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Prevalencia, factores de riesgo y terapias psicológicas asociados a la diabulimia: revisión sistemática en adolescentes y adultos<= span style=3D'font-size:24.0pt;line-height:115%;font-family:"Times New Roman",se= rif; mso-fareast-font-family:"Times New Roman";color:black'>

Prevalence, risk factors, and psychological therap= y associated with diabulimia: systematic review in adolescents and adults

= ¹

Nancy Sierra Ayala

https://orcid.org/0000-0001-6641-356X

Universidad Católi= ca de Cuenca, Ecuador.

nancy.sierra.02@est.ucacue.edu.ec

3

Johanna Cristina Luzuriaga Mera

https://orcid.org/0000-0001-85= 44-2964

Universidad Católi= ca de Cuenca, Ecuador.

johanna.luzuriaga@ucacue.edu.ec

= ²

Andrés Alexis Ramírez Coronel<= span style=3D'color:black'>

https://orcid.org/0000-0002-6996-0443

Universidad Católi= ca de Cuenca.

Laboratorio de Psicometría, Psicología Comparada y Etología, Health and Behavior Research Group (HBR) y Carrera de Enfermería Campus Azogues, Universidad Católica = de Cuenca, Ecuador.

andres.ramirez@ucacue.edu.ec

<= /span>

=

Artículo de Investigación Científica y Tecnológica

Enviado:16/12/2022

Revisado: 25/01/2023

Aceptado: 08/02/2023

Publicado:28/03/2023

DOI:      https://doi.org/10.33262/ap.v5i1.2.338

<= span style=3D'font-size:12.0pt;line-height:115%;font-family:"Times New Roman",= serif; mso-fareast-font-family:Calibri;color:blue'>

Cítese:

Sierra Ayala, N., Luzuriaga Mera, J. C., & Ramírez Coronel, A. A. (2023). Prevalencia, factores de riesgo y terapias psicológicas asociados a la diabulimia: revisión sistemática en adolescentes y adultos. AlfaPublicaciones, 5(1.2), 124–146. https://doi.org/10.33262/ap.v5i1.2.338

ALFA PUBLICACIONES, es una revista multidisciplinar, trimestral, que se public= ará en soporte electrónico tiene como misión contribuir a la &nbs= p; formación de profesionales competentes con visión humanística y crítica q= ue sean capaces de exponer sus resultados investigativos y científicos en la misma medida que se promueva mediante su intervención cambios positivos e= n la sociedad. https://alfapublicaciones.= com

La revista es editada por la Editorial Ciencia Digital (Editorial de prestigio registrada en la Cámara Ecuatoria= na de Libro con No de Afiliación 663) www.celibro.org.ec<= /a>

Esta revista está protegida bajo una licencia Creative Commons Attribution Non Commercial No Derivatives 4.0 International. Copia de la licencia: http://creativecommons.org= /licenses/by-nc-nd/4.0/

Pala= bras claves:=

Diabulimia, trastorno alimentario, diabe= tes mellitus tipo 1, prevalencia, factores de riesgo.

Resumen

Introducción. La Diabulimia (DB) hace referencia al trastor= no de la conducta alimentaria que puede manifestarse en pacientes diagnostic= ados con diabetes tipo 1, debido a que, de manera voluntaria, omiten inyectarse insulina, con el propósito de perder peso. Por lo que en torno al tema se sintetizó los resultados de las investigaciones más recientes. Objetivos. Examinar en la bibliografía de los últimos ci= nco ańos la prevalencia, factores de riesgo y terapias psicológicas asociados= a la DB en adolescentes y adultos. Además, se plantearon como objetivos específicos los siguientes: a) revisar en la literatura científica sobre = las prevalencias y terapias psicológicas de la DB en adolescente y adultos co= nsiderando la región, durante los últimos 5 ańos; y b) describir los factores de rie= sgo de la DB en adolescentes y adultos. Metodología. Revisión sistemática de la literatura científ= ica obtenida en bases de datos como: Pubmed, Scopus, Web of Science, Lilac y Google Scholar. Resultados. Luego del análisis de 32 artículos selecciona= dos que abordan a la DB se obtuvo una prevalencia promedio de 25.46 %. Los factor= es de riesgo asociados a la DB más frecuentes son: Índice de Masa Corporal a= lto, la insatisfacción con la imagen corporal, la falta de apoyo familiar, ser mujer y adolescente, presentar altos niveles de insatisfacción corporal y falta de apoyo social y familiar, asociado a los comentarios negativos so= bre el peso. El abordaje psicológico que más reporta es la Terapia Cognitiva Conductual y la técnica más efectiva es la Psicoeducación, así como las Intervenciones Psicosociales. Conclusión. En los estud= ios incluidos en esta revisión, el valor de la prevalencia no es un valor exa= cto debido a la escasez de estudios; sin embargo, se pudo evidenciar que Bras= il e Inglaterra son los países que mayor número de investigaciones realizan so= bre la temática; además, según los resultados de los estudios revisados, los pacientes de estos países presentaban un alto índice de Diabetes tipo I, = por lo que la DB es más frecuente. Los factores de riesgo mencionados en el apartado de resultados parecen ser un predictor importante para el padecimiento de DB. Respecto a las intervenciones psicológicas para el tratamiento de DB, se puede concluir que es necesaria la incorporación de diseńos longitudinales, que permitan que las investigaciones evalúen la efectivid= ad de las terapias psicológicas en el tratamiento de la diabulimia, debido a= que este tipo de estudios fueron escasos según la revisión realizada. = Área de estudio: Psicología.

Keywords:

Diabulimia, eating disorder, type 1 diabetes mellitus, prevalence, risk factors.

Abstract

Introduction: Diabulimia (DB) refers to the disorder of eating behavior that can manifest itself in patients diagnosed with type 1 diabe= tes, since they voluntarily omit to inject insulin to lose weight. Therefore, = the results of the most recent research on the subject were summarized. Ob= jectives. To review in the literature of the l= ast five years the prevalence, risk factors and psychological therapies associated with BD in adolescents and adults. In addition, the specific objectives were a) to review the scientific literature on the prevalence = and psychological therapies of BD in adolescents and adults considering the region, during the last 5 years; and b) to describe the risk factors of B= D in adolescents and adults. Methodology. Systematic review of scientif= ic literature obtained from databases such as: PubMed, Scopus, Web of Scienc= e, Lilac, and Google Scholar. Results. After the analysis of thirty-two sele= cted articles dealing with DB, an average prevalence of 25.46% was obtained. T= he most frequent risk factors associated with DB are high Body Mass Index, dissatisfaction with body image, lack of family support, being female and adolescent, presenting elevated levels of body dissatisfaction and lack of social and family support, associated with negative comments about weight= . The most reported psychological approach is Cognitive Behavioral Therapy, and= the most effective technique is Psychoeducation, as well as Psychosocial Interventions. Conclusion. In the studies included in this review,= the prevalence value is not an exact value due to the scarcity of studies; however, it could be evidenced that Brazil and England are the countries = with the greatest number of investigations on the subject; in addition, accord= ing to the results of the studies reviewed, the patients in these countries h= ad a high rate of type I diabetes, so that DB is more frequent. The risk facto= rs mentioned in the results section appear to be an important predictor for = the development of DB. Regarding psychological interventions for the treatmen= t of BD, it can be concluded that it is necessary to incorporate longitudinal designs that allow research to evaluate the effectiveness of psychological therapies in the treatment of diabulimia, since this type of studies were scarce according to the review conducted. Study: Psychology.<= o:p>

Introducción<= /b>

Un trastorno de la alimentación es una preocupación obsesiva por la comida y/o= el peso y la forma del cuerpo. Las personas con esta patología frecuentemente = presentan baja autoestima, culpa, vergüenza y secretismo; por lo tanto, se involucran= en comportamientos alimentarios desordenados. Esto puede incluir restricciones severas de la ingesta dietética, consumo rápido de grandes cantidades de alimentos (atracones), ejercicio excesivo y uso de laxantes y diuréticos pa= ra eliminar los alimentos del cuerpo a fin de evitar el aumento de peso (Chelvanayagam & James, 2018). Los trastornos alimentarios son= de dos a tres veces más comunes entre las personas con Diabetes Mellitus Tipo 1 (DM1) en comparación con la población general, al tiempo que se informan conductas alimentarias alteradas por debajo del umbral en hasta el 60% de las mujeres con DM1 ADDIN CSL_CITAT= ION {"citationItems":[{"id":"ITEM-1","itemDa= ta":{"DOI":"10.1111/dme.14108","ISSN":&q= uot;0742-3071","author":[{"dropping-particle":&quo= t;","family":"Wisting","given":"L.&= quot;,"non-dropping-particle":"","parse-names"= ;:false,"suffix":""},{"dropping-particle":&qu= ot;","family":"Snoek","given":"F.&q= uot;,"non-dropping-particle":"","parse-names"= :false,"suffix":""}],"container-title":"= Diabetic Medicine","id":"ITEM-1","issue":"6&= quot;,"issued":{"date-parts":[["2020","6= ","23"]]},"page":"1075-1076","title= ":"Terminology matters: ‘diabulimia’ is insufficient to describe eating disorders in individuals with Type 1 diabetes","type":"article-journ= al","volume":"37"},"uris":["http://= www.mendeley.com/documents/?uuid=3D13a64956-bf88-4117-b6e8-d331c8d09275&quo= t;]}],"mendeley":{"formattedCitation":"(Wisting & Snoek, 2020)","manualFormatting":"(Wisting y Snoe= k, 2020)","plainTextFormattedCitation":"(Wisting & Sno= ek, 2020)","previouslyFormattedCitation":"(Wisting & Sn= oek, 2020)"},"properties":{"noteIndex":0},"schema&= quot;:"https://github.com/citation-style-language/schema/raw/master/cs= l-citation.json"}(Wisting & Snoek, 2020).=

La DB es el trastorno de la conducta alimentaria en la que los pacientes con D= M1 restringen el uso de la insulina en cantidades suficiente para tratar de pe= rder peso, es más común en jóvenes de entre 15 y 30 ańos de edad, particularmente mujeres (Rodríguez & Llanes, 2020). El término “diabulimia” no es el diagnóstico oficial sino un término coloquial utilizado por los medios de comunicación para describir dicha condición. Se ha sugerido como término adecuado: Trastorno Alimentario con DM1 (Chelvanayagam & James, 2018). Autores como Wisting & Snoek (2020), consideran que en el caso de los profesionales, es importante adopt= ar una terminología adecuada.

La DB se caracteriza porque puede provocar la aparición temprana de complicaci= ones diabéticas graves, como ceguera y amputaciones (Sancanuto et al., 2017). Involucra una interacción compleja de factores, como la insulina, la glucosa en sangre, las emociones y la imagen corporal, que gravitan entorno= al cuidado de la diabetes y la salud mental (Torjesen, 2019).

Debido a lo expuesto, una revisión sistemática de la bibliografía respecto a la prevalencia, factores de riesgo y terapias= psicológicas asociados a la DB se constituye en una respuesta al problema evidenciado; p= or tanto, es la oportunidad para realizar una investigación que permita recole= ctar información con base científica que apoye a la implementación de tratamient= os eficaces. Esta beneficiará a los psicoterapeutas que tratan esta patología, personas que padecen el trastorno, y los futuros investigadores, quienes podrán, a partir de los datos, ampliar sus respectivos estudios.=

Pese a que la DB en pacientes con DM1 ha sido el foco principal de atención clín= ica y mediática, este trastorno también ocurre en personas con Diabetes Mellitus Tipo 2 (en adelante DM2). A su vez, el trastorno por atracón es una de las formas más habituales de trastorno alimentario en este grupo, su presencia tiene un efecto directo sobre la Hemoglobina Glicosilada (en adelante HbA1c= ), aunque también puede haber un efecto indirecto mediado por el Índice de Masa Corporal (en adelante IMC) (Winston, 2020).

Apuntan Chelvanayagam & James (2018), que detectar= la DB es un reto, por lo que los profesionales de la salud deben estar atentos al evaluar las razones del control glucémico variable y los cambios de peso. A criterio de estos autores, el manejo requiere una respuesta colaborativa del equipo de especialistas en diabetes junto con el equipo de salud mental. La= falta de pautas e integración entre las vías de atención especializada han sido seńaladas como factores que dificultan el diagnóstico (Zaremba et al., 2020).

Dicha dificultad diagnóstica puede deberse también a la sintomatología del trasto= rno relacionada con el estado hiperglucémico cuya persistencia se debe al tiemp= o y frecuencia de la DB, lo que implica la gravedad de los síntomas y aumento d= e la HbA1c (Hall et al., 2021).

Los factores relacionados que comúnmente afectan las características conductual= es involucradas en la aparición de la DB son: la relación familiar y de amigos= , el ser mujer, los factores culturales, ambientales, así como las propiedades cognitivas y físicas (Kinik et al., 2017). A su vez, entre el 30 y el 40% de las mujeres adolescentes y jó= venes no se administran la insulina en cantidades suficientes ya que regularmente= lo asocian con la pérdida de peso (Davidson, 2014). También un IMC más alto antes del diagnóstico, baja autoestima o antecedent= es de depresión, insatisfacción corporal, diagnóstico de diabetes entre los 7 = y 18 ańos de edad, y los antecedentes familiares de dieta o trastornos de la alimentación (Candler et al., 2018). Otros factores pueden ser los comentarios negativos de familiares, amigos y conocidos, y posiblemente la disminución de la vida sexual y las dudas sobre su aceptación por parte del sexo opuesto (Karastogiannidou et al., 2021).

En cuanto al tratamiento de este trastorno, la Terapia Cognitivo Conductual ba= sada en la relación colaborativa entre terapeuta y paciente genera un marco en el que el paciente descubre los procesos de identificación y evaluación de los pensamientos disfuncionales. Por tal razón, el objetivo de esta terapia es modificar aquellas creencias disfuncionales y proporcionarles a los pacient= es los métodos que les permitirán analizar en el futuro distintas creencias. <= /span>Callum & Lewis (2014), por su parte, consideran que la= Terapia Cognitivo-Conductual es la primera estrategia para el tratamiento de los trastornos alimentarios. Es así como este curso de tratamiento tiene una ta= sa de éxito del 40-50% en conseguir cambios a largo plazo en la conducta alimentaria de los pacientes.

Este modelo aplicado consta de 4 etapas y tiene un tiempo limitado (generalmente= 20 sesiones). Incluye la creación conjunta de una formulación, el monitoreo de= la alimentación y vinculación de este con pensamientos, emociones y comportamientos subyacentes. Una de las técnicas de mayor uso es la Psicoed= ucación que está dirigida a la reflexión sobre los efectos del mal uso de la insuli= na, las complicaciones físicas y los efectos adversos asociados con los comportamientos desadaptativos, además de control del peso, la alimentación constante y regular, una dieta equilibrada con una variedad de alimentos. El terapeuta aborda los pensamientos, sentimientos y comportamientos desadapta= tivos, incluida la sobreevaluación de la forma/peso del cuerpo y la comprensión del mecanismo de restricción dietética y los eventos que desencadenan los comportamientos disruptivos. A los pacientes se les enseńan habilidades que incluyen la resolución de problemas y métodos para regular los patrones del estado de ánimo. A medida que la terapia llega a su fin, tanto el paciente = como el terapeuta se concentran en diseńar un plan de prevención de recaída. En el caso puntual del manejo nutricional, se derivan a profesional del área cuyo objetivo es normalizar y estabilizar la dieta introduciendo comidas regulares (3 comidas y 3 refrige= rios al día) y fomentando una dieta equilibrada. La frecuencia de los refrigerios debe correlacionarse con el momento de las inyecciones de insulina. Debe ha= ber cierta flexibilidad con la dieta y un énfasis inicial en garantizar la seguridad del paciente (Partridge et al., 2020).

De la misma forma, las intervenciones psicosociales han demostrado su eficacia= en la reducción de síntomas; las posiblemente eficaces incluyen la terapia bas= ada en la familia y terapia individual de apoyo (Lock, 2015), la primera según Datta et al. (2022), era superior para lograr tasas de remisión -Nivel 1, b= ien establecido-. Esta terapia fomenta el control de los padres y el manejo de = los comportamientos de los trastornos alimentarios sin énfasis en cambiar el pensamiento patológico relacionado con la forma y el peso (Le Grange et al., 2015). Además, las intervenciones psicosociales pueden tener un efecto posi= tivo sobre el control metabólico (Torales et al., 2016).

Además, se recomienda aplicar un tratamiento de insulina flexible y realista y un régimen de control de glucosa en sangre, adaptado al estilo de vida del pac= iente. Estas intervenciones pueden reducir los episodios de atracón, ya que permit= en al paciente distinguir y controlar los episodios de hipoglucemia, que pueden ser un antecedente. Pueden promover cambios en la dieta y apoyar el cumplimiento de una ingesta con un índice glucémico más bajo. Considerando la necesidad de un equipo multidisciplinario en el tratamiento de= los pacientes con DB se considera nece= sario la evaluación psiquiátrica ya que el uso de antidepresivos han demostrado eficacia e= n el manejo de los síntomas afectivos asociados al diagnóstico de DB (Yahya et al., 2020).

Por lo que se consideró como objetivo central el examinar en la literatura científica la prevalencia, los factores de riesgo y las terapias psicológic= as asociados a la diabulimia en adolescentes y adultos mediante una revisión sistemática de la literatura.

Metodología

La calidad de la presente revisión sistemá= tica se basó en Preferred Reporting Items for Systematic reviews and Meta Analyses (P= RISMA). Se la desarrollo empleando las bases de da= tos: Pubmed, Scopus, Web of Science, Lilac y Google Scholar. Se emplearon las palabras clave “diabulimia”, “eating disorder”, “diabe= tes mellitus type 1”, “prevalence” y “risk factors”, usadas de ma= nera directa o combinada. Los artículos considerados para el presente análisis s= on 32 (ver figura 1).

Se cumplieron los siguientes criterios de inclusión: artículos de revistas académicas indexadas, publicados en el per= iodo 2017-2022, investigaciones de áreas como: Psicología, Psicoterapia, Medicin= a, Enfermería, Pediatría y Psiquiatría; muestra poblacional con adolescentes y adultos; estudios cuantitativos, cualitativos, correlacionales, validaciones de instrumentos; así como estudios entorno a la DB en personas con DM1 y publicados en el idioma inglés, portugués y espańol. A su vez, se excluyero= n: artículos con mayor data a la indicada, que no contemplen el tema completo, estudios de caso, revisiones bibliográficas, metaanálisis, tesis o investig= aciones de pregrado o posgrado, cartas al editor, reportajes y reseńas de libros.

Resultados

Investigaciones seleccionadas en la base de datos:

Tabla 1

Síntesis de los artículos seleccionados ordenados según región

A= utor/ańo

R= evista / Cuartil

B= ase de datos

P= aís

M= etodología

M= uestra/rango de edad/media de edad

P= revalencia de Diabulimia (%)<= /span>

F= actores de riesgo

T= erapias/ Técnicas y Enfoques

América

Gib= bings et al. (2021)

Diabetes care

Q1

Web of Science

Canadá

Correlacional

Longitudinal

168 con TA y 1.680 sin TA

8,0

Trastornos alimentarios

Terapia Cognitiva Conductua= l

Psicoeducación

Mer= win et al. (2018)

Psychosomatic Medicine=

Q1

Web of Science

EE. UU

Correlacional

Prospectivo

59 (+18)<= /p>

15,5

Edad, IMC, inicio de DM1

Terapia Cognitiva Conductua= l

Intervención psicológica

Kah= koska et al. (2018)

Obesity Medicine=

Q3

Scopus

EE. UU

Correlacional

Prospectivo

34 (12-17 ańos / mediana 14= ,4)

26,7

Ser mujer=

Terapia Cognitiva Conductua= l

Intervención psicosocial

Smi= th et al. (2020)

Jou= rnal of Pediatric Psychology

Q1<= o:p>

Web of Science

EE. UU

Correlacional

Prospectivo

818 (13-25 ańos)=

20,7

Ser mujer e insatisfacción corporal

Terapia Cognitiva Conductua= l

Psicoeducación

Ben= ítez-Agudelo et al. (2017)

Anuario de Psicología<= /o:p>

Q4

Google Scholar

Colombia<= /p>

Correlacional

Transversal

60 con DM2 - 30 con diabetes controlada y 30 con diabetes no controlada DNC (40-70 ańos)

59,0

Síntomas somáticos y depres= ión

Terapia Familiar=

Cos= ta et al., (2017)

Medicina (B. Aires)

Q4

Google Scholar

Argentina=

Correlacional

Transversal

433 pacientes con DM1 y 823= con DM2

12,0

Pacientes = con hipoglucemias, diabetes que reciben insulina alta

Terapia Cognitiva Conductua= l

Psicoeducación

Cardoso & Pimenta (2019)

Psi= que

Q4<= o:p>

Goo= gle Scholar

Bra= sil

Cor= relacional

Pro= spectivo

34 = con DM1 (18 - 55 ańos)

8,2=

Cas= os de diabetes en familia, conducta alimentaria

IMC alto

Ter= apia Cognitiva Conductual

Int= ervención Psicosocial

Gri= golon et al. (2019)

Eat= ing and Weight Disorders - Studies on Anorexia, Bulimia and Obesity

Q2

Scopus

Brasil

Correlacional=

Transversal

50 mujeres con DM1 y 100 sanas (11-16 ańos)

20,7

Trastornos alimentarios, IMC alto

Terapia Cognitiva Conductual

Psicoeducación

Rib= eiro et al. (2021)

Escola Anna Nery

Q3

LILAC=

Brasil

Cualitativo
Narración oral

4 mujeres (18-30 ańos)

3,2

Ser mujer

Terapia Cognitiva Conductual

Psicoeducación

Fri= tzen et al. (2021)

Arc= hives of Endocrinology and Metabolism

Q3<= o:p>

Google Scholar

Brasil

Correlacional=

Transversal

166 / 53,6% mujeres (22-45 ańos)

47,6

Angustia emocional <= /span>

Terapia Cognitiva Conductual

Psicoeducación

Eur= opa

Fal= căo & Francisco (2017)

Eat= ing and Weight Disorders - Studies on Anorexia, Bulimia and Obesity

Q2

PubMed

Portugal

Correlacional=

Prospectivo

128 (18-30 ańos)

2,5

Insatisfacción con imagen corporal=

Terapia Cognitiva Conductual

Intervención psicosocial

Tro= ncone et al. (2018)

Jou= rnal of Psychosomatic Research

Q1<= o:p>

Scopus

Italia

Correlacional=

Longitudinal<= /p>

81 (42 hombres, 39 mujeres) con DM1 (10-15 ań= os)

47,8

Presión social y IMC alto

Terapia Cognitiva Conductual

Psicoeducación

Calcaterra et al. (2020)

Dia= gnostics

Q2<= o:p>

Sco= pus

Ita= lia

Cua= ntitativo

Exp= loratorio

Tra= nsversal

40 = con DM1 (edad media 15,0 ± 2,6 ańos)

24,= 62

Ser mujer

Ter= apia de conducta y Familiar

Troncone et al. (2021)

Journal of Clin. Psyc. in Med. Set.

Q2<= o:p>

Sco= pus

Ita= lia

Cor= relacional

Tra= nsversal

200 (edad media: 15,24 ± 1,45)

36,= 5

IMC alto

Ter= apia Cognitiva Conductual

Psi= coeducación

Thomas et al. (2020)

Tec= hnical Report

Q4<= /span>

Goo= gle Scholar

Nue= va Zelanda

Cua= litativo

Des= criptivo

Ent= revistas

7 mujeres (18-37 ańos)

23,= 5

Con= trol glucémico, preocupación por ganar peso y desórdenes alimenticios, falta de apoyo familiar

Ter= apia Cognitiva Conductual

Int= ervención Psicosocial

Tabla 1=

Síntesis de los artículos seleccionados ordenados según región (continuación)=

Autor/ańo

Revista / Cuartil

Base de datos

País

Metodología

Muestra/rango de edad/media de edad

Prevalencia de Diabulimia (%)

Factores de riesgo

Terapias/ Técnicas y Enfoques

Coleman & Caswell (2020)

BMC Psychology

Q1 =

Pub= med

Ing= laterra

Cua= litativo

Exp= loratorio

45 adultos

87,= 0

IMC alto

Ter= apia Cognitiva Conductual y terapia Familiar

Partridge et al. (2020)

Pra= ctical Diabetes

Q4<= o:p>

Sco= pus

Ing= laterra

Cua= litativo

Des= criptivo

Ent= revistas

11 (19-69 ańos)

8,2=

Con= texto Familiar, comentarios negativos

Ter= apia Cognitiva Conductual

Zaremba et al. (2022)

Dia= betic Medicine

Q1<= o:p>

Sco= pus

Ing= laterra

Cua= litativo

Ent= revistas

15 = con DM1 (33 ± 11 ańos)

7,3=

Pre= sión perfeccionista

Ter= apia Cognitiva Conductual

Brewster et al. (2020)

British Journal of Diabetes

Q4

Web= of Science

Ing= laterra

Des= criptivo

Pro= spectivo

848 profesionales de la salud

39,= 0

Tra= stornos alimentarios

Ter= apia Cognitiva Conductual

Psi= coeducación

Verbist & Condon (2021)

Journal of Health Psychology

Q2

Sco= pus

Ing= laterra

Mix= to

Des= criptivo

Tra= nsversal

121= con DM1 (88% mujeres) / edad medi= a: 36 ± 6,5

51,= 2

IMC alto

Ter= apia Cognitiva Conductual

Apergi et al. (2020)

Psy= chiatriki

Q3<= o:p>

Pub= med

Gre= cia

Cua= ntitativo

Cor= relacional

100 (18-65 ańos)

35<= span style=3D'mso-bidi-font-style:italic'>,0

IMC alto

Ter= apia Cognitiva Conductual

Karastogiannidou et al. (2021)<= !--[if supportFields]>

Nut= rients

Q1<= o:p>

Pub= med

Gre= cia

Cor= relacional

Tra= nsversal

103 (76% mujeres) / edad media: 37

3,0=

IMC alto

Ter= apia Cognitiva Conductual

Nilsson et al. (2020)

Ped= iatric Diabetes

Q1<= o:p>

Sco= pus

Din= amarca

Cua= ntitativo

Cor= relacional

Tra= nsversal

192 (11-19 ańos)

38,= 6

Ser mujer

Ter= apia Cognitiva Conductual

Doyle et al. (2017)

Journal of Pediatric Health Care

Q3

Goo= gle Scholar

Din= amarca

Cor= relacional

Pro= spectivo

27 mujeres y 33 hombres (21 ± 2,5 ańos)

25,= 0

Sob= repeso y mal control glucémico.

Ter= apia Cognitiva Conductual

Şahin-Bodur et al. (2021)<= !--[if supportFields]>

Nut= rition Clinique et Métabolisme

Q4<= o:p>

Sco= pus

Tur= quía

Cor= relacional

Tra= nsversal

110 (hombres: 51,8%, mujeres: (48= ,2%) (10-19 ańos)

13,= 2

Ado= lescentes ser mujeres y dieta inadecuada

Ter= apia Cognitiva Conductual

Psi= coeducación

Akgül et al. (2018)

Journal of Pediatric Endocrinology and Metabolism

Q2<= o:p>

Sco= pus

Tur= quía

Cor= relacional

Tra= nsversal

24 hermanos sanos y 29 reclutados de la clínica ambulatoria sin antecedentes familiares de DM1 (10-18 ańos)

17,= 2

Eta= pa desarrollo adolescentes, IMC alto

Ter= apia familiar

Turan et al. (2022)

Ege Tıp Dergisi

Q4<= o:p>

Goo= gle Scholar

Tur= quía

Cor= relacional

Pro= spectivo

129= con DM1 (10-18 ańos)

36,= 4

IMC alto

Ter= apia Cognitiva Conductual

Lica et al. (2021)

Chi= ldren

Q2<= o:p>

Sco= pus

Rum= ania

Cor= relacional

Tra= nsversal

54 insulinodependiente y 52 sin diabetes (12 a 18 ańos)

34,= 2

Ser mujer

Ter= apia Cognitiva Conductual

Psi= coeducación

África

Olamoyegun et al. (2018)

Afr= ican Health Sciences

Q3<= o:p>

Web= of Science

Nig= eria

Cor= relacional

Pro= spectivo

213= / 9,9 % con DM1 y 90,1% con DM2 / edad media 58,6 ± 13= ,1

9,9=

Pac= ientes con tratamientos de insulina

Ter= apia Cognitiva Conductual

Int= ervención Psicosocial

Salah et al. (2022)

Journal of Eating Disorders

Q2

Web= of Science

Egi= pto

Cor= relacional

Pro= spectivo

60 = con DM1 / (12 - 17 ańos)

10,= 0

Ser mujer, aspectos emocionales, distorsión de imagen corporal, hipoglucemia =

Ter= apias convencionales para trastornos alimentarios

Asia

Al Hourani et al. (2020)

Eastern Mediterranean Health Journal

Q3

Web= of Science

Jor= dania

Cua= ntitativo

Cor= relacional

Pro= spectivo

497= con disglucemia (DG) y 504 sin disglucemia (SDG) (10-24 ańos)

11,= 9

Est= ilo de vida sedentario, falta de apoyo familiar

Ter= apia Cognitiva Conductual

Psi= coeducación

Aus= tralia

Watt et al. (2022)

Health & Social Care in the Community=

Q1<= o:p>

Sco= pus

Aus= tralia

Cor= relacional

Tra= nsversal

199= con TA (18 - 65 ańos)

31<= i>,0

Ser mujer

Fal= ta de control glucémico, conductas alimentarias desordenadas

Ter= apia Cognitiva Conductual

Psi= coeducación

Resultados y Discusión

Como producto de esta investigación se seleccionaron 32 artículos para determina= r la prevalencia, los factores de riesgo y terapias psicológicas asociados a la = DB en adolescentes y adultos. Los artículos seleccionados fueron, en su mayorí= a, estudios cuantitativos correlacionales (71%), seguidos de estudios cualitativos (18%) y estudios descriptivos (11%).<= o:p>

De estos estudios, considerando la región, los de Brasil e Inglaterra son los = que tienen mayor presencia porcentual en la selección final: 15% respectivamente. A su vez, las investigaciones desarrolladas en Italia, EE. UU y Turquía ocupan el 9% de la muestra, respectivamente, el porcentaje de diferencia está distribuido entr= e: Dinamarca, Grecia, Portugal, Colombia, Argentina, Nigeria, Nueva Zelanda, Jordania, Rumania, Canadá, Australia y Egipto.

Prevalencia=

Las investigaciones seleccionadas trabajaron con muestras de adultos en el 41% de los casos, y con población adolescente en el 59% restante.= La prevalencia de la DB en los estudios fue de 25.46 %. Esto permite constatar que, en líneas generales, los datos obtenidos no difieren significativamente de investigaciones previas; particularmente de aquellas revisiones bibliográfi= cas entorno a la DB, desarrolladas en ańos anteriores (De Paoli & Rogers, 2= 017; Ripoli et al., 2022; Hall et al., 2021).

Figura 2

Prevalencia de Diabulimi= a en función a los estudios revisados

La figura 2 permite constatar que en el contexto inglés se identificó el estud= io con un mayor nivel de prevalencia (87%), seguido por una investigación en Colombia, en la que se obtuvo una prevalen= cia del 59%: En los estudios desarrollados en Italia, Dinamarca, Rumania, Turquía, Brasil, Grecia y Australia se obtuvieron porcentajes entre el 40% al 30%, mientras = que en los países restantes el valor va del 29% al 2.5%. Estos resultados se corresponden con los obtenidos por Torjesen (2019), quien refleja que la ma= yor incidencia de ingresos hospitalarios por DB fue en Inglaterra y Gales.

Factores de riesgo

La literatura científica de los últimos cinco ańos identifica como factores de riesgo asociados a la presencia de DB los siguientes: la presencia de IMC alto fue un factor = de riesgo evidenciado por varios de los estudios (Akgül= et al., 2018; Tronc= one et al., 2018; Merwi= n et al., 2018; Cardo= so & Pimenta, 2019; Grigo= lon et al., 2019; Aperg= i et al., 2020; Karas= togiannidou et al., 2021; Verbi= st & Condon, 2021; Tronc= one et al., 2021; Turan= et al., 2022). Este resultado coincide con lo referido en la revisión sistemática de ADDIN CSL_CITAT= ION {"citationItems":[{"id":"ITEM-1","itemDa= ta":{"DOI":"10.12740/pp/39536","ISSN":&q= uot;0033-2674","abstract":"Cukrzyca wiąże się ze zwiększonym ryzykiem występowania problemów z odżywianiem, różnych w zależności od typu cukrzycy. Zespół napadowego objadania się występuje częściej u pacjentów z cukrzycą typu 2. Z kolei intencjonalne pomijanie dawek insuliny w celu uzyskania spadku masy ciała wystę= puje głównie wśród chorych z cukrzycą typu 1, choć u niektór= ych osób z cukrzycą typu 2 można również odnotować pomijanie dawek doustnych leków przeciwcukrzycowych. Do czynników ryzyka rozwoju zaburzeń odżywiania w przypadku pacjentów z cukrzycą należą: wiek, płeć żeńska, wyższa masa ciała, niezadowolenie z wyglądu własnego ciała, stosowa= nie w przeszłości różnych diet, dodatni wywiad w kierunku depres= ji. Słaba kontrola glikemii, nawracające epizody kwasicy ketonowej, c= zy też nawracająca hipoglikemia, wtórna do intencjonalnego przedawko= wania insuliny, nie zgłaszanie się na kontrolne wizyty lekarskie, manipulowanie posiłkami oraz obniżona samoocena powinny wzbudza&#= 263; niepokój. Konsekwencją zaburzeń odżywiania lub nieprawidłowych wzorców odżywiania u osób z cukrzycą jest słaba kontrola glikemii, a co za tym idzie większe ryzyko rozwoju powikłań tj. nefropatii, retinopatii czy przedwczesnego zgonu.Diabetes is associated with increased risk for eating disorders, vari= ous dependent on type of diabetes. Binge eating disorder is more common in pati= ent with type 2 diabetes (T2DM). Whereas, intentional omission of insulin doses for = the purpose of weight loss occurs mainly in patient with type 1 diabetes (T1DM), however, in some patients with type 2 diabetes omission of oral hypoglycemic drugs can be present. Risk factors for the development of eating disorders = in patients with diabetes include: age, female gender, greater body weight, bo= dy image dissatisfaction, history of dieting and history of depression. Poor glycemic control, recurrent episodes of ketoacidosis or recurrent episodes = of hypoglycemia, secondary to intentional insulin overdose, missed clinical appointments, dietary manipulation and low self-esteem should raise concern. The consequence of eating disorders or disordered eating patterns in patien= ts with diabetes is poor glycemic control and hence higher possibility of complications such as nephropathy, retinopathy and premature death.","author":[{"dropping-particle":""= ;,"family":"Racicka","given":"Ewa",= "non-dropping-particle":"","parse-names":fals= e,"suffix":""},{"dropping-particle":"&qu= ot;,"family":"Bryńska","given":"Ani= ta","non-dropping-particle":"","parse-names&q= uot;:false,"suffix":""}],"container-title":&q= uot;Psychiatria Polska","id":"ITEM-1","issue":"5&qu= ot;,"issued":{"date-parts":[["2015"]]},"= page":"1017-1024","title":"Eating Disorders in children and adolescents with Type 1 and Type 2 Diabetes: prevalence, risk factors, warning signs.","type":"article-journal","volume"= ;:"49"},"uris":["http://www.mendeley.com/documents= /?uuid=3Dba69cf7f-9936-4743-b602-ec83d7da7b73"]}],"mendeley"= :{"formattedCitation":"(Racicka & Bryńska, 2015)","manualFormatting":"Racicka y Bryńska (2015)","plainTextFormattedCitation":"(Rac= icka & Bryńska, 2015)","previouslyFormattedCitation":&qu= ot;(Racicka & Bryńska, 2015)"},"properties":{"noteIndex":0},"schema&= quot;:"https://github.com/citation-style-language/schema/raw/master/cs= l-citation.json"}Racic= ka & Bryńska (2015), don= de el IMC alto era uno de los factores de riesgo más presentes alrededor de los trastornos alimentarios en pacientes con diabetes tipo 1.

A su vez, otro factor identificado fue la insatisfacción con respecto a la im= agen corporal (Falcăo & Francisco, 2017; Troncone et al., 2018; Cardoso & Pimenta, 2019; Thomas et al., 2020; Verbist & Condon, 2021; Troncone et al., 2021; Ribeiro et al., 2021; Zaremba et al., 2022). Con estos resultado= s se ratifica lo apuntado en investigaciones previas, como es el caso de = Kinik et al. (2017) o Candler et al. (2018), quienes, a través de revisiones bibliográficas en periodos anteriores, también identificaron a la insatisfacción respecto a la imagen corporal, como factor asociado de la DB. Esto lleva a reflexionar sobre la importancia de la autopercepción positiva; pues cuando una persona acepta y respeta su cuerpo, se constituye en un fac= tor protector que puede disminuir la susceptibilidad a desarrollar un trastorno alimentario (MacNeill et al., 2017).

Otro factor de riesgo identificado en varios de los artículos revisados es la pe= rtenencia ser mujer (Nilsson et al., 2020; Smith et al., 2020; Ribeiro et al., 2021; Fritzen et al., 2021; Watt et al., 2022). Sin embargo, el estudio correlaci= onal prospectivo de Salah et al. (2022), llevado a cabo con 60 adolescentes egipcios, no encontró asociación significativa entre el género y la presenc= ia de DB. En tal caso, la identificación de ser mujer como factor asociado a l= a DB coincide con una revisión bibliográfica previa, que a partir de la explorac= ión de artículos publicados hasta el ańo 2019 identificaba dicho factor (Wisting & Snoek, 2020).

Sin embargo, es importante referir que uno de los artículos sistematizados no arrojó asociación significativa entre el sexo y la presencia de DB (Smith et al., 2020). Mientras que respecto de estos resultados Hall et al. (2021), destacaba que el ser mujer, sup= one mayor susceptibilidad a desarrollar trastornos alimentarios. Esta diferenci= a, puede deberse a la desigualdad en el número de participantes de cada estudi= o, así como a la generalización al hablar de trastornos alimentarios.

Cuarto factor identificado fue la falta de apoyo familiar; así fue referido por dos estudios (Thomas et al., 2020; Partridge et al., 2020). La identificación de dicho factor aproxima los hallazgos de la presente revisión con el trabajo = de Hastings et al. (2016), el cual, a partir de un análisis temático de las transcripciones de cinco grupos focales integrados por miem= bros de un equipo de apoyo en línea para personas con DB, determinó que los participantes reconocieron que la falta de apoyo familiar resulta un elemen= to clave para la recuperación, pues impide la validación externa de la identid= ad de recuperación, imposibilita la generación de estímulos para revelar la enfermedad a otras personas que podrían brindar apoyo e impide las interacciones positivas.

Por último, la edad también fue un factor de riesgo referido en los artículos seleccionados; es el caso del estudio de Al Hourani et al. (2020), que planteó = que las mujeres de menor edad son más propensas a padecer DB u otros desórdenes alimenticios; factor que ya fue referido en una revisión sistemática previa= de Rodríguez & Llanes (2020), donde se constataba que la DB resulta más co= mún en jóvenes de entre 15 y 30 ańos, particularmente mujeres. Así mismo en el estudio de Torjesen (2019), se apuntaba = que la DB resulta más común en jóvenes de entre 15 y 30 ańos de edad, particularmente mujeres.

Terapias y técnicas psicológicas

Los artículos seleccionados refirieron que, frente a los Trastornos de Conducta= Alimentaria en pacientes con Diabetes Mellitus tipo I, son varias las posibilidades y se destacan: Terapia Cognitiva Conductual, la Psicoeducación, y la Intervenció= n Psicosocial.

Respecto a la Psicoeducación, particularmente aquella que se enfoca en los trastorno= s de la conducta alimentaria. Hernández & Llanes (2020), sugirieren q= ue dicha terapia debía enfocarse en procesos que reestructuren la imagen corpo= ral, así como una autoestima favorable. Por su parte Thomas et al. (2020), agreg= aban que las intervenciones psicoeducativas con mujeres jóvenes deben tener como objetivo mejorar la autoeficacia en relación con el control de la diabetes,= la autoestima y el perfeccionismo.

En la presente revisión bibliográfica, se constató que el 47% de los artículos, recomendaron iniciar terapias psicoeducativ= as posterior al diagnóstico (Gibbings et al., 2021; Smith et al., 2020; Costa = et al., 2017; Grigolon et al., 2019; Ribeiro et al., 2021; Fritzen et al., 202= 1; Troncone et al., 2018; Troncone et al., 2021; Brewster et al., 2020; Verbis= t & Condon, 2021; Şahin-Bodur et al., 2021; Lica et al., 2021; Watt et al., 2022; Nilsson et al., 2020; Al Hourani et al., 2020). Estos resultados evid= encian su importancia, puesto que la Psicoeducación ha sido ratificada como una de= las técnicas más efectivas para el tratamiento de la diabulimia y otros desórde= nes en pacientes con diabetes (Luque et al., 2022).

La terapia mayormente referida en los artículos seleccionados es la Terapia Cognitiva Conductual el 12% de = la bibliografía analizada la nombran (Coleman & Caswell, 2020; Zaremba et = al., 2022; Doyle et al., 2017; Turan et al., 2022). Esta se sustenta en el Model= o Cognitivo Conductual a criterio de Hernández-Lira & Sánchez-Sánchez (2007), se constituy= e en un método colaborativo, que parte de la idea que las personas modifican su manera de pensar de modo más rápido si los motivos o las razones para cambi= ar se originan a partir de su propia introspección.

Otra de las terapias más referidas por la literatura científica fue la Intervenc= ión Psicosocial. Dicha terapia estuvo presente en el 12% de los estudios seleccionados (Cardoso & Pimenta, 2019; Falcăo & Francisco, 2017; Thomas et al., 2020; Olamoyegun et al., 2018). Fue definida por Alvis-Rizzo (2009), como una actividad dirigida a la solución de problemáticas sociales, que privilegia = la participación mancomunada tanto de intervenidos como de interventores en la construcción del cambio social y la emancipación. Respecto a la Intervenció= n Psicosocial Torales et al. (2016), refieren que= son diversos los investigadores que han centrado su trabajo en evaluar los distintos tipos de intervenciones psicológicas y sus efectos específicos en pacientes con diabetes. En general, las principales conclusiones son que las intervenciones psicosociales y el entrenamiento en estrategias de afrontami= ento están entre las que pueden tener un efecto positivo sobre el control metabólico.

En el estudio de Partridge et al. (2020), se seńaló que, en el caso de la= DB, además de las terapias psicológicas más formales que se ofrecen, existe un enfoque psicológico general, el cual incluye: desarrollo de compromiso, don= de se busca comprender las dificultades desde la perspectiva de la persona y a partir de ello acompańarla.

Por su parte Zaremba et al. (2022), se limitaron a presentar un kit= de herramientas, que consta de planti= llas de tratamiento, una guía de sesiones en terapia cognitiva conductual, herramientas de Psicoeducación y ejercicios para personas con DM1. Por últi= mo Merwin et al. (2018), proponen que los apoyos terapéuticos para personas con DB deben brindarse sin tener que depender de la autoconciencia de los pacientes.

Ante esto, hacen falta estudios que indaguen a mayor profundidad la efectividad = de las terapias psicológicas para la DB.

Limitaciones

Se identificaron ciertas limitaciones en la presente revisión sistemática: en primer lugar, puesto que se trata de un campo de estudio todavía novedoso, = existen pocos estudios a nivel mundial desarrollados entorno a los objetivos plante= ados al inicio de la investigación. En segundo lugar, hubo la existencia de un s= esgo involuntario en la revisión, debido a que se excluyeron artículos como revisiones sistemáticas bibliográficas, metaanálisis o estudios de caso, a partir de la aplicación de los criterios de inclusión y exclusión ya que es= tos estudios al no ser empíricos no realizan un análisis de prevalencia en una población, motivo por el cual se excluyeron; descritos en el acápite correspondiente. = La inclusión de revisiones bibliográficas, meta análisis o estudios de caso si= hubiese permitido identificar terapias psicológicas para el tratamiento de la diabulimia.

Respecto a las terapias psicológicas analizadas en los estudios, cabe mencionar que,= la aproximación a las diferentes terapias se redujo a una breve referencia al tratamiento específico psicológico para la DB, sin describir a profundidad = sus características.

Limitaciones en el di= seńo metodológico de los estudios

En líneas generales, los estudios presentan ciertas limitaciones tanto en lo metodológico como en el tamańo de las muestras. El reducido tamańo de la población con la que se trabajó, por ejemplo, fue una de las particularidad= es referidas por los propios investigadores. A su vez, en ciertos estudios com= o es el caso de Verbist & Condon (2021), los datos obtenidos no infirier= on causalidad.

Por otra parte, se presentaron posibles sesgos de selección, pues ciertos participantes que expresaron mayor interés por involucrarse en el estudio estuvieron más comprometidos a ofrecer información que otros (Troncone et al., 2021). A su vez, la falta de aleatorización en ciertas investigaciones socavó su capacidad para establec= er relaciones causales (Salah et al., 2022). Por último, varias investigacio= nes destacaron lo que es una característica de las investigaciones en torno a la DB: la incipiente producción científica sobre el tema, especialmente en el contexto latinoamericano y en la dimensión subjetiva de las mujeres con DM = (Ribeiro et al., 2021).

Conclusiones

·      =    El escaso número de estudios que midie= ron la prevalencia de DB, impide generalizar los resultados y atribuirla a contextos distintos, como puede ser el latinoamericano o más específicament= e el ecuatoriano.

·      =    La literatura científica de los últimos cinco ańos identifica como factores de riesgo asociados a la presencia de D= B, los siguientes: en primer lugar, un IMC alto; segundo, la insatisfacción con respecto a la imagen corporal; tercero, el ser mujer. En cuarto lugar, la f= alta de apoyo familiar, asociado a los comentarios negativos sobre el peso que imposibilita la generación de estímulos para revelar la enfermedad a otras personas que podrían brindar a= poyo e impide las interacciones positivas. Y finalmente, la edad; factor de ries= go referido tanto en los artículos seleccionados como en revisiones bibliográf= icas previas. Estos datos de prevalencia permiten concluir sobre la importancia = de que los terapeutas identifiquen de manera oportuna los factores descritos y considerarlos al momento de diseńar los tratamientos psicológicos requerido= s.

·      =    Finalmente, la revisión bibliográfica permitió identificar que, frente a los trastornos de conducta alimentaria en pacientes con DM I, las terapias, técnicas, tratamientos y enfoques psicológicos más referidos por la literatura científica de los últimos cinco ańos son: la Terapia Cognitiva Conductual, la Psicoeducación, y la Interven= ción Psicosocial.

·      =    Debido a lo expuesto, resultan necesar= ias futuras investigaciones, que además de trabajar con muestras poblacionales = más grandes, incorporen diseńos de tipo longitudinal que permitan evaluar la efectividad de ciertas terapias psicológicas en el tratamiento de la DB en = las poblaciones adolescentes y adultas. A su vez, sería recomendable llevar a c= abo investigaciones en otros países latinoamericanos (Colombia Perú, Ecuador o México) donde los índices de DM1 son altos y en los que conocer la prevalen= cia de DB y los factores de riesgo asociados a dicho trastorno podrían ser información clave para las campańas de concientización y prevención.

Implicaciones conceptuales

El principal aporte de la presente revisión es contribuir con información sobr= e la diabulimia debido a que, según los datos revisados, las investigaciones respecto a este tema son escasas, especialmente en el contexto latinoameric= ano. Además, se pudo determinar que para este trastorno uno de los factores ries= go más importantes es el contexto familiar y social. Finalmente, esta revisión sistemática pudo establecer que la diabulimia tiene mayor número de registr= os investigativos en Inglaterra en el continente europeo y en Brasil en el continente americano.

Abreviaturas

Se utilizaron las siguientes abreviaturas: DB =3D Diabulimia, DM1 =3D D= iabetes Mellitus tipo 1, DM2 =3D Diabetes Mellitus tipo 2, HbA1c =3D Hemoglobina Glicosilada, IMC =3D Índice de Masa Corporal, TA =3D Trastornos Alimenticio= s.

Agradecimiento: Este artículo fue desarrollado gracias al apoyo que brindó la Universidad Católi= ca de Cuenca, Unidad Académica de Posgrados y el programa “Smart University 2.= 0”

Referencias Bi= bliográficas

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Al Hourani, H., Ababneh, R., Khawaja, N., Khader, = Y., & Ajlouni, K. (2020). Eating disorders among Jordanian adolescents with= and without dysglycaemia: a comparative study. Eastern Mediterranean Health Journal, 26(12), 1502–1509. https://doi.org/10.26719/emhj.20.86<= o:p>

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Apergi, Κ., Romanidou, Μ., Abdelkhalek, Η., Tripsianis, G., & Gonidakis, F. (2020). Reliability and validi= ty of the Diabetes Eating Problem Survey in Greek adults with type 1 diabetes mellitus. Psychiatriki, 31(4), 310–3= 20. https://doi.org/10.22365/jpsych.2020.314.310

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Conflicto de intereses

Los autores indican no tener conflictos de intereses.

El artículo que se publica es de exclusiva responsabilidad de los autores y no necesariamente reflejan el pensamiento = de la Revista Alfa Publicaciones.

El artíc= ulo queda en propiedad de la revista y, por tanto, su publicación parcial y/o t= otal en otro medio tiene que ser autorizado por el director de la Revista Alfa Publicaciones.<= /o:p>

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/////////////////////////////////wAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAP////////////////////// /////////////////////////////////////////////////////////////////wAAAAD///8A AAD///////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// 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//////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //8AAAAA////AAAA//////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// 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//////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////8AAAAA////AAAA//////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// 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/////////////////////////////////////////////////////////wAAAAD///8AAAD///// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////8AAAAA////AAAA//////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// 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//////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// /////////////////////////////wAAAAD///8AAAD///////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////8AAAAA 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= ¹	Nancy Sierra Ayala	https://orcid.org/0000-0001-6641-356X
	Universidad Católi= ca de Cuenca, Ecuador. nancy.sierra.02@est.ucacue.edu.ec
3	Johanna Cristina Luzuriaga Mera	https://orcid.org/0000-0001-85= 44-2964
	Universidad Católi= ca de Cuenca, Ecuador. johanna.luzuriaga@ucacue.edu.ec
= ²	Andrés Alexis Ramírez Coronel<= span style=3D'color:black'>	https://orcid.org/0000-0002-6996-0443
	Universidad Católi= ca de Cuenca. Laboratorio de Psicometría, Psicología Comparada y Etología, Health and Behavior Research Group (HBR) y Carrera de Enfermería Campus Azogues, Universidad Católica = de Cuenca, Ecuador. andres.ramirez@ucacue.edu.ec <= /span>

=	Artículo de Investigación Científica y Tecnológica Enviado:16/12/2022 Revisado: 25/01/2023 Aceptado: 08/02/2023 Publicado:28/03/2023 DOI: https://doi.org/10.33262/ap.v5i1.2.338
<= span style=3D'font-size:12.0pt;line-height:115%;font-family:"Times New Roman",= serif; mso-fareast-font-family:Calibri;color:blue'>
Cítese:		Sierra Ayala, N., Luzuriaga Mera, J. C., & Ramírez Coronel, A. A. (2023). Prevalencia, factores de riesgo y terapias psicológicas asociados a la diabulimia: revisión sistemática en adolescentes y adultos. AlfaPublicaciones, 5(1.2), 124–146. https://doi.org/10.33262/ap.v5i1.2.338
		ALFA PUBLICACIONES, es una revista multidisciplinar, trimestral, que se public= ará en soporte electrónico tiene como misión contribuir a la &nbs= p; formación de profesionales competentes con visión humanística y crítica q= ue sean capaces de exponer sus resultados investigativos y científicos en la misma medida que se promueva mediante su intervención cambios positivos e= n la sociedad. https://alfapublicaciones.= com La revista es editada por la Editorial Ciencia Digital (Editorial de prestigio registrada en la Cámara Ecuatoria= na de Libro con No de Afiliación 663) www.celibro.org.ec<= /a>
		Esta revista está protegida bajo una licencia Creative Commons Attribution Non Commercial No Derivatives 4.0 International. Copia de la licencia: http://creativecommons.org= /licenses/by-nc-nd/4.0/
Pala= bras claves:= Diabulimia, trastorno alimentario, diabe= tes mellitus tipo 1, prevalencia, factores de riesgo.		Resumen Introducción. La Diabulimia (DB) hace referencia al trastor= no de la conducta alimentaria que puede manifestarse en pacientes diagnostic= ados con diabetes tipo 1, debido a que, de manera voluntaria, omiten inyectarse insulina, con el propósito de perder peso. Por lo que en torno al tema se sintetizó los resultados de las investigaciones más recientes. Objetivos. Examinar en la bibliografía de los últimos ci= nco ańos la prevalencia, factores de riesgo y terapias psicológicas asociados= a la DB en adolescentes y adultos. Además, se plantearon como objetivos específicos los siguientes: a) revisar en la literatura científica sobre = las prevalencias y terapias psicológicas de la DB en adolescente y adultos co= nsiderando la región, durante los últimos 5 ańos; y b) describir los factores de rie= sgo de la DB en adolescentes y adultos. Metodología. Revisión sistemática de la literatura científ= ica obtenida en bases de datos como: Pubmed, Scopus, Web of Science, Lilac y Google Scholar. Resultados. Luego del análisis de 32 artículos selecciona= dos que abordan a la DB se obtuvo una prevalencia promedio de 25.46 %. Los factor= es de riesgo asociados a la DB más frecuentes son: Índice de Masa Corporal a= lto, la insatisfacción con la imagen corporal, la falta de apoyo familiar, ser mujer y adolescente, presentar altos niveles de insatisfacción corporal y falta de apoyo social y familiar, asociado a los comentarios negativos so= bre el peso. El abordaje psicológico que más reporta es la Terapia Cognitiva Conductual y la técnica más efectiva es la Psicoeducación, así como las Intervenciones Psicosociales. Conclusión. En los estud= ios incluidos en esta revisión, el valor de la prevalencia no es un valor exa= cto debido a la escasez de estudios; sin embargo, se pudo evidenciar que Bras= il e Inglaterra son los países que mayor número de investigaciones realizan so= bre la temática; además, según los resultados de los estudios revisados, los pacientes de estos países presentaban un alto índice de Diabetes tipo I, = por lo que la DB es más frecuente. Los factores de riesgo mencionados en el apartado de resultados parecen ser un predictor importante para el padecimiento de DB. Respecto a las intervenciones psicológicas para el tratamiento de DB, se puede concluir que es necesaria la incorporación de diseńos longitudinales, que permitan que las investigaciones evalúen la efectivid= ad de las terapias psicológicas en el tratamiento de la diabulimia, debido a= que este tipo de estudios fueron escasos según la revisión realizada. = Área de estudio: Psicología.
Keywords: Diabulimia, eating disorder, type 1 diabetes mellitus, prevalence, risk factors.		Abstract Introduction: Diabulimia (DB) refers to the disorder of eating behavior that can manifest itself in patients diagnosed with type 1 diabe= tes, since they voluntarily omit to inject insulin to lose weight. Therefore, = the results of the most recent research on the subject were summarized. Ob= jectives. To review in the literature of the l= ast five years the prevalence, risk factors and psychological therapies associated with BD in adolescents and adults. In addition, the specific objectives were a) to review the scientific literature on the prevalence = and psychological therapies of BD in adolescents and adults considering the region, during the last 5 years; and b) to describe the risk factors of B= D in adolescents and adults. Methodology. Systematic review of scientif= ic literature obtained from databases such as: PubMed, Scopus, Web of Scienc= e, Lilac, and Google Scholar. Results. After the analysis of thirty-two sele= cted articles dealing with DB, an average prevalence of 25.46% was obtained. T= he most frequent risk factors associated with DB are high Body Mass Index, dissatisfaction with body image, lack of family support, being female and adolescent, presenting elevated levels of body dissatisfaction and lack of social and family support, associated with negative comments about weight= . The most reported psychological approach is Cognitive Behavioral Therapy, and= the most effective technique is Psychoeducation, as well as Psychosocial Interventions. Conclusion. In the studies included in this review,= the prevalence value is not an exact value due to the scarcity of studies; however, it could be evidenced that Brazil and England are the countries = with the greatest number of investigations on the subject; in addition, accord= ing to the results of the studies reviewed, the patients in these countries h= ad a high rate of type I diabetes, so that DB is more frequent. The risk facto= rs mentioned in the results section appear to be an important predictor for = the development of DB. Regarding psychological interventions for the treatmen= t of BD, it can be concluded that it is necessary to incorporate longitudinal designs that allow research to evaluate the effectiveness of psychological therapies in the treatment of diabulimia, since this type of studies were scarce according to the review conducted. Study: Psychology.<= o:p>

A= utor/ańo	R= evista / Cuartil	B= ase de datos	P= aís	M= etodología	M= uestra/rango de edad/media de edad	P= revalencia de Diabulimia (%)<= /span>	F= actores de riesgo	T= erapias/ Técnicas y Enfoques
*América*
Gib= bings et al. (2021)	Diabetes care Q1	Web of Science	Canadá	Correlacional Longitudinal	168 con TA y 1.680 sin TA	8,0	Trastornos alimentarios	Terapia Cognitiva Conductua= l Psicoeducación
Mer= win et al. (2018)	Psychosomatic Medicine= Q1	Web of Science	EE. UU	Correlacional Prospectivo	59 (+18)<= /p>	15,5	Edad, IMC, inicio de DM1	Terapia Cognitiva Conductua= l Intervención psicológica
Kah= koska et al. (2018)	Obesity Medicine= Q3	Scopus	EE. UU	Correlacional Prospectivo	34 (12-17 ańos / mediana 14= ,4)	26,7	Ser mujer=	Terapia Cognitiva Conductua= l Intervención psicosocial
Smi= th et al. (2020)	Jou= rnal of Pediatric Psychology Q1<= o:p>	Web of Science	EE. UU	Correlacional Prospectivo	818 (13-25 ańos)=	20,7	Ser mujer e insatisfacción corporal	Terapia Cognitiva Conductua= l Psicoeducación
Ben= ítez-Agudelo et al. (2017)	Anuario de Psicología<= /o:p> Q4	Google Scholar	Colombia<= /p>	Correlacional Transversal	60 con DM2 - 30 con diabetes controlada y 30 con diabetes no controlada DNC (40-70 ańos)	59,0	Síntomas somáticos y depres= ión	Terapia Familiar=
Cos= ta et al., (2017)	Medicina (B. Aires) Q4	Google Scholar	Argentina=	Correlacional Transversal	433 pacientes con DM1 y 823= con DM2	12,0	Pacientes = con hipoglucemias, diabetes que reciben insulina alta	Terapia Cognitiva Conductua= l Psicoeducación
Cardoso & Pimenta (2019)	Psi= que Q4<= o:p>	Goo= gle Scholar	Bra= sil	Cor= relacional Pro= spectivo	34 = con DM1 (18 - 55 ańos)	8,2=	Cas= os de diabetes en familia, conducta alimentaria IMC alto	Ter= apia Cognitiva Conductual Int= ervención Psicosocial
Gri= golon et al. (2019)	Eat= ing and Weight Disorders - Studies on Anorexia, Bulimia and Obesity Q2	Scopus	Brasil	Correlacional= Transversal	50 mujeres con DM1 y 100 sanas (11-16 ańos)	20,7	Trastornos alimentarios, IMC alto	Terapia Cognitiva Conductual Psicoeducación
Rib= eiro et al. (2021)	Escola Anna Nery Q3	LILAC=	Brasil	Cualitativo Narración oral	4 mujeres (18-30 ańos)	3,2	Ser mujer	Terapia Cognitiva Conductual Psicoeducación
Fri= tzen et al. (2021)	Arc= hives of Endocrinology and Metabolism Q3<= o:p>	Google Scholar	Brasil	Correlacional= Transversal	166 / 53,6% mujeres (22-45 ańos)	47,6	Angustia emocional <= /span>	Terapia Cognitiva Conductual Psicoeducación
*Eur= opa*
Fal= căo & Francisco (2017)	Eat= ing and Weight Disorders - Studies on Anorexia, Bulimia and Obesity Q2	PubMed	Portugal	Correlacional= Prospectivo	128 (18-30 ańos)	2,5	Insatisfacción con imagen corporal=	Terapia Cognitiva Conductual Intervención psicosocial
Tro= ncone et al. (2018)	Jou= rnal of Psychosomatic Research Q1<= o:p>	Scopus	Italia	Correlacional= Longitudinal<= /p>	81 (42 hombres, 39 mujeres) con DM1 (10-15 ań= os)	47,8	Presión social y IMC alto	Terapia Cognitiva Conductual Psicoeducación
Calcaterra et al. (2020)	Dia= gnostics Q2<= o:p>	Sco= pus	Ita= lia	Cua= ntitativo Exp= loratorio Tra= nsversal	40 = con DM1 (edad media 15,0 ± 2,6 ańos)	24,= 62	Ser mujer	Ter= apia de conducta y Familiar
Troncone et al. (2021)	Journal of Clin. Psyc. in Med. Set. Q2<= o:p>	Sco= pus	Ita= lia	Cor= relacional Tra= nsversal	200 (edad media: 15,24 ± 1,45)	36,= 5	IMC alto	Ter= apia Cognitiva Conductual Psi= coeducación
Thomas et al. (2020)	Tec= hnical Report Q4<= /span>	Goo= gle Scholar	Nue= va Zelanda	Cua= litativo Des= criptivo Ent= revistas	7 mujeres (18-37 ańos)	23,= 5	Con= trol glucémico, preocupación por ganar peso y desórdenes alimenticios, falta de apoyo familiar	Ter= apia Cognitiva Conductual Int= ervención Psicosocial

Autor/ańo	Revista / Cuartil	Base de datos	País	Metodología	Muestra/rango de edad/media de edad	Prevalencia de Diabulimia (%)	Factores de riesgo	Terapias/ Técnicas y Enfoques
Coleman & Caswell (2020)	BMC Psychology Q1 =	Pub= med	Ing= laterra	Cua= litativo Exp= loratorio	45 adultos	87,= 0	IMC alto	Ter= apia Cognitiva Conductual y terapia Familiar
Partridge et al. (2020)	Pra= ctical Diabetes Q4<= o:p>	Sco= pus	Ing= laterra	Cua= litativo Des= criptivo Ent= revistas	11 (19-69 ańos)	8,2=	Con= texto Familiar, comentarios negativos	Ter= apia Cognitiva Conductual
Zaremba et al. (2022)	Dia= betic Medicine Q1<= o:p>	Sco= pus	Ing= laterra	Cua= litativo Ent= revistas	15 = con DM1 (33 ± 11 ańos)	7,3=	Pre= sión perfeccionista	Ter= apia Cognitiva Conductual
Brewster et al. (2020)	British Journal of Diabetes Q4	Web= of Science	Ing= laterra	Des= criptivo Pro= spectivo	848 profesionales de la salud	39,= 0	Tra= stornos alimentarios	Ter= apia Cognitiva Conductual Psi= coeducación
Verbist & Condon (2021)	Journal of Health Psychology Q2	Sco= pus	Ing= laterra	Mix= to Des= criptivo Tra= nsversal	121= con DM1 (88% mujeres) / edad medi= a: 36 ± 6,5	51,= 2	IMC alto	Ter= apia Cognitiva Conductual
Apergi et al. (2020)	Psy= chiatriki Q3<= o:p>	Pub= med	Gre= cia	Cua= ntitativo Cor= relacional	100 (18-65 ańos)	35<= span style=3D'mso-bidi-font-style:italic'>,0	IMC alto	Ter= apia Cognitiva Conductual
Karastogiannidou et al. (2021)<= !--[if supportFields]>	Nut= rients Q1<= o:p>	Pub= med	Gre= cia	Cor= relacional Tra= nsversal	103 (76% mujeres) / edad media: 37	3,0=	IMC alto	Ter= apia Cognitiva Conductual
Nilsson et al. (2020)	Ped= iatric Diabetes Q1<= o:p>	Sco= pus	Din= amarca	Cua= ntitativo Cor= relacional Tra= nsversal	192 (11-19 ańos)	38,= 6	Ser mujer	Ter= apia Cognitiva Conductual
Doyle et al. (2017)	Journal of Pediatric Health Care Q3	Goo= gle Scholar	Din= amarca	Cor= relacional Pro= spectivo	27 mujeres y 33 hombres (21 ± 2,5 ańos)	25,= 0	Sob= repeso y mal control glucémico.	Ter= apia Cognitiva Conductual
Şahin-Bodur et al. (2021)<= !--[if supportFields]>	Nut= rition Clinique et Métabolisme Q4<= o:p>	Sco= pus	Tur= quía	Cor= relacional Tra= nsversal	110 (hombres: 51,8%, mujeres: (48= ,2%) (10-19 ańos)	13,= 2	Ado= lescentes ser mujeres y dieta inadecuada	Ter= apia Cognitiva Conductual Psi= coeducación
Akgül et al. (2018)	Journal of Pediatric Endocrinology and Metabolism Q2<= o:p>	Sco= pus	Tur= quía	Cor= relacional Tra= nsversal	24 hermanos sanos y 29 reclutados de la clínica ambulatoria sin antecedentes familiares de DM1 (10-18 ańos)	17,= 2	Eta= pa desarrollo adolescentes, IMC alto	Ter= apia familiar
Turan et al. (2022)	Ege Tıp Dergisi Q4<= o:p>	Goo= gle Scholar	Tur= quía	Cor= relacional Pro= spectivo	129= con DM1 (10-18 ańos)	36,= 4	IMC alto	Ter= apia Cognitiva Conductual
Lica et al. (2021)	Chi= ldren Q2<= o:p>	Sco= pus	Rum= ania	Cor= relacional Tra= nsversal	54 insulinodependiente y 52 sin diabetes (12 a 18 ańos)	34,= 2	Ser mujer	Ter= apia Cognitiva Conductual Psi= coeducación
*África*
Olamoyegun et al. (2018)	Afr= ican Health Sciences Q3<= o:p>	Web= of Science	Nig= eria	Cor= relacional Pro= spectivo	213= / 9,9 % con DM1 y 90,1% con DM2 / edad media 58,6 ± 13= ,1	9,9=	Pac= ientes con tratamientos de insulina	Ter= apia Cognitiva Conductual Int= ervención Psicosocial
Salah et al. (2022)	Journal of Eating Disorders Q2	Web= of Science	Egi= pto	Cor= relacional Pro= spectivo	60 = con DM1 / (12 - 17 ańos)	10,= 0	Ser mujer, aspectos emocionales, distorsión de imagen corporal, hipoglucemia =	Ter= apias convencionales para trastornos alimentarios
*Asia*
Al Hourani et al. (2020)	Eastern Mediterranean Health Journal Q3	Web= of Science	Jor= dania	Cua= ntitativo Cor= relacional Pro= spectivo	497= con disglucemia (DG) y 504 sin disglucemia (SDG) (10-24 ańos)	11,= 9	Est= ilo de vida sedentario, falta de apoyo familiar	Ter= apia Cognitiva Conductual Psi= coeducación
*Aus= tralia*
Watt et al. (2022)	Health & Social Care in the Community= Q1<= o:p>	Sco= pus	Aus= tralia	Cor= relacional Tra= nsversal	199= con TA (18 - 65 ańos)	31<= i>,0	Ser mujer Fal= ta de control glucémico, conductas alimentarias desordenadas	Ter= apia Cognitiva Conductual Psi= coeducación