Abstract
Aim:
To explore cross-sectional associations between executive function problems and disordered eating behaviors in teens with type 1 diabetes.
Methods:
Executive function was assessed by the Behavior Rating Inventory of Executive Function (BRIEF), self-report and parent proxy-report versions. Scores ≥60 (on Global Executive Composite, Behavioral Regulation Index, Metacognition Index, or clinical scales) indicated problems with executive function. Disordered eating behavior was assessed by the Diabetes Eating Problem Survey Revised (DEPS-R) and categorized as: <10 low, 10-19 moderate, and ≥20 high.
Results:
In the 169 teens (46% girls, median age 16.0 years [range 13.7-18.7], median diabetes duration 8.9 years [range 1.4-16.6]), 29% had moderate and 12% had high level of disordered eating behaviors. Executive function problems were present in 9% by self-report and 26% by parent proxy-report. Among teens with moderate/high level of disordered eating behaviors, 19% had executive function problems by self-report (vs 2% of teens with low level of disordered eating behaviors, p<0.001) and 33% had executive function problems by parent proxy-report (vs 20% of teens with low level of disordered eating behaviors, p=0.056). A greater level of disordered eating behaviors was associated with executive function problems by teen self-report on the General Executive Composite (p<0.001), Behavioral Regulation Index (p<0.001), emotional control clinical scale (p<0.001), and shift clinical scale (p<0.001), and by parent proxy-report on the task initiation clinical scale (p=0.008).
Conclusions:
Assessing executive function and screening for disordered eating behaviors in teens with type 1 diabetes could help identify a subset of teens at high risk for adverse outcomes and need for intervention.
Keywords: type 1 diabetes, disordered eating behaviors, executive function, adolescence
1. INTRODUCTION
Managing type 1 diabetes is challenging as it requires ongoing glucose monitoring, meal organization, carbohydrate counting, and making decisions about insulin administration. These activities demand neurocognitive competencies such as executive function. Executive function is a group of cognitive processes involved in complex behaviors, reasoning, and decision making [1]. Working memory, set-shifting, inhibitory control, and emotional control are examples of executive functions. Executive function plays an important role in problem-solving and self-control [1]. In persons with type 1 diabetes, executive function difficulties are associated with higher HbA1c levels [2, 3].
During adolescence, the challenges and burden of diabetes self-care may increase, and HbA1c levels generally increase [4]. During this sensitive developmental time, executive function continues to mature [5], and neurocognitive functioning and psychosocial status may influence diabetes management. Difficulties with cognitive and emotional self-regulation during late adolescence and emerging adulthood are associated with suboptimal diabetes management [6, 7].
Adolescence is a critical period of physical, cognitive, and emotional development when certain psychological concerns may emerge. For example, worries about body image and weight may lead to disordered eating behaviors and clinical eating disorders [8]. In persons with type 1 diabetes, disordered eating behaviors are associated with higher glucose levels, diabetes complications, and premature mortality [9-11]. Screening for psychosocial concerns and self-care deficits is recommended in persons with type 1 diabetes due to the potential impact on diabetes management, well-being, and short- and long-term physical health, as well as to avoid progression to clinical mental health conditions, such as eating disorders [12].
Previous research in the general population has suggested that problems with executive function are associated with disordered eating behaviors [13, 14] and clinical eating disorders [15, 16]. However, there is limited research about this association in persons with type 1 diabetes, especially in the vulnerable adolescent age group [17]. Problems with executive function may make it more difficult to carry out daily diabetes management tasks, which may lead to glucose levels outside of the target range. This may be compounded by disordered eating behaviors, especially those associated with insulin restriction or omission. Adolescents with type 1 diabetes may also engage in disordered eating behaviors as a way of dealing with frustrations and negative emotions about their diabetes. More knowledge about this relationship is critical to guide the design of tailored prevention and management measures.
The present study aimed to examine associations between problems with executive function and level of disordered eating behaviors in teens with type 1 diabetes, a group experiencing growth in executive function domains and at risk for emergence of disordered eating behaviors. It was hypothesized that problems with executive function would be associated with more disordered eating behaviors.
2. SUBJECTS, MATERIALS, AND METHODS
2.1. Study sample
Study participants were recruited from an academic pediatric diabetes center to participate in a longitudinal study aimed at improving self-care and glycemic outcomes in teens with type 1 diabetes [18]. Participants from one of the two study sites (56% of the main study sample) also completed this sub-study assessment of teen executive function. Inclusion criteria for study participation included: age 13-17 years, type 1 diabetes for at least 6 months, daily insulin dose ≥0.5 units/kg, HbA1c 6.5-11.0% (48-97 mmol/mol), and reading/writing comprehension in English. Exclusion criteria included any other major medical or psychiatric disorder warranting active treatment changes (e.g., treated thyroid conditions or celiac disease were not exclusions). The eligibility criteria and sample size were selected to assess the primary outcomes of the longitudinal study. The study protocol was approved by the Institutional Review Board. Written informed consent was obtained from parents and written assent was obtained from teens before study participation.
2.2. Data collection
Data were collected on the day of regularly scheduled clinical appointments. Teens and parents were interviewed by trained research assistants who collected demographic and diabetes management information. Teens and parents completed the surveys described in Section 2.3. Additional diabetes management information was obtained from electronic medical records. Teens were weighed and measured using an electronic scale and stadiometer, both appropriately calibrated, by trained personnel. Body mass index (BMI) percentiles were calculated using the Centers for Disease Control and Prevention growth charts [19]. Teens were categorized by weight status according to BMI percentile: underweight (<5th percentile), normal weight (5th to <85th percentile), overweight (85th to <95th percentile), and obese (≥95th percentile). Blood samples were obtained for measurement of HbA1c (ref. range: 4-6%, Roche Cobas Integra, Roche Diagnostics, Indianapolis, IN).
2.3. Measures
Parents completed the Behavior Rating Inventory of Executive Function (BRIEF) parent form to assess parent proxy-report of teen executive function [20]. Teens completed the Behavior Rating Inventory of Executive Function Self-Report (BRIEF-SR) [21] and the Diabetes Eating Problem Survey-Revised (DEPS-R) [22] to assess self-report of executive function and disordered eating behaviors, respectively.
2.3.1. Diabetes Eating Problem Survey-Revised (DEPS-R)
The DEPS-R is a validated screening measure that assesses self-report of general and diabetes-specific disordered eating behaviors, especially in persons using insulin therapy [22]. The survey contains 16 items, which are answered on a 6-point Likert scale (0=never, 1=rarely, 2=sometimes, 3=often, 4=usually, 5=always). The total score is the sum of all response items; scores range from 0 to 80, with higher scores indicating more disordered eating behaviors. The validated cut-off score of ≥20 indicates a high level of disordered eating behaviors and need for additional evaluation [22]. Scores from 10 to 19 have been described as a moderate level of disordered eating behaviors at which further assessment might be considered [23].
2.3.2. Behavior Rating Inventory of Executive Function (BRIEF)
The BRIEF is a validated questionnaire that assesses executive function. The youth self-report version has 80 items and the parent proxy-report version has 86 items [20, 21]. Items are answered on a 3-point Likert scale (Never, Sometimes, Often). The Global Executive Composite (GEC) total score represents overall executive function and is a summary of the Behavioral Regulation Index (BRI) and the Metacognition Index (MI). The BRI and MI are each composed of several clinical scales. The BRI contains the emotional control, inhibit, monitor, and shift clinical scales in the self-report version and the emotional control, inhibit, and shift scales in the parent proxy-report version. The MI is composed of organization of materials, plan/organize, task completion, and working memory scales in the self-report version and the monitor, organization of materials, plan/organize, initiate, and working memory scales in the parent proxy-report version. Raw scores were converted to age- and sex-adjusted T-scores, where higher scores indicate more problems with executive function. T-scores 60-64 on the GEC, BRI, MI, or the clinical scales are considered mildly elevated and T-scores ≥65 are considered clinically elevated. For these analyses, we defined executive function problems as T-scores ≥60 in order to include both those with mild and clinically elevated executive function problems.
2.4. Statistical analysis
Statistical analyses were performed using SAS software (version 9.4; SAS Institute, Cary, NC). Descriptive data are presented as mean±SD or n (percentage). Teens were categorized by level of disordered eating behavior according to DEPS-R score: <10 = low frequency of disordered eating behaviors, 10-19 = moderate frequency of disordered eating behaviors, ≥20 = high frequency of disordered eating behaviors. Teens also were categorized depending on the presence (BRIEF scores ≥60) or absence (BRIEF scores <60) of executive function problems. These categorical variables for level of disordered eating behaviors (low, moderate, high) and problems with executive function (present or not) were used in bivariate analyses. Mantel-Haenszel chi-square tests were used to compare percentages of those with executive function problems according to level of disordered eating behavior. Due to the number of comparisons, p<0.01 was considered statistically significant.
3. RESULTS
3.1. Participant characteristics
Demographic and diabetes management characteristics appear in Table 1. The study sample for analyses was composed of 169 teens and 168 parents. For one parent, total scores could not be calculated for several of the BRIEF scales because there were too many missing responses and thus this parent’s data were excluded. Youth (46% girls, 88% white) had a mean age of 15.9±1.3 years (median 16.0, range 13.7-18.7 years), and most were from two-parent families (87%) and had at least one parent with a college degree or higher (72%). Diabetes duration was 8.4±3.7 years (median 8.9, range 1.4-16.6 years) and 67% were treated with insulin pump therapy. Mean HbA1c was 8.5±1.2% (69±13 mmol/mol), and only 16% achieved the 2019 American Diabetes Association HbA1c target level of <7.5% (<58 mmol/mol). Normal weight was found in 56% of the teens, overweight in 31%, and obesity in 14%; none of the teens were underweight.
Table 1.
Participant characteristics
| All teens (N=169) |
Girls (n=77) |
Boys (n=92) |
|
|---|---|---|---|
| Age (years) | 15.9±1.3 | 16.0±1.3 | 15.9±1.3 |
| Diabetes duration (years) | 8.4±3.7 | 8.8±3.7 | 8.1±3.8 |
| Race/ethnicity (% non-Hispanic white) | 149 (88) | 68 (88) | 81 (88) |
| Family structure (% two-parent family) | 147 (87) | 68 (88) | 79 (86) |
| Parent education (% college degree or higher) | 122 (72) | 52 (68) | 70 (76) |
| Insulin regimen (% pump) | 114 (67) | 54 (70) | 60 (65) |
| Daily insulin dose (units/kg) | 0.97±0.28 | 0.92±0.26 | 1.02±0.29 |
| Blood glucose monitoring frequency (times/day) | 5.1±1.8 | 5.1±1.9 | 5.2±1.8 |
| Continuous glucose monitoring use (%) | 36 (21) | 11 (14) | 25 (27) |
| HbA1c (%, mmol/mol) |
8.5±1.2 69±13 |
8.5±1.2 69±13 |
8.5±1.1 69±12 |
| HbA1c <7.5% (<58 mmol/mol) (%) | 27 (16) | 11 (14) | 16 (17) |
| Weight status (%) | |||
| Normal weight | 94 (56) | 40 (52) | 54 (59) |
| Overweight | 52 (31) | 27 (35) | 25 (27) |
| Obese | 23 (14) | 10 (13) | 13 (14) |
| DEPS-R total score | 10±10 | 13±12 | 8±8 |
| Disordered eating behavior level (%) | |||
| Low (DEPS-R <10) | 99 (59) | 39 (51) | 60 (65) |
| Moderate (DEPS-R 10-19) | 49 (29) | 22 (29) | 27 (29) |
| High (DEPS-R >20) | 21 (12) | 16 (21) | 5 (5) |
Data presented are mean±SD or n (%).
3.2. Disordered eating behaviors assessed by DEPS-R
DEPS-R scores are shown in Table 1. Overall, 59% of teens had a low level of disordered eating behaviors (DEPS-R <10), 29% had a moderate level of disordered eating behaviors (DEPS-R 10-19), and 12% had a high level of disordered eating behaviors (DEPS-R ≥20). Disordered eating behaviors differed significantly between girls and boys (girls: 51% low, 29% moderate, 21% high; boys: 65% low, 29% moderate, 5% high; p=0.009).
3.3. Executive function problems assessed by BRIEF: Global Executive Composite (GEC), Behavioral Regulation Index (BRI), and Metacognition Index (MI) scores
According to the overall GEC score, 9% of teens had executive function problems (GEC ≥60) by teen self-report and 26% by parent proxy-report. Problems with behavioral regulation (BRI scores ≥60) were noted in 8% of teens by self-report and 18% of teens by parent proxy-report. Executive function problems related to metacognition (MI scores ≥60) were found in 10% of teens by self-report and 27% by parent proxy-report. Neither self-report nor parent proxy-report of executive function problems differed significantly between boys and girls.
3.4. Associations between executive function problems and disordered eating behaviors
Figure 1 displays the percent of teens with executive function problems (scores ≥60) according to level of disordered eating behaviors. Teen self-report of global executive function problems (GEC ≥60) was higher in the groups with moderate and high levels of disordered eating behaviors than in the group with a low level of disordered eating behaviors (p<0.001). There were significantly greater percentages of teens with behavioral regulation problems (BRI ≥60) in the groups with moderate and high levels of disordered eating behavior compared with those with a low level of disordered eating behaviors (p<0.001). The percentage of teens with executive function problems related to metacognition (MI ≥60) was highest in the group with a moderate level of disordered eating behaviors; however, the overall Mantel-Haenszel chi-square test was not significant (p=0.034). The rate of executive function problems on the GEC, BRI, and MI by parent proxy-report increased with a greater level of disordered eating behaviors, but the associations were not statistically significant.
Figure 1. Executive function problems according to disordered eating behavior level.
There were significantly greater percentages of teens with global executive function problems (GEC≥60) by teen self-report and behavioral regulation problems (BRI≥60) by teen self-report in the groups with moderate and high levels of disordered eating behaviors (GEC: p<0.001, BRI: p<0.001). Note: 99 teens had low risk for disordered eating behaviors, 49 teens had moderate risk, and 21 teens had high risk.
Table 2 shows the number and percent of teens with executive function problems (scores ≥60) on each of the BRI and MI clinical scales (by both teen self-report and parent proxy-report) according to level of disordered eating behaviors. By teen self-report, a greater level of disordered eating behaviors was associated with executive function problems on two of the BRI clinical scales: emotional control (p<0.001) and shift (p<0.001). By parent proxy-report, a greater level of disordered eating behaviors was associated with executive function problems on the MI clinical scale of initiate (p=0.008).
Table 2.
Executive function problems on Behavioral Regulation Index and Metacognition Index clinical scales (score ≥60) according to disordered eating behavior level
| Disordered Eating Behavior Level | P value | |||
|---|---|---|---|---|
| Low (N=99) |
Moderate (N=49) |
High (N=21) |
||
| Behavioral Regulation Index clinical scales: Youth self-report (% of teens ≥60) | ||||
| Emotional control | 2 (2) | 9 (18) | 6 (29) | <0.001 |
| Inhibit | 5 (5) | 3 (6) | 3 (14) | 0.175 |
| Monitor | 2 (2) | 4 (8) | 2 (10) | 0.059 |
| Shift | 2 (2) | 12 (24) | 4 (19) | <0.001 |
| Behavioral Regulation Index clinical scales: Parent proxy-report (% of teens ≥60) | ||||
| Emotional control | 16 (16) | 13 (27) | 8 (38) | 0.016 |
| Inhibit | 14 (14) | 9 (19) | 3 (14) | 0.747 |
| Shift | 20 (20) | 12 (25) | 6 (29) | 0.343 |
| Metacognition Index clinical scales: Youth self-report (% of teens ≥60) | ||||
| Organization of materials | 8 (8) | 8 (16) | 2 (10) | 0.416 |
| Plan/Organize | 3 (3) | 7 (14) | 2 (10) | 0.055 |
| Working memory | 6 (6) | 8 (16) | 3 (14) | 0.080 |
| Task completion | 9 (9) | 16 (33) | 4 (19) | 0.016 |
| Metacognition Index clinical scales: Parent proxy-report (% of teens ≥60) | ||||
| Organization of materials | 26 (26) | 23 (48) | 9 (43) | 0.023 |
| Plan/Organize | 24 (24) | 10 (21) | 7 (33) | 0.606 |
| Working memory | 29 (29) | 15 (31) | 7 (33) | 0.691 |
| Initiate | 18 (18) | 15 (31) | 9 (43) | 0.008 |
| Monitor | 21 (21) | 12 (25) | 8 (38) | 0.126 |
Data presented are n (%). P values obtained from Mantel-Haenszel chi-square tests. Disordered eating behavior level: Low = DEPS-R <10, Moderate = DEPS-R 10-19, High = DEPS-R >20. The Monitor scale is part of the Behavioral Regulation Index in the BRIEF youth self-report version and part of the Metacognition Index in the BRIEF parent proxy-report version. The Task Completion scale is included in the youth self-report version but not the parent proxy-report version. The Initiate scale is included in the parent proxy-report version but not the youth self-report version.
4. DISCUSSION
Executive function problems and disordered eating behaviors are two major challenges that can emerge during adolescence and potentially negatively impact self-care behaviors and glycemia [3, 6, 7, 23]. In our sample of 169 teens with type 1 diabetes, executive function problems were more prevalent among those with moderate to high levels of disordered eating behaviors compared with those who had low level of disordered eating behaviors, suggesting important associations between executive function problems and disordered eating behaviors in teens with type 1 diabetes.
Previous research in the general population has shown that executive function problems are associated with sub-clinical disordered eating behaviors [13, 14, 25, 26] and clinical eating disorders [15, 27]. In particular, studies have shown that problems in the specific domains of set-shifting and emotional control are associated with disordered eating behaviors and eating disorders [13, 14, 16]. Set-shifting refers to a person’s “ability to move freely from one situation, activity, or aspect of a problem to another, as the circumstances demand” [24]. Difficulty with set-shifting has been associated with anorexia and bulimia nervosa, suggesting that cognitive rigidity may be a risk and maintenance factor for eating disorders [16]. Treatment for type 1 diabetes requires careful attention to food intake, activity, glucose levels, insulin doses, and physical symptoms. Executive function problems may cause difficulties attending to these tasks, which may result in glucose levels outside of the target range that could be compounded by disordered eating behaviors, especially those associated with insulin restriction or omission.
In our sample, executive function problems on the emotional control and shift scales by teen self-report and initiate scale by parent proxy-report were associated with moderate to high levels of disordered eating behaviors. Broadley et al. similarly found that problems in the areas of shift and planning/organizing were associated with disordered eating behaviors in young adults with type 1 diabetes [17]. In a sample of 43 youth with type 1 diabetes, Young-Hyman et al. found that high levels of emotion dysregulation were associated with more bulimic symptoms [28]. Merwin et al. used ecological momentary assessment to explore predictors of insulin restriction in adults with type 1 diabetes over a 3-day period [29]. They found that higher levels of anxiety/nervousness and guilt were associated with greater likelihood of restricting insulin at the next meal/snack (odds ratios of 1.72 and 1.84 for every 1-point increase above the person’s average level of anxiety/nervousness and guilt, respectively). The authors suggest that helping people respond effectively to these emotions may decrease insulin restriction. Thus, the executive function domains of set-shifting and emotional control appear to be particularly relevant for disordered eating behaviors in both persons with and without type 1 diabetes.
Understanding the relationship between executive function and disordered eating behaviors in persons with type 1 diabetes is important. Disordered eating behaviors are difficult to treat once established and there have not been many evidence-based successful interventions for disordered eating in persons with type 1 diabetes [30]. Therefore, identification of factors that may make a person with type 1 diabetes more vulnerable to the development of disordered eating behaviors will allow clinicians to intervene before such behaviors have become established and are more difficult to treat. One recent study of adolescents with type 1 diabetes identified “yellow flags” for disordered eating behaviors [31]. Executive function problems can similarly be viewed as a “yellow flag”. If a clinician is aware that a teen has difficulties with executive function, from previous screening tests performed by schools or other providers or from family members’ reports of behaviors suggesting difficulties with executive function (e.g., no tolerance for changes in plans), the clinician can monitor for signs of disordered eating behaviors.
Second, treatments for eating disorders in general populations often include cognitive components. For example, difficulties with set-shifting are often targeted during clinical treatment for eating disorders, such as anorexia nervosa, through the use of cognitive remediation therapy [32]. Cognitive remediation therapy involves exercises to increase awareness of one’s thinking processes, encourage more adaptive thinking styles, and apply these skills to everyday situations [33]. In a sample of adolescents with anorexia nervosa, treatment with cognitive remediation therapy was associated with an improvement in shift scores on the BRIEF by both self-report and parent proxy-report [34]. Cognitive remediation therapy may be paired with emotion skills training, which focuses on recognizing, managing, and expressing emotions [35]. Cognitive remediation and emotion skills training could be helpful tools to manage set-shifting and emotional regulation problems in persons with type 1 diabetes and disordered eating behaviors. A better understanding of the relationship between executive function and disordered eating behaviors in persons with type 1 diabetes will be beneficial for efforts to develop effective treatments for disordered eating behaviors in persons with type 1 diabetes.
We assessed executive function by both teen self-report and parent proxy-report, allowing for more comprehensive evaluation of teen executive function. Most prior studies evaluating executive function in teens with type 1 diabetes have included teen self-report [3] or parent proxy-report of executive function [2], but not both. The higher prevalence of teen executive function problems by parent proxy-report than teen self-report observed in our sample is consistent with other data from adolescents with traumatic brain injury [36], adolescents with specific language impairment [37], and typically developing adolescents [36, 37]. It is important to recognize that when differences are observed between two raters, one rater is not necessarily better or more accurate than the other. Rather, both can provide important, complementary information. The BRIEF-SR manual states that “[The BRIEF-SR] is intended as an adjunct to parent and/or teacher observations of the same functions, such as those captured by the BRIEF Parent and Teacher Forms. Comparing all views of an individual’s functioning provides a more comprehensive set of assessment data, and similarities and differences between raters can be clinically useful.” [38] Although the prevalence of executive function problems differed between teen self-report and parent proxy-report, the direction of most associations between level of disordered eating behaviors and self-report/parent proxy-report of executive function were similar. Differences may be due in part to the fact that there is no parent proxy version of the DEPS-R and therefore parent proxy-report of executive function was compared with teen self-report of disordered eating behaviors in the analyses.
A strength of the present study is that the sample only included teens (13-17 years old), which makes the sample suitable to better understanding the association of problems with executive function and disordered eating behaviors in teens with type 1 diabetes. Another strength is the assessment of executive function by the BRIEF, which is composed of several clinical scales assessing different executive domains; other studies evaluate only a specific domain such as set-shifting [16, 39]. Although our assessments of executive function and disordered eating behaviors were based on self- and parent proxy-report surveys, both of the measures used (DEPS-R and BRIEF) are validated and widely-used measures for assessing the respective constructs of disordered eating behaviors and executive function.
Our study has a number of limitations. First, directionality or causality cannot be determined in this study given the cross-sectional nature of the analyses. Second, we were not able to assess associations of executive function problems with disordered eating behaviors using the clinically significant higher cut-point of ≥65 [24] on the BRIEF, as the percent of teens exceeding this threshold was relatively small by both youth and parent report. Nonetheless, the current analyses provide exploratory observations of likely clinically important associations between mildly elevated scores on the BRIEF with moderate and high risk for disordered eating behaviors using the validated DEPS-R scale. Next, although we used a p value of <0.01, there is still a possibility of type 1 error due to multiple comparisons. In particular, there was an unusual observation of greater executive function problems for the metacognition index in teens with moderate level of disordered eating behaviors and not a high level, suggesting possible type 1 error. In addition, the sample included a relatively high percent of teens from two-parent families and high parental educational attainment, potentially limiting generalizability. However, disordered eating behaviors are relatively common in such a demographic. The study sample was also limited to teens with an HbA1c of 6.5-11.0% (48-97 mmol/mol). The exclusion of teens with higher HbA1c levels may have excluded some teens with higher levels of disordered eating behaviors and/or executive function problems. Future studies, including longitudinal research, are needed to better understand the associations between executive function problems and disordered eating behaviors, especially in more diverse samples of teens with type 1 diabetes, to inform specific interventions in order to preserve physical and mental health of teens for the present and future.
In summary, executive function problems were associated with disordered eating behaviors in our sample of teens with type 1 diabetes. If clinicians are aware of potential difficulties with executive function, they can also be alert for disordered eating behaviors and intervene at the first sign before such behaviors become established and more difficult to treat. A better understanding of the relationship between executive function problems and disordered eating behaviors in persons with type 1 diabetes will help to develop effective treatments for this population. Indeed, in a special issue of Diabetic Medicine commemorating the 25th anniversary of the Psychosocial Aspects of Diabetes Study Group, Broadley et al. cited the need for additional research, stating that “further investigation into cognitive correlates of disordered eating in diabetes could be fruitful, as cognitive interventions for disordered eating have been explored in populations without diabetes and may present an opportunity for treatment or prevention in people with diabetes” [30]. In teens with type 1 diabetes and disordered eating behaviors, a focus on executive function -- and any specific domains that are impaired -- may be a new target in the management of disordered eating behaviors to prevent progression to clinical eating disorders.
Bulleted novelty statement:
Executive function problems are associated with disordered eating behaviors in the general population, but there is limited research in persons with type 1 diabetes, especially adolescents.
In a sample of 169 teens with type 1 diabetes, executive function problems (particularly related to emotional control, set-shifting, and task initiation) were more prevalent among those with more disordered eating behaviors.
In clinical practice, assessment of executive function and disordered eating behaviors could help identify teens with type 1 diabetes in need of intervention due to their high risk for adverse outcomes.
ACKNOWLEDGEMENTS
Funding: This work was supported by the National Institutes of Health (grant numbers R01DK095273 and P30DK036836); JDRF (grant number 2-SRA-2014-253-M-B); Bringing Science Home; Fundación Alicia Koplowitz; the Katherine Adler Astrove Youth Education Fund; the Maria Griffin Drury Pediatric Fund; and the Eleanor Chesterman Beatson Fund. The content is solely the responsibility of the authors and does not necessarily represent the official views of these organizations. None of these organizations were involved in the study design, data collection, data analysis, manuscript preparation, or publication decisions.
Footnotes
Prior publication: Portions of this manuscript were presented as an oral presentation at the 78th Scientific Sessions of the American Diabetes Association, June 2018, Orlando, FL.
Conflict of interest: The authors report no relevant potential conflicts of interest.
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