"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.

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.

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.

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.

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.

Interdisciplinary Cognitive-Behavioral Therapy as Part of Lumbar Spinal Fusion Surgery Rehabilitation: Experience of Patients With Chronic Low Back Pain.

BACKGROUND: Patients receiving lumbar spinal fusion surgery often have persisting postoperative pain negatively affecting their daily life. These patients may be helped by interdisciplinary cognitive-behavioral therapy which is recognized as an effective intervention for improving beneficial pain coping behavior, thereby facilitating the rehabilitation process of patients with chronic pain. PURPOSE: The purpose of this study was to describe the lived experience of patients recovering from lumbar spinal fusion surgery and to explore potential similarities and disparities in pain coping behavior between receivers and nonreceivers of interdisciplinary cognitive-behavioral group therapy. METHODS: We conducted semistructured interviews with 10 patients; 5 receiving cognitive-behavioral therapy in connection with their lumbar spinal fusion surgery and 5 receiving usual care. We conducted a phenomenological analysis to reach our first aim and then conducted a comparative content analysis to reach our second aim. RESULTS: Patients' postoperative experience was characterized by the need to adapt to the limitations imposed by back discomfort (coexisting with the back), need for recognition and support from others regarding their pain, a relatively long rehabilitation period during which they "awaited the result of surgery", and ambivalence toward analgesics. The patients in both groups had similar negative perception of analgesics and tended to abstain from them to avoid addiction. Coping behavior apparently differed among receivers and nonreceivers of interdisciplinary cognitive-behavioral group therapy. Receivers prevented or minimized pain by resting before pain onset, whereas nonreceivers awaited pain onset before resting. CONCLUSION: The postoperative experience entailed ambivalence, causing uncertainty, worry and insecurity. This ambivalence was relieved when others recognized the patient's pain and offered support. Cognitive-behavioral therapy as part of rehabilitation may have encouraged beneficial pain coping behavior by altering patients' pain perception and coping behavior, thereby reducing adverse effects of pain.