As many as 40.2 percent of women with type I diabetes between the ages of 15 and 30 intentionally take less insulin than they need. This is according to a study that took place at Joslin Diabetes Center in Boston and was published in Diabetes Care (October 1994).
341 women between the ages of 13 and 60 filled out surveys for the study, and also had their glycosylated hemoglobin checked within 30 days of completing the survey.
The survey was extensive, taking approximately 40 minutes to complete, and included groups of questions monitoring hypo-glycemic fear, general distress, diabetes specific distress, presence of disordered eating behavior, beliefs about insulin and weight, adherence to diabetes control regimen, acceptable blood glucose levels and prevalence of regimen manipulation. It was found by compiling the results of the survey that a total of 31 percent intentionally omitted insulin, with 8.8 percent reporting frequent omission. This represents the total number of women who omitted for any reason.
Of the 31 percent who intentionally omitted insulin, about half of these did so primarily for weight control. The other half, who did not omit for weight control, did so for a variety of other reasons including being emotionally overwhelmed by having the disease.
The women that reported omitting insulin also showed a decreased rate of self-care, including blood glucose monitoring and adherence to a meal plan, and an increased fear of weight gain if they sufficiently controlled their glucose levels.
The highest incidence of insulin omission occurred in the 15-30 age range, where the percentage of women omitting was 40.2 percent.
The study pointed to the highest occurrence of emergency room visits, diabetes related hospitalizations, retinopathy and neuropathy in the women who omitted insulin purely for weight control, but all of the women who omitted had an increase in complications.
The highest correlation to weight-related omission was found in the women who had high levels of diabetes related distress and who responded positively to the survey statement “I am afraid of getting my blood sugars in control because I will gain weight.”
It was also found that the omitters aimed for a range of blood glucose that was higher than those who did not omit insulin.
No significant difference was found between the age, number of daily injections, duration of diabetes, education, body mass or prescribed insulin amounts between the women who did not omit and those who did.
Omitters were more likely than non-omitters to directly manipulate their regimen through practices such as adjusting their insulin intake to control their weight, promoting the spilling of ketones into the urine through eating and putting off blood glucose testing to ignore insulin needs.
The study concluded that physicians need to be aware of the concerns that women in particular have with balancing glycemic control and weight management.
41 percent of the women who omitted insulin had completed college. They knew the importance of taking care of themselves, but unfortunately insulin omission can be as addictive to the woman with diabetes as bingeing and purging is to the person with bulimia. Even more frightening are the risks, which are even greater for the woman with diabetes who faces a huge increase in complications from her disease if she continues her self-destructive behavior.
With the proper counseling and education it should be possible for women to maintain glycemic control while still watching their weight.
|Weight Related||Non-Weight related||Non-Omitters|
|The table clearly shows the increase in side effects of women who omit insulin for any reason, and the even higher incidence of side effects for the women who omit to lose weight. For example, women who omit to lose weight have a 300 percent increase in neuropathy than the women who omit for other reasons. No reason was given in the study for the high HbA1c levels in the non-omitters.|
Comment from Karen Tenreiro, Psy.D.
“I would just like to respond to the article about insulin omission. I want to emphasize that insulin omission for weight loss is characterized as bulimia. I think this was not clearly identified but rather only compared to bulimia. As an eating disorder specialist I would want patients to know that insulin omission is very dangerous and should be treated as an eating disorder by a mental health care practitioner as well as their endocrinologist and diabetes educator.”