To our knowledge, this is the first report of weight-related issues and weight-loss practices comparing youth with type 1 and type 2 diabetes by sex. Whereas desiring to lose weight, worrying about weight, and having ever tried to lose weight were very common and not unexpected findings among type 2 diabetic youth, these characteristics were not uncommon among type 1 diabetic youth either, particularly among females, of whom 11% were obese. We found that reporting any unhealthy weight-loss practice was more common among type 1 than type 2 diabetic youth. Obese females and overweight/obese males were more likely to report any of these unhealthy practices than healthy weight youth. Among females but not males, there was an association between poor glycemic control and reporting any unhealthy weight-loss practice.
We compared the weight-loss practices of the 2,837 type 1 diabetic youth in SEARCH with results from diabetes clinic cohorts from Minnesota (n
= 143), eastern Canada (n
= 361), and Philadelphia (n
= 295) (9
). Exercise for weight-loss was more common in SEARCH participants (females 93.4%; males 96.9%) than among youth in Minnesota (89.9 and 47.9%, respectively) or Philadelphia (77.8 and 62.5%, respectively) for weight loss or maintenance (10
). In the Canadian study, only 12% of females reported dieting for weight loss compared with 79% in SEARCH. Of the unhealthy practices, for females and males, 7.4 and 1.4% from the Minnesota study and 6.7 and 2.6% from Philadelphia, respectively, reported fasting, compared with 6.2% of females and 5.3% of males in SEARCH. Skipping insulin was more prevalent in the Minnesota (10.3%) than in the SEARCH (2.6%) or Philadelphia (1.5%) females but not in males (1.4, 1.3, and 1.3%, respectively). Skipping insulin was also more common in the female Canadian cohort (11%), although these researchers also included underdosing in their measure (23
). Disordered eating in the Minnesota study was also associated with poor glycemic control in both sexes (10
). In the Philadelphia cohort, older females with higher BMI and A1C exhibited significantly more weight-control behaviors (22
). In SEARCH, we found that glycemic control was associated with any unhealthy weight-loss practice in females but not in males. The composite measure that we used for any unhealthy weight-loss practice in the current article differs from that in other studies. We found no published studies of weight-loss practices among type 2 diabetic youth with which we could compare our results.
The prevalence of healthy and unhealthy weight-loss practices reported by the SEARCH cohort could not be directly compared with the YRBSS because of the subgroups asked the questions (in SEARCH, those who had ever tried to lose weight; in YRBSS, those who tried for weight loss or maintenance) and different time frames specified for these questions (SEARCH, ever; YRBSS, past 30 days). In general, healthy practices, diet and exercise, were more common among SEARCH participants for weight loss than among YRBSS respondents for weight loss or maintenance (7
). SEARCH males had a prevalence of unhealthy practices similar to that of those in YRBSS, whereas SEARCH females were more likely to fast and use vomiting or laxatives for weight-loss than females in YRBSS for weight loss or maintenance.
Of the youth aged ≥10 years in the SEARCH study cohort who completed a study visit, ~21% were overweight and 22% were obese. Data from the National Health and Nutrition Examination Survey for 2003–2006 demonstrated that 16.5% of U.S youth aged 12–19 years were overweight (BMI ≥85th–<95th percentile) and 17.6% were obese (BMI ≥95th percentile), whereas 15 and 17% of youth aged 6–11 years were overweight and obese, respectively (24
). The higher prevalence of overweight and obesity among youth in SEARCH compared with the general U.S. population is to be expected, given that 15% of youth in the SEARCH study have type 2 diabetes, a condition that is strongly associated with obesity.
Strengths and limitations
Our study includes >3,000 racially/ethnically diverse youth with diabetes, including >500 youth with type 2 diabetes, probably the largest cohort of its kind in the U.S. Our data allowed us to compare the weight-related issues and weight-loss practices of youth with type 1 diabetes with those of youth with type 2 diabetes and by sex using the same methodology and survey questions. This study has several limitations. Because weight-loss practices may have occurred recently or in the distant past, we were not able to report associations between clinical indicators and individual weight-loss practice. Instead, we used a composite measure of “any unhealthy weight-loss practice” as a marker for a history of such unhealthy behavior. Additionally, we could not assume that the respondents’ current BMI category was reflective of BMI at the time of these practices or whether these practices occurred before or after diabetes diagnosis. Although we characterized eating less food, fewer calories, or foods lower in fat as a healthy weight-loss practice, some youth may have overrestricted their food/calorie intake. Finally, despite extensive efforts to optimize recruitment, ~47% of eligible youth completed the SEARCH study visit (25
Summary and clinical implications
In this cohort of youth with type 1 and type 2 diabetes, overweight and obesity were common and 60% of females and 38% of males reported ever trying to lose weight. Healthy weight-loss practices such as dieting and physical activity were quite common among these youth with type 1 and type 2 diabetes. Youth with type 2 diabetes were more likely than those with type 1 diabetes to report using any unhealthy weight-loss practice; females exhibited a higher prevalence of unhealthy practices than did males. In addition, among females, poor glycemic control was associated with reporting any unhealthy weight-loss practice and perceiving that they were overweight.
Given the high prevalence of overweight and obesity among type 2 diabetic youth, the increasing prevalence of these conditions in type 1 diabetic youth (5
), and the pressures on some overweight and obese youth to lose weight, it is likely that approaches to weight management will not always be healthy ones. Such practices may have a negative effect on diabetes management, including glycemic control, a risk factor for future complications. Physicians and other health care professionals caring for diabetic youth, particularly females, need to identify those with unhealthy weight-loss practices and provide them with more healthy weight-management strategies in the context of their ongoing diabetes management.