Pathways to Binge Eating Among Black Adults With Type 2 Diabetes: A Grounded Theory Qualitative Study

Abstract

OBJECTIVE

Black adults with type 2 diabetes (T2D) are at higher risk for binge eating and often face challenges in achieving blood glucose control, which may be due to untreated disordered eating. Little is known about the influences on their eating behaviors in the context of T2D. This study explores factors influencing binge eating in Black adults with T2D and the perspectives of the diabetes self-management education and support (DSMES) providers treating them.

RESEARCH DESIGN AND METHODS

Black adults with T2D experiencing at least two self-reported binge eating episodes a month (n = 14) and DSMES providers (n = 8) who treated this population participated in in-depth interviews. Interviews explored experiences with managing T2D and facilitators of binge eating. A constructivist grounded theory approach was used to analyze the data and develop a framework explaining factors influencing binge eating in this population.

RESULTS

Participants identified multilevel stressors and barriers that influenced their binge eating episodes and treatment. These factors ranged from societal to individual-level and physiological factors that led to active food restriction, emotional eating, feelings of deprivation, and binge eating. Providers acknowledged limited training in disordered eating and weight stigma and identified gaps in current DSMES.

CONCLUSIONS

Binge eating in Black adults with T2D is shaped by structural, cultural, and psychological factors. Incorporating culturally responsive guidance, emotion-focused coping strategies, and routine screening for disordered eating into diabetes care may improve engagement and glycemic outcomes for this population.

Introduction

In the U.S., non-Hispanic Black adults have a type 2 diabetes (T2D) prevalence of 12.7%, representing the second-highest prevalence of this chronic disease among racial and ethnic groups. Indeed, the incidence and burden of T2D continues to rise, disproportionately impacting minoritized populations (1,2). T2D is also the seventh leading cause of death nationally, with higher diabetes-related mortality among Black adults (1).

Disordered eating behaviors are a growing concern among adults with T2D (3). Of particular concern may be binge eating, which is defined as the subjective experience of loss of control while eating, irrespective of the actual food consumed (4). Approximately 7–20% of patients with T2D report binge eating (5,6), which is linked to worsened HbA_1c and fasting glucose, reduced insulin sensitivity, and a younger age of diagnosis for T2D (5,7).

Recurring binge eating episodes (i.e., at least once per week over 3 months) can progress to binge eating disorder (BED), a DSM-5 disorder associated with increased risk for T2D, obesity, hypertension, and other metabolic disorders by decreasing insulin sensitivity and with mental health and gastrointestinal issues (8). Prevalence rates of BED range from 2.5 to 29.6% in people with T2D (3). While BED is the most common eating disorder among individuals with T2D, it remains underreported and underdiagnosed (9,10). Inversely, individuals with T2D are at higher risk for BED, which may be influenced by restrictive eating behaviors associated with diabetes control strategies (e.g., calorie restriction for weight loss, avoiding foods with high added sugar content), and may lead to increased risk of binge eating behaviors (10,11). Individuals who have T2D and binge eating behaviors have reported feelings of deprivation, guilt, shame, and failure (9,10). Individuals with BED also have greater difficulty adhering to diabetes self-management behaviors, including meal planning, carbohydrate consistency, medication adherence, and glucose monitoring. During binge eating episodes, individuals usually consume foods higher in calories, carbohydrates, sugar, and fat, which contributes to decreased insulin sensitivity, higher fasting blood glucose levels, and increased insulin resistance (7,12).

Racial disparities in binge eating exist among adults with T2D (13,14). Black adults with T2D reported six times the odds of binge eating compared with other racial and ethnic groups (14). Despite this knowledge, less is known about factors influencing binge eating among Black adults with T2D, which may differ from those experienced by White adults. When BED treatment and T2D self-management are integrated into treatment, outcomes such as eating behavior, a reduction in the frequency of binge eating episodes, and glycemic control improve for both binge eating and T2D (11). As a result, culturally relevant interventions that address the overlap between T2D and binge eating need to be designed for diverse subgroups and further tested, particularly for longer-term effects (13,15,16). A first step toward the design of this intervention would be to understand relevant dynamics that may influence the development of binge eating. Thus, the purpose of this study was to explore the factors affecting binge eating among Black adults with T2D and the diabetes self-management education and support (DSMES) providers who treat this population. Findings will provide a knowledge base to develop an intervention that includes the voices of Black adults affected by binge eating to improve T2D self-management and quality of life, as well as the voices of DSMES providers, with the overall goal of narrowing disparities in treatment outcomes.

Research Design and Methods

Using semistructured interviews, a constructivist grounded theory approach explored diabetes self- management processes among Black adults with T2D who feel out of control around food (hereafter referred to as patient participants) and among DSMES providers who treat this population (hereafter referred to as provider participants). Through initial, focused, and theoretical coding, categories were derived from participants’ experiences and used to construct a conceptual model to explore the factors affecting binge eating among Black adults with T2D (17). Study procedures were approved by the University of North Carolina at Chapel Hill Institutional Review Board.

Recruitment and Sample

Purposive, convenience, snowballing, and theoretical sampling techniques were used to recruit the patient and provider participants (18–21). Patient participants were eligible if they 1) identified as Black, 2) were age ≥18 years, 3) were diagnosed with T2D, and 4) reported experiencing two or more loss-of-control eating episodes in the prior month. These inclusion criteria were designed to capture participants who may be at risk for more severe binge eating and BED and to reach a broad cohort due to the exploratory nature of this study. Provider participants were eligible if they 1) treated Black adults with T2D, 2) delivered DSMES to Black adults with T2D, and 3) treated Black adults with T2D who reported binge eating. The rationale for including both patients and providers was to allow for a multifaceted view of the factors affecting the eating behaviors in this population, including elements visible and potentially hidden to patients.

Procedures

Potential participants were recruited through flyers, social media advertisements, and messages sent to university listservs. Patient and provider participants consented to participate in the research study and then completed a demographic questionnaire via a secure, electronic platform (Qualtrics). The questionnaire captured sociodemographic characteristics, including age, gender, and income, as well as history of receiving or providing DSMES treatment. For provider participants, the questionnaire also collected their professional role. Patient participants were asked additional questions to determine whether they had been diagnosed with T2D and the presence, quantity, and size of loss-of-control eating episodes in the past month. These questions were adapted from the Eating Disorder Examination Questionnaire, a self-report scale used to determine the presence of behaviors associated with eating disorders (22). Patient participants were eligible to participate if they reported at least two episodes of loss-of-control eating in the past month, indicating their risk for BED. The rationale for this inclusion criterion was due to evidence that the presence of loss of control, despite the amount of food eaten, is central to psychological measures of distress common with BED (23).

After completing the Qualtrics survey, participants were scheduled for a single-session semistructured interview that explored factors that influenced eating behaviors, treatment, and diabetes self-management. Patient interviews covered four domains: eating behaviors, managing emotions and eating behaviors, treatment experiences, and treatment recommendations. Providers were asked questions across three domains: assessing client eating behaviors, experience with treatment modalities and interventions, and treatment recommendations. Interview questions were open ended to allow participants to drive conversations. Interviews continued until theoretical saturation was reached, meaning until no new categories emerged (18). All interviews were conducted by a research project coordinator (T.H.-C.) and two research assistants (H.W. and K.O.) via secure online videoconferencing software and were ∼45–70 min in length and audio recorded. Patient participants were compensated with a $40 Visa gift card, and provider participants were compensated with a $100 Visa gift card for their time. Interviews were transcribed verbatim by a third-party service and checked for accuracy by the research team.

Data Analysis

Constructivist grounded theory was used to analyze interview data in an iterative, comparative, and interactive manner (18). In alignment with grounded theory procedures, data collection and analysis occurred simultaneously, with emergent findings informing further data collection (18). Researchers first read interview transcripts to familiarize themselves with the data. Coding occurred in two major phases: initial coding and focused coding (18). The initial coding phase involved independently conducting line-by-line coding using the analytic software, Atlas.ti (version 22). Three research assistants (H.W., K.O., and J.R.) and one project coordinator (T.H.-C.) independently reviewed and coded transcripts, then switched transcripts with fellow team members to review and offer suggestions. They subsequently double-coded their initial set of transcripts and integrated the feedback into the final coding. Researchers engaged in several team meetings to develop focused codes. In a constant comparative method, initial codes that were more frequent or significant were used to sort, synthesize, organize, and analyze data (18). Focused codes were then grouped into theoretical categories. In several team meetings, the analytic properties and relationships among categories and focused codes were examined (18).

The codebook was developed iteratively and included 11 focused codes, 62 line-by-line codes, and code definitions. Any areas of disagreement were discussed among the team until a consensus was reached. Memo writing occurred throughout data collection and theory building to capture emergent hunches, insights, comparisons, new questions, and decisions. Memos enabled researchers to engage the data in a critically reflexive manner, develop ideas, and modify subsequent data collection (18).

Results

In total, 22 participants, including 14 patient participants and 8 provider participants, consented to participate in this study. An overview of demographic characteristics for patient and provider participants is presented in Table 1 and Table 2, respectively. Most patient participants (n = 13) and provider participants (n = 8) identified as women. The mean (SD) age of patient and provider participants was 57.29 (14.4) and 42.00 (10.3) years, respectively. On average, patient participants’ length of diabetes diagnosis was 2.8 (14.4) years. Overall, 57% of patient participants reported binge eating episodes at least three or more times per month. Provider participants had been in practice for a mean of 5.1 (2.6) years, and 63% reported treating Black adults with T2D for ≥7 years.

Table 1.

Demographic characteristics of patient participants (n = 14)

Characteristic	Participants
Race
African American or Black	14 (100.0)
Gender
Woman	13 (92.9)
Man	1 (7.1)
Age (years)	57.3 (14.4)
Marital status
Single	4 (28.6)
Married	6 (42.9)
Divorced	4 (28.6)
Number of children	1.29 (1.1)
Education
Some college, no degree	2 (14.3)
Associate’s degree (2-year college)	2 (14.3)
Bachelor’s degree (4-year college)	2 (14.3)
Master’s degree or higher	7 (50.0)
Employment status
Full-time	9 (64.3)
Part-time	2 (14.3)
Self-employed	1 (7.1)
Retired	2 (14.3)
Household gross income, $
<10,000 or refused/unknown	3 (21.4)
50,000–79,999	4 (28.6)
80,000–99,999	2 (14.3)
≥100,000	5 (35.7)
Income meets financial need
Yes	12 (85.7)
No	2 (14.3)

Data are n (%) for categorical variables and mean (SD) for continuous variables.

Table 2.

Demographic characteristics of provider participants (n = 8)

Characteristic	Participants
Race
African American/Black	7 (87.50)
White	1 (12.50)
Gender
Woman	7 (87.5)
Man	1 (12.50)
Age (years)	42 (10.33)
Education
Master’s degree	7 (87.50)
Doctoral degree	1 (12.50)
Length of time delivering treatment to Black adults with T2D (years), n (%)
Two providers	1–2
One provider	3–4
Five providers	≥7
Clinical profession, n
Registered dietitian	4
Physician assistant	1
Nurse practitioner	1
Registered nurse	1
Pharmacist	1
Employment status
Full-time	6 (75.00)
Part-time	2 (25.00)

Data are n (%) for categorical variables and mean (SD) for continuous variables unless otherwise indicated.

The Binge Eating Initiation Model in Black Adults With T2D

The study participants’ thorough and comprehensive descriptions provided a foundation for the conceptual model, binge eating initiation, which explains the process of binge eating initiation and maintenance in Black adults with T2D (Fig. 1). This model was adapted from ecological systems theory (24) and was used as the theoretical lens to consider the socioecological, cultural, and emotional factors that Black adults with T2D experienced through the process of engaging in binge eating behavior. The model indicates two main pathways through which binge eating began: 1) as a response to emotional eating and 2) as a response to restrictive eating behaviors in the management of T2D.

Figure 1.

Binge eating initiation model.

Socioecological Context of Binge Eating

Foundational to the binge eating initiation model are the socioecological conditions of participants’ lives, including systemic racism, social determinants of health, weight stigma, and the coronavirus disease 2019 (COVID-19) pandemic. For example, systemic racism, sexism, and other forms of discrimination embedded in health care systems contributed to patients’ hesitancy to access treatment and engaging in episodes of restriction and binge eating. Some patient participants were concerned with being tokenized in health care settings because of their identity. Provider participants expanded this concern by describing how current diabetes education and care have been centered around a Eurocentric approach and may not be adequate to meet the needs of Black patients. For example, one provider participant reflected on this while discussing their patient: “From a dietitian or nutrition perspective? I definitely think it’s Eurocentric nutrition recommendations…that telling people to cut out…their cultural foods, telling people that they can’t have [it].…Telling people that it’s because they ate X, Y, and Z, that they now have these medical conditions is gross and…lazy and untrue.”

Provider participants also acknowledged the social determinants of health as overarching barriers that needed to be addressed before patients could address T2D. Namely, provider participants described how the lack of housing opportunities, food insecurity, limited access to nutritional foods, racism, and minority stress act as stressors and barriers that impede Black patients from effectively addressing their T2D. For example, one provider participant shared: “Cost, not just like of the education itself, but cost of missing work, cost of childcare, cost of transportation…I mean, these are real, real barriers.…We really need our health care providers to be respectful and listen to their clients and provide culturally relevant education…in weight stigma as well, and, fat patients are significantly less likely to seek medical care because they’ve been discriminated against. And, that happens for, for Black and Brown people as well. So we, as health care people need to do a better job.”

Cultural and Familial Factors

Some patient participants and all provider participants expressed a multifaceted relationship with food that served as a foundation for eating behaviors. Approximately 36% of participants described food as “joy,” reporting that consuming food was a rewarding and pleasurable experience that was often done in the presence of close friends and family. One patient participant shared this in their reflection about their relationship with food: “It’s just like a good, it’s a good feeling. Yeah. I need some to, I enjoy it is really a good feeling. Mm it’s. Like a, a releaser, a stress releaser, a relaxation. It’s just a good feeling. You know, it’s just simple.”

In addition, patient participants also reported that parental feeding habits from their formative years persisted into adulthood and continued to shape their current eating patterns. For example, patient participants discussed the strong familial emphasis during childhood on finishing all the food on their plate regardless of satiety, which some believe promoted overeating (Table 3).

Table 3.

Binge eating initiation conceptual model representative participant quotes

Model components	Patient participants’ quotesa	Provider participants’ quotesa
Component I: socioecological context of binge eating	“Insurance doesn’t wanna pay for a lot of things even though they want you to be healthy, you know, they have all these in the media threats about, you know, insurance is gonna go up and insurance is not gonna insure people who have chronic conditions. But then when you say, ‘Okay, well will you help pay for the preventative things?’ You know, the insurance doesn’t cover those things. But now if I go to any doctor right now today, I qualify immediately for gastric surgery, whichever one I want. But if I call the insurance company and say, ‘Okay, would you pay for me to see a dietitian?’ You know, then it’s questionable, or ‘Would you pay for me to see a counselor for this?’ It’s questionable. ‘Would you pay for me to get a personal trainer to help me exercise?’ I need, you know, someone to truly hold me accountable. You’re not gonna get that at the YMCA or any other, you know, Onelife Fitness place. The insurance don’t pay for that.”	“I’ve taken care of patients who are, um, victims of gun violence, you know, who have lost a child who’ve lost a loved one to gun violence, who, um, you know, were asked to vacate their place because they couldn’t afford the rent, you know? And they’re now living in a hotel room, just trying to, just trying to make it, you know, so it, it all goes back, you know, to that social determinant stuff. Boy, I tell you that social determinant will is something else because a lot of people are just really trying to survive. How do you tell someone, you know, you gotta make sure you take good care of your diabetes, where they don’t know where they gonna live tomorrow. Until we deal with some of the basic stuff, we’re really not gonna get ahold to the diabetes piece at, you know, the way we want to, you know?”
	“I was diagnosed several years ago, many years ago, and I got myself together and, and I can’t, I don’t know if I can totally blame it on the type 2 diabetes, but it makes me think the more, I think about type 2 diabetes, the more I eat wrong. If I don’t think about it and I understand how dangerous it is and I understand what the repercussions are, and I understand all that, but the more I focus on that I’m a type 2 diabetic, it’s just like a kid—When you tell ’em don’t eat that or they can’t, they gonna eat it because we told ’em not to eat it. And I think that might be what I’m experiencing right now, because in this last 2 years of COVID, it has gotten very bad. Um, I eat sweets all the time constantly and it, and then when I think about the fact that I’m type 2, then I get this guilty feeling, but it doesn’t seem like I’m able to stop doing it.”	“I mean, like what gaps don’t exist is the better question. Um, and I say that I’m a little tongue and cheek, but by and large, diabetes education is researched by, for, intended, and practiced on White patients. The vast majority of dietitians are White. The vast majority of physicians are White. Like every area of diabetes management is lacking, um, particularly, particularly foods, but, but particularly, um, like social support. Um, you know, I mentioned earlier that, uh, systemic racism in, in medical treatment affects folks. Um, but also systemic racism, like just out in the world, we know that, you know, what’s called minority stress affects cortisol levels, affects inflammation, increases folks’ risk for developing things like type 2 diabetes. Like those are major, major, major problems.”
Component II: cultural and familial factors	“’Cause I was one of those kids when you was little, not saying if said I was fat, nobody in my family was heavy. Right. But I grew up with a family where you didn’t waste food. When it came time, if you started eating, you make sure you eat, what’s put in front of you. You don’t waste it. And you certainly don’t say, ‘I don’t want this.’ You know? ’Cause my, my dad made me sure to know. He said, I’ve been in Korea, I’ve been in Japan, and I’ve seen children your age who didn’t have nothing to eat. He said, so you just eat what you’re given. Now you can say upfront, don’t give me a lot on my plate. But if it’s put on your plate, you need to make sure you take care of it.”	“So I’ve also seen patients who that’s how they were taught to eat, you know, clean their plate. This is when you eat, this is when you eat, you know, you eat when you’re sad, you eat when you’re happy, you eat when whatever. Um, and so all of those kind of can lead to loss of control.”
	“But I don’t, um, well I believe my eating always started off wrong anyway from even from childhood.…’Cause I think my grandmother pacified me cuz my, um, you know, I, I was raised with my grandparents versus my, um, mother who was an addict. So the pacifying of, you know, sweets or, you know, something. So that, that was the start. So now I pacify myself with, you know, the sweets and so forth. So it’s a learned behavior from childhood.”	“In the African American community, we’re taught to eat what’s on our plate, eat everything, you know, um, and we eat when we can...and so that has some, you know, something built in our, in our mind where we are eating everything on our plates.”
Component III: binge eating as a response to deprivation in eating behaviors	“I don’t feel like I am managing at all. I’m not, and I know I’m not, so what I do, I find myself doing, I just won’t eat. There are times I just won’t eat because I know if I start eating, then I’m going to eat and I’m gonna eat and eat.”	“Oftentimes, folks will...get a diabetes diagnosis or even a prediabetes diagnosis and feel like they need to dramatically decrease their carbohydrate consumption. Lots of my clients will, you know, cut out sugars completely or try to cut out sugars completely, feel like they’re supposed to cut out all white foods...they’ll make these drastic restrictions in their carbohydrate consumption, um, which isn’t helpful.”
	“So there’s some things I just don’t buy, uh, until I, until I feel like, ‘Okay, you haven’t had this in a while, so you can have some Oreos now’; it’s like you’re not gonna have Oreos again for at least a month or 2 months.”	“And so then you create this space where they’re like, well, I just don’t wanna have fruit because it’s got sugar. I just don’t wanna have vegetables that have carbs. I just don’t wanna have dessert. I like, it’s, it creates this space where they just avoid anything that would actually provide the nutritional value because it contains carbs.”
Component IV: binge eating as a response to negative emotions	“You eat just because it’s there, that’s just, what, what it is, so it doesn’t matter whether it was food or snacks, sweets, and stuff like that, but yeah, that’s normally like most of my time, my overeating time is like when it’s, um, a stressful situation or I’m trying to get prepared for something.”	“They’ve been told that they’re not supposed to have. And so then they feel guilty. They feel ashamed. And for a lot of folks that turn, that leads to, well, I’ve already, I’ve already messed up. I’ve already ruined my blood sugars today, or I’ve already ruined my diet, my, my diet today. I might as well keep going. Um, and, and so sometimes folks will continue to eat or eat more just because of that intense feeling of shame.”
	“So I used to be stressed and I would go grab like candy, cake, cookies. Those are my, those are the things that I, those are my go-to emotional roller coaster types of foods.”	“Whether that’s like stuff from childhood or just like the stress of being an adult. Um, microaggressions, uh, relationships, like, you know, whatever the case may be. I think not having an appropriate outlet for that. Like that food becomes the place that they have an outlet, especially if they grew up in an environment where you just don’t go to therapy because that’s for crazy people.”

^aBehaviors and observations were not mutually exclusive.

Binge Eating as Response to Deprivation in Eating Behaviors

Active engagement in food restriction was described by patient and provider participants. In fact, all patients (n = 14) and some providers (n = 4) described patient experiences with skipping meals, not buying specific foods, or avoiding foods that may be pleasurable to limit binge eating behavior. Patient participants described navigating the perception that certain foods were categorized as good or bad and that there were certain foods and quantities they should or should not eat. For example, one patient participant shared: “Snacking is one of my big issues…because I love sweets. So, and I love fried food. Fried chicken is my favorite thing to eat. Then I can have that every day if, yeah. So yes, my issue is, um, eating the wrong stuff…I love all bad food.”

When foods perceived as bad were consumed, patient participants expressed feelings of guilt and shame. Similarly, provider participants described observing these negative feelings around food consumption and this food labeling among their patients. One provider participant reflected the following: “They believe that foods are bad and that their weights need to be controlled…especially for, Black and indigenous and Latina clients of color. They have been taught that their cultural foods are bad…they feel that they need to…not eat the foods that…they grew up with that are they’re tied to their families, um, and eat a more like westernized, European, Mediterranean type diet…they’re terrified to eat.”

For example, one patient participant described how they constantly reminded themselves to avoid specific foods to limit binge eating behavior. They stated: “If I am eating, it’s out of the house.…I don’t bring it in the house. Uh, literally just saying to myself, ‘[Retracted], you don’t need that. [Retracted], you don’t need that.’”

Patient and provider participants alike reported this behavior was motivated by the perception that specific foods need to be avoided when managing T2D. For example, to improve their health and weight, patient participants described engaging in short-term diets that involved limiting certain food groups. Patient and provider participants discussed the preconceived notion that leads patients to believe that restriction is beneficial to self-management of weight and T2D (n = 7). Nearly all patient participants (n = 13) held this perception, and some providers (n = 4) described patients holding this perception. One provider participant described how these preconceived notions have been internalized by patients: “I see a general emphasis on eating less. And part of that is for blood glucose management. But part of that is also because folks are under the impression that they need to lose weight to improve their diabetes management. Or a lot of folks feel like they got diabetes because of their weight. And so a lot of folks are trying to, to lose weight, to improve their health…and are doing really dangerous things in order to do so.”

Nearly half of patients (n = 6) described engagement in active food restriction, such as struggling with eating at night and attempting to only eat within daytime hours to help with weight and food cravings. Provider participants described how their patients engaged in restrictive eating throughout the day and then experienced binge eating episodes due to excessive hunger. Similarly, patient participants described how skipping meals would lead to binge eating. One patient participant explained it as follows: “I didn’t eat breakfast or lunch, so when I got home, I just ate everything in sight. I was really hungry….Or sometimes I’ll find like, I’ll go to like one fast food restaurant and get one thing and then I’ll go to another one and like, like, say, I’ll go to like McDonald’s to get one meal, but then I’ll go to Wendy’s to get a drink, but then when I’m at Wendy’s I’ll be like, ‘Hmm, I want this too.’ So I get it, you know, just to get it cause I like it.

Binge Eating as a Response to Negative Emotions

Patient participants described eating and binge eating to cope with negative emotions, including personal, familial, or systemic stress or stressors, trauma, depression, and boredom. For example, one patient described how the stress of the COVID-19 pandemic and the loss of their classmates triggered their binge eating to cope: “Pressure probably, uh, probably a little bit of pressure. ’Cause I was, I had a cousin that was in the hospital and…they told me she had COVID and then…some deaths of classmates…and that’s probably what triggered it, you know, that was satisfying for me for the moment anyways.”

Another patient described how they had switched coping strategies from smoking to food: “So I put down the cigarettes as that crutch; I picked up the crutch of food.” This was also observed and discussed by providers among their patients. Despite episodes of binge eating, participants expressed trying to use food to gain control when feeling out of control in their daily life.

Additionally, having busy work schedules and limited time influenced patient participants’ ability to eat regularly, which may have influenced their eating habits and contributed to their binge eating. Mindless eating was reported as a significant challenge, which involved putting little thought into their eating behavior and centering food intake decisions around convenience. Additionally, some participants described eating as a distraction from other life events.

Furthermore, patient participants described emotional eating as a coping mechanism for their T2D diagnosis, work, health concerns, deaths among loved ones, family issues, and feelings of depression and anxiety. Participants reported the use of food as a primary method for managing stress and negative emotions. Additionally, patient and provider participants reported binge eating behaviors when engaging in emotional eating. After the eating episode was over, participants described the presence of additional negative emotions, such as guilt and shame about losing control of their eating. Participants would respond to these emotions by eating more and furthering their binge eating cycle. A provider described how emotional eating caused patients with T2D to struggle with binge eating: “And people are just trying to feed their feelings with whatever, you know, for some it’s food, I…think the, the psychological piece is really wearing people down. And we found comfort in food. You know, I mean, it goes back to, you know, big mama’s table, ‘Baby, you feel bad. I’m so sorry. Here’s a fried chicken. That’s a fried potato. This’ll make you feel better.’ It’s cultural stuff, you know what I’m saying? And sometimes it’s very difficult to break that because it’s just been embedded in our brains…for so long.”

Together, these insights underscore the need for diabetes care models that more fully integrate cultural context, emotional well-being, and structural realities into the support provided to Black adults with T2D.

Conclusions

The purpose of this study was to explore factors affecting binge eating among Black adults with T2D and DSMES health care providers who treat this population. The binge eating initiation model developed from these data offers a novel explanation of how binge eating emerges and is maintained within the lived experiences of Black adults with T2D. As participants described, binge eating commonly began through two interconnected pathways—as a response to emotional eating and as a response to restrictive eating behaviors in the management of T2D—each shaped by broader socioecological forces such as racism, food insecurity, and cultural food norms. By integrating multilevel influences into a single framework, the model illustrates how structural stressors, culturally informed relationships with food, and diabetes-related dietary pressures converge to heighten vulnerability to binge eating, providing a comprehensive and culturally grounded understanding of binge eating that may inform future DSMES programs.

Patient and provider participants identified socioecological factors central in shaping binge eating behaviors. These socioecological factors, along with racial discrimination, significantly influenced one’s ability to attain their health goals among undeserved and minoritized groups with chronic diseases (25–28). Among Black individuals, coping mechanisms for racial discrimination at diverse life stages may include maladaptive eating behaviors and binge eating behaviors (29–32). This may complicate self-management strategies among those living with T2D (33). Though not mentioned by the patient participants, food insufficiency, food insecurity, and limited access to healthy foods were additional barriers mentioned by provider participants. Food insufficiency and/or low socioeconomic status have been associated with T2D and binge eating behaviors in prior studies (34,35). Less is known about the relationship of low socioeconomic status or food insufficiency with co-occurring T2D and binge eating.

One pathway to binge eating initiation was the use of food to cope with negative emotions. The use of food as a stress coping mechanism has been cited as a factor in the experiences of vicious cycles of binge eating–restriction–psychological distress (36), which seem to be heightened among already stressed Black adults with T2D. Black adults have reported emotional eating related to racism, discrimination, and chronic stress (37). For example, among Black adults who were experiencing vicarious racial discrimination, there were higher rates of maladaptive eating behaviors (30). Future research should examine the differential impact of various stressors on binge eating in this population, as well as systemic interventions that may improve collective coping skills and support.

In this sample, patient participants described a relationship with food that was layered and complex, often peppered by snacking, cultural expression of love and joy, and feeling judgment from mainstream clinicians that their cultural foods were bad. In previous research, Black Americans describe cultural values of kinship, symbolism, and family traditions related to food (38). Moreover, Black adults have reported that even after a T2D diagnosis, they rather adhere to their preferred cultural foods by using healthier versions (38). However, they have also reported feeling dissuaded from consuming cultural foods or preferred foods, expressing their desire to separate their Black identity from the negative connotation given to their cultural foods (39).

Restrictive eating was another factor affecting binge eating, accompanied by numerous messages that dietary restriction is necessary to manage weight and a T2D diagnosis (40,41). Prior research has shown that adults with T2D reported that the desire for weight loss drove dieting and restriction, which was often interspersed with periods of binge eating (11). Although dietary restriction is often prescribed to improve glycemia and manage body weight, it may increase psychological distress, loss of muscle mass, frailty (42), and the risk of binge eating (7). Future research may need to identify alternative ways to improve glycemic control without encouraging restrictive eating behaviors.

Implications for Clinical Practice

Findings from this study highlight the need for diabetes care that more fully addresses the cultural, emotional, and structural contexts shaping eating behaviors among Black adults with T2D. Participants described binge eating emerging from both emotional coping and restrictive diabetes‐related eating patterns, which may reveal gaps in DSMES models that emphasize dietary control without attending to its unintended consequences. Routine screening for binge eating and related disordered eating behaviors should be integrated into diabetes care, particularly given that providers in this study reported limited training and noted that restrictive messages can trigger loss‐of‐control eating (43). Incorporating emotion‐ focused coping strategies, trauma‐informed approaches, and culturally respectful guidance around food may reduce feelings of deprivation, shame, and fear associated with diabetes recommendations. Addressing structural barriers such as racism, food insecurity, and limited access to culturally relevant nutrition resources should be considered central to diabetes management. In addition, providing training on weight bias awareness would also be important for DSMES providers. Overall, these findings support a more holistic, culturally responsive DSMES framework that promotes both metabolic and psychological well‐being.

Strengths and Limitations

A key strength of this study is its novel contribution. To our knowledge, it is the first qualitative investigation to examine facilitators of binge eating among Black adults with T2D, addressing a gap in the existing literature. Including both patient and provider perspectives strengthened ecological validity by capturing dynamics that may be visible to one group but not the other, resulting in a more comprehensive understanding of multilevel influences on eating behaviors. Limitations include a small, purposive sample recruited largely through community and university networks, which may limit generalizability. In addition, participants self‐identified as experiencing binge eating, potentially reflecting individuals more aware of or willing to discuss these behaviors. Finally, grounded theory findings represent coconstructed interpretations and may not capture all pathways to binge eating in this population.

In summary, this study identifies multilevel factors shaping binge eating among Black adults with T2D and underscores the need for culturally responsive diabetes care. Two primary pathways—restrictive eating and emotional coping—consistently contributed to binge eating, each embedded within broader socioecological stressors such as racism, food insecurity, and weight stigma. The resulting binge eating initiation model offers a framework for understanding how structural, cultural, and psychological factors converge to influence eating behaviors. These findings support the development of interventions that incorporate culturally respectful guidance, emotion‐ focused coping strategies, and routine screening for disordered eating to improve both glycemic outcomes and overall well‐being.

Funding Statement

This research was supported by American Diabetes Association grant 11-21-ICTSHD-12 and National Institute of Diabetes and Digestive and Kidney Diseases grant K23DK129832.