The End of Diabetes: The Eat to Live Plan to Prevent and Reverse Diabetes

Suicide is terrifyingly and astonishingly typical in men and women with type 1 diabetes. That was the unavoidable takeaway from a symposium at the 2022 Scientific Sessions conference put on by the American Diabetes Association.

First, the data. A 2017 systematic review and analysis published in the European Journal of Endocrinology found that an astonishing 7.7% of deaths among individuals with type 1 diabetes were “attributable to suicide.” To put that into context, consider the numbers for the United States as a whole in 2019, the last year before the Covid-19 pandemic began to affect death totals. About 47,500 Americans died by suicide in 2019, accounting for 1.7% of total deaths.

Professor Katharine Barnard-Kelly, PhD, of the RESCUE Collaborative Community, outlined the prevalence of suicide in type 1 diabetes in a powerful speech. She believes that the jaw-dropping numbers above only scratch the surface: “the reality is that suicide is likely grossly under-reported.”

Suicide is, moreover, only the most extreme expression of an entire range of self-harm behaviors. The World Health Organization has estimated that for each one completed act of suicide, there are 20 suicide attempts. And that doesn’t even begin to address non-lethal self-harm practices such as cutting, burning, and head banging, which are believed to be rife within the diabetes community.

Diabetes and Mental Health Burdens

It is beyond well-established that individuals with type 1 diabetes are more likely to suffer from depression, anxiety, and other associated mental health problems. Less commonly discussed is the frequency with which these problems spiral towards self-harm, suicidal ideation, and suicide itself.

A second presenter, Dexcom’s Dr. Daniel Cherñavvsky, MD, discussed a survey of diabetes healthcare professionals on the subjects of suicide and self-harm; the panel included doctors, nurses, psychologists, dietitians, and diabetes educators. The results showed that most of these professionals guessed that many of their patients had encountered depression but that extremely few had ever deliberately injured themselves, experienced suicidal ideation, or attempted suicide. It seems probable that most healthcare professionals underestimate the scope of the self-harm issue, perhaps dramatically.

In the general population, suicide is more common among men; the highest suicide pace in America belongs to middle-aged white men. But Dr. Barnard-Kelly emphasized that suicide in diabetes cuts across all demographics: “the data is that this is an problem that affects everybody across the ages.”

The issue may be particularly prevalent in teens with type 1 diabetes. Those years are an unusually stressful time for young people with diabetes. We know that of all patients, teens have the highest A1C as an age group, a fact that will be completely understandable to anyone that’s been a teen with diabetes themselves (or lived with one). As Dr. Barnard-Kelly speculated, confronting the inescapable reality of the condition during a tender emotional time can be “overwhelming,” easily feeding the feelings of isolation and negativity associated with suicidal ideation.

Self-Harm and Insulin Therapy

The nature of type 1 diabetes management leads to unique opportunities for self-harm. Keeping insulin perpetually on hand means, as Dr. Barnard-Kelly put it, “very easy access to a very powerful method of taking one’s own life.”

Insulin abuse can take a variety of forms, including intentional insulin omission (as seen in diabulimia), over-bolusing or “rage bolusing,” and even binge eating to purposefully increase blood sugars. Both hypoglycemia and hyperglycemia can be lethal.

Dr. Barnard-Kelly believes that a high percentage of hospital admissions among previously diagnosed patients for DKA may be due to suicide attempts, but “we have no way of identifying this or discovering it.” Meanwhile, a 2009 study found that in 160 situations of insulin overdose, “nearly 90% were either suicidal or parasuicidal, whereas only 5% of cases were deemed accidental.” Unfortunately, most of these cases are not identified by mainstream treatment protocols.

Insulin overdose, according to the speakers, is the most common method of suicide in people with type 1 diabetes.

What Can Be Done?

Much of the symposium was devoted to how health care professionals should tackle the problem. While the connection between diabetes and mental health problems is widely recognized, many medical professionals think that they are not properly equipped to facilitate with suicide and self-harm.

Several of the experts in the symposium were associated with the RESCUE Collaborative Community, an organization dedicated to reducing the ratees of suicide and self-harm in people with diabetes. Made of up volunteers from every part of the diabetes community, this group is trying to develop models to better predict self-harm and suicide, and to design better screening and intervention “bundles” for health care professionals to put into practice.

Unfortunately, there are no easy answers to the problem. Dr. Shideh Majidi, MD MSCS, of Washington, D.C.’s Children’s National Hospital, discussed the most promising screening techniques available to providers today, but many diabetes care providers assert that they don’t have the time to add this kind of routine evaluation to their practices.

According to Dr. Cherñavvsky, most healthcare professionals are at least moderately comfortable asking about suicide and self-harm. But “some do not touch the subject at all.”

Relatively few have received advanced training on how to help patients with suicide or self-harm, Dr. Cherñavvsky stated. “The majority of diabetes health care providers consider mental health assessment as their responsibility, but feel that more training and resources are needed.”

Kelly Close, an influential advocate and founder of The diaTribe Foundation, outlined the potentially toxic emotional stew that can lead to suicide: “Lethal suicide attempts happen at the intersection of ‘I am alone,’ ‘I am a burden,’ and the means or capability to finish suicide.” It may be fair to say that most people with type 1 diabetes are familiar with the feeling of isolation and know what it feels like to be a burden to others. And all people with diabetes are perpetually carrying the means and capability to complete suicide with them.

The subject of suicide remains highly stigmatized, and it can be difficult to help people in danger to feel comfortable enough to talk about these issues directly.

For those concerned about a patient or loved one that may hurt his or herself, Dr. Kelly-Barnard emphasized the importance of addressing the issue in an undo and non-judgmental fashion: “isolation can be reinforced by the judgment that people feel when they try and raise [these issues].” She stated that most people who have attempted suicide report being “met with hostility and anger about how selfish they are, and how they should have reached out for help.”

Diabetes Daily has cultivated a page of mental health resources for people with diabetes. If you’re worried about yourself or someone else, we encourage you to use a resource such as the United States’ National Suicide Prevention Lifeline.

Diabetes Daily

The End of Diabetes: The Eat to Live Plan to Prevent and Reverse Diabetes