Disordered Eating Behaviors Among Adolescents and Young Adults with Type 1 Diabetes Treated with Insulin Pumps and Hybrid Closed-Loop Systems

Abstract

Background and Aims:

Disordered eating behaviors (DEB) are more common among individuals with type 1 diabetes (T1D) compared to those without, and for insulin pump users may be associated with higher hemoglobin A1c (HbA1c). We investigated DEB risk factors among insulin pump-treated individuals with T1D and clinical characteristics of hybrid closed-loop (HCL) systems' users by DEB level.

Methods:

An observational, cross-sectional study of 167 insulin pump-treated individuals with T1D, 13–21 years of age. Data were obtained from patients' medical charts with additional self-reported questionnaires, including assessment of DEB.

Results:

DEB were found in 71 (42.5%) individuals, and positively associated with female sex (β = 2.98 [standard error (SE) = 1.31], P = 0.025), body mass index (BMI)-Z-score (β = 2.12 [SE = 0.64], P = 0.001), HbA1c (β = 1.40 [SE = 0.45], P = 0.02), and higher rate of pump discontinuation (β = 4.48 [SE = 1.99], P = 0.026). The use of HCL systems compared to insulin pumps was associated with higher BMI-Z-score (odds ratio [OR]: 3.46 [95% confidence interval, CI: 1.52–7.87], P = 0.003) and tendency to lower HbA1c level (OR: 0.44 [95% CI: 0.18–1.09], P = 0.078) among individuals without DEB, and with lower HbA1c level (OR: 0.29 [95% CI: 0.10–0.83], P = 0.022) and higher socioeconomic status (OR: 1.73 [95% CI: 1.09–2.74], P = 0.020) among individuals with DEB.

Conclusions:

DEB are common among individuals with T1D treated with insulin pumps and are associated with higher HbA1c levels. Among T1D individuals with DEB, HCL system use is associated with lower HbA1c compared to insulin pump treatment. Our findings highlight the importance of regular screening for DEB and its risk factors to improve pump treatment and diabetes management. Moreover, individuals with DEB using HCL systems may benefit from reduced HbA1c levels.

Introduction

Disordered eating behaviors (DEB) include a range of eating pathologies that do not meet a formal eating disorder diagnosis, such as binge eating, restricting food intake, rigid dietary rules, and purging to reduce body weight.^1
–3 A higher prevalence of DEB in adolescents with type 1 diabetes (T1D) has been demonstrated, compared to their peers.⁴ T1D is associated with an increased risk for DEB that may include strict dietary rules, restrictions related to diabetes treatment, diabetes distress, elevated body weight, or body shape dissatisfaction.^5
–7

Adolescents with T1D and DEB have distinctive clinical characteristics associated with higher weight, binge eating, purging, and poor diabetes self-management such as manipulation of insulin treatment by restriction or omission with the purpose of losing or maintaining weight.^3,5,8,9 The combination of T1D and DEB is associated with higher hemoglobin A1c (HbA1c) level and increased risk of both short- and long-term complications of T1D, as well as increased mortality.⁹

An increasing number of people with T1D use advanced diabetes technologies. Data from large diabetes registries show that insulin pump users represent 40%–60% of individuals with T1D.^10,11 Therefore, for this growing population of individuals treated with insulin pumps, it is important to identify DEB and their risk factors. In a systematic literature review that aimed to present the potential advantages and disadvantages of diabetes technology use in people with T1D and DEB, evidence on diabetes technology and DEB was scarce with most studies reporting findings related to insulin pumps.¹¹ The majority of studies was based on case reports and observational data. The results of these analyses are heterogeneous: Some studies found an association between insulin pump use and DEB, suggesting that insulin pumps may be associated with a decrease in DEB, whereas other studies did not show any association between insulin pump use and DEB.¹¹

Despite progress in the availability of technologies to support diabetes management, most adolescents and young adults do not reach glycemic targets.¹² Hybrid closed-loop (HCL) systems are automated insulin devices that combine a closed-loop algorithm controller with insulin pumps and continuous glucose monitoring (CGM), which are characterized by the coexistence of automated insulin delivery (through the algorithm) and insulin delivery initiated by the user.¹² HCL systems were reported to be associated with improved HbA1c levels and reduced risk of hypoglycemia.¹²

The literature on HCL systems and DEB are scarce; one case report study of an adolescent female showed she omitted insulin for weight loss, while using the HCL system, by incorrectly calibrating glucose values.¹³ However, a previous study found that even among children, adolescents, and adults with high HbA1c levels at baseline, HbA1c levels were significantly lower after HCL intervention compared to after sensor-augmented pump therapy intervention.¹⁴ We hypothesized that HbA1c levels will be lower among adolescents and young adults with DEB who use HCL systems, than among those who use insulin pumps.

In this study, the primary aim was to assess the prevalence of DEB among adolescents and young adults with T1D, as well as risk factors for DEB among those treated with insulin pumps. The secondary aim was to examine the associations of clinical characteristics of adolescents and young adults with T1D, using HCL systems compared to insulin pumps, with regard to DEB.

Materials and Methods

Study design and participants

This is an observational, cross-sectional study, including adolescents and young adults with T1D treated at the National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, a major tertiary hospital. Our tertiary care center serves all sectors of the Israeli population, including children, adolescents, and young adults of varied ethnic origins and socioeconomic status from both urban and rural areas. The research team members approached suitable individuals based on study criteria during their routine visits to the clinic. Participants were recruited between October 2022 and July 2023.

The inclusion criteria were as follows: adolescents and young adults with T1D 13–21 years of age, with diabetes duration of more than 6 months, who had been treated with insulin pumps for at least 3 months or had been treated with insulin pumps in the past. Excluded from the study were adolescents and young adults with known eating disorders, medical conditions related to nutritional status (e.g., various syndromes and the use of medications that may impact weight or diabetes management), psychiatric disorders, or inability to complete the study questionnaires. The assessment was done using electronic questionnaires sent to the participants or by filling out questionnaires during their clinic visit.

Insulin delivery system implementation

At our center, adolescents and young adults of any age considering insulin pump therapy must undergo a multidisciplinary diabetes team assessment for pump treatment. The decision to initiate insulin pump therapy is individual and not guided by defined criteria. Before its initiation, young adults, and adolescents with their parents, attend a session conducted by a diabetes nurse and dietician who explain insulin adjustments and pump operations. In our country, all individuals are equally reimbursed by their health insurance agency for all insulin pump costs.

From 2022, the use of HCL systems at the first stage by children (≥6 years of age) and adolescents (HbA1c ≥8.5%) and at the second stage by all children (≥6 years of age) and adolescents, as well as an upgrade for adults, are equally reimbursed by the health insurance agencies. In addition to the commercially available products, people with T1D also use self-built “D.I.Y.” artificial pancreas systems. The algorithms work with existing pump technologies, and the code is released to open-source repositories, making it freely available for others to build.

Data collection

Data collected from the medical chart review included the following: sex, age, socio economic status, diabetes duration, height, weight, HbA1c, pump treatment duration, use of CGM, and the current insulin regimen. Insulin regimen was defined as pump treatment for participants who had used an insulin pump for at least 3 months, or as pump discontinuation for participants whose current insulin regimen is multiple daily injections with documentation of pump treatment in the past. In addition, for those treated with pump therapy, data analysis included a distinction between treatment with insulin pump and treatment with HCL system for participants who had used HCL for at least 2 months, and the automatic mode more than half of the time.

Body mass index (BMI) was calculated as weight (kg)/height² (m²) and standardized to age and sex according to the standards of the Centers for Disease Control and Prevention.¹⁵ Weight status was categorized as underweight and normal weight for BMI values ≤84th percentile (z-score <1.036), overweight for BMI between 85th and 94th percentile (z-score between 1.036 and 1.645), and obese for BMI ≥95th percentile (z-score ≥1.645).¹⁶ Capillary HbA1c was measured by the DCA 2000 analyzer (Bayer Diagnostics, Inc.).

The socioeconomic position (SEP) was analyzed based on the Israel Central Bureau of Statistics' characterization and classification of statistical areas within municipalities and local councils by the socioeconomic level of the population in 2015.¹⁷ The SEP clusters are scored between 1 and 10, with 1 representing the lowest and 10 the highest rating.

The Rabin Medical Center Ethics Committee approved the study. Participants or their legal guardians provided informed consent approving their participation in the study.

Measures

Diabetes Eating Problem Survey-Revised

DEB were screened by using the Diabetes Eating Problem Survey-Revised (DEPS-R).¹⁸ The DEPS-R is a 16-item diabetes-specific self-reporting screening tool for disordered eating. The DEPS-R questionnaire includes different features associated with DEB, such as a drive for thinness, eating pathologies, and diabetes management. The DEPS-R has good internal consistency (Cronbach's α = 0.86) and is validated for use in the pediatric population. The questionnaire is scored on a 6-point Likert scale from 0 to 5 (never to always), with higher scores indicating more DEB. A score ≥20 indicates an increased risk for DEB. Acceptable internal consistency was observed in the current sample of adolescents and young adults (α = 0.83).

Problem Areas in Diabetes Survey-Pediatric Version

Burden related to living with T1D was assessed using the Problem Areas in Diabetes Survey-Pediatric Version (PAID-Peds).¹⁹ The PAID-Peds is a 20-item diabetes-specific self-reporting screening tool that assesses burden associated with T1D. The PAID-Peds has good internal consistency (Cronbach's α = 0.94) and is validated for use in the pediatric population. The questionnaire is scored on a 5-point Likert scale from 0 to 4 (agree to disagree), with higher scores indicating greater burden related to living with diabetes. Acceptable internal consistency was observed in the current sample of adolescents and young adults (α = 0.90).

Dietary regimen

Dietary regimen (i.e., specific food choice behaviors related to managing T1D) was assessed using a six-item dietary regimen questionnaire that was developed for a cross-sectional larger study,²⁰ which included 818 adolescents and adults with T1D and that aimed to examine diabetes-specific risk factors for DEB. The Dietary Regimen questionnaire is a diabetes-specific self-reporting tool to assess specific food choice behaviors associated with T1D. The Dietary Regimen questionnaire has acceptable internal consistency among adolescents (Cronbach's α = 0.82). The questionnaire is scored on a 5-point Likert scale from 1 to 5 (very true to very untrue), with lower scores indicating a more restrictive dietary regimen. Acceptable internal consistency was observed in this sample of adolescents and young adults (α = 0.76).

Disinhibited eating

Disinhibited eating (i.e., the experience of eating when blood glucose is thought to be dropping or low) was assessed by using two items of behavioral indicators of disinhibited eating, which included relinquishing control over the type and amount of food when blood glucose is perceived to be low. In addition, one item of emotional indicators was used to examine guilt, shame, or regret for disinhibited eating when blood glucose is perceived to be low.

The disinhibited eating items were developed for a cross-sectional larger study,²¹ which included 276 adolescents and adults with T1D, and aimed to examine if individuals with T1D are less restrained in their eating when they think their blood glucose is low and whether this contributes to insulin omission. The disinhibited eating items are a diabetes-specific self-reporting tool to assess disinhibited eating when blood glucose is thought to be low. The items are scored on 6-point Likert scales from 0 to 5 (never to always) with higher scores indicating greater disinhibited eating when blood glucose is perceived to be low. Acceptable internal consistency was observed in this sample of adolescents and young adults (α = 0.62).

Statistical analysis

IBM SPSS Statistics, version 23.0 (IBM Corp. Armonk, NY) was used for analysis.

The Kolmogorov-Smirnov test was applied to test the normality of continuous data. The data are expressed as number (percent) for categorical variables; means ± standard deviations for normally distributed variables; and medians and interquartile range for skewed distributions. Variables were compared between groups using independent t-tests (for normally distributed variables) or Mann–Whitney test (for skewed variables) or chi square test (for categorical and ordinal variables). Pearson's (for normally distributed variables) or Spearman (for skewed variables) correlation tests were applied to examine correlations between DEPS-R scores and continuous clinical variables.

To examine risk factors for DEB using DEPS-R score, we conducted a multivariate linear regression analysis. The model included all the variables that showed association (significant or a tendency, P < 0.2) to DEPS-R score in the univariate test (BMI-Z score, HbA1c, pump discontinuation, PAID-Peds score, dietary regimen score, and disinhibited eating score), and potential confounders (sex, age, SEP, diabetes duration, pump use duration, and HCL systems use).

A multiple logistic regression analysis stepwise backward LR was performed to examine clinical characteristics associated with the use of HCL systems compared to the use of insulin pump. The model included the following variables: sex, age, BMI-Z score, SEP, diabetes duration, HbA1c, pump duration, PAID-Peds score, and disinhibited eating score.

To examine the association according to DEB level, the statistical analyses were stratified according to DEB (score <20 vs. score ≥20).

Results

Participant characteristics

Of the 180 adolescents and young adults invited to answer the questionnaires, 167 accepted with a response rate of 92.7%. No significant difference in age, sex distribution, BMI-Z score, or HbA1c levels was found between the 167 participants and the 13 nonparticipants (data not shown).

Of the 167 adolescents and young adults (50.3% female) who completed the DEPS-R questionnaire, 71 (42.5%) scored above the cutoff on the DEPS-R (≥20), indicating a high risk for DEB, and 24.2% achieved a target HbA1c level below 7.0%. In addition, 146 (87.4%) were treated with insulin pumps versus 21 (12.6%) with pump discontinuation. Among those treated with insulin pumps, 32 (21.9%) used HCL systems. The characteristics of the study cohort are presented in Table 1.

Table 1.

Clinical Characteristics of the Study Cohort

Parameter	N = 167
Female, n (%)	84 (50.3)
Age (years), mean (SD)	17.0 (2.09)
SEP median (range)	7 (3.0–8.0)
BMI-Z score, mean (SD)	0.52 (0.99)
BMI categories, n (%)
UN/NW	109 (66.5)
OW	36 (22.0)
O	19 (11.6)
Diabetes duration (years), mean (SD)	7.28 (4.28)
HbA1c %, median (IQR)	7.6 (7.0–8.4)
Pump duration (years), mean (SD)	5.42 (4.05)
Pump discontinuation, n (%)	21 (12.6)
CGM, n (%)	142 (85)
DEPS-R score, mean (SD)	19.0 (10.6)
DEPS-R ≥ 20, n (%)	71 (42.5)
PAID-Peds score, mean (SD)	38.79 (19.10)
Dietary regimen score, mean (SD)	21.04 (5.12)
Disinhibited eating score, mean (SD)	7.78 (3.35)

BMI-Z score, z-score for body mass index; CGM, continuous glucose monitoring; DEPS-R, Diabetes-specific Eating Problems Survey-Revised; HbA1c, hemoglobin A1c; IQR, interquartile range; NW, normal weight; O, obese; OW, overweight; PAID-Peds, Problem Areas in Diabetes Survey-Pediatric Version; SD, standard deviation; SEP, socioeconomic position; UN, underweight.

Risk factors for DEB among insulin pump-treated adolescents and young adults with T1D

Table 2 depicts correlations between clinical and diabetes management characteristics and DEPS-R score. DEPS-R score was positively related to BMI-Z score, HbA1c level, PAID-Peds score, and disinhibited eating score. Females had higher DEPS-R scores than males (22.72 [10.42] vs. 15.25 [9.44], respectively, P < 0.001). The DEPS-R scores of adolescents and young adults with pump discontinuation tended to be higher than for those who continued pump treatment (22.23 [11.01] vs. 18.54 [10.50], respectively, P = 0.136).

Table 2.

Correlations Between Diabetes Eating Problem Survey-Revised Scores and Clinical and Diabetes Management Characteristics

Parameter
Age	r_p = 0.08 P = 0.303
SEP	r_s < 0.01 P = 0.925
BMI-Z score	r_p = 0.32 P < 0.001
Diabetes duration	r_p = 0.09 P = 0.911
HbA1c median, % (IQR)	r_s = 0.26 P = 0.001
Pump duration	r_p = 0.05 P = 0.514
PAID-Peds	r_p = 0.60 P < 0.001
Dietary regimen	r_p = −0.13 P = 0.083
Disinhibited eating	r_p = 0.42 P < 0.001

Bold indicates statistical significance.

Table 3 presents linear regression analysis of variables associated with DEPS-R score. Female sex, higher BMI-Z score, shorter diabetes duration with longer pump use duration, higher HbA1c, higher PAID-Peds score, higher disinhibited eating score, and pump discontinuation were positively associated with a higher risk for DEB.

Table 3.

Linear Regression Model for Diabetes Eating Problem Survey-Revised Score and Clinical and Diabetes Management Characteristics

	β (SE)	P
Gender-female	2.98 (1.31)	0.025
Age (years)	0.02 (0.33)	0.952
SEP	−0.50 (0.26)	0.061
BMI-Z score	2.12 (0.64)	0.001
Diabetes duration (years)	−0.82 (0.26)	0.002
HbA1c (%)	1.40 (0.45)	0.002
Pump duration (years)	0.63 (0.27)	0.022
Pump discontinuation (years)	4.48 (1.99)	0.026
HCL systems-yes	0.88 (1.66)	0.596
PAID-Peds score, mean (SD)	0.26 (0.04)	<0.001
Dietary regimen score, mean (SD)	−0.08 (0.12)	0.496
Disinhibited eating score, mean (SD)	0.49 (0.22)	0.031

Bold indicates statistical significance.

HCL systems, hybrid closed-loop systems; SE, standard error.

Clinical characteristics associated with the use of HCL systems compared to insulin pumps according to DEB level

Of 146 adolescents and young adults (51.4% female) using an insulin delivery system when filling out the questionnaires, 32 (21.9%) were on HCL systems (63.3% Medtronic 780G system, 33.3% “D.I.Y.” artificial pancreas systems, and 3.3% Tandem system); 13 (40.6%) of the HCL system users scored above the cutoff on the DEPS-R (≥20).

Table 4 presents comparisons of clinical characteristics among participants treated with insulin pumps and those treated with HCL systems, stratified by DEB level. For participants without DEB, when comparing the two groups, we found that those treated with HCL systems had a higher BMI-Z score (0.88 ± 0.72 vs. 0.08 ± 0.89 kg/m², respectively, P = 0.001) and the percentage of participants with overweight (23.5% vs. 9.2%, respectively) and obesity (17.6% vs. 3.1%, respectively) were also higher (P = 0.016).

Table 4.

Clinical Characteristics of Adolescents and Young Adults Using Insulin Pumps Overall and Stratified by the Disordered Eating Behaviors Level and by the Type of Insulin Delivery System

		DEPS-R < 20 N = 85			DEPS-R ≥ 20 N = 61
	All N = 146	Pump	HCL	P	Pump	HCL	P
Gender Female	75 (51.4)	25 (37.9)	9 (47.4)	0.314	31 (64.6)	10 (76.9)	0.313
Age (years) Mean (SD)	17.01 (2.09)	16.95 (2.29)	16.62 (2.07)	0.575	17.31 (1.90)	16.69 (1.70)	0.299
SEP	7.0 (3.0–8.0)	7.0 (5.0–8.0)	6.0 (2.0–7.0)	0.120	6.0 (2.0–8.0)	8.0 (6.0–8.5)	0.016
BMI-Z score, mean (SD)	0.52 (0.95)	0.08 (0.89)	0.88 (0.72)	0.001	0.87 (0.92)	1.01 (0.69)	0.608
BMI categories, n (%)
UN/NW	96 (67.1)	57 (87.7)	10 (58.8)	0.016	23 (47.9)	6 (46.2)	0.979
OW	32 (22.4)	6 (9.2)	4 (23.5)		17 (35.4)	5 (38.5)
O	15 (10.5)	2 (3.1)	3 (17.6)		8 (16.7)	2 (15.4)
Diabetes duration, (years) mean (SD)	7.26 (4.36)	6.89 (4.60)	7.15 (4.17)	0.830	7.74 (4.18)	7.51 (4.24)	0.864
HbA1c median, % (IQR)	7.5 (6.9–8.2)	7.5 (6.8–8.0)	7.3 (6.9–7.5)	0.120	7.9 (7.3–8.7)	7.5 (6.6–8.1)	0.034
Pump duration, (years) mean (SD)	5.70 (4.07)	5.35 (4.30)	5.58 (4.07)	0.833	6.13 (4.07)	6.11 (2.96)	0.991
PAID-Peds score, mean (SD)	38.83 (19.33)	31.86 (16.39)	27.36 (12.42)	0.273	48.07 (17.49)	57.81 (21.39)	0.105
Dietary regimen score, mean (SD)	21.07 (5.19)	21.73 (5.24)	21.10 (4.29)	0.637	20.33 (5.55)	20.58 (4.92)	0.887
Disinhibited eating score, mean (SD)	7.87 (3.36)	6.40 (3.07)	7.05 (2.48)	0.419	9.20 (3.15)	11.25 (2.26)	0.040

Bold indicates statistical significance.

DEB, disordered eating behaviors.

For participants with DEB, when comparing the two groups, we found that those treated with HCL systems had a lower HbA1c (7.5% [6.6–8.1] vs. 7.9% [7.3–8.7], respectively, P = 0.034), higher SEP (8 [6.0–8.5] vs. 6.0 [2.0–8.0], respectively, P = 0.016), and higher disinhibited eating score (11.25 ± 2.26 vs. 9.20 ± 3.15, respectively, P = 0.04), although disinhibited eating score was not statistically significant when adjusted for the other variables in the multiple regression analysis (Table 5).

Table 5.

Multiple Logistic Regression of Insulin Delivery System (Hybrid Closed-Loop System vs. Insulin Pump) Stratified by Disordered Eating Behaviors Level

	All			DEPS-R < 20			DEPS-R ≥ 20
	OR	95% CI	P	OR	95% CI	P	OR	95% CI	P
BMI-Z score mean (SD)	2.54	1.40–4.60	0.002	3.46	1.52–7.87	0.003	—	—	—
HbA1c (%)	0.35	0.18–0.65	0.001	0.44	0.18–1.09	0.078	0.29	0.10–0.83	0.022
SEP	—	—	—	—	—	—	1.73	1.09–2.74	0.020

Bold indicates statistical significance.

Logistic regression analysis with backward LR, the following variables were entered on step 1: sex, age, BMI-Z score, SEP, diabetes duration, HbA1c, pump duration, PAID-Peds score, and disinhibited eating score.

CI, confidence interval; OR, odds ratio.

Multiple logistic regression was performed on clinical characteristics. The final model included the following clinical characteristics for HCL systems treatment: a higher BMI-Z score (odds ratio [OR]: 2.45 [95% confidence interval, CI: 1.40–4.60], P = 0.002) and lower HbA1c (OR: 0.35 [95% CI: 0.18–0.65], P = 0.001). Specifically, participants without DEB had a higher BMI-Z score (OR: 3.46 [95% CI: 1.52–7.87], P = 0.003) and a lower HbA1c level (OR: 0.44 [95% CI: 0.18–1.09], P = 0.078), and participants with DEB had a lower HbA1c (OR: 0.29 [95% CI: 0.10–0.83], P = 0.022) and a higher SEP (OR: 1.73 [95% CI: 1.09–2.74], P = 0.020) (Table 5).

Discussion

This study assessed the prevalence of DEB among adolescents and young adults with T1D, who had been treated with insulin pumps (at present or in the past), and evaluated clinical and diabetes management risk factors for DEB. In addition, we compared the type of insulin delivery system (insulin pumps vs. HCL systems) with clinical characteristics among adolescents and young adults with and without DEB. In general, 87.4% of them were treated with insulin pumps versus 12.6% with pump discontinuation. Among those treated with insulin pumps, 21.9% were on HCL systems. About 40% of our cohort had a DEPS-R score above the cutoff, indicating a high rate of DEB in the studied population of adolescents and young adults with T1D.

Female sex, elevated BMI-Z score, shorter diabetes duration with prolonged pump treatment duration, higher HbA1c level, higher diabetes distress, higher disinhibited eating, and pump discontinuation were found to be risk factors for DEB. Among participants treated with insulin pumps, the HCL system was associated with higher BMI-Z scores and lower HbA1c compared to those treated with insulin pumps. When divided into DEB levels, for those without DEB, the HCL system was associated with higher BMI-Z scores and tendency to lower HbA1c than among those treated with insulin pump. Nevertheless, for those with DEB, the HCL system was associated with lower HbA1c and higher socioeconomic status than among those treated with insulin pump.

Despite treatment with insulin pumps, DEB in our study were high, similar to a previous study,⁶ and even slightly higher than in other studies.^22,23 DEB were more pronounced in females and were associated with elevated BMI-Z score and HbA1c levels, as in other studies.^22,23 It is possible that the increased BMI-Z score in our cohort contributed to the high rate of DEB. Elevated weight is a clinical concern in people with T1D. Previous follow-up studies found a significant increase in the percentage of T1D individuals with overweight and obesity.²⁴ Furthermore, previous studies have shown a substantial increase in incidence rates of eating disorders in the post-COVID-19 pandemic period in the adolescent population, which was particularly pronounced in adolescent females.²⁵ In addition, this discrepancy may be due to different methodologies. In contrast to previous studies, the assessment in our study was done mainly by using electronic questionnaires sent to the participants, which may have promoted open self-disclosure.

We found that pump discontinuation was a risk factor for DEB in our cohort of adolescents and young adults with T1D who had been treated with insulin pumps at any time. This association between pump discontinuation and DEB was previously reported in a few studies.^26,27 Some adolescents treated with insulin pumps may experience an increased focus on nutrition, pressure, and demand for diabetes care from their families and routine medical teams.²⁸ For those adolescents, especially those with DEB, this may eventually lead to pump discontinuation. Other common reasons for pump discontinuation, mainly among adolescent girls, are related to physical experiences, concern about body image, and social acceptance with pump use.^6,27,29 It was demonstrated in previous studies that these factors also relate to DEB⁶; therefore, it is possible they cause both DEB and pump discontinuation. Thus, it is essential to be aware of the association between pump discontinuation and DEB, especially in adolescent girls treated with insulin pumps. Enhanced support may be required to maximize persistence of pump therapy.

Consistent with previous studies, in our cohort, both diabetes distress and disinhibited eating were associated with DEB among adolescents and young adults with T1D.^7,9,21,30 Our data suggest that, despite insulin pump treatment, factors associated with T1D treatment may contribute to DEB, such as careful attention to food choices, regular blood glucose monitoring, and other burdens related to diabetes management. In addition, negative feelings about T1D may lead to diabetes management problems and increased vulnerability to DEB. Our results highlight the importance of helping adolescents and young adults with T1D treated with insulin pumps to develop skills to cope with diabetes distress, and to address antecedents to disinhibited eating to manage diabetes, especially in this high-risk population, to reduce DEB.

Previous studies have examined differences in the clinical characteristics of people treated with insulin pumps versus HCL systems.^14,31 However, those with DEB have different clinical characteristics than those without DEB.³² Therefore, there may be a difference in clinical characteristics between those treated with insulin pumps and those treated with HCL systems with regard to DEB. To our knowledge, this is the first study that evaluated the differences between insulin pump users and those using HCL systems according to DEB levels.

We found that adolescents and young adults treated with HCL systems had higher BMI-Z scores than those treated with insulin pumps. When stratified by DEB level, this association was maintained only in the group without DEB. In line with this, a multicenter 3-month follow-up study found that the mean overall body weight of adolescents tended to increase and that of adults significantly increased while using the HCL system.³¹ In another multicenter study of randomly assigned participants with high baseline HbA1c, a tendency toward greater weight gain while using the HCL system was observed.¹⁴

In contrast to these studies, several studies found no difference in weight gain while using HCL system. For example, in a multicenter 3-month flow-up study, there was no change in BMI in adults or BMIz-scores of children while using the HCL system.³³ Likewise, in a 6-month randomized, multicenter trial of an HCL system or sensor-augmented pump, there was no significant difference between the groups with regard to weight change.³⁴ Since increased weight is a concern in people with T1D on various insulin regimens,²⁴ it may be important to assist individuals with T1D to find healthful strategies for optimal dietary management.

Overall, participants treated with HCL systems had lower HbA1c than those treated with insulin pumps. Importantly, this study extends previous research by demonstrating that this association was maintained among adolescents and young adults with DEB. Our findings align with previous randomized and follow-up studies among children, adolescents, and adults, as well as those with high HbA1c when initially using the technology, showing that HCL systems were associated with a reduction in HbA1c.^14,31,33,34 HCL system may deal with typical eating patterns of adolescents and young adults, specifically those with DEB, which include restricting insulin for meals and especially when snacking.^35,36 However, additional large population studies are needed to test this assumption.

Our findings did not show that using HCL systems, compared to insulin pumps, was associated with socioeconomic status. This was not surprising, given that the HCL system is prescribed and reimbursed equally to all children and adolescents with T1D in our country. However, the association between HCL systems use and higher socioeconomic status was found only among adolescents and young adults with DEB. In previous studies, it was found that higher socioeconomic status was associated with a better uptake of technology use.^37,38 Further studies with a larger population are needed to examine these associations.

Our study has several limitations. First, this study was cross-sectional and, therefore, did not allow for a causal conclusion, and was exposed to potential confounding, although adjustment for various confounders. Thus, randomized clinical trials are needed to determine potential associations between DEB, insulin pumps, and HCL systems. In addition, the small sample size of participants treated with HCL systems may affect the ability to detect additional effects; larger samples are needed to determine potential associations between clinical characteristics and HCL system users among adolescents and young adults with DEB.

In addition, blood glucose levels were only assessed using HbA1c levels, without additional CGM metrics data that can contribute to the assessment. Another limitation is lack of data related to the pubertal stage of participants, which included a relative broad age range, although adjustment for age was done. In addition, filling out the questionnaires was done using both methods, mainly electronically as well as manually during the clinic visit, but no significant difference was found in DEPS-R scores between the two methods. Also, our findings are based on data of adolescents and young adults with T1D in our country, who may differ from adolescents and young adults with T1D in other countries.

The strengths of this study include the use of a validated, standardized, diabetes-specific screening tool to evaluate DEB. An additional strength is our ability to study clinical characteristics associated with treatment with HCL systems according to different levels of DEB.

Conclusions

In conclusion, DEB are common among adolescents and young adults with T1D treated with insulin pumps. DEB were associated with various clinical parameters, including female sex, high BMI-Z score and HbA1c, higher diabetes distress, higher disinhibited eating, and pump discontinuation. For adolescents and young adults with T1D and DEB, HCL systems are associated with lower HbA1c without aggravation in BMI-Z scores. Our findings suggest that regular screening for DEB and risk factors for DEB are essential and may have implications on the persistence of pump therapy and achieving lower HbA1c. In addition, adolescents and young adults with DEB who are treated with insulin pumps may benefit by changing to an HCL system, which may reduce their HbA1c levels.

Footnotes

Authors' Contributions

T.P.L. was involved in conceptualization, contributed to methodology and data collection, carried out the formal analysis and investigation, wrote and prepared the original draft, reviewed and edited the article, and participated in supervision. S.S. was involved in conceptualization, contributed to methodology, wrote and prepared the original draft, reviewed and edited the article, and participated in supervision. MP was involved in conceptualization and reviewed and edited the article. REB was involved in conceptualization, contributed to methodology, and reviewed and edited the article. M.G.K. was involved in data collection and reviewed and edited the article. M.Y.G. was involved in the formal analysis and investigation and reviewed and edited the article. A.L. contributed to the methodology and data collection. T.P.L. is the guarantor of this work and, as such, has full access to all data in the study, and takes responsibility for the integrity of data and the accuracy of data analysis. All authors critically revised the article and approved the final version.

Availability of Data and Material

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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