AMSTERDAM — More than 90% of all teenagers with type 1 diabetes omit insulin doses at least occasionally to prevent weight gain, according to the results of an international observational study presented by Dr. Soren E. Skovlund at the annual meeting of the European Association for the Study of Diabetes.
The practice is associated with significantly poorer glycemic control. “Screening for and dialog with adolescents about omission of insulin injections may be particularly warranted in those who exhibit concern about their weight or engage in weight-reducing activities,” said Dr. Skovlund, global director of patient-focused programs at Novo Nordisk A/S, Bagsvaerd, Denmark.
A total of 2,062 adolescents aged 11–18 years with type 1 diabetes of at least 1 year's duration completed the survey, conducted in 2005 by the Novo-Nordisk-funded Hvidoere Study Group. The respondents were from 21 centers in Europe, Australia, Japan, and North America. There was one U.S. center, at Children's Hospital, Los Angeles.
The study group was equally divided between genders. Both genders had a mean age of 14.5 years, and mean diabetes duration of 6.3 years for the females and 5.9 years for the males. Mean body mass indices were 22.8 kg/m
Each was asked to complete an extensive questionnaire covering topics such as lifestyle, self-management and health behaviors, treatment goals, family dynamics, well-being and quality of life, diabetes burden, and weight perception/dieting. Also included was the question: “How often do you miss insulin to control your weight?” Possible responses were “never,” “once a month,” “once a week,” or “every day.”
The majority—91.7% of the females and 93.0% of the males—checked “once a month.” “Never” was a distant second, reported by 5.1% of females and 4.2% of males, followed by “once a week” (2.5% female/1.9% male) and “every day” (0.7% female/0.9% male).
“This was not just in general, but specifically to avoid weight gain. Clearly, people are connecting the two aspects,” Dr. Skovlund said.
The nearly equal proportion of males and females is striking. “A lot of the insulin omission literature has focused on this being a female phenomenon. … But we have certainly also seen it in boys.”
Those who reported omitting insulin doses either daily or weekly (“high omitters”) had poorer metabolic control, and averaged a significant difference of half a percentage point in hemoglobin A1c values, compared with the “low omitters,” those who omitted never or monthly (8.99% female/8.61% male vs. 8.24% female/8.08% male). Insulin omission remained significantly correlated with HbA1c after controlling for age and diabetes duration, but not gender.
Insulin omission also was highly correlated with other weight-loss behaviors, such as fasting, restricting certain food groups, vomiting, and use of diet pills/laxatives, as well as reduced well-being and quality of life. None of the associations significantly differed by center. Insulin omission was reported both by patients on multiple daily injections as well as those on insulin pumps (who made up approximately 20% of the overall group).
Dr. Francine R. Kaufman, a pediatric endocrinologist who heads the Los Angeles center said: “Kids miss doses all the time. … The question is why.” In the United States the practice of omitting insulin for weight control has been dubbed “diabulemia,” she noted in an interview.
But the thought process may not always be straightforward. Teens might rationalize that they didn't eat as much as they did, or that they don't need as much insulin as they actually do. Often, it's not about completely omitting a dose but of not taking enough for the amount of food consumed. “A lot of it is not totally willful, [more like] miscalculating the dose.”
The literature has focused on this as a female phenomenon, but 'we have certainly also seen it in boys.' DR. SKOVLUND
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