An intensive low-energy diet programme, similar to the NHS Type 2 Diabetes Path to Remission, significantly improved eating disorder symptoms in people with type 2 diabetes and excess weight who were at risk of developing eating disorders, according to a University of Oxford study published today in The Lancet Psychiatry.
Participants enrolled in a total diet replacement (TDR) programme experienced significant improvements in eating disorder symptoms which persisted six months after the programme finished when participants had regained some weight. This directly addresses a research gap highlighted by recent National Institute for Health and Care Excellence (NICE) guidance on the use of 'Low-energy and very-low-energy diets for adults' in Overweight and obesity management, which noted a lack of evidence on the psychological impact of restrictive diets.
"As a dietitian, I've seen first-hand how both eating disorders and type 2 diabetes can impact the quality of people's lives," said lead author Dr Elena Tsompanaki , a registered dietitian who led the study as part of her doctoral research at the Nuffield Department of Primary Care Health Sciences, University of Oxford. "Our findings challenge the assumption that weight loss programmes worsen eating disorder symptoms in vulnerable people, potentially opening up important treatment options that many patients might have previously been denied."
The researchers recruited 56 participants with type 2 diabetes (diagnosed within the last six years), overweight or obesity, and existing eating disorder symptoms identified via a validated questionnaire (called Eating Disorders Examination Questionnaire or EDE-Q). Half were assigned to receive a low-energy (~860 kcal/day) TDR programme with behavioural support for six months – similar to the NHS Path to Remission programme- while the control group received usual diabetes care from their GP. It assessed four types of symptoms: restraint eating, eating concerns, shape concerns, and weight concerns.
Key findings:
Eating disorder symptoms significantly improved in the TDR group compared to usual care at 6 months (-0.8 points EDE-Q difference) and this benefit persisted at 12 months (-0.7 points).
The TDR group also saw significant reductions in depression and diabetes distress symptoms at 6 and 12 months compared to usual care.
The TDR group lost more weight at 6 months (-13.9kg vs -3.7kg), but the difference between groups was no longer statistically significant at 12 months.
- Crucially, no participants were suspected of developing a new eating disorder.
Professor Susan Jebb , OBE, study author and Professor of Diet and Population Health at the Nuffield Department of Primary Care Health Sciences, who was also involved in evaluating the NHS Path to Remission programme, commented: "The NHS Path to Remission programme is already showing promising results, with 27% of participants achieving diabetes remission at one year. Our new findings provide reassurance that these programmes can be safely offered to patients with symptoms of eating disorders, providing an opportunity for them to benefit from these effective treatments."
The findings are important as there have been concerns that weight loss programmes, like the NHS Path to Remission, might not be safe or appropriate for people at high risk of eating disorders who might otherwise benefit from weight loss.
Dr Dimitrios Koutoukidis , senior author also based at the Nuffield Department of Primary Care Health Sciences, added: "This study provides crucial reassurance that this type of intervention does not appear to harm, and may even benefit, people with type 2 diabetes already experiencing eating disorder symptoms. It suggests that receiving structured support to lose weight may improve not only the physical health of this vulnerable group but also aspects of their mental health too.
"Low-energy total diet replacement programmes can be a very effective option for those who wish to give them a go to manage their diabetes," Dr Tsompanaki concluded. "I hope these results help patients and healthcare professionals feel more confident in navigating the discussion around these treatment options."
Limitations include the small sample size and participant demographics (see Notes). The team, who worked with patient advisors throughout the study, are continuing to follow-up participants to explore how their eating disorder symptoms change in the longer term.
