An open trial of app-assisted acceptance and commitment therapy (iACT) for eating disorders in type 1 diabetes

Abstract

Background Eating disorders (EDs) among individuals with type 1 diabetes (T1D) increase the risk of early and severe diabetes-related medical complications and premature death. Conventional eating disorder (ED) treatments have been largely ineffective for T1D patients, indicating the need to tailor treatments to this patient population and the unique conditions under which ED symptoms emerge (in the context of a chronic illness with unrelenting demands to control blood glucose, diet and exercise). The current study was a pilot open trial of iACT, a novel intervention for EDs in T1D grounded in Acceptance and Commitment Therapy (ACT). iACT was based on the premise that ED symptoms emerge as individuals attempt to cope with T1D and related emotional distress. iACT taught acceptance and mindfulness as an alternative to maladaptive avoidance and control, and leveraged personal values to increase willingness to engage in T1D management, even when it was upsetting (e.g., after overeating). A tailored mobile application (“app”) was used in between sessions to facilitate the application of ACT skills in the moment that individuals are making decisions about their diabetes management. Methods Adults with T1D who met criteria for an ED completed 12 sessions of iACT (with three optional tapering sessions). In addition to examining whether treatment was acceptable and feasible (the primary aim of the study), the study also examined whether iACT was associated with increased psychological flexibility (i.e., the ability to have distressing thoughts/feelings about diabetes while pursuing personally meaningful values), and improvements in ED symptoms, diabetes management and diabetes distress. Results Treatment was acceptable to T1D patients with EDs and feasible to implement. Participants reported increased psychological flexibility with diabetes-related thoughts/feelings, and less obstruction and greater progress in pursuing personal values. There were large effects for change in ED symptoms, diabetes self-management and diabetes distress from baseline to end-of-treatment (Cohen’s d = .90–1.79). Hemoglobin A1c also improved, but the p-value did not reach statistical significance, p = .08. Conclusions Findings provide preliminary evidence for iACT to improve outcomes for T1D patients with EDs and support further evaluation of this approach in a controlled trial. Trial registration NCT02980627. Registered 8 July 2016.

Brief assessment of diabetes‐specific psychological flexibility in racially and income diverse youth with type 1 diabetes

“…Past diabetes studies of interventions to increase psychological flexibility have largely focused on adults with T2D, 10 racially homogenous samples, 12 and utilized modest sample sizes 13 . It is unknown if/how interventions to increase psychological flexibility can improve health and quality of life in diverse youth with T1D.…”

“…Past diabetes studies of interventions to increase psychological flexibility have largely focused on adults with T2D, 10 racially homogenous samples, 12 and utilized modest sample sizes. 13 It is unknown The results of the present study should be interpreted within its limitations.…”

“…10,11 An app-assisted ACT intervention for teens and adults with T1D and eating disorders demonstrated large effects for change in eating disorder symptoms, diabetes self-management, and diabetes distress (ds ranged from 0.90 to 1.79), and over half the sample experienced clinically meaningful reductions in HbA1c of at least 0.5%. 12 In a sample of 32 children and adolescents with type 1 or 2 diabetes, completing an ACT intervention was associated with significantly decreased total perceived stress (d = À0.93) and increased health self-efficacy (d = 2.64) compared to treatment-asusual. 13 To further develop and refine interventions for youth with T1D, it is important to have valid, reliable, and measurement invariant tools for measuring psychological flexibility.…”

“…In two randomized controlled trials (RCTs), completing a daylong ACT workshop developed for adults with T2D improved HbA1c in the ACT group compared to the control group (small‐moderate effect sizes) and improved self‐care activities (moderate effect sizes) 10,11 . An app‐assisted ACT intervention for teens and adults with T1D and eating disorders demonstrated large effects for change in eating disorder symptoms, diabetes self‐management, and diabetes distress ( d s ranged from 0.90 to 1.79), and over half the sample experienced clinically meaningful reductions in HbA1c of at least 0.5% 12 . In a sample of 32 children and adolescents with type 1 or 2 diabetes, completing an ACT intervention was associated with significantly decreased total perceived stress ( d = −0.93) and increased health self‐efficacy ( d = 2.64) compared to treatment‐as‐usual 13 .…”

Eating disorders early app use mediates treatment effect on clinical improvement

“…There is much unknown about how people work with their devices or how much they can adhere to an intervention when the setting is digital (Linardon et al, 2021). A better understanding is needed regarding whether program engagement, that is, time spent and number of tasks completed on the app, mediates digital ED program effect on clinical outcomes (Merwin et al, 2021). Additionally, early change is a predictor of overall program outcome (Hilbert et al, 2019) but has not been extensively studied in digital interventions.…”