Cognitive Behaviour Therapy and Disordered Eating in T1D
Natalie Zaremba, Amy Harrison, Jennie Brown, Divina Pillay, Emmanouela Konstantara, Janet Treasure, David Hopkins, Judith Prins, Bastiaan de Galan, Khalida Ismail, Giesje Nefs and Marietta Stadler
Experiences of receiving and delivering a novel complex intervention for type 1 diabetes and disordered eating: Process evaluation of the Safe management of people with Type 1 diabetes and EAting Disorders studY (STEADY). Diabet Med. 2026 Jun 11:e70377. doi: 10.1111/dme.70377. Online ahead of print.
Disordered eating in people with type 1 diabetes (T1DE) is a serious and common problem, associated with poor glycaemic outcomes, increased complications and significant psychological burden. Yet standard eating disorder treatments are not designed to accommodate the unique demands of diabetes self-management, leaving many people falling between services without adequate, integrated care. The STEADY intervention — Safe management of people with Type 1 diabetes and EAting Disorders studY — was developed to address this gap through a cognitive behaviour therapy (CBT) framework specifically adapted for T1DE, co-designed with people with lived experience and healthcare professionals. Following a feasibility randomised controlled trial that demonstrated proof of concept, this process evaluation was conducted by researchers from King's College London, Radboud University Medical Center, Diabeter, Tilburg University, and institutions across the Netherlands and the UK, to assess the acceptability, appropriateness and feasibility of STEADY, and to explore in depth how the intervention was experienced by both those who received it and those who delivered it.
Thirteen participants who received STEADY therapy and three healthcare professionals (HCPs) delivering therapy completed validated person-reported outcome measures (PROMs) assessing acceptability, appropriateness and feasibility, and took part in semi-structured interviews. Interviews were analysed using reflexive thematic analysis in an iterative, multidisciplinary process.
Key findings:
- STEADY was rated as highly acceptable, appropriate and feasible by both participants and HCPs: All PROM scores exceeded the threshold of 16 indicative of high implementation success — for participants (Acceptability 18.4, Appropriateness 18.2, Feasibility 18.0) and for HCPs (Acceptability 17.7, Appropriateness 17.3, Feasibility 17.7).
- Participants described a clear path of therapeutic growth: Through STEADY, participants developed insight into how their T1D and eating difficulties were intertwined, learned new skills to challenge unhelpful beliefs, and experienced transformative shifts in self-perception, self-compassion and confidence in managing their diabetes. Several described gaining skills to handle blood glucose fluctuations more effectively as a direct result of integrating diabetes education with emotional therapy.
- The integration of T1D and eating disorder expertise was central to STEADY's impact: Many participants described years of being passed between services without integrated support — often failing to meet eligibility criteria for eating disorder services because of insufficient clinical severity, or failing to progress in generic CBT because their therapist lacked diabetes knowledge. STEADY addressed this unmet need directly, allowing diabetes data such as CGM readings to be used therapeutically alongside emotional work.
- The therapeutic relationship was foundational: Building trust took time and was particularly important given the shame many participants associated with T1DE. For most, having a therapist who understood the complexity and day-to-day reality of living with T1D — without needing it explained — was deeply meaningful and qualitatively different from prior therapeutic experiences.
- HCPs emphasised specialist knowledge, multidisciplinary working and clinical flexibility as essential: Therapists found that standard CBT protocols required significant adaptation to accommodate acute physical health risks, high glycaemic variability and the lifelong nature of T1D. Weekly multidisciplinary team meetings enabled skill sharing and clinical supervision, which therapists experienced as both professionally enriching and essential to safe delivery.
- Twelve sessions was considered insufficient for more complex presentations: Both participants and HCPs flagged that the standard CBT course length was often not enough to address the depth and chronicity of T1DE, particularly where additional comorbidities, trauma or ambivalence to change were present. Preparatory work prior to active therapy was recommended for future iterations.
- Practical adaptations improved engagement: Virtual delivery increased accessibility and flexibility without compromising therapeutic quality. The STEADY app was appreciated as a convenient repository for tools, though participants generally preferred other formats such as email or handwritten notes for active exercises. Suggested future additions included content on hormonal influences on glucose management and longer-term relapse support, reflecting the lifelong nature of T1D.
This process evaluation provides a rich account of how STEADY works in practice — from the perspective of both those who received it and those who delivered it. The substantial overlap in themes across both groups strengthens confidence in the intervention's mechanisms and coherence, and offers clear directions for refining STEADY ahead of a full-scale randomised controlled trial.
Concluding, the authors state
"Our findings demonstrate that STEADY is acceptable, appropriate and feasible for individuals with mild to moderate severity T1DE. The substantial alignment between participant and therapist perspectives offers clear directions for refining the intervention and support implementation in a full-scale RCT."-
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