“Is insulin delivery method associated with diabetes distress among people with type 1 diabetes?”

Research from the US suggests no difference in diabetes-related distress among adults with type 1 diabetes with a free choice of insulin pumps versus multiple daily insulin injections.

By Christopher Todaro


For people with type 1 diabetes, managing diabetes typically involves either multiple daily insulin injections or ‘continuous subcutaneous insulin infusion’ (i.e. an insulin pump). Recent UK multi-centre randomised control trials (1, 2) have compared clinical and psychosocial outcomes by insulin delivery method (i.e. injection or pump) among people with type 1 diabetes who have attended structured diabetes education or psycho-education training sessions. Study findings suggest that clinical outcomes, such as HbA1c, are largely equivalent across insulin delivery method, though insulin pump use is associated with greater satisfaction with diabetes treatment. However, in these studies, participants were randomly allocated to an insulin delivery method. Research is also needed to understand clinical and psychosocial outcomes in real-world settings when people with type 1 diabetes are given a free choice (with no cost implications) of their preferred insulin delivery method.

Dr Wardian and colleagues aimed to explore the cross-sectional association between chosen insulin delivery method and HbA1c, body mass index (BMI) and diabetes-related distress among adults with type 1 diabetes. Diabetes distress refers to the emotional burden of managing diabetes, including feelings of frustration, worry and helplessness.

Data were collected during medical appointments (between June 2015 and August 2016) at the U.S. Air Force Diabetes Center of Excellence (DCOE), which consults with active duty military members, retirees, and family members. People with diabetes (most of whom had type 1) were given a free choice to continue with their current delivery method (insulin pump, multiple daily injections), or to switch to the other method at no extra personal cost. Medical records were reviewed retrospectively. Data collected included Hba1c, BMI and diabetes distress. Diabetes distress was assessed with the 17-item Diabetes-related Distress Scale (DDS-17), which includes four domains:

  • Emotional burden e.g. “Feeling that diabetes is taking up too much of my mental and physical energy every day”
  • Physician-related distress e.g. “Feeling that my doctor doesn’t know enough about diabetes and diabetes care”
  • Regimen-related distress e.g. “Not feeling confident in my day-to-day ability to manage diabetes”
  • Interpersonal distress e.g. “Feeling that friends or family don’t appreciate how difficult living with diabetes can be”

The total sample included 203 people with diabetes, of whom 57.6% chose to use an insulin pump and 42.4% chose multiple daily injections. Those using an insulin pump were more likely to be men, Caucasian, and had been living with diabetes for longer compared to those who chose to inject insulin. The number of people who switched their insulin delivery method was not reported.

The study revealed no significant difference between insulin delivery groups in BMI, HbA1c or diabetes distress scores. In fact, low levels of diabetes distress were reported for both groups across the four domains.

Unfortunately, it is difficult to interpret these findings due to study limitations. These include: 1) data were not reported for those who switched insulin delivery methods and how long participants had been using a particular delivery method, and; 2) the study is cross-sectional. This means we don’t know whether participants had lesser or greater diabetes-related distress before/after switching insulin delivery methods. Finally, overall, the group had low levels of diabetes distress, suggesting they may not be representative of the broader population of adults with type 1 diabetes. Further research is needed to track clinical/psychosocial outcomes over time and sample under-represented groups with moderate/high distress.

Nonetheless, this study tentatively offers further support for unrestricted choice of insulin delivery method, to suit the preferences and priorities of the person with diabetes. The authors conclude that freedom of choice in insulin device preferences may be partly responsible for minimal diabetes distress.

Check out our previous blogs on diabetes distress here. 

Wardian, J. L., True, M. W., Folaron, I., Colburn, J., Tate, J. M., & Beckman, D. J. The Choice Should Be Yours: Diabetes-Related Distress by Insulin Delivery Method for People with Type 1 Diabetes. Diabetes Technology & Therapeutics. 2019; Vol 22 (1); 1-5; https://doi.org/10.1089/dia.2019.0228