Validation of the Turkish parent-reported Diabetes Eating Problem Survey-Revised (DEPS-R) for screening disordered eating behaviors in adolescents with Type 1 diabetes

Abstract

Background

Adolescents with Type 1 diabetes are at increased risk of eating disorders, which have been associated with suboptimal metabolic control and an increased risk of complications. Reliable and culturally adapted screening tools are essential for early identification. However, the parent-reported version of the Diabetes Eating Problem Survey–Revised (DEPS-R) has not yet been validated in Turkish; therefore, this study aimed to evaluate its validity and reliability in adolescents aged 10–17 years years with type 1 diabetes.

Methods

This methodological validation study included 96 adolescents (45 boys, 51 girls) aged 10–17 years with Type 1 diabetes and their parents. Linguistic and cultural adaptation procedures were conducted in accordance with standard cross-cultural validation guidelines. Parents completed the parent-reported DEPS-R and the Problem Areas in Diabetes–Parents of Teens (P-PAID-T). Adolescents completed the self-reported DEPS-R. Construct validity was assessed using correlation analyses. Exploratory and confirmatory factor analyses were performed to evaluate structural validity. Internal consistency was assessed using Cronbach’s alpha, and test–retest reliability was examined using intraclass correlation coefficients (ICC).

Results

The parent-reported DEPS-R demonstrated good internal consistency (Cronbach’s α = 0.852; McDonald’s ω = 0.851) and good test–retest reliability (ICC = 0.83), with a strong correlation between the two administrations (r = 0.89). Exploratory and confirmatory factor analyses supported a single-factor structure and demonstrated with acceptable model fit (χ²/df = 1.629; RMSEA = 0.080; CFI = 0.874; TLI = 0.848). Parent-reported DEPS-R scores were correlated with self-reported DEPS-R scores (r = 0.506, p < 0.001) and P-PAID-T scores (r = 0.458, p < 0.001), supporting construct validity. A positive correlation was also observed between duration of diabetes and DEPS-R scores (r = 0.223, p = 0.029). No significant associations were observed between DEPS-R scores and metabolic indicators, including HbA1c, ketoacidosis episodes, or diabetes-related hospital visits.

Conclusion

The Turkish parent-reported DEPS-R is a valid and reliable instrument for screening disordered eating behaviors in adolescents with Type 1 diabetes. Its use in both clinical and research settings may facilitate early detection and improve understanding of the relationship between eating behaviors and metabolic outcomes in this high-risk population.

Plain language summary

Disordered eating has been reported to be more common among adolescents with type 1 diabetes than among their healthy peers. In this group, disordered eating may lead to poorer metabolic control and make diabetes management more difficult. However, questionnaires completed by adolescents may not always fully reflect actual behaviors, as young people may underreport certain behaviors or may not always be fully aware of them. For this reason, parent-reported assessments such as the parent reported Diabetes Eating Problem Survey–Revised (DEPS-R) may provide an additional and useful perspective for identifying eating-related problems in adolescents with type 1 diabetes. In this study, we evaluated a parent-reported version of the DEPS-R in Turkish families of adolescents with type 1 diabetes. Our findings suggest that this parent-reported version is a reliable tool for identifying possible eating-related problems. Using parent-reported assessments of disordered eating may help healthcare professionals recognize problems earlier and provide timely support for adolescents with type 1 diabetes and their families.

Introduction

Adolescence is a developmental period characterized by significant changes in body image, an increased desire to control body weight, and consequently a heightened risk for disordered eating behaviors. Eating disorders are psychiatric conditions marked by inappropriate eating or weight management behaviors that can lead to serious health consequences [1].

Individuals with diabetes may be particularly susceptible to food-related problems due to the structured dietary management required for optimal glycemic control, including careful portion control, meal planning, and continuous monitoring of carbohydrate intake in relation to insulin dosing [2]. The coexistence of diabetes and eating disorders represents a complex and potentially life-threating clinical condition that may increase morbidity and mortality[3]. Individuals affected by both conditions struggle to maintain appropriate body weight and glycemic control, which may lead to metabolic complications such as cardiovascular disease,, neuropathy and kidney failure as well as psychological problems including stress, anxiety, and depression [4]. Meta-analyses have reported that adolescents with type 1 diabetes (T1D) have a higher risk of eating disorders compared with their age-matched peers[5].

Importantly, the clinical consequences of disordered eating behaviors differ substantially between healthy adolescents and those with T1D. While disordered eating in the general population primarily leads to psychological distress and nutritional deficiencies, in adolescents with T1D it directly interferes with insulin management. Behaviors such as insulin restriction or omission for weight contol may result in chronic hyperglycemia, recurrent diabetic ketoacidosis, poor glycemic control, and an increased risk of early microvascular and macrovascular complications [6]. Consequently, the coexistence of T1D and disordered eating is associated with increased morbidity and mortality[3].

The American Diabetes Association Professional Practice Committee’s Standards of Care in Diabetes—Children and Adolescents (2024 and 2026) report that adolescents with T1D are at increased risk for disordered eating behaviors and eating disorders [7, 8] and recommend the use of DEPS-R (child reporting) to facilitate early diagnosis and intervention [7].

The Diabetes Eating Problem Survey–Revised (DEPS-R) is one of the most commonly used diabetes-specific screening tools developed to assess disordered eating behaviors in individuals with T1D [9]. Unlike general eating disorder instruments, the DEPS-R includes diabetes-specific behaviors, such as insulin restriction or omission, which are particularly relevant for adolescents with T1D. Previous psychometric studies of the self-reported DEPS-R have generally demonstrated acceptable internal consistency, construct validity, and clinical utility in identifying disordered eating behaviors in pediatric and adolescent T1D populations [10, 11]. These studies have also supported the use of the DEPS-R total score as an indicator of diabetes-specific disordered eating risk.

Despite recommendations for screening, the identification of disordered eating behaviors in adolescents with T1D remains challenging in routine clinical practice. Adolescents may minimize or conceal symptoms and may not consistently disclose sensitive eating- and insulin-related behaviors. Incorporating parent-reported screening may therefore complement adolescent self-report by providing an external, developmentally relevant perspective and potentially improving early detection. The available validation study of the parent-reported DEPS-R reported good internal consistency (Cronbach’s α = 0.89) and good agreement with the CYP-reported DEPS-R (ICC = 0.746), suggesting that this format may offer clinical benefit in screening children and young people with T1D[12]. However, evidence regarding the parent-reported version of the DEPS-R remains limited [12].

Further studies are needed to evaluate its psychometric properties across different languages and cultural contexts. Although the Turkish version of the adolescent self-reported DEPS-R has demonstrated acceptable psychometric properties[11] a validated Turkish adaptation of the parent-reported format has not yet been established. This gap highlights the need to examine the reliability, construct validity, and factorial structure of the parent-reported DEPS-R in the Turkish context.

In the present study, the measurement model tested by confirmatory factor analysis was guided by the theoretical structure of the DEPS-R as a diabetes-specific screening instrument and by previous psychometric evidence supporting the interpretation of the scale through a total score. Given the limited evidence available for the parent-reported form, CFA was used to evaluate whether the proposed factorial structure was applicable to the Turkish parent-reported version in adolescents with T1D. Therefore, this study aimed to translate and culturally adapt the parent-reported DEPS-R into Turkish and to evaluate its psychometric properties among adolescents with T1D and their parents.

Methods

Study design and sample

This methodological study aimed to evaluate the validity and reliability of the Turkish version of the Diabetes Eating Problem Survey-Revised (DEPS-R), developed for parents of children diagnosed withT1D, through parental reports. The study was conducted with adolescents aged 10–17 years who were followed at the Pediatric Endocrinology and Diabetes Clinic of İstanbul University Cerrahpasa-Cerrahpasa Faculty of Medicine and one parent of each adolescent. A total of 96 adolescents with T1D and their corresponding parents were included in the study. Parents whose native language was Turkish and who voluntarily agreed to participate were eligible for inclusion. Parents who were currently receiving psychiatric treatment and adolescents with any chronic disease other than T1D were excluded from the study.

Sample size adequacy was evaluated according to contemporary recommendations for factor analytic studies. Kline reported that minimum sample size requirements for factor analysis may vary substantially depending on model characteristics and the extent of missing data (30–460) [13]. Given the unidimensional structure of the parent-reported DEPS-R and the relatively simple measurement model evaluated in this study, a sample of 96 participants was considered adequate for the planned psychometric analyses.

This study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval for the study was obtained from the Tokat Gaziosmanpaşa University Health and Sports Sciences Research Ethics Committee (Decision No: 01.09); date: 07.11.2025). All participants’ parents provided written informed consent, and adolescents gave their assent before taking part in the study. The purpose of the study was explained to the participants, and they were given the assurance that their answers would remain confidential.

Measurement

Data were collected using a structured questionnaire. The questionnaire included a researcher-designed form to obtain information on parental sociodemographic characteristics, including sex, marital status, educational level, and self-reported history of eating disorders. It also included items assessing clinical and treatment-related characteristics of adolescents with Type 1 diabetes, such as insulin therapy modality (multiple daily injections or insulin pump), regular attendance at scheduled clinical visits, unexpected hospital visits due to Type 1 diabetes within the previous year, and the number of diabetic ketoacidosis (DKA) episodes during the same period. In addition, parents were asked whether they had concerns regarding the possibility of disordered eating behaviors in their children. The questionnaire also included the parent-reported and adolescent Self-Report Version Diabetes Eating Problem Survey-Revised (DEPS-R) with the Problem Areas in Diabetes–Parents of Teens (P-PAID-T) scale to assess disordered eating behaviors and diabetes-related parental distress. HbA1c values were obtained from participants’ medical records to ensure the accuracy of clinical information.

Diabetes Eating Problem Survey–Revised (DEPS-R; parent-reported version)

This version of the Diabetes Eating Problem Survey–Revised (DEPS-R) consists of 16 items designed to evaluate parents’ perceptions of their child’s eating behaviors. Each item is rated on a 6-point Likert scale ranging from 0 (‘Never’) to 5 (‘Always’). Similar to the adolescent self-report version, the parent-reported DEPS-R is a disease-specific instrument developed to screen for the risk of disordered eating behaviors in youth with diabetes. The parent-reported DEPS-R was validated by Harrington et al. [12], and the original version demonstrated good internal consistency, with a Cronbach’s alpha coefficient of 0.89.

Turkish adaptation of parent-reported DEPS-R

Permission to adapt the parent-reported DEPS-R into Turkish was obtained from the original author via email. The translation and cross-cultural adaptation process was conducted according to the framework proposed by Beaton et al. [14] and supported by contemporary recommendations for cross-cultural adaptation and validation of measurement instruments [15].

The original questionnaire was translated into Turkish independently by two bilingual translators fluent in both Turkish and English. One translator had a medical/clinical background, while the other had no professional experience in the health field. The two translations were reviewed and synthesized into a single preliminary Turkish version. This version was then back-translated into English by two native English speakers who were proficient in Turkish. The back-translated versions were compared with the original questionnaire to assess conceptual and linguistic equivalence. Subsequently, an expert committee consisting of professionals with experience in diabetes care, nutrition, and questionnaire adaptation reviewed all versions of the instrument. The committee evaluated the semantic, conceptual, and cultural equivalence of each item and assessed the clarity, relevance, and cultural appropriateness of the translated content. Particular attention was paid to identifying expressions, terms, or concepts that might not be fully appropriate or easily understood within the Turkish cultural context. Where necessary, such expressions were revised based on expert recommendations to ensure conceptual consistency while improving cultural relevance and comprehensibility for Turkish parents of adolescents with Type 1 diabetes. The pre-final Turkish version was pilot-tested with a small group of parents from the target population. Cognitive feedback was obtained regarding item clarity, comprehensibility, and interpretation. Based on participant feedback and expert recommendations, minor revisions were made to optimize the wording of several items. The final Turkish version of the scale was established through consensus among the translators, expert committee members, and the research team.

Problem Areas in Diabetes – Parent Version (P-PAID-T)

The Problem Areas in Diabetes – Parent Version (P-PAID-T) is a structured instrument consisting of 15 items designed to assess the emotional and psychosocial difficulties experienced by parents related to their child’s diabetes management. Each item is rated on a 6-point Likert scale ranging from 1 (‘Not a problem’) to 6 (‘A serious problem’). The original version of the scale was developed by Shapiro et al.l [16]. and demonstrated excellent internal consistency, with a Cronbach’s alpha coefficient of 0.93. The Turkish validity and reliability study of the scale was conducted by Sari et al.l [17]. who reported a Cronbach’s alpha value of 0.901 for the Turkish version. In present study The Cronbach alpha coefficient of the PAID-T was 0.908.

Diabetes Eating Problem Survey–Revised (DEPS-R; adolescent self-report version)

The Diabetes Eating Problem Survey–Revised (DEPS-R) is a 16-item instrument designed to assess eating-related behaviors in adolescents with diabetes. Each item is rated on a 6-point Likert scale ranging from 0 (‘Never’) to 5 (‘Always’). The DEPS-R is a diabetes -specific screening tool developed to identify the risk of disordered eating behaviors. The scale was adapted for adolescents by revising the original adult version developed by Antisdel et al.l [18]. and the adolescent version introduced by Markowitz et al.l [9]. The original adolescent version demonstrated good internal consistency, with a Cronbach’s alpha of 0.86. The Turkish adaptation of the adolescent DEPS-R was conducted by Altınok et al.l [11]. who reported a Cronbach’s alpha value of 0.847. In the present study, the Cronbach’s alpha coefficient for the adolescent self-report DEPS-R was 0.854.

Procedure

Construct validity

Construct validity was examined by assessing the relationship between the Parent-reported DEPS-R and the P-PAID-T form. Correlation strength was interpreted according to established criteria: 0–0.20 very weak, 0.20–0.39 weak, 0.40–0.59 moderate, 0.60–0.79 strong, and 0.80–1.00 very strong association[19]. Since total scores showed normal distribution, Pearson’s correlation analysis was performed.

Explanatory factor analysis (EFA)

An exploratory factor analysis (EFA) was performed to investigate the underlying factor structure of the parent-reported DEPS-R. The Kaiser-Meyer-Olkin (KMO) metric was used to examine sampling adequacy, and Bartlett’s test of sphericity was employed to determine whether the data was suitable for factor analysis. Factor loadings of 0.40 or higher were considered meaningful for the factor structure [20, 21].The KMO value was calculated as 0.801 indicating that the dataset was suitable for factor analysis and that the sample size was sufficient [22].

Exploratory factor analysis was performed using Principal Axis Factoring (PAF). The suitability of the data for factor analysis was confirmed by the Kaiser-Meyer-Olkin measure of sampling adequacy (KMO = 0.801) and Bartlett’s test of sphericity (χ² (120) = 575.079, p < 0.01). Although the eigenvalue criterion suggested additional factors, inspection of the scree plot demonstrated a clear break after the first factor, indicating a dominant underlying dimension. Given that the original DEPS-R was developed as a unidimensional instrument, and considering the acceptable factor loadings observed for all items, the one-factor structure was retained.

Confirmatory factor analysis (CFA)

The factorial structure of the parent-reported DEPS-R was assessed using confirmatory factor analysis. Goodness-of-fit indices, such as chi-square divided by degrees of freedom (CMIN/df), root mean square error of approximation (RMSEA), goodness-of-fit index (GFI), adjusted goodness-of-fit index (AGFI), normed fit index (NFI), Tucker-Lewis index (TLI), and comparative fit index (CFI), were used to evaluate model fit. Model fit was interpreted according to recommended cut-off criteria reported in the literature [23].

Both EFA and CFA were conducted using the same sample of 96 parent–adolescent pairs. The sample was not divided into independent EFA and CFA subsamples because the sample size was relatively small, and splitting the dataset would have substantially reduced the statistical power and stability of the analyses.

Reliability and internal consistency

The reliability of the measurement model was evaluated using Cronbach’s alpha, McDonald’s omega, Composite Reliability (CR), and Average Variance Extracted (AVE) coefficients. For the Turkish Parent-reported DEPS-R, internal consistency was primarily examined through Cronbach’s alpha and McDonald’s omega values. Coefficients above 0.60 were considered acceptable, whereas values exceeding 0.70 indicated good reliability [20]. In the present study, the scale demonstrated satisfactory internal consistency, with a Cronbach’s alpha coefficient of 0.852 and a McDonald’s omega of 0.851.

Test–retest reliability

Test–retest reliability was assessed by administering the questionnaire twice with a 15-day interval. A two-way mixed-effects model was used to compute Pearson’s correlation coefficient and the intraclass correlation coefficient (ICC) under the assumption of absolute agreement. A very strong association between the two measurements was shown by a Pearson correlation coefficient better than 0.80 [19]. ICC values were interpreted according to Oremus et al. (2012) as follows: values below 0.40 indicate poor reliability, values between 0.40 and 0.75 indicate fair-to-good reliability, and values above 0.75 represent excellent reliability [24].

Statistically analysis

All statistical analyses were performed using IBM SPSS Statistics (Version 25, IBM Corp., Armonk, NY, USA) and AMOS (Version 31.0, IBM Corp.). Sociodemographic variables and scale scores were summarized using descriptive statistics, including means, standard deviations, frequencies, and percentages. The distribution of the variables was evaluated using skewness and kurtosis coefficients. Following commonly accepted recommendations, values between − 2 and + 2 were considered indicative of an approximately normal distribution [25].

Internal consistency of the Parent-reported DEPS-R was evaluated using Cronbach’s alpha coefficient. Factorial validity was evaluated through confirmatory factor analysis (CFA) conducted in AMOS 31. Model fit was assessed using multiple goodness-of-fit indices, and acceptable model fit thresholds were interpreted according to commonly recommended criteria reported in the literature.

Convergent validity was examined by calculating Pearson correlation coefficients between the Parent-reported DEPS-R and the P-PAID-T form. Test–retest reliability was evaluated in a subgroup of 30 participants who completed the questionnaire twice with a 15-day interval. Temporal stability was assessed using Pearson correlation analysis and the ICC based on a two-way mixed-effects model with absolute agreement. Agreement between measurements was further examined using Bland–Altman analysis. For all analyses, statistical significance was defined as p < 0.05.

Results

Table 1 presents demographic characteristics and clinical data for adolescents and parents. Among the parents included in the study, 85.4% were female and 14.6% were male. Regarding marital status, 94.8% were married and 5.2% were unmarried. In terms of educational level, 3.1% were literate without formal education, 40.6% had completed primary school, 14.6% middle school, 27.1% high school, and 14.6% were university graduates. Additionally, 6.3% of the parents reported having an eating disorder.

Table 1.

Demographic and clinical variables of children and parents

Variables	X ± SD
Parent age	43.1 ± 5.6
	n (%)
Parent gender
Female  Male	82 (85.4) 14 (14.6)
Parent working status
Yes  No	29 (30.2) 67 (69.8)
Parent educational status
Illiterate  Primary  Middle school  High school  University	3 (3.1) 39 (40.6) 14 (14.6) 26 (27.1) 14 (14.6)
Parental eating disorder
Yes  No	6 (6.3) 90 (93.7)
Parent worried about child eating behaviours
Yes  No	18 (18.8) 78 (81.2)
Child insulin regimen
Multiple daily injection  Insulin pump	88 (91.7) 8 (8.3)
Attendance at diabetes clinic appointments
Yes  No	89 (92.7) 7 (7.3)
Unexpected hospital visits due to Type 1 diabetes
Yes  No	22 (22.9) 74 (77.1)
Child experience of ketoacidosis in the last year (Parent reported)
0  1  2	87 (90.6) 3 (3.1) 6 (6.3)
	X ± SD
HbA1C from patient records	8.15 ± 2.02
P-PAID-T	42.9 ± 15.36
DEPS-child	14.27 ± 11.15
Parent-reported DEPS-R	12.5 ± 10.07

P-PAID-T Problem Areas in Diabetes- Parent, DEPS-R The Diabetes Eating Problems Survey-Revised

Among adolescents, 91.7% were using multiple daily insulin injections, whereas 8.3% were using an insulin pump. Regarding parental concerns about the possibility of eating disorders in their children, 81.3% reported no concern, while 18.8% expressed concern.

A total of 92.7% reported attending their scheduled clinical appointments. Moreover, 22.9% had experienced at least one unexpected hospital visit due to T1D in the past year.

When the frequency of diabetic ketoacidosis (DKA) episodes in the past year was assessed, 90.6% reported no episode, 3.1% reported one episodes and 6.3% reported two episodes.

The mean HbA1c level obtained from medical records was 8.15 ± 2.2%. The mean P-PAID-T score among parents was 42.9 ± 15.36. The mean parent-reported DEPS-R score was 12.5 ± 10.07, while the mean child-reported DEPS-R score was 14.27 ± 11.15.

The data were appropriate for factor analysis, according to the findings of the exploratory factor analysis (EFA). Good sample adequacy was indicated by the Kaiser–Meyer–Olkin (KMO) value of 0.801. Bartlett’s sphericity test yielded a statistically significant result (χ² (120) = 575.079, p < 0.01). Factor loadings ranged between 0.415 and 0.750. The lowest factor loading was observed for Item 2 (0.415), whereas the highest loading was observed for Item 3 (0.750). All items exceeded the commonly accepted threshold of 0.40 and were therefore retained in the scale.

Item means and standard deviations are presented in Table 2. Item means ranged from 0.10 ± 0.51 (Item 10) to 1.63 ± 1.17 (Item 15), indicating variability in response distribution across items.

Table 2.

Item factor loadings, descriptive statistics, and internal consistency of the DEPS-R

Item	Factor loadings	X ± SD
DEPSR-1	0.447	1.06 (1.09)
DEPSR-2	0.415	1.12 (1.09)
DEPSR-3	0.750	0.68 (1.09)
DEPSR-4	0.495	0.97 (1.33)
DEPSR-5	0.637	1.14 (1.38)
DEPSR-6	0.551	0.94 (1.22)
DEPSR-7	0.631	0.99 (1.27)
DEPSR-8	0.640	0.18 (0.69)
DEPSR-9	0.727	0.17 (0.61)
DEPSR-10	0.567	0.10 (0.51)
DEPSR-11	0.588	0.35 (0.84)
DEPSR-12	0.564	1.30 (1.64)
DEPSR-13	0.586	0.52 (0.97)
DEPSR-14	0.664	0.66 (1.11)
DEPSR-15	0.535	1.63 (1.17)
DEPSR-16	0.454	0.71 (1.38)
Cronbach alpha	0.852
McDonald’s omega	0.851

Kaiser–Meyer–Olkin (KMO) = 0.801; χ2 (120) = 575,079; Barlett test of sphericity (p) < 0.01

The internal consistency of the scale was good, as indicated by a Cronbach’s alpha coefficient of 0.852 and a McDonald’s omega of 0.851.

Confirmatory factor analysis (CFA) was conducted to evaluate the construct validity of the model. The χ²/df (CMIN/df) value was 1.629, indicating a good model fit. The RMSEA value was 0.080, suggesting an acceptable fit. Regarding incremental and absolute fit indices, GFI was 0.829, AGFI was 0.865, NFI was 0.810, TLI was 0.848, and CFI was 0.874. All indices met the acceptable fit criteria based on commonly recommended threshold values (Table 3).

Table 3.

Threshold criteria for acceptable and good model fit indices

Index	Thresholds for acceptable fit	Thresholds for good fit	Value	Acceptable/good model fit indices
CMIN/df	≤ 5.00	≤ 3.00	1.629	Good
RMSEA	≤ 0.08	≤ 0.05	0.080	Acceptable
GFI	≥ 0.80	≥ 0.90	0.829	Acceptable
AGFI	≥ 0.85	≥ 0.95	0.865	Acceptable
NFI	≥ 0.80	≥ 0.95	0.810	Acceptable
TLI	≥ 0.80	≥ 0.95	0.848	Acceptable
CFI	≥ 0.85	≥ 0.95	0.874	Acceptable

CMIN/df Chi-squared goodness-of-fit, RMSEA Root Mean Square error of Approximation, GFI Goodness of Fit Index, AGFI Adjusted Goodness of Fit Index, NFI Normed Fit Index, TLI Tucker-Lewis index, CFI Comparative-Ft Index

Construct validity was evaluated by examining the correlations between the parent-reported DEPS-R scores and demographic and clinical variables (Table 4). Parent-reported DEPS-R scores were not significantly correlated with adolescent age (r = 0.000, p = 1.000), parent age (r = 0.056, p = 0.588), unexpected hospital visits due to T1D in the past year (r = − 0.085, p = 0.412), history of ketoacidosis (r = 0.076, p = 0.461), or HbA1c levels (r = 0.111, p = 0.282). A statistically significant positive correlation was observed between duration of diagnosis and parent-reported DEPS-R scores (r = 0.223, p = 0.029). Parent-reported DEPS-R scores were also positively correlated with P-PAID-T scores (r = 0.418, p < 0.001), supporting convergent validity. Additionally, a moderate positive correlation was observed between parent-reported DEPS-R and child-reported DEPS-R scores (r = 0.506, p < 0.001).

Table 4.

Construct validity analyses

Adolescent age	Parent Reported DEPS-R
	r	0.000
	p	1.000
Parent age	r	0.056
	p	0.588
Duration of diagnosis	r	0.223
	p	0.029
Parent reported Type 1 DM related unexpected visit to hospital in the last year	r	– 0.085
	p	0.412
Parent reported ketoacidosis experience	r	0.076
	p	0.461
HbA1c	r	0.111
	p	0.282
P-PAID-T	r	0.418
	p	< 0.001
DEPS-R	r	0.506
	p	< 0.001

P-PAID-T Problem Areas in Diabetes- Parent, DEPS-R The Diabetes Eating Problems Survey-Revised

Values presented in bold are statistically significant at p < 0.05

Discussion

The present study aimed to evaluate the Turkish validity and reliability of the parent-reported version of the Diabetes Eating Problem Survey–Revised (DEPS-R) in adolescents with T1D. The findings indicate that the Turkish parent-reported DEPS-R demonstrated satisfactory psychometric properties. The scale showed good internal consistency (Cronbach’s α = 0.852, McDonald’s ω = 0.851) and both exploratory and confirmatory factor analyses supported an acceptable and coherent factor structure. In addition, significant moderate correlations were observed between parent-reported DEPS-R scores and both P-PAID-T scores and child-reported DEPS-R scores, supporting construct validity of the scale. However parent-reported DEPS-R scores were not significantly associated with metabolic indicators such as HbA1c, history of diabetic ketoacidosis, or diabetes-related hospital visits.

Disordered eating behaviors are already recognized as a significant concern in children and adolescents; however, they carry particular clinical importance among those with T1D. In this population, disordered eating behaviors may directly interfere with metabolic control [26]. Impaired metabolic control increases the risk of diabetes-related complications and adversely affects long-term health outcomes [27, 28]. Previous studies have shown that poor metabolic control in individuals with T1D is associated with a substantially increased risk of both microvascular and macrovascular complications, as well as higher mortality risk [29, 30]. When disordered eating behaviors are examined specifically in adolescence, evidence suggests that their prevalence is higher among adolescents with T1D compared with their healthy peers[31]. The unique demands of diabetes management—including carbohydrate counting, weight concerns, blood glucose monitoring insulin administration, and fear of hypoglycemia—may contribute to increased vulnerability to maladaptive eating attitudes and behaviors in this group [2]. In this context, parent-reported assessments represent as an important complementary source of information. Children and adolescents may underreport or minimize problematic eating behaviors due to denial, embarrassment, fear of stigma, or limited insight. Therefore, parental observation may provide additional clinically relevant information. In the present study, a significant moderate correlation was observed between the parent-reported DEPS-R and the child/adolescent self-reported DEPS-R (r = 0.506, p < 0.001), suggesting that parental reports reflect, to a meaningful extent, the adolescents’ own perceptions of disordered eating behaviors. This finding supports the concurrent validity of the parent-reported version while also highlighting its potential utility as a screening instrument in clinical settings.

Although some studies using adolescent self-reported DEPS-R scores have reported significant associations with HbA1c levels [32], no significant association between parent-reported DEPS-R scores and HbA1c was observed in the present study, which is consistent with the findings of the original parent-reported DEPS-R study[12]. One possible explanation is that parents may not be fully aware of certain disordered eating behaviors that occur outside their observation, particularly diabetes-specific behaviors such as intentional insulin restriction or covert eating patterns. In addition, HbA1c is influenced by multiple factors beyond eating behaviors, including diabetes duration, treatment adherence, physical activity, psychosocial factors, and diabetes management practices[33]. Therefore, the absence of a significant association may reflect the complex and multifactorial nature of glycemic control rather than a lack of clinical relevance of eating-related concerns. Furthermore, the cross-sectional design of the study may have limited the ability to detect longer-term relationships between parent-reported eating behaviors and metabolic outcomes.

Previous research indicates that diabetes duration may be associated with disordered eating, as individuals with eating disorders were reported to have a significantly longer duration of diabetes compared to those without (6 vs. 5 years, p = 0.04) [34]. However, another study conducted in population aged 9–18 years failed to demonstrate a significant association between diabetes duration and self-reported DEPS-R scores in regression analyses (r = 0.058, p = 0.531) [35]. In the present study, a positive correlation was observed between years since T1D diagnosis and parent-reported DEPS-R scores (r = 0.223, p = 0.029). This finding suggests that longer diabetes duration may reflect the cumulative psychological and behavioral burden associated with chronic disease management. Over time, the ongoing demands of glycemic monitoring, insulin administration, dietary regulation, and weight-related concerns may increase susceptibility to maladaptive eating attitudes and behaviors [2]. Furthermore parent-reported DEPS-R scores were positively correlated with P-PAID-T scores (r = 0.458, p < 0.001), indicating that higher levels of disordered eating behaviors were associated with greater diabetes-related parental distress. Similarly, in the original validation study of the parent-reported DEPS-R, a significant positive correlation was observed between DEPS-R and P-PAID-T scores (r = 0.484, p < 0.001) The comparable magnitude of these correlations across studies strengthens the construct validity of the Turkish version and suggests that the relationship between disordered eating behaviors and parental diabetes-related distress is consistent across cultural contexts. This pattern supports the conceptual link between adolescent’s eating-related difficulties and increased emotional burden within families managing T1D.

Confirmatory factor analysis (CFA) further supported the proposed single-factor structure. The χ²/df ratio (1.629) indicated good model fit, while the RMSEA value (0.080) suggested an acceptable level of fit. Although the incremental fit indices (CFI = 0.874, TLI = 0.848) were slightly below the conventional 0.90 threshold, they approached acceptable levels and may still be considered supportive of the proposed model, particularly in the context of cross-cultural adaptation and parent-report measurement. Overall, these findings indicate that the Turkish parent-reported version of the DEPS-R demonstrates an acceptable and theoretically consistent factor structure.

Consistent with the original parent-reported DEPS-R study, which reported a Cronbach’s alpha of 0.89, the internal consistency coefficient in the present study was also high (Cronbach’s α = 0.852), indicating good internal consistency. In addition to internal consistency, the current study provides evidence for temporal stability, as test–retest reliability was found to be acceptable (ICC = 0.83 and r = 0.89) Notably, the original parent-reported DEPS-R validation did not report test–retest reliability, representing an important gap that our study helps to address [12].

Another relevant issue is the absence of an established cut-off score for the parent-reported version. Similar to the original parent-reported DEPS-R study [12], a clinical cut-off could not be proposed in the present study, primarily due to limitations in sample size and the absence of diagnostic comparison measures. Although the original DEPS-R developers [9] suggested that scores of 20 or above may indicate disordered eating behaviours requiring further discussion and possible referral, this threshold was developed for the adolescent self-reported version and cannot be directly transferred to the parent-reported version. This is because parent and adolescent reports may reflect different perspectives on eating-related behaviours and concerns. Future studies should evaluate the diagnostic accuracy of the parent-reported DEPS-R against structured clinical interviews and establish clinically meaningful cut-off values to improve its utility as a screening instrument.

An additional consideration is the relatively low proportion of insulin pump users in our sample (8.3%) compared with rates reported in some international studies. Differences in healthcare systems, reimbursement policies, accessibility of diabetes technologies, and local clinical practices may contribute to this variation. Because diabetes technologies may influence both glycemic management and psychosocial outcomes, variations in technology use should be considered when comparing findings across populations. Furthermore, information regarding continuous glucose monitoring (CGM) use was not systematically collected in the present study, which may represent a limitation and should be addressed in future research.

Limitations

Some limitations should be considered when interpreting the findings of this study. The sample size was relatively limited, which may affect the generalizability of the results. Another limitation of this study is that both EFA and CFA were conducted using the same sample. Although independent samples are recommended for cross-validating factor structures, the sample was not divided in the present study because of the relatively small sample size and the risk of further reducing statistical power. Therefore, the use of the same sample may limit the independent confirmation and replicability of the factorial structure and may increase the risk of overfitting. Future studies with larger and independent samples are needed to cross-validate the factor structure of the Turkish parent-reported DEPS-R. In addition, the study was conducted among adolescents with Type 1 diabetes and their parents; therefore, the findings should be interpreted within the context of this specific population. Furthermore, detailed dietary intake data, such as food records or food frequency questionnaires, were not collected. Future studies including comprehensive dietary assessments and larger samples may help to further clarify the relationship between eating behaviors and diabetes-related outcomes.

Conclusion

This study provides preliminary evidence supporting the validity and reliability of the Turkish parent-reported DEPS-R in adolescents aged 10–17 years with T1D. The findings from exploratory and confirmatory factor analyses, together with construct validity testing, suggest that the instrument may have acceptable psychometric properties for use in this clinical population.

Given the well-established association between disordered eating behaviors and suboptimal metabolic control in T1D, the availability of a culturally adapted and psychometrically validated parent-reported screening tool represents a significant contribution to both clinical practice and research. The parent-report format may be particularly valuableduring adolescence, a developmental period during which insight and self-report accuracy may be limited, and family involvement remains central to diabetes management.

The Turkish DEPS-R (parent version) may help support the early detection of disturbed eating patterns, enable timely multidisciplinary intervention and potentially mitigate the progression of diabetes-related complications. Moreover, its use in future longitudinal and interventional studies may help elucidate the bidirectional relationship between eating behaviors, glycemic control, and psychosocial outcomes in adolescents with T1D. Further empirical evidence is needed before drawing firm conclusions regarding its broader clinical utility and its potential role in improving long-term metabolic and psychological outcomes in this high-risk population.

Abbreviations

AVE

Average variance extracted

CFA

Confirmatory factor analysis

CR

Composite Reliability

DEPS-R

Diabetes Eating Problem Survey–Revised

EFA

Explanatory factor analysis

P-PAID-T

Problem Areas in Diabetes-Parents of Teens

Author contributions

NA, FA, KE, DGK, and EY contributed to the study design and drafted the manuscript. DGK, EB, HT, and OE contributed to data collection and manuscript preparation. NA and FA performed the data analysis and contributed to manuscript preparation. All authors read and approved the final manuscript.

Funding

The study has no funding.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

This study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval for the study was obtained from the Tokat Gaziosmanpaşa University Health and Sports Sciences Research Ethics Committee (Decision No: 01.09); date: 07.11.2025). Written informed consent was obtained from the parents of all participants, and adolescents provided assent before participating in the study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.