having observed an increasing trend of eating disorders in the general population in Taiwan, we aimed to investigate clinical and behavioral correlates of disordered eating and insulin restriction behavior and its association with psychological health in a clinical sample of youths with DM. We found that 17.6% of the young patients with DM restricted insulin use, and 6.3% self-medicated for weight control. Fluctuating glucose levels and body image issues were found to be correlated with disordered eating and insulin restriction behaviors, which were also significantly linked to risks for anxiety and depression. These findings may warrant scrutiny in assessing eating behavior and insulin use among young patients with DM in East Asian settings.

Introduction

Type 1 diabetes mellitus (T1DM) accounts for 10–15% of all diagnosed cases of diabetes each year, and its incidence is increasing with time [1]. Managing T1DM is a complex process that requires strict adherence to a structured plan, including appropriate nutritional management, prescribed pharmacotherapy, regular blood sugar monitoring, and regular physical exercise [2]. Patients with T1DM are at risk for disordered eating and eating disorders due to specific patterns and featured management, such as insulin-related weight gain and diet for hypoglycemic prevention [3]. On the other hand, type 2 DM (T2DM) manifests as hyperglycemia that usually ensues as a consequence of excessive body fat and insulin resistance [4]. Disordered eating, particularly binge eating behavior, is not uncommon in patients with T2DM [5]. Worth clinical attention, their presenting symptoms may differ from those commonly seen in non-diabetic eating disorders [5, 6].

Restricting insulin against dosing instructions provided by doctors is a readily available method for weight control [7]. However, this method warrants clinical attention in patients with T1DM because it may increase the risk of eating disorders and metabolic problems leading to an increased risk of diabetic complications, such as retinopathy, neuropathy, and hospitalization for diabetic ketoacidosis [6]. Deliberate insulin reduction or omission has been associated with recurrent hypoglycemia and hyperglycemia with diabetic ketoacidosis events that are further associated with elevated mortality risks [8]. Moreover, diabetes treatment associated with insulin use and adolescent weight changes may also increase the incidence of persistent eating problems [9]. Additionally, adolescence is considered a sensitive period that is a risk factor for disordered eating behavior, which is seen at a higher rate in patients with T1DM and T2DM than in their peers without diabetes [4, 10]. While inappropriately restricting insulin has been extensively investigated for its association with poorer health in individuals with T1DM, less has been researched on the insulin-treated counterparts of T2DM, where they need insulin injections as their primary treatment because they fail to reach their glycemic goal with other hypoglycemic medications [11,12,13].

There is substantial evidence supporting a correlation between mental health issues and poor glycemic control in adolescents and young adults (AYAs) with DM [14,15,16]. Early detection and appropriate intervention of comorbid emotional and behavioral symptoms are therefore urged when providing diabetes care to this vulnerable age group. However, empirical data on psychobehavioral issues, such as disordered eating and insulin restriction (DE/IR) behaviors, among AYAs with DM is relatively scarce in East Asian social settings. One prior study a decade ago found that Taiwanese adolescents with T1DM exhibited more disturbed eating behaviors than their adolescent counterparts without diabetes, but it did not investigate IR practice [17]. Having observed an increasing trend of eating disorders in general Taiwanese AYAs in recent years [18], we aimed to investigate the clinical and behavioral correlates of DE/IR behavior and its association with psychological health in a clinical sample of AYAs with DM.

Methods

Study subjects

We recruited patients with T1DM and T2DM aged 10–30 years, who received the diagnosis before age 18 years and were regularly tracked in the pediatric outpatient clinic at a single medical center that received referrals from a catchment area of nearly 3 million residents in southern Taiwan [19]. A total of 179 cases receiving insulin as their primary treatment were initially accessed, and 24 chose not to participate, leaving 142 patients for analysis (Fig. 1). In routine clinical practices in Taiwan, we tested for islet autoantibodies and performed the glucagon stimulation test to distinguish between T1DM and T2DM in cases who needed basal-and-bolus insulin as their main therapy, because patients with T1DM received a catastrophic illness status eligible for partial medical fee waiver. Those with negative islet autoantibodies (i.e., glutamic acid decarboxylase 65 antibodies) and an appropriate C-peptide level (i.e., 0.7 nmol/l for fasting and 1.1 nmol/l for post-glucagon C-peptide levels) in response to glucagon stimulation were deemed T2DM [20]. This study was approved by the Institutional Review Board of the Cheng Kung University Hospital (A-BR-107-033).

Fig. 1
figure 1

The flowchart for the selection of patients; DM: diabetes mellitus

Full size image

Collection of clinical data

We reviewed medical charts to obtain relevant clinical data, including gender, type of DM, disease duration, body mass index (BMI) at onset and present, and insulin dosing. BMI was calculated by dividing a patient’s weight in kilograms by their height in square meters. We determined the z-score of BMI according to gender and age-specific BMI charts using the Taiwan children and adolescent growth chart published in 2010 [21]. Multiple visit-to-visit hemoglobin A1c (HbA1c) levels were recorded over one year prior to the enrollment date. Aligned with previous research, we calculated the mean, standard deviation (SD), coefficient of variation (CV), and visit-to-visit variability score (VS) of the HbA1C levels to reflect patient glycemic control and fluctuation [22, 23]. In addition, we calculated the insulin dose-adjusted A1c (IDAA1c) according to the following formula: HbA1c (%) + 4 × insulin dose (units/kg/day). Using both total insulin dose and HbA1C in the same formula can reduce the influence of the treatment regimen when considering glycemic control [24].

Eating behavior

We used two specific questionnaires to obtain the eating behavior among AYAs with DM: the 21-item revised Three-Factor Eating Questionnaire (TFEQ-R21) and the modified SCOFF (mSCOFF) questionnaire. The TFEQ-R21 has been validated for evaluating eating behavior among adolescents in three aspects, including emotional eating (EE), uncontrolled eating (UE), and cognitive restraint (CR) [25]. The original SCOFF questionnaire is a reliable and valid screening instrument encompassing five dichotomous items (i.e., intentional vomiting, loss of control over food, unhealthy weight loss, body image disturbance, and intrusive food thoughts), and its Mandarin version has been validated in a Taiwanese setting [26]. Like the original SCOFF score reflecting the number of disordered eating behaviors, with a score of 2 or greater considered a risk for the occurrence of eating disorders [27], the mSCOFF questionnaire replacing the final item (intrusive food thoughts) with insulin restriction with the question “Do you ever deliberately take less insulin than you should?” has been proposed for the young population with diabetes because adolescent patients may deliberately adopt insulin restriction as an alternative behavior for weight control [28, 29]. In this context, patients might restrict insulin doses inappropriate to carbohydrate intake against their doctors’ dosing instructions. The cutoff of 2/5 on the mSCOFF questionnaire may suggest DE/IR behavior with a decent index of sensitivity (80%) and specificity (90%) as compared to the Eating Disorder Inventory-3, and a score above the threshold therefore requires a thorough psychological interview in patients with diabetes [29]. For the above reasons, we used the mSCOFF questionnaire to evaluate DE/IR behavior.

Body image and weight-control behavior

A single item was used to ask how the participants viewed their body size. The answers were rated on a 5-point Likert-like scale from very thin (score = 1) to very heavy (score = 5) [30]. Moreover, we screened five different types of weight control behavior (i.e., restricting insulin use, dieting, self-medicating weight-loss or laxative pills, induced vomiting, and over-exercising) in the past three months using dichotomous questions.

Psychological wellbeing

We used the Hospital Anxiety and Depression Scale (HADS) to measure participants' psychological wellbeing in two domains (i.e., anxiety and depression), and each domain had seven items rated using a four-point Likert-type scale [31]. The psychometric properties of the HADS Mandarin version were supported in Taiwanese youth [30]. After reverse coding the negatively worded items and adding up all the item scores, higher scores on the HADS represents higher levels of anxiety and depression. In the present analysis, a domain score of 11 or greater indicates risks for anxiety or depression [31, 32].

Statistical analysis

We summarized the clinical, behavioral, and psychological variables using descriptive statistics and compared these variables between patients with T1DM and T2DM using Student's t and Chi-square tests as appropriate. A Pearson correlation analysis was applied to examine the bivariate correlation between psychological and behavioral variables of interest. Firstly, we used univariate and multivariate logistic regression analyses to identify potential clinical and behavioral correlates of DE/IR behavior, defined by an mSCOFF score of 2 or greater. Further, we used hierarchical regression analyses, recursively controlling for clinical and behavioral confounders, to evaluate the effects of DE/IR behavior on psychological wellbeing. Specifically, Model 1 tested the univariate association between mSCOFF scores and anxiety and depression. Model 2 controlled for behavioral parameters. Model 3 controlled for clinical and behavioral parameters. Covariates, including age, gender, and types of DM, were included in all models. A stepwise predictor selection was used with a significance level of 0.05 for entry and 0.1 for stay in the multivariate analyses. Odds ratios (ORs) with a 95% confidence interval (CI) were reported for the predictors remaining in the final model.

Results

Table 1 describes the demographic and clinical parameters of the patients with DM (N = 142) at the time of data collection. Among them, 110 (77.5%) had T1DM, and the rest had T2DM and used basal-and-bolus insulin as their primary treatment because of unsatisfied diabetic control with other hypoglycemic medications. There was no difference regarding age at enrollment or gender between T1DM and T2DM. However, the disease duration was longer among patients with T1DM (9.41 ± 6.23 years) than those with T2DM (2.94 ± 3.66 years). The mean BMI z-score at enrollment was lower among T1DM (0.52 ± 1.55) than T2DM (2.99 ± 2.71) patients. There was a higher mean HbA1c and IDAA1c in patients with T1DM than those with T2DM. Conversely, HbA1C-SD and HbA1C-CV were lower in patients with T1DM than those with T2DM. Moreover, patients with T2DM had a greater concern for body image and were more likely to use weight-control medications or restrict insulin use. Stratifying the patients by weight status, we observed a trend that patients who had overweight/obesity tended to have more DE/IR behaviors (Additional file 1: Table S1).

Table 1 The demographic and clinical parameters of the patients stratified by type 1 and type 2 diabetes mellitus
Full size table

The Cronbach's alpha values for the questionnaires employed in our study were acceptable (ranges: 0.62–0.93), except the one for the mSCOFF, which was only 0.41 (Table 2). In bivariate correlation analysis, scores on the mSCOFF were correlated with those on the CR subscale of the TFEQ-R21, both the depression and anxiety subscales of the HADS and body image. Moreover, scores on the EE and UE subscales of the TFEQ-R21 were correlated with those on the anxiety subscale of the HADS. Scores on body image were also correlated with those on the depression and anxiety subscales of the HADS. In univariate regression analysis, we found that several factors, including TFEQ-R21 CR (OR = 2.37, [95%CI 1.04–5.40]), body image (OR = 2.07, [95%CI 1.25–3.44]), dieting (OR = 6.48, [95%CI 2.50–16.77]), and over-exercising (OR = 8.42, [95%CI 1.51–46.85]), were associated with an mSCOFF score of 2 or greater (Table 3). However, in the full multivariate regression analysis, only HbA1c-SD (OR = 2.18, [95%CI 1.07–4.42]), body image (OR = 1.83, [95%CI 1.05–3.20]), and dieting (OR = 4.74, [95%CI 1.70–13.23]) were associated with an mSCOFF score of 2 or greater.

Table 2 Validation and correlation analysis on the employed questionnaires
Full size table
Table 3 Univariate and multivariate regression analyses of the physiological and behavioral correlates with mSCOFF scores
Full size table

Further, in an attempt to examine the association between DE/IR behavior and anxiety and depression based on the HADS questionnaire, we found that mSCOFF scores were consistently associated with depression and anxiety based on the HADS questionnaire, even after controlling clinical and behavioral parameters (Table 4). In the fully adjusted model, an mSCOFF score of 2 or greater was associated with a 17% increase in the OR for anxiety and a 12% increase in the OR for depression based on the HADS questionnaire.

Table 4 The hierarchal regression analyses of the association between mSCOFF scores, behavioral and clinical parameters, anxiety and depression
Full size table

Discussion

To the best of our knowledge, this paper is the first to investigate psychosocial and metabolic correlates of insulin restriction among AYAs with DM in Taiwan. We observed that patients with T2DM were more likely to have body image concerns and adopt medications and inappropriate insulin restriction against their doctors’ dosing instructions as weight-control measures. Moreover, DE/IR behavior was associated with psychological distress, such as anxiety and depression based on the HADS questionnaire, which requires clinical attention when consulting these patients in practice.

In this study, we found that 11% of the patients with T1DM had at one point restricted their insulin use. The prevalence was slightly lower than those reported in Western societies [3, 33]. This prevalence may correspond to a lower prevalence of eating disorders in an East Asian social setting [18]. However, nearly half of the patients with T2DM who need basal-and-bolus insulin as their treatment strikingly reported inappropriately restricting insulin use against their doctors’ instructions (i.e., deliberately taking less insulin than required), and a greater proportion of body image concern and disordered eating was seen in the patients with T2DM than those with T1DM. Marked weight gain may ensue if insulin doses are too high or incorrectly distributed when using insulin therapy in T2DM [34]. In our questionnaire, the item explicitly indicated that young patients adjusted insulin doses because of fear of weight gain rather than changes in carbohydrate intake. In adults with T2DM, the reasons for refusing insulin can be attributed to psychological factors, such as fear and a negative perception of insulin, as well as cognitive factors, such as questioning the efficacy of insulin and seeking insulin-free therapy (e.g., GLP-1 receptor agonists) [35]. Further, refusing insulin may be attributable to lifestyle changes caused by psychosocial, peer pressure, and family-related factors that affect the quality of care in youths with T2DM [36]. As early-onset T2DM is more likely to be associated with greater risks of cardiovascular diseases and diabetic complications than adult-onset T2DM and T1DM [22, 36], how the insulin restriction behavior is related to the cardiometabolic outcomes should be carefully investigated among youths with T2DM who usually receive less attention than their peers with T1DM.

The mSCOFF has a similar level of internal consistency to the original SCOFF, which has been widely used in clinical practice and has acceptable psychometric properties for Chinese adolescents [37, 38]. Moreover, we found that mSCOFF scores were correlated with those of the CR subscale of the TFEQ-R21, both subscales of the HADS, and body image, indicating its external validity as a crucial psychosocial assessment to screen eating psychopathology. Using a cutoff mSCOFF score of 2 or greater to define DE/IR behavior, we did not find any significant association between DE/IR behavior and HbA1c levels or BMI. Our results are somehow inconsistent with those in Hsu et al.’s study [17], where BMI and HbA1C were found to be associated with the severity, but not symptoms, of bulimia on the self-report Bulimic Investigatory Test, Edinburgh (BITE), and only BMI significantly predicted oral control and dieting subscales on the Eating Attitude Test-26 (EAT-26). However, BITE and EAT-26 did not capture insulin restriction behavior, and this discrepancy in survey modalities may explain the inconsistency in findings. Despite so, we found a significant association between DE/IR behavior and HbA1c-SD, extending some more evidence that DE/IR behavior may have clinical relevance to stability in glycemic excursion in these patients. Further, in the hierarchal regression analyses, DE/IR behavior was consistently associated with depression and anxiety based on the HADS questionnaire, while BMI and metabolic parameters were not. These findings aligned with those found in a recently published paper on a Chinese cohort of T1DM youths and adults [39] and may suggest DE/IR behavior plays a central part in the interrelationships among body image concerns, externalizing and internalizing behaviors, and diabetic control. In another qualitative research paper, the authors identified low compliance to insulin intake among other psychological factors (e.g., fear of gaining weight) related to eating problems in Malaysian adolescents with T1DM via screening questionnaires and in-depth interviews [40]. Taken together, DE/IR behavior appears to be an essential indicator of multifaceted psychosocial challenges that AYAs with DM may encounter along with their diseases [41]. Healthcare providers for AYAs with DM should be aware of these counseling needs and integrate them into routine assessments, such as the mSCOFF, in addition to physical and biochemical check-ups [3].

Some limitations warrant attention when interpreting the results of this study. First, the analysis was cross-sectional, and thus the direction of causality may not be determined. Despite so, our findings on the association between DE/IR behavior and depression and anxiety based on the HADS questionnaire suggest the worth of vigilant monitoring of psychological and behavioral wellbeing among AYAs with DM. Meanwhile, a longitudinal and prospective follow-up is needed to address this issue. Second, the lack of reporting of oral medications in patients with T2DM may affect the estimates for clinical parameters of glycemic control. Third, the cohort was mainly derived from a single tertiary referral center, thus limiting the generalizability of the results. Also, due to a limited number of patients mixed with T1DM and T2DM and a wide range of ages from children aged 10 to adults aged 30 years, we were therefore unable to stratify our analysis by DM types. A multicenter registry of young patients with DM is needed to thoroughly investigate the occurrence and correlates of DE/IR behavior in the local population with specific regards to DM types and age groups.

Conclusion

In a social context with a relatively lower prevalence of eating disorders, DE/IR behavior is not uncommon among AYAs with DM using insulin as their primary treatment. Given its relevance to psychological and glycemic outcomes, DE/IR behavior should be meticulously screened in health care provided to AYAs with DM. Appropriate psychological support and nutritional and dietary guidance are needed to ensure their healthy trajectory.

Availability of data and materials

The study does not have ethical approval to share data.

References

  1. Atkinson MA, Eisenbarth GS, Michels AW. Type 1 diabetes. Lancet. 2014;383:69–82.

    Article  PubMed  Google Scholar 

  2. Chiang JL, Maahs DM, Garvey KC, Hood KK, Laffel LM, Weinzimer SA, et al. Type 1 diabetes in children and adolescents: a position statement by the American Diabetes Association. Diabetes Care. 2018;41:2026–44.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Troncone A, Affuso G, Cascella C, Chianese A, Pizzini B, Zanfardino A, et al. Prevalence of disordered eating behaviors in adolescents with type 1 diabetes: results of multicenter Italian nationwide study. Int J Eat Disord. 2022;55:1108–19.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Yahya AS, Khawaja S, Williams PS, Naguib M. Binge eating disorder and type 2 diabetes: epidemiology and treatment approaches. Prog Neurol Psychiatry. 2022;26:33–7.

    Article  Google Scholar 

  5. Harris SR, Carrillo M, Fujioka K. Binge-eating disorder and type 2 diabetes: a review. Endocr Pract. 2021;27:158–64.

    Article  PubMed  Google Scholar 

  6. Toni G, Berioli MG, Cerquiglini L, Ceccarini G, Grohmann U, Principi N, et al. Eating disorders and disordered eating symptoms in adolescents with type 1 diabetes. Nutrients. 2017;9:906.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Jaensch L, Goddard G, Oxlad M, Franke E. 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. Can J Diabetes. 2023;47:532–42.

    Article  PubMed  Google Scholar 

  8. Nielsen S, Emborg C, Mølbak AG. Mortality in concurrent type 1 diabetes and anorexia nervosa. Diabetes Care. 2002;25:309–12.

    Article  PubMed  Google Scholar 

  9. Young-Hyman DL, Davis CL. Disordered eating behavior in individuals with diabetes: importance of context, evaluation, and classification. Diabetes Care. 2010;33:683–9.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Hanlan ME, Griffith J, Patel N, Jaser SS. Eating disorders and disordered eating in type 1 diabetes: prevalence, screening, and treatment options. Curr Diab Rep. 2013;13:909–16.

    Article  Google Scholar 

  11. Herpertz S, Albus C, Lichtblau K, Köhle K, Mann K, Senf W. Relationship of weight and eating disorders in type 2 diabetic patients: a multicenter study. Int J Eat Disord. 2000;28:68–77.

    Article  PubMed  Google Scholar 

  12. Mannucci E, Tesi F, Ricca V, Pierazzuoli E, Barciulli E, Moretti S, et al. Eating behavior in obese patients with and without type 2 diabetes mellitus. Int J Obes Relat Metab Disord. 2002;26:848–53.

    Article  PubMed  Google Scholar 

  13. Pinna F, Diana E, Sanna L, Deiana V, Manchia M, Nicotra E, et al. Assessment of eating disorders with the diabetes eating problems survey - revised (DEPS-R) in a representative sample of insulin-treated diabetic patients: a validation study in Italy. BMC Psychiatry. 2017;17:262.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Bernstein CM, Stockwell MS, Gallagher MP, Rosenthal SL, Soren K. Mental health issues in adolescents and young adults with type 1 diabetes: prevalence and impact on glycemic control. Clin Pediatr (Phila). 2013;52:10–5.

    Article  PubMed  Google Scholar 

  15. Northam EA, Lin A, Finch S, Werther GA, Cameron FJ. Psychosocial well-being and functional outcomes in youth with type 1 diabetes 12 years after disease onset. Diabetes Care. 2010;33:1430–7.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Lawrence JM, Standiford DA, Loots B, Klingensmith GJ, Williams DE, Ruggiero A, et al. Prevalence and correlates of depressed mood among youth with diabetes: the SEARCH for Diabetes in Youth study. Pediatrics. 2006;117:1348–58.

    Article  PubMed  Google Scholar 

  17. Alice Hsu YY, Chen BH, Huang MC, Lin SJ, Lin MF. Disturbed eating behaviors in Taiwanese adolescents with type 1 diabetes mellitus: a comparative study. Pediatr Diabetes. 2009;10:74–81.

    Article  PubMed  Google Scholar 

  18. Tsai MC, Gan ST, Lee CT, Liang YL, Lee LT, Lin SH. National population-based data on the incidence, prevalence, and psychiatric comorbidity of eating disorders in Taiwanese adolescents and young adults. Int J Eat Disord. 2018;51:1277–84.

    Article  PubMed  Google Scholar 

  19. Chou WC, Chou YY, Pan YW, Tsai MC. Is non-stimulated C-peptide at diagnosis a good predictive value for insulin use at two years after diagnosis in pediatric diabetic patients? Medicina (Kaunas). 2021;29(57):902.

    Article  Google Scholar 

  20. Tung YC, Lee JS, Tsai WY, Hsiao PH. Evaluation of beta-cell function in diabetic Taiwanese children using a 6-min glucagon test. Eur J Pediatr. 2008;167:801–5.

    Article  PubMed  Google Scholar 

  21. Chen W, Chang MH. New growth charts for Taiwanese children and adolescents based on World Health Organization standards and health-related physical fitness. Pediatr Neonatol. 2010;51:69–79.

    Article  PubMed  Google Scholar 

  22. Rosa LCGFD, Zajdenverg L, Souto DL, Dantas JR, Pinto MVR, Salles GFDCM, Rodacki M. HbA1c variability and long-term glycemic control are linked to diabetic retinopathy and glomerular filtration rate in patients with type 1 diabetes and multiethnic background. J Diabetes Complic. 2019;33:610–5.

    Article  Google Scholar 

  23. Yang CY, Su PF, Hung JY, Ou HT, Kuo S. Comparative predictive ability of visit-to-visit HbA1c variability measures for microvascular disease risk in type 2 diabetes. Cardiovasc Diabetol. 2020;19:105.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Mortensen HB, Hougaard P, Swift P, Hansen L, Holl RW, Hoey H, et al. New definition for the partial remission period in children and adolescents with type 1 diabetes. Diabetes Care. 2009;32:1384–90.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Lin YW, Lin CY, Strong C, Liu CH, Hsieh YP, Lin YC, et al. Psychological correlates of eating behavior in overweight/obese adolescents in Taiwan: psychometric and correlation analysis of the Three-Factor Eating Questionnaire (TFEQ)-R21. Pediatr Neonatol. 2021;62:41–8.

    Article  PubMed  Google Scholar 

  26. Huang PC, Wu HY, Chang CS, Lee KT, Tseng MC, Chen CY, et al. Disordered eating behavior and associated risk factors amongst obese outpatients at a weight management clinic in a medical center. Tw J Fam Med. 2013;24:189–202.

    Google Scholar 

  27. Hill LS, Reid F, Morgan JF, Lacey JH. SCOFF, the development of an eating disorder screening questionnaire. Int J Eat Disord. 2010;43:344–51.

    PubMed  Google Scholar 

  28. Bächle C, Stahl-Pehe A, Rosenbauer J. Disordered eating and insulin restriction in youths receiving intensified insulin treatment: results from a nationwide population-based study. Int J Eat Disord. 2016;49:191–6.

    Article  PubMed  Google Scholar 

  29. Zuijdwijk CS, Pardy SA, Dowden JJ, Dominic AM, Bridger T, Newhook LA. The mSCOFF for screening disordered eating in pediatric type 1 diabetes. Diabetes Care. 2014;37:e26–7.

    Article  PubMed  Google Scholar 

  30. Lin CY, Tsai MC, Liu CH, Lin YC, Hsieh YP, Strong C. Psychological pathway from obesity-related stigma to depression via internalized stigma and self-esteem among adolescents in Taiwan. Int J Environ Res Public Health. 2019;16:4410.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983;67:361–70.

    Article  PubMed  Google Scholar 

  32. Hsu CJ, Shen D, Chan TC, Cho YT, Tang CH, Chu CY. Correlation between anxiety and depression risk and atopic dermatitis severity in Taiwan: a cross-sectional study. JAAD Int. 2022;7:22–30.

    Article  PubMed  PubMed Central  Google Scholar 

  33. De Paoli T, Rogers PJ. Disordered eating and insulin restriction in type 1 diabetes: a systematic review and testable model. Eat Disord. 2018;26:343–60.

    Article  PubMed  Google Scholar 

  34. Pfeiffer AF, Klein HH. The treatment of type 2 diabetes. Dtsch Arztebl Int. 2014;111:69–81.

    PubMed  PubMed Central  Google Scholar 

  35. Wang HF, Yeh MC. Psychological resistance to insulin therapy in adults with type 2 diabetes: mixed-method systematic review. J Adv Nurs. 2012;68:743–57.

    Article  PubMed  Google Scholar 

  36. Kao KT, Sabin MA. Type 2 diabetes mellitus in children and adolescents. Aust Fam Physician. 2016;45:401–6.

    PubMed  Google Scholar 

  37. Wan Wahida WMZ, Lai PSM, Abdul HH. Validity and reliability of the english version of the sick, control, one stone, fat, food (SCOFF) in Malaysia. Clin Nutr ESPEN. 2017;18:55–8.

    Article  PubMed  Google Scholar 

  38. Leung SF, Lee KL, Lee SM, Leung SC, Hung WS, Lee WL, et al. Psychometric properties of the SCOFF questionnaire (Chinese version) for screening eating disorders in Hong Kong secondary school students: a cross-sectional study. Int J Nurs Stud. 2009;46:239–47.

    Article  PubMed  Google Scholar 

  39. Lv W, Zhong Q, Guo J, Luo J, Dixon J, Whittemore R. Instrument context relevance evaluation, translation, and psychometric testing of the Diabetes Eating Problem Survey-Revised (DEPS-R) among people with type 1 diabetes in China. Int J Environ Res Public Health. 2021;18:3450. https://doi.org/10.3390/ijerph18073450.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Sien PLM, Jamaludin NIA, Samrin SNA, Shanita NS, Ismail R, Anuar Zaini A, et al. Causative factors of eating problems among adolescents with type 1 diabetes mellitus: a qualitative study. J Health Psychol. 2020;25:1310–8.

    Article  PubMed  Google Scholar 

  41. Troncone A, Chianese A, Zanfardino A, Cascella C, Confetto S, Piscopo A, et al. 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. J Clin Psychol Med Settings. 2020;27:727–45.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

None.

Funding

The study was supported by the research grant awarded to Tsai MC from the National Cheng Kung University Hospital (NCKUH-11002053).

Author information

Authors and Affiliations

  1. Department of Pediatrics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan

    Wei-Chih Chou

  2. Division of Genetics, Endocrinology, and Metabolism, Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan

    Yen-Yin Chou, Yu-Wen Pan & Meng-Che Tsai

  3. Department of Genomic Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan

    Yen-Yin Chou, Tsung-Ying Ou & Meng-Che Tsai

  4. Department of Pediatrics, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Dalin, Taiwan

    Tsung-Ying Ou

  5. Department of Medical Humanities and Social Medicine, College of Medicine, National Cheng Kung University, 138 Shengli Road, Tainan, 704, Taiwan

    Meng-Che Tsai

  6. Department of Pediatrics, Shin Huey Shin Hospital, Kaohsiung, Taiwan

    Wei-Chih Chou

Authors
  1. Wei-Chih Chou
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Yen-Yin Chou
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Yu-Wen Pan
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Tsung-Ying Ou
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Meng-Che Tsai
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

WCC and MCT conceived the study. WCC, YYC, YWP, and TYO collected data. WCC conducted and MCT supervised the statistical analysis. WCC drafted, and YYC, YWP, and MCT critically reviewed the manuscript. All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

Corresponding author

Correspondence to Meng-Che Tsai.

Ethics declarations

Ethics approval and consent to participate

The Institutional Review Board of the Cheng Kung University Hospital has approved this study (A-BR-107-033). Informed consent was obtained from all individuals and their guardians, if applicable, included in this study.

Competing interests

The authors declare no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Chou, WC., Chou, YY., Pan, YW. et al. Correlates of disordered eating and insulin restriction behavior and its association with psychological health in Taiwanese youths with diabetes mellitus. J Eat Disord 11, 158 (2023). https://doi.org/10.1186/s40337-023-00888-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s40337-023-00888-8

Keywords

Journal of Eating Disorders

ISSN: 2050-2974