"In the medical field, insulin is predominantly recognised as a fundamental component of treatment for type 1 diabetes mellitus and frequently employed in managing type 2 and gestational diabetes mellitus [1]. Pharmacological insulin is typically delivered via subcutaneous injection, and to enhance insulin replacement for individuals with diabetes, manufacturers have created diverse insulin formulations, such as insulin analogues [2]. This has led to the development of insulin analogues with rapid onset, appearing in the bloodstream within 5–10 min of injection and dissipating within 4–6 h, while longer-acting insulins can persist in the system for over 24 h [2]. Extensive knowledge on the adverse effects of insulin has been accumulated through diabetes treatment, where it serves a clear therapeutic role [1]. While individuals with diabetes may grapple with weight gain [3] notably, however, hypoglycaemia stands out as the most frequently observed side effect [2] and its significance is magnified by the potential progression to a coma and, ultimately, death [4]. Nevertheless, in the context of gyms and the fitness community globally, insulin takes on a distinct reputation that spans the domain of enhancement rather than therapy. We recognise the evolving landscape where medicinal products, including insulin, are increasingly sought after for non-health-related purposes, blurring the lines between lifestyle enhancement and medical treatment. Hall posits that this phenomenon reflects a broader trend in late capitalism's ‘economy of the self’, where pharmaceutical drugs are utilised to enhance various aspects of life, from performance at work to image in social contexts, thereby raising pertinent public health concerns [5]. For insulin specifically, its' appeal stems from its potential to induce weight gain, owing to its anabolic effects on both muscle and adipose tissue [6], rendering it an enticing choice for those seeking to increase their muscle mass and overall physique [3, 7, 8].

"Extant work has identified the use of insulin remains a pervasive issue within the strength training community [3, 6-8], particularly among people who use image and performance enhancing drugs (IPED). Research has demonstrated that bodybuilders are able to readily access their insulin and syringes through local sources such as friends, training partners, gym contacts, over social media [9] or community pharmacies [6, 10], however, literature points to public health issues associated with counterfeit insulin, with deaths occurring due to the use fake insulin [11]. Those who use insulin in this way often administer it without monitoring their blood glucose levels, leading to reported instances of hypoglycaemia [7, 8]. Biologically, administering insulin improperly can lead to hypoglycaemia, where blood sugar levels drop dangerously low, potentially resulting in seizures, loss of consciousness and, in severe cases, death due to lack of glucose reaching vital organs like the brain [2]. Scholars identified some time ago that it is crucial for the medical, research and fitness communities to be informed about these patterns of use and promote educational initiatives among individuals at risk [3, 6]. However, as we contend, this call has been largely unanswered as insulin use has continued to grow beyond the strength sport community and into general IPED-using communities. Among the IPED-using community more broadly, the use of insulin is reflective of a development of social drug use practices which bring alongside them increased dangers and warrant a unified harm reduction approach. Therefore, the current study sought to focus on articulations and understandings of risk in relation to insulin in narratives of IPED use."

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