Improvement of Care & Outcome


Ferda Evin, Sascha R. Tittel, Barbara Piccini, Roque Cardona-Hernandez, Dick Mul, Nicole Sheanon, Thekla von dem Berge, Vit Neuman, Martin Tauschmann, Damla Gökşen

Basal and Bolus Insulin Distribution According to Treatment Modality: Data from SWEET Diabetes Registry. Pediatric Diabetes. 2023 Aug 9; 8837506.

Intensive insulin therapy is necessary for people with T1D (PWD) to prevent acute and long-term complications. For multiple daily injections (MDI) treatment it is already known that 40%−50% basal insulin dose (BD) as part of the total daily dose (TDD) is effective for lowering HbA1c. ISPAD recommends 30%−50% basal insulin, but there are also guidelines which do not specify this. In clinical practice BD percentages can even reach 95%, probably for noncompliant PWDs. This study, co-authored by Dick Mul of Diabeter, aimed to assess differences in BD/TDD ratios according to treatment modality/use of technology, and also to assess if there are associations between BD/TDD ratios and HbA1c and body mass index (BMI).


This study used data from the SWEET database. Inclusion criteria were: age between 2.5 and 18 years, ≥2 years diabetes duration and at least 1 clinical visit between June 2010 and  December 2021. In total 38,956 PWDs from 122 centers in 57 countries were included. Data were grouped according to four treatment modality groups (i.e. combinations of increasing use of technology like insulin pump and continous glucose monitoring [CGM] use): MDI without CGM; MDI with CGM; insulin pump without CGM; insulin pump with CGM: 37%. Each group was stratified according to:

  • Sex
  • Age: <7 years; 7−11 years; 12−18 years
  • BMI SDS: ≤2; -1.9 to ≤1; 1 to ≤2; >2
  • HbA1c: ≤5%; 7.6%−9%; >9%

Key findings:

  • 49% were female, median (IQR) age and diabetes duration were 15 (12−17) years and 6 (4−9) years, respectively
  • Treatment modality:
    • MDI without CGM: 33%
    • MDI with CGM: 18%
    • Insulin pump without CGM: 12%
    • Insulin pump with CGM: 37%
  • In all four treatment modality groups, there were no differences between sex, BMI-SDS categories and HbA1c categories, with one exception:
    • for the 7−11 year age group BD/TDD decreased with increasing use of technology
  • Males, younger age and lower HbA1c all associated with a lower BD/TDD ratio
  • After adjusting for sex, age and diabetes duration there was no association between use of technology and BD/TDD



Concluding, the authors state

"… due to the large sample size, even small differences can be classified as statistically different, and the clinical relevance is arguable. Moreover, no association was found between BD/TDD and treatment modalities. Longitudinal studies are needed to assess the impact of basal/bolus insulin distribution on glycemic outcome and body composition in children and adolescents with T1D" -

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