Intensive insulin therapy is associated with the delayed onset and reduced risk of the development of microvascular complications in type 1 diabetes and is therefore recommended for most patients, including children and adolescents. Intensification of insulin therapy can be accompanied by increased weight gain, and fear of weight gain can represent a major barrier to adherence to intensive regimens. This is particularly true for adolescent girls who may have poor self-esteem and body image issues, and adopt behaviors such as insulin omission and disordered eating to prevent weight gain. Strategies to reduce insulin-associated weight gain include lifestyle interventions to improve nutritional intake and increase physical activity. The use of pharmacologic agents that minimize weight gain such as the inclusion of insulin detemir, agents that alter satiety and insulin sensitizers should also be considered and investigated further. In addition to understanding treatment strategies to limit insulin-related weight gain, the diabetes healthcare team should be aware of the early warning signs of disordered eating and insulin omission in the adolescent so that appropriate referral for psychologic intervention can occur.