Binge eating disorder

Binge eating disorder (BED) is an eating disorder characterized by frequent and recurrent binge eating episodes with associated negative psychological and social problems, but without the compensatory behaviors common to bulimia nervosa, OSFED, or the binge-purge subtype of anorexia nervosa.

BED is a recently described condition,Template:Sfn which was introduced to distinguish binge eating similar to that seen in bulimia nervosa but without characteristic purging. Individuals who are diagnosed with bulimia nervosa or binge eating disorder exhibit similar patterns of compulsive overeating, neurobiological features such as dysfunctional cognitive control and food addiction, and biological and environmental risk factors.<ref name="Set-shifting ability across the spe">Template:Cite journal</ref> Some professionals consider BED to be a milder form of bulimia, with the two conditions on the same spectrum.<ref name="Hay2009">Template:Cite journal</ref>

Binge eating is one of the most prevalent eating disorders among adults,<ref name="Saguy Gruys 2010">Template:Cite journal</ref> though it receives less media coverage and research about the disorder compared to anorexia nervosa and bulimia nervosa.

Signs and symptoms

Binge eating is the core symptom of BED; however, not everyone who binge eats meets qualifications for BED.<ref name="Fariburn, 2013">Template:Cite bookTemplate:Page needed</ref> An individual may occasionally binge eat without experiencing many of the negative physical, psychological, or social effects of BED. This may be considered disordered eating rather than a clinical disorder. Precisely defining binge eating can be problematic;Template:Sfn however, binge eating episodes in BED are generally described as having the following potential features:

• Eating much faster than normal,<ref name="NHS choices">Template:Cite web</ref> perhaps in a short space of time<ref name="Michalska2016" />
• Eating until feeling uncomfortably full<ref name="NHS choices" />
• Eating a large amount even when not hungry<ref name="NHS choices" />
• Subjective loss of control over how much or what is eaten<ref name="ICD-11 Beta Draft" />
• Planning and allocating specific times for bingeing<ref name="NHS choices" />
• Eating alone or secretly<ref name="NHS choices" />
• Not being able to remember what was eaten after the binge<ref name="NHS choices" />
• Feelings of guilt, shame, or disgust following a food binge<ref name="NHS choices" /><ref name="ICD-11 Beta Draft" />
• Body image disturbance<ref>Template:Cite journal</ref>

In contrast to bulimia nervosa, binge eating episodes are not regularly followed by activities intended to compensate for the amount of food consumed,Template:Sfn such as self-induced vomiting, laxative or enema misuse, or strenuous exercise.<ref name="ICD-11 Beta Draft" /> BED is characterized more by overeating than dietary restriction.<ref name=nationaleatingdisorders>Template:Cite web</ref> Those with BED often have poor body image and frequently diet, but are unsuccessful due to the severity of their binge eating.<ref name=nationaleatingdisorders/>

Obesity is common in persons with BED,<ref name="Wilfley, 2002">Template:Cite book</ref> as are depression,Template:Sfn low self-esteem, stress and boredom.<ref name="Michalska2016">Template:Cite journal</ref> Regarding cognitive abilities, individuals showing severe binge eating symptoms may experience small dysfunctions in executive functions.<ref>Template:Cite journal</ref> Those with BED are also at risk of non-alcoholic fatty liver disease,<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> menstrual irregularities such as amenorrhea,<ref name="Binge eating and menstrual dysfunct">Template:Cite journal</ref> and gastrointestinal problems such as acid reflux and heartburn.<ref name="Associations among binge eating beh"/>

Causes

As with other eating disorders, binge eating is considered an "expressive disorder"—a disorder that is an expression of deeper psychological problems.<ref name="Set-shifting ability across the spe"/> People who have binge eating disorder have been found to have higher weight bias internalization, which is characterized by low self-esteem, unhealthy eating patterns, and body dissatisfaction.<ref>Template:Cite journal</ref> Binge eating disorder commonly develops as a result of or side effect of depression, as it is common for people to turn to comfort foods when they are feeling down.<ref>Template:Cite news</ref>

There was resistance to granting binge eating disorder the status of a fully fledged eating disorder because many perceived binge eating disorder to be caused by individual choices.<ref name="Saguy Gruys 2010"/> Previous research has focused on the relationship between body image and eating disorders, and concludes that disordered eating might be linked to rigid dieting practices.<ref>Template:Cite journal</ref> In the majority of cases of anorexia, extreme and inflexible restriction of dietary intake leads at some point to the development of binge eating, weight regain, bulimia nervosa, or a mixed form of eating disorder not otherwise specified. When under a strict diet that mimics the effects of starvation, the body may be preparing for a new type of behavior pattern, one that involves the consumption of a large amount of food in a relatively short period of time.<ref>Template:Cite web</ref><ref>Template:Cite news</ref><ref>Template:Cite journal</ref>

Some studies show that BED aggregates in families and could be genetic. However, very few published studies of the genetics of BED exist.

Research suggests that environmental factors and the impact of traumatic events can cause binge eating disorder. One study showed that women with binge eating disorder experienced more adverse life events in the year before the onset of the disorder, and that binge eating disorder was positively associated with how frequently negative events occurred.<ref name=Mazzeo>Template:Cite journal</ref> Additionally, the research found that individuals who had binge eating disorder were more likely to have experienced physical abuse, perceived risk of physical abuse, stress, and body criticism.<ref name="Mazzeo"/> Other risk factors may include childhood obesity, critical comments about weight, low self-esteem, depression, and physical or sexual abuse in childhood.<ref>Template:Cite journal</ref> A systematic review concluded that bulimia nervosa and binge eating disorder are impacted by family separations, losses and big life changes, and negative parent-child interactions<ref>Template:Cite journal</ref> A few studies have suggested that there could be a genetic component to binge eating disorder,<ref name="Saguy Gruys 2010"/> though other studies have shown more ambiguous results. Studies have shown that binge eating tends to run in families, and a twin study by Bulik, Sullivan, and Kendler has shown a "moderate heritability for binge eating" at 41 percent.<ref>Template:Cite journal</ref> Studies have also shown that eating disorders such as anorexia and bulimia reduce coping abilities, which makes it more likely for those suffering to turn to binge eating as a coping strategy.<ref>Template:Cite journal</ref>

"In the U.S, it is estimated that 3.5% of young women and 30% to 40% of people who seek weight loss treatments can be clinically diagnosed with binge eating disorder."<ref>Template:Cite web</ref>

Diagnosis

International Classification of Diseases

The 2017 update to the American version of the ICD-10 includes binge eating disorder (BED) under F50.81.<ref>Template:Cite web</ref> ICD-11 may contain a dedicated entry (6B62), defining BED as frequent, recurrent episodes of binge eating occurring at least once a week or more over several months which are not regularly followed by inappropriate compensatory behaviors aimed at preventing weight gain.<ref name="ICD-11 Beta Draft">Template:Cite web</ref>

According to the World Health Organization's ICD-11 classification of BED, the severity of the disorder can be classified as mild (1-3 episodes/week), moderate (4-7 episodes/week), severe (8-13 episodes/week) and extreme (>14 episodes/week).<ref name=":0">Template:Cite journal</ref>

Diagnostic and Statistical Manual

Initially considered a subject for further research exploration, binge eating disorder was first included in the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1994, proposed a feature of an eating disorder. In 2013, it gained formal recognition as a psychiatric condition in the DSM-5.<ref name=":0" /> Until 2013, binge eating disorder was categorized as an Eating Disorder Not Otherwise Specified, an umbrella category for eating disorders that don't fall under the categories for anorexia nervosa or bulimia nervosa. Before DSM-5, Eating Disorder Not Otherwise Specified, which included BED, was diagnosed more often than both anorexia nervosa and bulimia nervosa.<ref name=":6">Template:Cite journal</ref> Because it was not a recognized psychiatric disorder in the DSM until 2013, it has been difficult to obtain insurance reimbursement for treatments.<ref>Template:Cite webTemplate:Self-published inline</ref> The disorder now has its own category under DSM-5, which outlines the signs and symptoms that must be present to classify a person's behavior as binge eating disorder. Studies have confirmed the high predictive value of these criteria for diagnosing BED.<ref>Template:Cite conference</ref>

One study found that the method for diagnosing BED is for a clinician who typically diagnose using the DSM-5 criteria or taking the Eating Disorder Examination.<ref name=":0" /> The Structured Clinical Interview for DSM (SCID-5) takes no more than 75 minutes to complete and has a systematic approach which follows the DSM-5 criteria. The Eating Disorder Examination is a semi-structured interview that identifies the frequency of binges and associated eating disorder features.<ref name=":0" />

The DSM-5 characterizes diagnosis under several categories—mild, moderate, severe, and extreme—each determined by the number of binges the patient exhibits per week. Mild: 1-3 episodes per week, Moderate: 4-7 episodes per week, Severe: 8-13 episodes per week, Extreme: 14 or more episodes per week<ref>Template:Cite bookTemplate:Page needed</ref>

Further, the remission states are classified under the following. Partial Remission: Following a previous diagnosis, the average frequency of binge eating episodes decreases to less than one episode per week for a sustained period. Full Remission: Following a previous diagnosis, none of the criteria have been met for a sustained period.<ref>Template:Cite bookTemplate:Page needed</ref>

Management

Counseling and some medication, such as certain stimulants (e.g., lisdexamfetamine), selective serotonin reuptake inhibitors (SSRIs), and GLP-1 receptor agonists, may help people with a binge eating disorder (BED).<ref>Template:Cite journal</ref> Some recommend a multidisciplinary approach in the treatment of the disorder.<ref name="Michalska2016" />

Medication

Lisdexamfetamine

Template:See also As of July 2024, lisdexamfetamine is the only pharmacotherapy approved by the USFDA and TGA for BED<ref name="BED rapid review">Template:Cite journal</ref><ref name="BED neuroplasticity">Template:Cite journal</ref> Evidence indicates that its effectiveness in treating BED may be partially due to a psychopathological overlap with Attention deficit hyperactivity disorder, a cognitive control disorder that also benefits from treatment with lisdexamfetamine.<ref name="BED ADHD overlap">Template:Cite journal</ref><ref name="BED secondary outcomes">Template:Cite journal</ref>

Medical reviews of randomized controlled trials have established that lisdexamfetamine, administered at doses between 50 and 70 mg, is safe and effective for treating BED.<ref group="sources" name="BED efficacy"><ref name="BED rapid review" /><ref name="BED neuroplasticity" /><ref name="BED secondary outcomes" /><ref name="BED systematic review">Template:Cite journal</ref><ref name="BED review">Template:Cite journal</ref></ref> These reviews consistently report fewer binge eating episodes during the week<ref name="BED efficacy" group="sources" /> Furthermore, a meta-analytic systematic review included a 12-month study showing the medication was effective for a long period of time.<ref name="BED systematic review" /> Two reviews have found lisdexamfetamine to be superior to placebo in several secondary outcomes, including persistent binge eating cessation, reduction of obsessive-compulsive binge eating symptoms, body weight, and triglycerides.<ref name="BED secondary outcomes" /><ref name="BED systematic review" />

Lisdexamfetamine is a pharmacologically inert prodrug that confers its therapeutic effects for BED after conversion to its active metabolite, dextroamphetamine, which acts in the central nervous system.<ref name="BED neuroplasticity" /> Dextroamphetamine increases the activity of dopamine and norepinephrine to the prefrontal cortex, which makes major decision-making for the body.<ref name="BED ADHD overlap" /><ref name="BED systematic review" /><ref>Template:Cite book</ref> Lisdexamfetamine, like all pharmaceutical amphetamines, possesses direct appetite suppressant effects, which may be therapeutically beneficial for BED and its associated comorbidities.<ref name="BED secondary outcomes" /><ref name="BED systematic review" /> Neuroimaging studies involving BED-diagnosed participants suggest that long term effects in the brain that result in people getting better even after stopping their initial medication<ref name="BED rapid review" /><ref name="BED neuroplasticity" /><ref name="BED systematic review" />

Off-label medications

Three other classes of medications are also used to treat binge eating disorder: antidepressants, anticonvulsants, and anti-obesity medications.<ref name="Marazziti2012" /> Antidepressant medications of the selective serotonin reuptake inhibitor (SSRI) have been found to effectively reduce episodes of binge eating and reduce weight.<ref name="Marazziti2012" /> Similarly, anticonvulsant medications such as topiramate and zonisamide may be able to effectively suppress appetite.<ref name="Marazziti2012" /> The long-term effectiveness of medication for binge eating disorder is currently unknown.<ref name="Iacovino2012" /> For BED patients with manic episodes, risperidone is recommended. If BED patients have bipolar depression, lamotrigine is the appropriate choice.

Trials of antidepressants, anticonvulsants, and anti-obesity medications suggest that these medications are superior to placebo in reducing binge eating.<ref name="Bodell & Devlin, 2011">Template:Cite book</ref> Medications are not considered the treatment of choice because psychotherapeutic approaches, such as CBT, are more effective than medications for binge eating disorder. A meta-analysis concluded that using medications did not reduce binge-eating episodes and BMI posttreatment at 6–12 months. This indicates the possibility of relapse from not taking the medication anymore.<ref name=":1" /> Medications also do not increase the effectiveness of psychotherapy, though some patients may benefit from anticonvulsant and anti-obesity medications, such as phentermine/topiramate, for weight loss.<ref name="Bodell & Devlin, 2011" />

Blocking opioid receptors decreases food intake. Additionally, bupropion and naltrexone together may cause weight loss. Combining these alongside psychotherapies like CBT may lead to better outcomes for BED.<ref>Template:Cite journal</ref>

GLP-1 receptor agonist medications such as semaglutide (Ozempic), dulaglutide (Trulicity), and liraglutide (Saxenda) have been used for treating BED in recent years. Often prescribed for lowering appetite and subsequent weight loss in people with diabetes mellitus and obesity, they can successfully stop or reduce obsessive thoughts about food, binging urges, and other impulsive behaviors.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> Some users, reported sudden improvement in "food noise" - constant unstoppable thoughts about food, even not being physically hungry, which can be a symptom of BED.<ref>Template:Cite news</ref><ref>Template:Cite news</ref> To this promising treatment is on the up for success, but additional research is needed as of January 2024.<ref>Template:Cite journal</ref>

Counseling

Cognitive behavioral therapy (CBT) treatment has been demonstrated as a more effective form of treatment for BED than behavioral weight loss programs. About 50% of individuals with BED achieve complete remission from binge eating and 68-90% will reduce the amount of binge eating episodes they have.<ref name=":0" /> CBT has also been shown to be an effective method to address self-image issues and psychiatric comorbidities (e.g., depression) associated with the disorder.<ref name="Westerburg2013" /> The goal of CBT is to interrupt binge-eating behavior, learn to create a normal eating schedule, change the perception around weight and shape, and develop positive attitudes about one's body.<ref name=":0" /> While CBT has been effective in eliminating BED, it most of the time does not result in a person losing weight.<ref>Template:Cite journal</ref> Recent reviews have concluded that psychological interventions such as psychotherapy and behavioral interventions are more effective than pharmacological interventions for the treatment of binge eating disorder.<ref name="Iacovino2012" /> A meta-analysis concluded that psychotherapy based on CBT not only significantly improved binge-eating symptomatology but also reduced a client's BMI significantly at posttreatment and longer than 6 and 12 months after treatment.<ref name=":1">Template:Cite journal</ref> Behavioral weight loss treatment has been proven to be effective as a means to achieve weight loss amongst patients.<ref>Template:Cite journal</ref>

Surgery

Bariatric surgery has also been proposed as another approach to treat BED, and a recent meta-analysis showed that approximately two-thirds of individuals who seek this type of surgery for weight loss purposes have BED. Bariatric surgery recipients who had BED before receiving the surgery tend to have poorer weight-loss outcomes and are more likely to continue to exhibit eating behaviors characteristic of BED.<ref name="Westerburg2013"/>

Lifestyle interventions

Other BED treatments include lifestyle changes like weight training, peer support groups, and investigation of hormonal abnormalities.

Prognosis

Individuals with BED often have a lower overall quality of life and face social difficulties.<ref name="Iacovino2012"/>Early behavior changes can predict a full recovery for the future.

Individuals who have BED commonly have other conditions such as depression, personality disorder, bipolar disorder, substance abuse, body dysmorphic disorder, kleptomania, irritable bowel syndrome, fibromyalgia, or an anxiety disorder.<ref name="Westerburg2013"/><ref name="Marazziti2012">Template:Cite journal</ref> They may also have history of attempted suicide and reoccurring panic attacks.<ref name="Michalska2016" />

While people of a normal weight may overeat occasionally, an ongoing habit of consuming large amounts of food in a short period of time may ultimately lead to weight gain and obesity. The main physical health consequences of this type of eating disorder are brought on by the weight gain resulting from calorie-laden bingeing episodes. Mental and emotional consequences of binge eating disorder include social weight stigma and emotional loss of control.<ref name=nationaleatingdisorders/> Up to 70% of individuals with BED may also be obese,<ref name="Michalska2016" /> and therefore obesity-associated morbidities such as high blood pressure<ref name="Michalska2016" /> and coronary artery disease,<ref name="Michalska2016" /> type 2 diabetes mellitus, gastrointestinal issues (e.g., gallbladder disease), high cholesterol levels, musculoskeletal problems and obstructive sleep apnea<ref name="Westerburg2013"/><ref name="Iacovino2012"/><ref>Template:Cite web</ref> may also be present. One study found a 42% obesity rate in those who have received a BED diagnosis.<ref name=":6" /> Additionally, a higher morbid obesity prevalence was observed in this population compared to a population without eating disorders.<ref name=":6" />

Epidemiology

General

The prevalence of BED in the general population is approximately 1-3%.<ref name="Perkins2006">Template:Cite journal</ref>

BED cases usually occur between the ages of 12.4 and 24.7, but prevalence rates increase until the age of 40.<ref name=":2" />

Age

Binge eating disorder is the most common eating disorder in adults.<ref name="Iacovino2012">Template:Cite journal</ref>

The limited amount of research that has been done on BED shows that rates of binge eating disorder are fairly comparable among men and women.<ref>Template:Cite journal</ref> The lifetime prevalence of binge eating disorder has been observed in studies to be 2.0 percent for men and 3.5 percent for women, higher than that of the commonly recognized eating disorders, anorexia nervosa and bulimia nervosa.<ref name="Westerburg2013">Template:Cite journal</ref> However another systematic literature review found the prevalence average to be about 2.3% in women and about 0.3% in men.<ref name=":0" /> Lifetime prevalence rates for BED in women can range anywhere from 1.5 to 6 times higher than in men.<ref name=":2" /> One literature review found that point prevalence rates for BED vary from 0.1 percent to 24.1 percent depending on the sample.<ref name=":2">Template:Cite journal</ref> This same review also found that the 12-month prevalence rates vary between 0.1 percent to 8.8 percent.<ref name=":2" /> Adolescents also have a high risk of binge eating behavior. Incidence rates of 10.1 and 6.6 per 10,000 person years have been observed in male and female adolescents in the U.S., respectively.<ref name=":6" />

Sexuality

Recent studies found that eating disorders, with the inclusion of BED, are found to be prominent in LGBTQ groups due to higher rates of depression when compared to the general population. This could be due to the stress and discrimination this population experiences.<ref>Template:Cite journal</ref> Furthermore, adolescent and young adult sexual minority males binge at higher rates than their heterosexual counterparts.<ref name=":7">Template:Cite journal</ref>

Race and ethnicity

Given that the research for BED is not supported on the topic of ethnicity, it makes it difficult to understand how common BED is.<ref name=":2" /> However, the racial makeup of BED distinctly varies from anorexia nervosa and bulimia nervosa.<ref name=":6" /> BED has the same effect no matter the color of someone's skin.<ref name="Saguy Gruys 2010"/>Many studies surround BED being focused on white women.<ref>Template:Cite journal</ref> One literature review found information citing no difference between BED prevalence among Hispanic, African American, and White women while other information found that BED prevalence was highest among Hispanics followed by Black individuals and finally White people.<ref name=":2" /> A 2021 study has observed "higher rates of BED as compared to other ethnic groups" for African Americans.<ref name=":8">Template:Cite journal</ref> The likelihood of reporting eating disorder symptoms is also lower in some groups, including African Americans.<ref name=":8" /> Asian-Americans also face decreased reporting of ED symptoms. This can be partly attributed to "significantly higher thin-ideal internalization" compared to other ethnic groups.<ref name=":8" />

Migration can also influence BED risk. Mexican-American immigrants have been observed to face a greater risk of BED following migration.<ref name=":6" />

Socioeconomic status

People with low socioeconomic status often face many problems in the diagnosis and treatment of eating disorders like BED. These barriers include longer clinical waiting times, worse care, and less clinical investigation for individuals that "defy illness stereotypes".<ref name=":9">Template:Cite journal</ref> The costs associated with specialized mental health care pose another barrier for low socioeconomic status individuals.<ref name=":9" /> Furthermore, associated factors such as food insecurity and environmental stress have been shown to contribute to higher rates of eating disorders, such as BED, in these populations.<ref name=":9" /> Food security has been found to be a notable predictor of eating disorder behaviors. Low food security has been shown to increase the prevalence and frequency of binge eating.<ref name=":8" /> Researchers have been called on to reframe eating-related disorders to better fit low socioeconomic status populations and improve future investigations.<ref name=":9" />

Worldwide Prevalences

BED is not something only to be found in Western countries. Evidence of increasing eating disorder prevalence has been observed in "non-Western countries and among ethnic minorities".<ref name=":6" /> Though the research on binge eating disorders tends to be concentrated in North America, the disorder occurs across cultures.<ref>Template:Cite journal</ref> Increasing globalization has influenced the prevalence of eating disorders outside of the West.<ref name=":6" /> In the US, BED is present in 0.8% of male adults and 1.6% of female adults in a given year.<ref name="DSM5">Template:Cite book</ref>

The prevalence of BED is lower in Nordic countries compared to Europe in a study that included Finland, Sweden, Norway, and Iceland.<ref name=":3">Template:Cite journal</ref> The point prevalence ranged from 0.4 to 1.5 percent and the lifetime prevalence ranged from 0.7 to 5.8 percent for BED in women.<ref name=":3" />

In a study that included Argentina, Brazil, Chile, Colombia, Mexico, and Venezuela, the point prevalence for BED was 3.53 percent.<ref name=":4">Template:Cite journal</ref> Therefore, this particular study found that the prevalence for BED is higher in these Latin American countries compared to Western countries.<ref name=":4" />

The prevalence of BED in Europe ranges from <1 to 4 percent.<ref>Template:Cite journal</ref>

Co-morbidities

BED often happens with diabetes, stroke, and heart disease.<ref name=":2" />

People who experience OCD or bipolar disorder have a greater chance of dealing with BED.<ref name=":2" />

Additionally, 30 to 40 percent of individuals seeking treatment for weight loss can be diagnosed with binge eating disorder.<ref name="Westerburg2013"/>

Underreporting in men

Men often do not report a personal issue of BED.<ref name=":3" /> Underreporting could be a result of measurement bias due to how eating disorders are defined.<ref name=":3" /> The current definition for eating disorders focuses on thinness.<ref name=":3" /> However, eating disorders in men tend to center on muscularity and would therefore warrant a need for a different measurement definition.<ref name=":3" /> Overvaluation rates of body weight or shape in adolescent males are significantly lower than their female counterparts (4.9% and 24.2%, respectively). Little is known if this discrepancy is an indicator of later onset of body image distortion in males or a consequence of female-centric diagnostic frameworks for eating disorders.<ref name=":7" />

The lack of representation of men in eating disorder research has been hindered by historical perceptions of eating disorders as a "female phenomenon".<ref name=":7" /> Researchers have been called on to address this gap by advancing methods of "identification, assessment, classification, and treatment" for eating disorders in a male-specific context, specifically in young men.<ref name=":7" />

Frequency

BED is the most common eating disorder, with 47% of people with eating disorders having BED, 3% of them have anorexia nervosa, and 12% of them have bulimia nervosa.<ref name=":5">Template:Cite web</ref> Over 57% of people with BED are female<ref name=":5" /> and it often begins in the late teens or early 20s.<ref>Template:Cite web</ref>

History

The disorder was first described in 1959 by psychiatrist and researcher Albert Stunkard as "night eating syndrome" (NES).<ref>Template:Cite journal</ref> The term "binge eating" was coined to describe the same bingeing-type eating behavior but without the exclusive nocturnal component.<ref>Template:Cite journal</ref>

There is less research on BED than there is on anorexia or bulimia.

See also

• Prader–Willi syndrome

Reference notes

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References

Bibliography

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External links

• Template:Commons category-inline
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• Binge Eating Disorder on National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)