NEWS - The Journal of Clinical Endocrinology & Metabolism

NDOCRINOLOGY & METABOLISM NEWS
NEWSE
70 years with an intact uterus, for approximately 3
years after they stopped taking estrogen-plus-progestin.
The participants underwent a yearly health
exam and mammogram, with biopsies performed
as needed. After three years, the previously established
risk of heart disease was diminished, but overall
risks, including that of stroke, blood clots, and
cancer, remained. Specifically, the risk of breast cancer
continued at a rate similar to that seen during
treatment; women who had stopped taking combined
therapy were 27% more likely to develop
breast cancer than those on placebo. The study also
found that other effects of combined therapy, such
as decreased risk of colorectal cancer and hip fractures,
also stopped when therapy ended. In sum, the
global risk index was 12% higher in women assigned
to combined hormonal therapy than
placebo.
Elizabeth G. Nabel, M.D., NHLBI director, said the
article “confirms the study’s primary conclusion that
combination hormone therapy should not be used
to prevent disease in healthy, premenopausal
women.” Added Michael Lauer, M.D., director of
the NHLBI Division of Prevention and Population Sciences:
“All the accumulated risks do not simply
disappear.”
Yet outside physicians did not draw as negative a
conclusion. “The take-home message is that there
are risks while you’re taking it and most of those
risks appear to go away when you stop,” said Elizabeth
Barrett-Connor, M.D., professor and division
chief of epidemiology at the University of California
in San Diego. “The not-so-good news is that the risk
of cancer doesn’t go away.” The bottom line, she
said, is that, “The risks of combined hormone therapy
are very small and the benefits are very small.
The trick here is how to advise women in the way
that is best for their health and quality of life and not
to scare them.”
Similarly, in his practice, Robert Barbieri, M.D.,
gynecology and reproductive biology professor at
Harvard Medical School in Boston, Massachusetts,
takes the age of his patients under consideration. “I
think the risks are quite modest with someone in
their 40s and 50s,” he said. “If I see people in their
60s with hormone replacement therapy, I take a
more active stance in trying to get them to stop it.”
(JAMA [March 5, 2008] 299(9):1036)
Restricting Insulin Doses Increases
Mortality Risk
Women with type 1 diabetes who reported taking
less insulin than prescribed had a three-fold
greater risk of death and higher rates of complications
than those who did not skip needed insulin
shots, researchers at the Joslin Diabetes Center report
in the March issue of Diabetes Care. This reported
danger casts further light onto what is referred
to in the popular press as “diabulimia,” an
eating disorder in which people with type 1 diabetes
deliberately take less insulin than they need for the
purposes of weight loss. The attention to diet,
weight, and glycemic control associated with diabetes
management can trigger this behavior, observed
more often in younger females.
In their study, 234 women from age 13 to 60 with
type 1 diabetes were followed for 11 years. At the
study’s onset, 30% of these women reported taking
less insulin than they should for a number of reasons,
including weight concerns and related eating
disorders, as well as other psychological symptoms
such as depression, anxiety, or fear of hypoglycemia.
Researchers found that, compared to those
who regularly took insulin, the insulin restrictors had
increased mortality along with higher rates of nephropathy
and foot problems. This was true even
though the mean age of death was actually younger
for insulin restrictors compared to insulin takers: 45
years versus 58 years.
“There is a subset of women for whom their fears
of weight gain and their extreme desire for thinness
interferes with appropriate diabetes self-care,” said
lead author, Ann Goebel-Fabbri, Ph.D., psychologist
and instructor at Harvard Medical School, who
noted that other studies have shown women with
diabetes are nearly 2.5 times more likely to develop
an eating disorder than women without diabetes.
Goebel-Fabbri and her team propose a screening
question appropriate for routine diabetes care—
“Do you take less insulin than you should”—to increase
the likelihood of earlier detection of this
problem and improve access to specialty treatment
referrals for these high-risk patients.
“Raising awareness of the impact of insulin restriction
among clinicians who treat type 1 diabetes
is extremely important so that they can make appropriate
assessments and referrals to mental
health professionals who are experienced in the
treatment of people with diabetes,” said study coauthor
Katie Weinger, Ed.D., R.N., and assistant
professor of psychiatry at Harvard Medical School.
Warning signs of insulin restriction can include
unexplainable spikes in their hemoglobin A1c;
weight loss; unusual pattern of intense exercise;
lack of marks from finger sticks; lack of prescription
refills for diabetes medications; repeated problems
with diabetic ketoacidosis; amenorrhea; and blood
glucose records that do not match hemoglobin A1c.
Making an eating disorder diagnosis, however,
can be somewhat tricky cautioned Jennifer Larsen,
M.D., diabetes, endocrinology, and metabolism
section chief at the University of Nebraska Medical
Center. “It’s not so clear cut. Some tools used to
identify eating disorders can be globally abnormal
for many patients with diabetes.” (Diabetes Care
[March 2008] 31(3):415)
Climate and Metabolic Syndrome
There may be a predisposition towards metabolic
disorders and diabetes based on the climate in
which people live, according to a recent population
genetics study performed by University of Chicago
researchers. The notion isn’t too far-fetched. Previ-
“There is a subset of
women for whom
their fears of weight
gain and their
extreme desire for
thinness interferes
with appropriate
diabetes self-care,”
Ann Goebel-Fabbri,
Ph.D., on her study
showing that women
with type 1 diabetes
who restrict their
insulin have a threefold
greater risk of
death and disease
complications.
NEWS
J Clin Endocrinol Metab, April 2008, 93(4):17A–20A jcem.endojournals.org 19A