Obesity, type 2 diabetes and eating disorders in young people

With obesity and type 2 diabetes on the rise in young people, safe and effective treatment is vital. A session at the recent Diabetes UK Professional Conference explored the latest thinking. Lisa Buckingham reports.

Prior to the pandemic, rates of paediatric obesity were plateauing in most high income countries but COVID-19 meant that rates started to increase again, said Dr Hiba Jebeile, postdoctoral research fellow and research dietician at the University of Sydney in her presentation on paediatric weight management and eating disorder risk.

Behavioural weight management is the first-line treatment and a key element of that is dietary change. These interventions result in modest reductions in weight-related outcomes, improvement in cardio-metabolic health and improved quality of life.

However, she said, there is a concern among some eating disorders professionals that weight management interventions may contribute to the development of eating disorders.

She highlighted that eating disorders are serious, chronic mental illnesses with high morbidity and mortality, characterised not only by disordered eating behaviours but also eating attitudes, such as body dissatisfaction, worries and anxieties about eating and overvaluation of weight or shape.

They can take several years to develop, starting with risk factors such as those above. Some then move on to a subclinical eating disorder where they’re engaging in extreme eating behaviours but not reaching the frequency required for a clinical diagnosis, and then a smaller proportion will go on to develop a clinical eating disorder such as anorexia nervosa or bulimia nervosa.

Obesity and eating disorders were once thought to be at the opposite ends of the spectrum, said Dr Jebeile, but we now know that they share some risk factors. For example, environmental factors such as internalised beauty ideals, cognitive risk factors such as weight concern and behavioural risk factors such as unhealthy weight control behaviours. The interventions for obesity, such as weight tracking and dietary change, can be problematic and perpetuate weight stigma.

Another issue is that the age of onset of eating disorders tends to be around adolescence. Youth with obesity are vulnerable to eating disorders because it feeds into a framework that begins with pressure to be thin or thin idealisation. They may experience weight-related teasing from friends or family, and also engage with social media, which can promotes the thin ideal. They are also likely to engage in dieting behaviours, often unsupervised, and are more likely to develop depression (a risk factor for eating disorders).

This perfect storm means that obesity clinicians are raising questions about when and how to treat obesity for fear of triggering an eating disorder.

Dr Jebeile’s team at the University of Sydney has been looking at this intersection between weight management and eating disorders. They carried out a series of systematic reviews with the aim of assessing the impact of weight management interventions with a dietary component conducted in children and adolescents with overweight or obesity.

Most of the studies included standard interventions such as an increase in fruit/vegetables, calorie prescription of 1000-1900 kcal a day and an increase in physical activity. A small number addressed eating behaviours, body image and self-esteem.

They found that there was either a reduction or no change in eating disorder risk post-intervention and at follow-up. Other eating disorder risk factors such as depression, anxiety and self-esteem showed a similar pattern. However, a small number of youth in a small number of studies presented with an undiagnosed eating disorder or depression, or developed these during or following treatment. Longer term data is needed. 

Overall, she said, professionally supervised programmes appear to be safer than self-directed dieting. It’s not exactly clear why this is but it may be due to a respectful and supportive environment, structured and moderate dietary interventions, and they tend to include support developing healthy routines and self-efficacy around eating, which are two factors in particular that are known to improve disordered eating.

There is also support for behaviour change, such as exercise, along with frequent and extended contact with healthcare professionals. The studies they looked at that included extended contact had better outcomes. The inclusion of exercise may also be a factor because it’s associated with improved mental health.

Her recommendations for clinical practice are:

• Where possible, work in or with a multi-disciplinary team
• Promote a safe, inclusive and supportive clinical environment
• Provide a high-quality, multi-component intervention that includes structured dietary advice
• Consider baseline screening and regular monitoring for eating disorders, depression and refer on as needed

With regard to screening for eating disorders, there aren’t clear guidelines on how to do this. In general, she said, open-ended questions or a questionnaire with follow-up for clinical assessment are best. The core risk factors that should be looked for are overvaluation of weight and shape, binge eating/purging/loss of control, extreme dieting or obsessive behaviours.

In 2020, they formed the Eating Disorders In weight-related Therapy (EDIT) collaboration, which aims to look in more detail at the small group of young people who may develop disordered eating or an eating disorder during a weight-management intervention. For more information on this, visit editcollaboration.com or follow @EDIT_Collab on Twitter.

Dr Jebeile summarised by saying that youth with obesity are vulnerable to eating disorders, but structured weight management is not associated with an increase in risk for most children and adolescents. However, a small subset is at risk and we need to identify who they are. Longer term data is needed and screening/monitoring during an intervention is important. Her team is carrying out work around this and hopes to come up with recommendations.

The psychosocial aspects of type 2 diabetes

Following on from this session, Dr Giesje Nefs, an assistant professor and psychology research lead from Tilburg University, presented on the psychosocial aspects of type 2 diabetes in young people.

A rise in type 2 diabetes is seen around puberty and young people who develop it have suboptimal biomedical outcomes, such as higher metformin monotherapy failure rate and a more rapid functional decline of the beta cell. Some studies also show that they manifest early signs of cardiovascular conditions.

Youth-onset type 2 diabetes is a complex condition and it’s difficult for interventions to be effective because of this complexity. Depression rates are significantly higher, it’s strongly associated with obesity and comes at a time of life of growing independence and focus on peers. Their environment also has an impact – i.e. whether they live safely and have access to healthy foods. Family income, education and ethnicity also play a part.

To get a better idea of lived experience, she said, it’s best to read qualitative work such as interviews and literature from focus groups. There are two broad themes that have emerged from the work that’s been done – the first is the difficulties of integrating type 2 diabetes into daily life, such as adjustments to routine to become more healthy, developing the executive and emotional skills to deal with the condition, and breaking environmental behaviour patterns such as the rest of the family continuing to eat unhealthily.

The second theme is the emotional side of dealing with change or loss, such as feeling different to peers, fear of rejection and not feeling understood.

The lived experience of parents is also important – there can be a strong sense of guilt, a desire to treat all of their children equally but being unable to, juggling the child’s type 2 diabetes with other life obligations and financial constraints.

Mental health co-morbidities are very common in youth with type 2 diabetes. One study found a prevalence rate of up to 25% with neuropsychiatric disorders. Other work has found elevated depressive symptoms of between 10-25% and eating problems such as binge eating affecting 5-20%, with disordered eating behaviours in 50%.

In comparison to peers with type 1 diabetes, adolescents with type 2 diabetes have higher depressive symptoms. And they also have higher depressive symptoms in comparison to adults with type 2 diabetes.

Behavioural and psychosocial interventions thus far have been limited and are often combined with type 1 diabetes.

Dr Nefs ran through the evidence for various interventions, including cognitive behavioural therapy (CBT). This is used with a view to changing dysfunctional thoughts or changing relation to thoughts with mindfulness-based cognitive therapy (MBCT). The data is limited to adolescent girls at risk for type 2 diabetes and it found that short-term effects of CBT are similar to health education and performed even better in youth with depressive symptoms. A comparison of MBCT and CBT found that MBCT showed a greater decrease in depression, insulin resistance and BMI.

She also highlighted the TODAY study from 2012. A randomised controlled trial comparing metformin, metformin plus rosiglitazone and metformin plus lifestyle interventions in 10-17 year olds with type 2 diabetes. It focused on weight loss through behavioural change and family support. The primary conclusion was that metformin plus lifestyle did not differ significantly in effects from metformin alone or metformin plus rosiglitazone.

Occupational therapy (OT) showed more encouraging results in a study in young adults with type 1 and 2 diabetes. OT was individually tailored and aimed to resolve barriers towards action with bi-weekly sessions. It found a reduction in HbA1c at six months as well as an improvement in diabetes-related quality of life and habit strength for glucose monitoring.

She concluded that we can use interventions from the type 1 population, but they need to be adapted appropriately. Interventions need to be tailored to culture, family and developmental stage, and a participatory approach is essential. We also need a focus on person-reported outcomes beyond the biomedical.

The LEGEND study

To finish the session, Dr Pooja Sachdev, a consultant in paediatric diabetes and endocrinology at Nottingham Universities NHS Health Trust, spoke about the Low EnerGy diEt iN adolescents with type 2 Diabetes (LEGEND) study, which has received funding from Diabetes UK. Their research plan for the study was a replication of the DiRECT study but in young people as they are physically, socially and psychologically different. The results of DiRECT cannot be safely extrapolated into young people.

Dr Sachdev detailed the evolution of the study design, during which much input from young people on what would make it easier and harder was taken into account, along with input from the DiRECT team and other researchers. The aims of the feasibility study are as follows:

• To understand recruitment and retention rates to inform a full RCT of a low-energy diet (LED) for young people with type 2 diabetes, what the barriers and motivators are and how to optimise them
• To provide estimates of the weight loss needed for remission
• To understand the positive and potential negative effects of a period of LED on the biological, psychological and social wellbeing of adolescents
• To identify pathways involved in the pathogenesis of type 2 diabetes in young people and prognostic markers of disease progression or response to the intervention

Participants will be aged 12 up to 18 years old and recruitment will begin in autumn 2022.

For more on the topics raised in this article, enrol on the following EASD e-Learning modules:

• Understanding the causes of type 2 diabetes – and how to achieve remission
  Written and presented by Professor Roy Taylor
• Obesity and the pathogenesis and outcomes of type 2 diabetes
  Written and presented by Professor Naveed Sattar

See also our special panel discussion on issues around obesity and weight management in The briefing room

Any opinions expressed in this article are the responsibility of the EASD e-Learning Programme Director, Dr Eleanor D Kennedy.