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Insulin restriction leads to higher rate of mortality, complications

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The risk for mortality and diabetes-related complications are increased in patients with diabetes who take less insulin than prescribed.

Researchers at Joslin Diabetes Center in Boston, Baylor College of Medicine in Texas and other institutions completed an 11-year follow-up study of 234 women with type 1 diabetes to determine the effect of insulin restriction on morbidity and mortality. Participants were a mean age of 45 years.

The researchers measured eating disorder symptoms, diabetes self-care and distress along with fear of hypoglycemia and psychological distress. At baseline, 71 women (30%) reported insulin restriction.

Insulin restriction was responsible for a 3.2 increase in mortality. Women who skipped on their insulin died at a younger age (45 years vs. 58 years, P<.01) and reported higher rates of foot problems and nephropathy. More symptoms of eating disorders and more frequent insulin restriction were reported at baseline by women who died (P<.05), according to the study. – by Stacey L. Adams

Diabetes Care. 2008;31:415-419.

The authors give a fascinating analysis of the adverse consequence of deliberate omission of insulin doses among women with type 1 diabetes. Approximately 1/3 of women reported this behavior, often in the context of psychiatric illness, including depression and eating disorders, and their mortality after more than 10 years of follow-up was more than three times greater than women who did not exhibit this behavior. This effect was additive to that of higher HbA1c levels in multivariate analysis. We know that psychiatric illness is itself a marker of increased risk, so it is impossible to determine from the report whether omitting insulin doses is causally related to death, or, perhaps more likely, whether it is a marker of being a person with a variety of stress-related factors putting them at high risk. In any event, this should be regarded as an important finding. Patients who do omit insulin doses should be given particularly careful counseling, based on this, as well as many other studies.

– Zachary T. Bloomgarden, MD

Endocrine Today Editorial Board member