this was a cross - sectional epidemiological survey of the nationwide , population - based norwegian childhood diabetes registry ( ncdr ) .
the participants were recruited from the ncdr between 1 april 2010 and 31 march 2011 . in our study , a total of 1816 individuals with type 1 diabetes aged 1119 years in the ncdr were invited to participate in the study .
the ncdr , a nationwide , population - based registry established in 2006 , includes all newly diagnosed children with diabetes .
all the pediatric departments in norway perform an annual examination of all their patients with diabetes and report the results to the ncdr . the final sample consisted of 770 children and adolescents with type 1 diabetes aged 1119 years ( 42.40% response rate ) .
participants were somewhat younger than nonparticipants ( 14.6 vs. 15.1 years ; p  0.001 ) , had slightly lower hba1c ( 8.5 vs. 8.7% ; p  0.01 ) , and had somewhat shorter duration of type 1 diabetes ( 5.3 vs. 6.1 years ; p  0.001 ) than nonparticipants ; however , the effect sizes were very small ( 0.2 , 0.1 , and 0.2 , respectively ) .
these groups did not differ with respect to zbmi or age at onset of type 1 diabetes .
written consent was obtained from participants and their parents , if the participant was below the age of 16 years .
questionnaires were distributed to the participants at their regularly scheduled appointments at their local outpatient diabetes clinics .
the deps ( 14 ) was the first measure designed to screen for deb in type 1 diabetes , such as insulin restriction to lose weight .
the original instrument consisted of 28 items but has recently been revised to create the deps - r , a brief 16-item version that can be completed in less than 10 min and has demonstrated good psychometric properties ( 13 ) .
responses are scored on a 6-point likert scale ranging from 0 to 5 , and higher scores indicate greater pathology . the eat ( 12 )
is a generic screening measure of eating pathology used internationally to detect pathologic eating attitudes and behaviors . a 12-item norwegian version ,
eat-12 has been developed ( 15 ) and has demonstrated adequate psychometric properties ( 16 ) .
hba1c was determined for all participants by high - performance liquid chromatography ( tosoh g7 ; tosoh europe n.v . ,
tessenderlo , belgium ) at the same central diabetes control and complications trial  standardized laboratory .
bmi was calculated from weight and height ( kg / m ) and standardized to a z - score ( zbmi ) according to age and sex because the participants were primarily younger than 18 years using the centers for disease control and prevention ( cdc ) growth charts for 2000 ( 17 ) .
weight was categorized in four groups according to the world health organization ( 18 ) : underweight ( bmi < 18.5 kg / m ) , normal weight ( bmi 18.524.9 kg / m ) , overweight ( bmi 2529.9 kg / m ) , and obese ( bmi 30 kg / m ) .
data were assessed as part of the annual extended diabetes examination at the local diabetes outpatient clinic .
nonparametric tests were used for skewed data . for the deps - r and the eat-12 ,
convergent validity between the deps - r and the eat-12 was investigated with spearman population correlation coefficient (  ) . in line with cohen
( 19 ) , correlations of 0.100.29 were interpreted as small , 0.300.49 as medium , and 0.501.0 as large .
correlations were also carried out to explore relationships with other constructs hypothesized to covary with deps - r scores , such as hba1c , zbmi , age , and sex .
a principal axis factoring ( paf ) was used to explore the factor structure of deps - r .
the data were considered suitable for paf because the kaiser - meyer - olkin measure of sampling adequacy value was > 0.6 and the bartlett test of sphericity value was significant .
effect sizes were calculated by means of cohen d value , and the guidelines used for interpreting this value were as follows : 0.20 , small effect ; 0.50 , moderate effect ; and 0.80 , large effect ( 19 ) .
statistical analyses were conducted with spss version 18 ( ibm corporation , armonk , ny ) .
this was a cross - sectional epidemiological survey of the nationwide , population - based norwegian childhood diabetes registry ( ncdr ) .
the participants were recruited from the ncdr between 1 april 2010 and 31 march 2011 . in our study , a total of 1816 individuals with type 1 diabetes aged 1119 years in the ncdr were invited to participate in the study .
the ncdr , a nationwide , population - based registry established in 2006 , includes all newly diagnosed children with diabetes .
all the pediatric departments in norway perform an annual examination of all their patients with diabetes and report the results to the ncdr . the final sample consisted of 770 children and adolescents with type 1 diabetes aged 1119 years ( 42.40% response rate ) .
participants were somewhat younger than nonparticipants ( 14.6 vs. 15.1 years ; p  0.001 ) , had slightly lower hba1c ( 8.5 vs. 8.7% ; p  0.01 ) , and had somewhat shorter duration of type 1 diabetes ( 5.3 vs. 6.1 years ; p  0.001 ) than nonparticipants ; however , the effect sizes were very small ( 0.2 , 0.1 , and 0.2 , respectively ) .
these groups did not differ with respect to zbmi or age at onset of type 1 diabetes .
was obtained from participants and their parents , if the participant was below the age of 16 years .
questionnaires were distributed to the participants at their regularly scheduled appointments at their local outpatient diabetes clinics .
the deps ( 14 ) was the first measure designed to screen for deb in type 1 diabetes , such as insulin restriction to lose weight .
the original instrument consisted of 28 items but has recently been revised to create the deps - r , a brief 16-item version that can be completed in less than 10 min and has demonstrated good psychometric properties ( 13 ) .
responses are scored on a 6-point likert scale ranging from 0 to 5 , and higher scores indicate greater pathology . the eat ( 12 )
is a generic screening measure of eating pathology used internationally to detect pathologic eating attitudes and behaviors . a 12-item norwegian version , eat-12 has been developed ( 15 ) and has demonstrated adequate psychometric properties ( 16 ) .
hba1c was determined for all participants by high - performance liquid chromatography ( tosoh g7 ; tosoh europe n.v . ,
tessenderlo , belgium ) at the same central diabetes control and complications trial  standardized laboratory .
bmi was calculated from weight and height ( kg / m ) and standardized to a z - score ( zbmi ) according to age and sex because the participants were primarily younger than 18 years using the centers for disease control and prevention ( cdc ) growth charts for 2000 ( 17 ) .
weight was categorized in four groups according to the world health organization ( 18 ) : underweight ( bmi < 18.5 kg / m ) , normal weight ( bmi 18.524.9 kg / m ) , overweight ( bmi 2529.9 kg / m ) , and obese ( bmi 30 kg / m ) .
data were assessed as part of the annual extended diabetes examination at the local diabetes outpatient clinic .
nonparametric tests were used for skewed data . for the deps - r and the eat-12 ,
convergent validity between the deps - r and the eat-12 was investigated with spearman population correlation coefficient (  ) . in line with cohen
( 19 ) , correlations of 0.100.29 were interpreted as small , 0.300.49 as medium , and 0.501.0 as large .
correlations were also carried out to explore relationships with other constructs hypothesized to covary with deps - r scores , such as hba1c , zbmi , age , and sex .
a principal axis factoring ( paf ) was used to explore the factor structure of deps - r .
the data were considered suitable for paf because the kaiser - meyer - olkin measure of sampling adequacy value was > 0.6 and the bartlett test of sphericity value was significant .
effect sizes were calculated by means of cohen d value , and the guidelines used for interpreting this value were as follows : 0.20 , small effect ; 0.50 , moderate effect ; and 0.80 , large effect ( 19 ) .
statistical analyses were conducted with spss version 18 ( ibm corporation , armonk , ny ) .
as shown below , mean age of the 770 participants was 14.6 ( 2.1 ) years and age at onset of type 1 diabetes was 8.9 ( 3.6 ) years . mean type 1 diabetes duration was 5.3 ( 3.4 ) years , mean zbmi was 0.3 ( 0.9 ) , and mean hba1c was 8.5% ( 1.4% ) .
pubertal state was categorized by tanner stage 15 as prepubertal ( tanner stage 1 ) pubertal ( tanner stage 24 ) , and postpubertal ( tanner stage 5 ) .
participant characteristics the cronbach  coefficients for the deps - r were 0.89 , 0.81 , and 0.90 for the entire sample , males , and females , respectively . for the eat-12 , coefficients were 0.74 for the whole sample , 0.63 for males , and 0.76 for females .
the deps - r was significantly and positively correlated with the eat-12 (  = 0.65 ; p  0.01 ) ( table 2 ) .
additional significant , although small , correlations were found between the deps - r and zbmi (  = 0.28 ; p  0.01 ) , hba1c (  = 0.22 ; p  0.01 ) , age (  = 0.27 ; p  0.01 ) , and sex (  = 0.27 ; p  0.01 ) .
the eat-12 was also significantly correlated with hba1c ; however , this was an even smaller correlation (  = 0.08 ; p  0.05 ) .
correlations between deps - r and eat-12 , hba1c , zbmi , age , and sex the deps - r norms ( sd ) for the total sample , males , and females were as follows : 11.0 ( 10.7 ) , 7.7 ( 7.4 ) and 14.2 ( 12.4 ) , respectively .
mean deps - r score was more than three times higher in the obese group than in the underweight group , and two times higher in the oldest than in the youngest age group .
table 3 presents the deps - r scores according to sex , age , and zbmi category .
norms according to different categories of age and weight after the suitability of data for factor analysis was assessed , paf was performed on the 16 items of the deps - r .
the kaiser - meyer - olkin value was 0.92 , and the bartlett test of sphericity reached statistical significance , supporting the factorability of the correlation matrix .
paf revealed three components with eigenvalues > 1 , explaining 38.7 , 8.5 , and 7.4% of the variance , respectively , accounting for a total of 54.6% of the variance .
on the basis of eigenvalues and inspection of the scree plot , three components were chosen for further investigation . to assist in the interpretation of these three components ,
all three components showed relatively strong loadings and items loaded exclusively on one component , with the exception of one item ( item 13 ) .
further examination of the three factors was conducted by running correlations with the deps - r total score and hba1c .
factor 1 correlated more strongly with both the deps - r total score ( 0.91 ; p < 0.001 ) and hba1c ( 0.27 ; p
< 0.001 ) than did factors 2 ( 0.88 ; p < 0.001 and 0.16 ;
p < 0.001 , respectively ) and 3 ( 0.47 ; p < 0.001 and 0.09 ; p < 0.05 , respectively )
pattern matrix for paf with oblimin rotation of three - factor solution of the deps - r items to examine sex differences in factor structure , the paf was also conducted separately for males and females .
when investigating males only , however , the intercorrelations among the items were not strong enough ( 20 ) , and consequently the data were not considered appropriate for factor analysis .
as shown below , mean age of the 770 participants was 14.6 ( 2.1 ) years and age at onset of type 1 diabetes was 8.9 ( 3.6 ) years . mean type 1 diabetes duration was 5.3 ( 3.4 ) years , mean zbmi was 0.3 ( 0.9 ) , and mean hba1c was 8.5% ( 1.4% ) .
( tanner stage 1 ) pubertal ( tanner stage 24 ) , and postpubertal ( tanner stage 5 ) . participant characteristics
the cronbach  coefficients for the deps - r were 0.89 , 0.81 , and 0.90 for the entire sample , males , and females , respectively .
for the eat-12 , coefficients were 0.74 for the whole sample , 0.63 for males , and 0.76 for females .
the deps - r was significantly and positively correlated with the eat-12 (  = 0.65 ; p  0.01 ) ( table 2 ) .
additional significant , although small , correlations were found between the deps - r and zbmi (  = 0.28 ; p  0.01 ) , hba1c (  = 0.22 ; p  0.01 ) , age (  = 0.27 ; p  0.01 ) , and sex (  = 0.27 ; p  0.01 ) . the eat-12 was also significantly correlated with hba1c ; however , this was an even smaller correlation (  = 0.08 ; p  0.05 ) .
correlations between deps - r and eat-12 , hba1c , zbmi , age , and sex
the deps - r norms ( sd ) for the total sample , males , and females were as follows : 11.0 ( 10.7 ) , 7.7 ( 7.4 ) and 14.2 ( 12.4 ) , respectively .
mean deps - r score was more than three times higher in the obese group than in the underweight group , and two times higher in the oldest than in the youngest age group .
table 3 presents the deps - r scores according to sex , age , and zbmi category .
after the suitability of data for factor analysis was assessed , paf was performed on the 16 items of the deps - r .
the kaiser - meyer - olkin value was 0.92 , and the bartlett test of sphericity reached statistical significance , supporting the factorability of the correlation matrix .
paf revealed three components with eigenvalues > 1 , explaining 38.7 , 8.5 , and 7.4% of the variance , respectively , accounting for a total of 54.6% of the variance . on the basis of eigenvalues and inspection of the scree plot ,
three components were chosen for further investigation . to assist in the interpretation of these three components ,
all three components showed relatively strong loadings and items loaded exclusively on one component , with the exception of one item ( item 13 ) .
further examination of the three factors was conducted by running correlations with the deps - r total score and hba1c .
factor 1 correlated more strongly with both the deps - r total score ( 0.91 ; p < 0.001 ) and hba1c ( 0.27 ; p
< 0.001 ) than did factors 2 ( 0.88 ; p < 0.001 and 0.16 ;
p < 0.001 , respectively ) and 3 ( 0.47 ; p < 0.001 and 0.09 ; p < 0.05 , respectively ) .
pattern matrix for paf with oblimin rotation of three - factor solution of the deps - r items to examine sex differences in factor structure , the paf was also conducted separately for males and females .
when investigating males only , however , the intercorrelations among the items were not strong enough ( 20 ) , and consequently the data were not considered appropriate for factor analysis .
this study replicates and extends previous research demonstrating the psychometric properties of the deps - r for children and adolescents .
internal consistency was found to be very good ( 0.89 ) and consistent with the original validation study of deps - r ( 13 ) , which reported a cronbach  of 0.86 . in contrast , the cronbach  for eat-12 was 0.74 in our study .
data also supported the construct validity of the deps - r , as indicated by significant and positive correlations with the eat-12 .
additional positive , although relatively weak , correlations were found with hba1c , zbmi , and age , constructs previously found to be associated with deb ( 13,21 ) .
the relatively small correlations between the deps - r and other variables are in line with earlier studies ( 13 ) .
this underscores the importance of screening for deb in young patients with type 1 diabetes , because clinical variables such as zbmi and hba1c seem to be poor indicators of deb in this population .
when comparing the deps - r with the eat-12 , the deps - r generally appears to be a better screening tool than the eat-12 for deb in young patients with type 1 diabetes .
in addition to convincing internal consistency , the deps - r was more strongly correlated with hba1c than was the eat-12 , although both correlations were relatively weak .
also , previous research comparing the deps with the 26-item eat found that deps scores were more strongly correlated with formally diagnosed eating problems than were eat scores .
these findings might be explained by the fact that the deps and the deps - r can identify diabetes - specific deb , such as insulin omission to lose weight , which is a core feature of deb in type 1 diabetes .
such diabetes - specific behaviors are not likely to be detected by the use of generic screening tools , indicating the risk of false negatives associated with these measures . norms of the deps - r were established in this study , and significant differences were found between males and females .
our results are similar to those reported in the previous deps - r validation study ( 13 ) .
the norms were additionally categorized according to zbmi and age and demonstrated a threefold increase in debs in the obese group relative to the underweight group and a twofold increase in the oldest age group ( 1719 years ) relative to the youngest age group ( 1113 years ) .
determining fixed norms is challenging because of the variability in mean scores between different weight and age categories . in a clinical setting ,
we therefore recommend interpreting the deps - r score in relation to the patients zbmi and age .
both higher zbmi and higher age appear to be risk factors for the development of debs among adolescents and children with type 1 diabetes .
this finding is consistent with studies of eating pathology in the general population ( 22,23 ) .
because the factor structure of the deps - r has not been previously reported , paf was conducted .
although our model identified three factors , it is difficult at this point to establish obvious subscales related to these three factors .
one possible interpretation is that factor 1 appears to address maladaptive eating habits , factor 2 the preoccupation with thinness or weight , and factor 3 the concept of maintaining high blood glucose values to lose weight .
further examination of the three factors showed that factor 1 correlated more strongly with hba1c than did factors 2 and 3 . even though three factors were identified , it is unclear at this time whether the deps - r would benefit from using this factor structure for scoring purposes .
the ease of administration and short administration time already make the deps - r clinically useful as a screening tool in busy clinical settings .
nonetheless , the factor structure could be worth considering for further psychometric work on the deps - r .
it is possible that scores on each factor could facilitate treatment recommendations according to which factors the individual scores highest .
as expected , and in line with other studies of deb ( 13,22 ) , females scored significantly higher than males on both the deps - r and the eat-12 .
this is consistent with previous research demonstrating that females are at higher risk of developing deb than males , both among patients with type 1 diabetes and in the general population ( 24 ) .
it is also possible that males have underreported their symptoms of eating pathology compared with females .
this has also been suggested in studies of other types of pathology ( 25,26 ) .
further , when males and females were analyzed separately , internal consistency and construct validity of the deps - r were stronger among females .
for example , the cronbach  coefficient was lower among males ( 0.81 ) than among females ( 0.90 ) .
weaker validity among males has been previously demonstrated in studies conducted with other measures of disordered eating ( 21,27 ) .
because of sex disparities in prevalence rates of disordered eating ( 28 ) , assessment tools have largely been developed with female populations ; however , some studies suggest that traditional assessments may fail to provide a comprehensive assessment of male - specific eating , weight , and shape concerns ( 29 ) .
items focused predominantly on restricted eating and a desire for thinness may not reflect the dual presence of a drive for thinness and a drive for muscularity that characterizes the lean , mesomorphic body ideal unique to boys and men .
this may contribute to the lower validity coefficients for the deps - r among males in this study and raises the general issue of whether existing screening tools provide an adequate assessment of deb among men . in norway , all patients with type 1 diabetes are offered the same modern and intensive insulin treatment independent of social status .
the strengths of this study include the high number of participants , the population - based national registry inclusive of > 95% of all eligible children and adolescents , and the validation of deps - r against an established measure of disturbed eating and somatic data .
first , the response rate was relatively low ( 42% ) , and participants were on average 6 months younger with a shorter duration of illness ; however , effect sizes were small .
second , it fails to compare the deps - r with a diagnostic interview such as the eating disorder examination ( 30 ) .
comparison with the eating disorder examination would allow an investigation of the ability of the deps - r to identify clinical eating disorder diagnoses .
future research is warranted to validate the deps - r against a diagnostic interview . in conclusion , because of the significant risks of morbidity and mortality associated with the occurrence of disordered eating and type 1 diabetes together in youth , screening and early intervention for deb should be routinely included in standard diabetes care ( 3 ) .
the deps - r is a valid screening tool for deb in type 1 diabetes , is easy to administer , and is a potentially important addition to clinical practice .
there were significant differences in deps - r scores according to sex , age , and zbmi , and we therefore recommend that these aspects be considered when interpreting deps - r scores .
 objectivethe purpose of this study was to examine the psychometric properties of the diabetes eating problem survey  revised ( deps - r ) in a large sample of young patients with type 1 diabetes , to establish norms , and to validate it against the eating attitudes test12 ( eat-12).research design and methodsa total of 770 children and adolescents aged 1119 years with type 1 diabetes completed the deps - r and the eat-12 . 
 in addition , age- and sex - standardized bmi and hba1c data were obtained from the norwegian childhood diabetes registry . 
 in addition to tests of validity , principal axis factoring was conducted to investigate the factor structure of the 16-item deps-r.resultsthe deps - r demonstrated satisfactory cronbach  ( 0.89 ) and was significantly correlated with the eat-12 ( 0.65 ; p < 0.01 ) , indicating convergent validity . 
 the mean ( sd ) deps - r scores were 11.0 ( 10.7 ) for the total sample and 7.7 ( 7.4 ) and 14.2 ( 2.4 ) for males and females , respectively.conclusionsthis study replicates and extends previous research demonstrating the psychometric properties of the abbreviated 16-item deps - r . 
 findings support the utility of this important screening tool to identify disturbed eating in young patients with type 1 diabetes . 
RESEARCH DESIGN AND METHODS
Design
Participants
Procedure
Measures
Statistical analyses
RESULTS
Participant characteristics
Internal consistency
Construct validity
Normative data
Factor analysis
CONCLUSIONS