European Journal of Pediatrics

, Volume 177, Issue 12, pp 1831–1836 | Cite as

Mealtime insulin bolus adherence and glycemic control in adolescents on insulin pump therapy

  • Engelina SpaansEmail author
  • Kornelis J. J. van Hateren
  • Klaas H. Groenier
  • Henk J. G. Bilo
  • Nanne Kleefstra
  • Paul L. P. Brand
Original Article


Poor self-management contributes to insufficient glycemic control in adolescents with type 1 diabetes (T1DM). We assessed the effects on glycemic control of adherence to self-measurement of blood glucose (SMBG) and insulin boluses in 90 adolescents with T1DM on insulin pump therapy over a 2-month period. We compared the number of insulin boluses and SMBGs around main meals to the “gold standard” of optimal diabetes management (SMBGs and a bolus before each main meal and SMBG before bedtime). The mean (95% CI) HbA1c levels were 2.9(1.7 to 4.0) mmol/mol lower for every additional insulin bolus and 3.1(1.6 to 4.5) mmol/mol lower for every additional SMBG. Patients performing SMBG and bolusing around each main meal had considerably lower HbA1c levels than those unable to do (95% CI for difference 4.3 to 10.4 mmol/mol and 11.5 to 20.1 mmol/mol respectively). For each additional mealtime bolus/day, the odds ratio of achieving target HbA1c levels of <58 mmol/mol was 6.73 (95% CI 2.94–15.38), after adjustment for gender, age, diabetes duration, and affective responses to SMBG in a multiple logistic regression model.

Conclusion: Glycemic control in adolescents with T1DM on insulin pump therapy is strongly dependent on adherence to insulin boluses around mealtimes.

What is Known:

• In mixed groups of children and adolescents, insulin bolus frequency and self-monitoring of blood glucose (SMBG) frequency were determinants of HbA1c levels.

• Adherence to insulin boluses and SMBG is particularly challenging in adolescents.

What is New:

• In adolescents on insulin pump therapy, each additional insulin bolus, particularly around mealtime, was significantly associated with approximately 3 mmol/mol lower HbA1c levels.

• This beneficial effect of mealtime bolusing was strongest for the evening meal.


Adherence Mealtime bolus Type 1 diabetes Adolescent Self-management Insulin pump 



Continuous subcutaneous insulin infusion


Hemoglobin A1c


Self-measurement of blood glucose


Type 1 diabetes mellitus


Authors’ contributions

ES designed the study, performed acquisition, interpreted the data, and is the main author of this manuscript. KH helped with data interpretation and drafting the manuscript, KG performed the statistical analysis, HB and NK critically revisited the manuscript and deigned the study, and PB participated in drafting and revising critically the manuscript. All authors gave final approval.


This study was supported by a grant from the Isala & Science Fund, Zwolle, the Netherlands.

Compliance with ethical statements

Conflict of interest

The authors declare that they have no conflict of interest.

Informed consent

Both parents (or legal guardians) and patients provided written informed consent for data recording and anonymized data analysis and publication for scientific purposes. The study was approved by the Medical Ethics Committee of Isala Hospital, Zwolle, the Netherlands (number 41428-075-12).


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Diabetes CenterIsalaZwolleThe Netherlands
  2. 2.Isala Women and Children’s HospitalZwolleThe Netherlands
  3. 3.Langerhans Medical Research GroupOmmenThe Netherlands
  4. 4.Department of General PracticeUniversity of Groningen and University Medical Center GroningenGroningenThe Netherlands
  5. 5.Department of Internal MedicineUniversity of Groningen and University Medical Center GroningenGroningenThe Netherlands
  6. 6.UMCG Postgraduate School of MedicineUniversity of Groningen and University Medical Center GroningenGroningenThe Netherlands

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