Michael Levine's Eating Disorders Prevention/Sociocultural Factors Newsletter
NO. 39: (i) Prevention; (ii) Screening; (iii) Soc Media, Pt. 1 (n = 2); (iv) BI, Pt. 3 (n = 2); (v) DE, Pt. 1 (n = 2); and (vi) DE & Diabetes (n = 2)
Colleagues (N now = 1197 in 48 countries),
Please (a) continue to send me any and all announcements (e.g., conferences, awards, webinars, prevention resources, your recent publications); and (b) pass along the following to anyone who would like to join this free email list.
REQUEST FOR RESEARCH PARTICIPATION AND/OR ASSISTANCE RECRUITING
from [our own] Ms. Taylor Penwell at the University of Montana, for her Masters thesis study
entitled
Coaching Experiences for Eating Disorder Recovery
Received this morning (California time), 18 June 2024, via an email from our own Ms. Taylor Penwell (USA).
ML NOTE 1: Ms. Penwell, her graduate mentor (our own Dr. Caitlin Martin-Wagar), and I would appreciate it if you would (a) participate in this study, if eligible; and/or (b) pass this along to any people in recovery who using or might be working with a coach and/or clinicians, physicians, nurse practitioners, etc., who provide therapy and care for who people who use a coach.
[Ms. Penwell writes:] I am requesting help with recruitment for my master's thesis project.
Coaching Experiences for Eating Disorder Recovery
We are recruiting individuals for a fully online, short (15-25 minute) survey about experiences and perspectives of using a coach (e.g., eating disorder recovery coach, mental health coach, etc.) for eating disorder recovery.
Eligible individuals include:
- 18 years or older living in the United States
- current or past eating disorder (suspected or formal diagnosis)
- current or past use of a coach for eating disorder recovery
If you have any questions, please email taylor.penwell@umontana.edu.
If you would like to participate, please use the following link: https://umt.co1.qualtrics.com/jfe/form/SV_50IJWHjrzg3s7nE
Thank you!
Taylor Penwell, B.A. (she/her/hers) | Clinical Psychology Graduate Student | University of Montana | Laboratory for Eating Disorders and Equity
CALL FOR MANUSCRIPTS for a
Special Issue of
The Lancet Regional Health – Americas, focusing on
Weight Stigma and Discrimination in Latin America and the Caribbean
Co-Edited by our own Dr. Stuart Flint (England) and Dr. Taissa Vila (Brazil)
Closing date for submission is June 30, 2025
Received via a 28 June 2024 Google Scholar alert.
ML NOTE 2: This call for papers has been issued in the form of a short article/editorial, as follows. Below is a large part, but not all, of this publication:
Flint, S. W., & Vila, T. (2024). Weight stigma and discrimination in Latin America and the Caribbean: A call for papers. The Lancet Regional Health – Americas. Advance online publication. https://doi.org/10.1016/j.lana.2024.100779
Full text of the “call” available in article form at: https://www.thelancet.com/action/showPdf?pii=S2667-193X%2824%2900106-6
E-mail addresses: s.w.flint@leeds.ac.uk, taissa.vila@lancet.com
ML NOTE 3: Drs. Flint and Via and I would appreciate it if you would share this call for papers with any and all who might be interested in contributing to this special issue.
CALL FOR MANUSCRIPTS for a Special Issue of The Lancet Regional Health – Americas, focusing on Weight Stigma and Discrimination in Latin America and the Caribbean
Co-Edited by our own Dr. Stuart Flint (England) and Dr. Taissa Vila (Brazil)
Despite the similarities in prevalence and prevention initiatives, there has been a dearth of empirical examination of weight stigma and discrimination that has emerged from LAC. In other regions including North America and Europe, weight stigma is well-documented across society (e.g., within education, workplace and healthcare) and has been identified as a key factor associated with mental and physical health concerns, as well as health, economic and social inequalities.
Studies have also indicated that, despite the common misconception that obesity is becoming normalised, there has been a concomitant increase in weight stigma alongside the increasing prevalence of obesity, with no sign that weight bias is decreasing.
With obesity a key public health priority and the detrimental impacts of experiencing weight stigma and discrimination as highlighted elsewhere, it is imperative that evidence is gathered that examines its prevalence, impact and implications within our region.
To address the paucity of empirical evidence examining weight stigma and discrimination in Latin America and the Caribbean, The Lancet Regional Health Americas will dedicate a theme issue on the topic. Accepted papers will be published as they are ready and compiled into the thematic issue in early 2026. We welcome high-quality submissions that examine the impact of weight stigma and discrimination on health and within healthcare and health policy.
Studies that explore the experiences of people living with overweight and obesity within healthcare and in response to national and local obesity policies that have been implemented are particularly welcomed as are weight stigma and discrimination interventions.
We are also interested in receiving submissions that examine how and in what ways current health policy, interventions and services might have a counterproductive impact including leading to or exacerbating weight stigma and discrimination practices. Finally, studies that explore the cultural and region-specific challenges related to weight stigma and discrimination are welcomed, particularly where they highlight key considerations for healthcare and policy.
The closing date for submission is June 30, 2025. Please indicate in your cover letter that your submission is intended for this call for papers. We look forward to reading your research, which will help to improve the understanding of weight stigma and discrimination within LAC, and in doing so, provide insights to improve policy, healthcare practice and the lives of people living with overweight or obesity.
Research Publication Categories in This Newsletter
(i) Prevention; (ii) Screening; (iii) Social Media, Part 1 (n = 2); (iv) Body Image, Pt. 3 (n = 2); (v) Disordered Eating, Part 1 (n = 2); and (vi) Disordered Eating and Diabetes (n = 2)
CONGRATULATIONS to our own
Dr. Nicole Paraskeva (England), Ms. Sharon Haywood (England), and Dr. Phillippa Diedrichs (England) and colleagues, including distinguished scientist-practitioner-mentor Dr. Dasha Nicholls (England), for publication of the Prevention research article in #1.
Dr. Kelsie Forbush (USA) and colleagues for publication of the Screening research article in #2.
Drs. Kendrin Sonneville (USA) and Samantha Hahn (USA) and colleagues for publication of the Social Media research article in #3.
Dr. Viren Swami (England/Malaysia) for publication of the Body Image research review article in #5.
Dr. Janet Treasure (England) and colleagues for publication of the Disordered Eating and Diabetes research correspondence described in #9.
Prevention
1. Paraskeva, N., Haywood, S., Hasan, F., Nicholls, D., Toledano, M. B., & Diedrichs, P. C. (2024). An exploration of having social media influencers deliver a first-line digital intervention to improve body image among adolescent girls: A qualitative study. Body Image, 51. Advance online publication. https://doi.org/10.1016/j.bodyim.2024.101753
Email address for correspondence: Nicole.Paraskeva@uwe.ac.uk
ABSTRACT. Social media influencers are popular among adolescents and could offer a unique way to reach young people at scale with body image interventions. This study explored girls’ and influencers’ views on having influencers deliver body image interventions through vlogs (video blogs) and to gain insight into their preferred format, content, and views on factors that encourage engagement with vlogs. Twenty-one UK based participants were recruited. Three online focus groups were conducted with adolescent girls (n = 16) aged 14–18 years and one with influencers (n = 5) aged 24–33 years, who had a collective following of over 1.5 million subscribers across social media platforms.
Data were analysed using reflexive thematic analysis and four themes were generated: Choosing an influencer whose messages and core values are aligned with the topic of body image; the importance of influencer authenticity and personal experience; collaborating on content creation with mental health professionals; and the need for long-form (i.e., 10–20 min) content to address serious topics.
Findings suggest having influencers deliver body image interventions to young people could be a useful approach. Results highlight the need to engage with end users from the outset of intervention development to increase the likelihood of intervention effectiveness and engagement.
Screening
ML NOTE 4: In regard to the article described below in #2, according to SAS Code Examples — Bayesian Unidimensional IRT Models: Graded Response Model — “In unidimensional item response theory (IRT) models, an instrument (test) consists of a number of items (questions) that require responses that are to be chosen from a predetermined number of categories (options). The purpose of the instrument is to measure a single latent trait of the test subjects. The latent trait is assumed to be measurable and . . . an individual’s location within this range, θ, is assumed to be a continuous random variable . . . When there are more than two categories and the categories are ordered, meaning that some responses indicate more (or less) of the latent trait being measured . . . the purpose of the graded response model is to enable you to estimate the probability that a test subject will choose a particular response for each item, to estimate the levels of the latent traits of the test subjects, and to evaluate how well the items, individually and collectively, measure the test subject’s latent trait.
2. Chen, Y., Forbush, K. T., & Pleskac, T. J. (2024). Bayesian graded response models for eating-disorder risk estimation using screening data. Computational Brain & Behavior. Advance online publication. https://doi.org/10.1007/s42113-024-00204-w
Full text available for download at: https://link.springer.com/article/10.1007/s42113-024-00204-w#citeas
ABSTRACT. To facilitate eating disorder (ED) diagnosis, individuals usually undergo a brief screening before being referred for a full-scale diagnostic assessment. ED screening tools typically use self-report Likert-type questions to assess ED symptoms. Individuals are classified into low-risk and high-risk groups by comparing their aggregated scores with a Receiver-Operating-Characteristic-determined cut-off point. However, binary classification by cut-off points could result in low positive predictive value (i.e., true positives) in low-prevalence populations, neglects differences in item-level discriminability, and requires a large sample size to determine the cut-off point.
In this study, we built a Bayesian Graded Response Model (Bayesian-GRM) to generate ED risk predictions from screening responses. The Bayesian-GRM was implemented in a dataset of 1397 college students screened using two screeners: the SCOFF and the Brief Assessment of Stress and Eating (BASE). First, the Bayesian-GRM, coupled with a logistic regression component to account for gender differences, was fit to a training dataset with both responses to screening questions and ED diagnoses. The fitted model was then used to predict ED risk based on responses to screening questions only.
We showed that, by accounting for population-level prevalence and gender, the Bayesian-GRM approach provided accurate individual ED risk estimates that were true to data. By accounting for item-level discriminability, the Bayesian-GRM was able to distinguish individuals with or without an ED with a better accuracy. Using a bootstrap study, we also showed that the Bayesian-GRM could provide relatively robust and stable ED risk estimates in small samples (for example, a sample with 90 women and 90 men).
We concluded that the Bayesian GRM method is highly feasible for analyzing ED screening data and identifying individuals with a high risk of ED, and its application would enable lower resources and costs for future studies seeking to evaluate the performance of ED screening tools.
Social Media, Part 1 of 2
3. Moufawad, M., Hoque, A., Kells, M., Sonneville, K. R., & Hahn, S. L. (2024). Social media use and weight bias internalization: association moderated by age and weight perception. Journal of Eating Disorders, 12, 84. https://doi.org/10.1186/s40337-024-01043-7
Full text available for download at: https://jeatdisord.biomedcentral.com/articles/10.1186/s40337-024-01043-7
ABSTRACT. Background: The current study examined whether weight perception or age moderated associations between time spent on image-based social media and weight bias internalization (WBI). Methods: Data come from the baseline visit of the Tracking Our Lives Study, a randomized control trial of college women (n = 200). Participants completed questionnaires assessing time spent on social media (continuous, overall and individual platforms Instagram, Facebook, and Snapchat), WBI (continuous), weight perception (perceive their weight as “overweight” vs. do not perceive their weight as “overweight”), age (continuous, 18–49 years), and confounders (race/ethnicity, parent education, sexual orientation, and BMI). Adjusted zero-inflated Poisson regressions were performed to determine if weight perception and age moderated associations between time spent on image-based social media and WBI.
Results: As expected, we found a positive association between overall time spent on image-based social media and WBI (β = 0.826, p < 0.001). In moderation analyses, the strength of the association was weakened among women who perceived their weight as “overweight” (β=-0.018, p = 0.006). Associations also weakened with age (β=-0.001, p < 0.001). The association between time spent on Instagram and WBI was also weakened with age (β=-0.014, p = 0.018), which was the only significant moderation found for individual social media platforms. Conclusions: Our results suggest that image-based social media use is more strongly associated with increases in WBI among younger women.
Plain English summary: There is research reporting that college women who spend an increased amount of time on image-based social media apply more negative-based weight stereotypes to oneself, leading to weight-based self-degradation. This is known as weight bias internalization. However, there may be things that make social media more or less harmful for college women. The goal of this study was to see if a woman’s age or their perception of their weight changed the relationship between the amount of time spent on image-based social media and weight bias internalization. Data come from 200 college women who completed questionnaires to determine time spent on social media, their level of weight bias internalization, how they perceived their weight, age, and other demographics.
Results showed that women who perceive their weight as “overweight” had a weaker association between time spent on all image-based social media and weight bias internalization, as did older women. Our results suggest that younger women may be more susceptible to influences on social media that increase their weight bias internalization. These results can be used to identify those who may benefit from interventions aimed at reducing weight bias internalization and prevent later health consequences as a result of having more weight bias internalization.
4. Ko, C., & Kimm, C. (2024). Adolescent female users’ avatar creation in social virtual worlds: Opportunities and challenges. Behavioral Sciences, 14(7), 539. https://doi.org/10.3390/bs14070539
Full text available for download at: https://www.mdpi.com/2076-328X/14/7/539
ABSTRACT. Many adolescent females are active online, finding creative ways to express themselves through evolving social media technologies. Social virtual worlds (SVWs), distinguished by extensive avatar customization features, provide them with unique opportunities to craft virtual identities and explore diverse facets of self-presentation. This study investigates adolescent females’ construction of avatars in Zepeto, a South Korea-based global SVW platform.
Employing social representation theory (SRT) as a theoretical framework, this study conducted in-depth interviews with adolescent female Zepeto users to uncover their perceptions of and motivations behind avatar creation in SVWs, as well as to explore how the interplay of virtual and real worlds presents them with various opportunities and challenges. While the prospects of SVWs remain uncertain, examining how these young users interpret and experience SVWs contributes to identifying potential strategies to enhance the sustainability of these platforms.
Body Image, Part 3 of (now) 5
5. Swami, V. (2024). Associations between nature exposure and body image: A critical, narrative review of the evidence. Acta Psychologica, 248, 104355. https://doi.org/10.1016/j.actpsy.2024.104355
Full text available for download: https://www.sciencedirect.com/science/article/pii/S0001691824002324
ABSTRACT. Researchers, practitioners, and policy-makers are having to deal with the negative impact of body image concerns in populations globally. One cost-effective way of promoting healthier body image outcomes is through exposure to natural environments. A growing body of research has shown that spending time in, interacting with, and even just looking at natural environments can promote healthier body image outcomes.
In this narrative review, I consider the different forms of evidence documenting an association between nature exposure and body image (i.e., cross-sectional and mediational, experimental and quasi-experimental, comparative, prospective, experience sampling, and qualitative research). Beyond this, I shine a critical light on the available evidence, highlighting concerns with methodological (i.e., who research has focused on and what types of natural environments have been considered), psychometric (i.e., how body image and nature exposure are measured), and conceptual issues (how the association is explained).
I conclude that, although there are issues affecting the way the existing body of research is to be understood, there are reasons to be hopeful that nature exposure can be leveraged to promote healthier body image outcomes in diverse populations.
6. Mendes, A. L., Coimbra, M., Canavarro, M. C., & Ferreira, C. (2024). How do early affiliative memories explain body image shame? A 12-month longitudinal study in adolescent girls. Appetite. Advance online publication. https://doi.org/10.1016/j.appet.2024.107576
Email address for correspondence: alaurammendes@gmail.com
ABSTRACT. Objective: This study aimed to explain adolescent girls’ body image shame across a 12- month longitudinal design, and its relationship with early parental memories of warmth and safeness and fear of receiving compassion from others.
Design and methods: Participants included 231 adolescent girls, who completed self-report measures at three different periods: baseline (W1), 6-month follow-up (W2), and 12-month follow-up (W3). Descriptive and correlational analyses were performed, and differences between participants at the different waves were explored through repeated measures ANOVA. A cross-lagged panel model tested the mediational effect of fears of receiving compassion on the association between early affiliative memories (W1) and body image shame (W3).
Results: ANOVA results found significant differences throughout time in memories of warmth and safeness (tending to diminish) and in body image shame (tending to rise). Correlation analysis revealed that all variables were significantly associated in the expected directions, across the three waves. Finally, path analysis revealed that early affiliative parental memories (in W1) had a direct effect on body image shame (in W3), through the fear of receiving compassion from others (in W2), accounting for 85% of body image shame’s variance (W3).
Conclusions: These findings indicate that the lack of early affiliative memories often leads to the development of defensive mechanisms such as fears of receiving compassion from others which in turn can foster isolation and distant relationships, enhancing feelings of inferiority and inadequacy, which in female adolescents can emerge centred on body image – body image shame.
This study further highlights the importance of prevention and intervention strategies based on compassion to specifically target fears of receiving compassion from others, in adolescent girls dealing with feelings of inferiority and shame regarding their body.
Disordered Eating, Part 1 of 3
7. Santoniccolo, F., & Rollè, L. (2024). The role of minority stress in disordered eating: A systematic review of the literature. Eating and Weight Disorders, 29, 41 (2024). https://doi.org/10.1007/s40519-024-01671-7
Full text available for download at: https://link.springer.com/article/10.1007/s40519-024-01671-7#citeas
ABSTRACT. Purpose: Sexual and gender minorities (SGMs) show a heightened risk of disordered eating compared to heterosexual and cisgender people, a disparity which may be caused by exposure to minority-specific stressors, such as discrimination and violence. This systematic review aims to summarize available evidence on the role of minority stress in disordered eating and SGM-specific aspects.
Methods: Following PRISMA guidelines, scientific search engines (EBSCO, PUBMED, Web of Science) were screened up to 31st of January 2024, including English-language original research papers containing analyses of the relationship between minority stress and disordered eating. 2416 records were gathered for screening. After application of inclusion and exclusion criteria, thematic analysis was conducted regarding 4 research questions: effects of minority stress on disordered eating, mediating factors, specificities of SGMs and differences between identity categories.
Results: 30 studies were included. Several aspects of minority stress are reliably associated with different forms of disordered eating. The relationship between minority stressors and disordered eating is mediated by aspects such as shame, body shame, or negative affect. SGMs show several specificities, such as the presence of a role of LGBTQIA + communities and additional gender-related pressures. Bisexual people and gender minorities appear to feature comparatively higher risks, and gender-related factors shape paths leading to disordered eating risk.
Conclusion: Minority stress is an important predictor of disordered eating, making SGM people’s health particularly at risk. Institutional and organizational anti-discrimination policies are needed, as well as further research. Clinical interventions may benefit from exploring and incorporating how minority stressors impact SGM people. Evidence level: I, Systematic review.
8. Peschel, S. K. V., Fürtjes, S., Voss, C., Sigrist, C., Berwanger, J., Ollmann, T. M., Kische, H., Rückert, F., Koenig, J., & Beesdo-Baum, K. (2023). Temporal associations between experiential avoidance and disordered eating behaviors in adolescents and young adults: Findings from an epidemiological cohort study with ecological momentary assessment. Eating and Weight Disorders, 28, 58. https://doi.org/10.1007/s40519-023-01584-x
Full text available for download at: https://capmh.biomedcentral.com/articles/10.1186/s13034-024-00752-w
ABSTRACT. Background: Disordered eating behaviors (DEBs), a risk factor for the development of eating disorders (EDs), are prevalent in young people and different DEBs frequently co-occur. Previous studies on DEB-patterns have largely used traditional retrospective questionnaires to assess DEBs. In addition, most previous studies did not specifically exclude individuals with clinical EDs, which limits current knowledge concerning purely subclinical patterns of DEBs. In the present study, we aimed to explore phenotypes and group sizes of subclinical patterns of DEBs reported in everyday life via smartphone-based ecological momentary assessment (EMA) in adolescents and young adults from the general population without lifetime EDs. In secondary analyses, we further aimed to investigate whether DEB-patterns would be associated with additional previously identified risk factors for ED-development.
Methods: EMA was conducted in a community sample of 14–21-year-olds from Dresden, Germany, over four days for up to eight times a day and covered engagement in four DEBs: skipping eating, restrained eating, eating large amounts of food, and loss-of-control eating. Data were analyzed from N = 966 individuals without lifetime EDs with an EMA compliance rate of at least 50% (81.9% of the total sample; average compliance: 84.6%). Latent profile analyses were performed to identify subclinical patterns of DEBs, stratified by sex. Associations between symptomatic profiles and ED-risk factors were tested via regression analyses.
Results: Based on theoretical deliberations, statistical indices, interpretability, and parsimony, a three-profile solution, namely no DEBs, high-mixed DEBs, and low-mixed DEBs, was selected for both sexes. Both symptomatic profiles in both sexes were associated with more unfavorable manifestations in additional ED risk factors compared to the no DEBs profile, with the highest number of associations being observed in the female high-mixed profile. Conclusions: The present findings suggest that problematic manifestations of DEBs in young people may occur even in the absence of an ED diagnosis and that they are associated with additional risk factors for EDs, warranting increased efforts in targeted prevention, early identification and intervention in order to counteract symptom progression.
Disordered Eating and Diabetes
9. Ismail, K., Turner, D., Brown, J., Rosenthal, M., Ayis, S., Garrett, C., Hopkins, D., Treasure, J., Valabhji, J., Thomas, S., & Stadler, M. (2024). An integrated diabetes and mental health intervention for people with type 1 diabetes and severe disordered eating: A prospective proof-of-concept cohort study [Correspondence]. The Lancet: Diabetes & Endrocrinology, 12(7), 442-444. https://doi.org/10.1016/S2213-8587(24)00123-2
Full text available for download at: https://www.thelancet.com/journals/landia/article/PIIS2213-8587(24)00123-2/fulltext
ABSTRACT. (None; here are the first 3 paragraphs). Disordered eating is a phenomenon that affects approximately 30% of people with type 1 diabetes, and is characterised by omission of some amount of insulin secondary to fear of weight gain. Depending on the dose and type of insulin omitted, the subsequent persistent hyperglycaemia, polyuria, and osmotic diuresis results in a catabolic and dehydrated state, characterised by rapid weight loss. Rapid re-insulinisation after diabetic ketoacidosis can lead to oedema and rapid weight gain, often experienced as uncomfortable physical sensations, reinforcing the individual's negative belief that insulin is causing weight gain, promoting a recurring cycle of insulin omission. Type 1 diabetes with disordered eating is associated with earlier onset of microvascular complications and a three-times increased risk of mortality compared with type 1 diabetes alone. Low-intensity psychological interventions have not been found to be effective in improving glycaemic control in this group of people.
We developed diagnostic criteria and a risk score for type 1 diabetes and disordered eating (the T1DE risk score). We also developed an innovative hub-and-spoke service that integrates diabetes and mental health treatments. We aimed to determine whether use of the service would improve HbA1c rates of hospital admissions for diabetic ketoacidosis, severe hypoglycaemia, T1DE risk score, and patient-reported outcomes, consisting of symptoms of depression, anxiety, disordered eating, and diabetes distress.
This prospective uncontrolled proof-of-concept cohort study included patients with type 1 diabetes and disordered eating referred to the service between March 28, 2019, and June 6, 2022. The service was set in Greater London, UK, which has an ethnically and socioeconomically diverse population of 8·8 million residents, with the hub of the service being based in one teaching hospital (King's College Hospital, London, UK) and the spokes comprising 25 hospital-based diabetes centres.
10. Lindgreen, P., Willaing, I., Clausen, L., Ismail, K., Kjærulff, E. M., & Cleal, E. (2024). Discussions about binge eating and type 2 diabetes in a Facebook group: A qualitative analysis. International Journal of Eating Disorders. Advance online publication. https://doi.org/10.1002/eat.24242
Full text available for download at: https://onlinelibrary.wiley.com/doi/full/10.1002/eat.24242
ABSTRACT. Objective: Binge eating has adverse health effects and may be 10 times more common in people with type 2 diabetes (T2D) than in the general population. Still, binge eating is not consistently addressed in diabetes treatment. People with T2D and binge eating may, therefore, seek guidance on the topic on social media. The study objective was to explore discussions about binge eating among members of a T2D-specific Facebook group. Method: Interactions among members of the Facebook group were observed over 8 months and supplemented by keyword searches within group content. The data were imported into NVivo12 and analyzed using Interpretive Description.
Results: The overarching theme described how group members exchanged guidance concerning co-existing T2D and binge eating based on personal experiences while trying to resolve co-members' misapprehensions regarding binge eating. Two subthemes were generated, describing frequently discussed topics relating to binge eating triggers and inhibitors. Triggers were confusion about the health impacts of carbohydrates and encounters with unsupportive clinicians, while inhibitors included the possibility of speaking openly about binge eating with peers and hunger cues being suppressed by glucagon-like peptide 1 receptor agonists.
Discussion: Social media may constitute an important source of support for people with T2D and binge eating, as the topic is typically not addressed in routine care. Besides being aware of the extent of binge eating in people with T2D and the health risks involved, clinicians should keep in mind that people with both conditions may seek information on social media that can affect diabetes management.