Insulin Restriction and Associated Morbidity and Mortality in Women with Type 1 Diabetes

  1. Ann E. Goebel-Fabbri, PhD1,,2,
  2. Janna Fikkan, MA1,
  3. Debra L. Franko, PhD3,
  4. Kimberly Pearson, MD2,,4,
  5. Barbara J. Anderson, PhD5 and
  6. Katie Weinger, EdD (katie.weinger{at},,2
  1. 1Joslin Diabetes Center
  2. 2Harvard Medical School
  3. 3Northeastern University
  4. 4Massachusetts General Hospital
  5. 5Baylor College of Medicine


    Objective: To determine whether insulin restriction increases morbidity and mortality in women with type 1 diabetes.

    Research Design and Methods: This is an 11-year follow-up study of women with type 1 diabetes. 234 women (60% of original cohort) participated in the follow-up. Mean age was 45 years and mean diabetes duration was 28 years at follow-up. Mean BMI was 25kg/m2 and mean HbA1c was 7.9%. Measures of diabetes self-care behaviors, diabetes-specific distress, fear of hypoglycemia, psychological distress, and eating disorder symptoms were administered at baseline. At follow-up, mortality data were collected through state and national databases. Follow-up data regarding diabetes complications were gathered by self-report.

    Results: Seventy-one women (30%) reported insulin restriction at baseline. Twenty-six women died during follow-up. Based on multivariate Cox regression analysis, insulin restriction conveyed a three-fold increased risk of mortality after controlling for baseline age, BMI, and HbA1c. Mean age of death was younger for insulin restrictors (45 vs. 58 years, p<0.01). Insulin restrictors reported higher rates of nephropathy and foot problems at follow-up. Deceased women reported more frequent insulin restriction (p<0.05) and reported more eating disorder symptoms (p<0.05) at baseline than their living counterparts.

    Conclusions: Our data demonstrate that insulin restriction is associated with increased rates of diabetes complications and increased mortality risk. Mortality associated with insulin restriction appeared to occur in the context of eating disorder symptoms, rather than other psychological distress. We propose a screening question appropriate for routine diabetes care to improve detection of this problem.


      • Received October 22, 2007.
      • Accepted November 30, 2007.

    This Article

    1. Diabetes Care
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