Psychosocial Aspects


Giesje Nefs

The Psychological Implications of Automated Insulin Delivery Systems in Type 1 Diabetes Care. Front. Clin. Diabetes Healthc., 2022 May 3;3:846162.


Automated insulin delivery (AID) systems, also known as (advanced) hybrid closed-loop insulin systems, are dramatically improving glycemic outcomes in type 1 diabetes management. Increasing automation is realized by increasingly sophisticated algorithms. Various commercial systems are available, even some dual-hormone systems. There also are online communities building their own, unregulated Do-It-Yourself (DIY) systems. This review by Giesje Nefs aimed to provide an overview of the psychological aspects around the use of these systems.

Key findings:

  • Technological advancements do not seem to add to diabetes-specific distress.
  • These systems lead to a reduction of self-management burden and worries, increased flexibility and spontaneity, improvements in relationships and improved sleeping.
  • Still, there are people with diabetes (PWDs) who stop using the closed-loop feature or the system altogether, due to reimbursement and supply difficulties, technology frustrations, wear-related issues, unexpectedly high work load, fears and preferences, life intrusions and discouragement.
  • DIY systems have their own disadvantages, related to the mental burden associated with uptake/use, difficulties with adjusting settings, fear of disapproval by health professionals, technical or logistic barriers, and individual concerns.
  • As AIDs are still far from perfect, determining what is the appropriate level of trust one can put in the system is difficult, especially in exercise and meal situations. For many people the functioning of these systems is very much a ‘black box’.
  • On the other hand, some people are so reliant on the systems that they are worried about having to manage their blood glucose levels on their own again, e.g. when the system breaks down. This reliance may also lead to forgetting certain skills needed to regulate blood glucose levels.
  • Many people feel the need to have more control over these systems, leading to overriding or ‘tricking’ the systems. This may be an underreported problem as people do not want HCPs/carers to know they are doing this.
  • Bodily concerns, already an important issue for older insulin pumps, may become even more of an issue due to the need of having more than one device attached to the body.
  • More studies are needed to assess if findings can be generalized to underrepresented and underserved populations. Also differences in age are likely to pose different challenges.
  • Future studies should also be performed with new instruments: patient-reported outcome measures (PROMs) updated with new psychological issues arising with further technology advancements.
  • Psychological factors may not necessarily predict suitability for AID treatment, as PWDs with higher HbA1c levels who initially do not seem to suitable for these systems, actually trust these systems more and gain more from using them. Vice versa, more technology savvy PWD with lower HbA1 values tend to interfere with the system more.
  • Ideally psychological influences, e.g. stress, will be taken into account in future algorithms.
  • Initial and ongoing support is important to manage expectations PWDs have of these systems.



Concluding, the author states

"Psychology offers several tools for measuring the quality of life impact of AID systems and may bring important insights for addressing cognitive, emotional or behavioral barriers towards optimal use. Central to all efforts is an ongoing dialogue, with efforts to maximize benefits and minimize burdens of AID therapy and with sensitivity to the personal trade-off between both." -

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