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or ED with diabetes cohorts could be found. Therefore screening recommendations are derived from the extant literature, and treatment recommendations are adapted from DEB interventions with healthy populations (Kelly 2005, Goebel-Fabbri 2009).

      If DEB is suspected, screening should be implemented as follows:

      1. Use diabetes-specific measurement tools to distinguish between behavior that indicates regimen adherence versus DEB to control weight, independent of glycemic control goals (Goebel-Fabbri 2009, Young-Hyman 2011a).

      2. Evaluate overall psychological adjustment to establish whether behaviors indicate DEB, psychiatric morbidity, and/or poor adjustment to the diagnosis and requirements of treatment regimen (noncompliance). Patients with known psychiatric morbidity should be screened for DEB when unexplained poor glycemic control, weight gain, and/or weight loss occurs (Kelly 2005).

      3. Evaluate insulin and other medication dosing/amount and episodes of hypoglycemia as potential causes for lack of satiety and/or loss of control over food intake. Evaluate accuracy of internal cues indicating need for food or treatment (with medication) in the context of blood glucose level (Goebel-Fabbri 2009).

      4. Evaluate potential contributions of dietary prescription and information (MNT) to attitudes and behaviors regarding food intake, including food preoccupation and self-evaluation of actual or subjective dietary restraint and binging (ADA 2007).

      5. Assess patients’ expectations for achieving good glycemic control: at what cost to psychosocial adjustment, quality of life, eating behaviors, and weight.

      If screening indicates DEB, formal evaluation and care should be implemented:

      1. Refer for psychological/psychiatric evaluation. Once ED/DEB is established by questionnaire/interview, referral for treatment to a mental health professional familiar with the medical management of diabetes and treatment of DEB should be made (ADA 2007).

      2. When treatment for DEB is begun, the treating professional as well as key individuals in the patient’s social support network in treatment (parents for children and teens, partners or close family/community members for adults) should be incorporated into the diabetes management team (Criego 2009).

      3. Depending on severity of symptoms, medications (antidepressant and antianxiety) and hospitalization should be considered.

      4. Routine monitoring of DEB symptoms at medical management visits is also an integral part of the ongoing treatment process so that appropriate adjustments to the diabetes care regimen can be made (ADA 2007, Criego 2009). Careful evaluation of the contribution of prescribed diabetes care behaviors, knowledge, intent of behavior, and glycemic and weight goals should be conducted. Incorporation of diabetes treatment personnel into the DEB treatment plan helps to ensure that the prescription for regimen behaviors can be adjusted as needed (Goebel-Fabbri 2009).

      5. Use of cognitive behavioral therapy, interpersonal therapy, and integrative cognitive therapy with adjunctive pharmacotherapy to address significant psychiatric symptoms are recognized treatment approaches in the nondiabetic population and should be provided to those with diabetes. Based on successful intervention methods, treatment can be individually or group administered by a trained professional (usually a behaviorally trained psychologist, social worker, or dietitian) who is familiar with the treatment of both DEB and diabetes (de Zwaan 2004, Pike 2004, Tantleff-Dunn 2004, Peterson 2004).

      6. Interventions should target specific maladaptive behaviors (such as manipulation of insulin or medication omission) to ensure health, and should target cognitions about body image, self-esteem, autonomy, interpersonal relationships, and disease self-efficacy, particularly control of glucose and weight, depending upon symptoms reported, to improve mental health. Recommendations follow procedures used in the general population but with the addition of self-management behavior, which needs to be addressed with the diabetes care team in the context of preserving glycemic control. If metabolic derangements (severe hypoglycemia and ketoacidosis) are found to be associated with DEB, metabolic derangements must first be stabilized via medical management (ADA 2007).

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