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Mealtime insulin BOLUS score increases prior to clinic visits in youth with type 1 diabetes
  1. Andrew McConville1,
  2. Amy E Noser1,
  3. Mark A Clements2,3,4,
  4. Susana R Patton5
  1. 1Clinical Child Psychology Program, University of Kansas, Lawrence, Kansas, USA
  2. 2Division of Endocrinology, Department of Pediatrics, Children’s Mercy Hospitals and Clinics, Kansas City, Missouri, USA
  3. 3University of Missouri-Kansas City, Kansas City, Missouri, USA
  4. 4University of Kansas Medical Center, Kansas City, Kansas, USA
  5. 5Nemours Center for Healthcare Delivery Science, Nemours Children’s Health System, Jacksonville, Florida, USA
  1. Correspondence to Dr Susana R Patton; Susana.Patton{at}


Introduction Multiple studies confirm the occurrence of ‘white coat adherence’ (WCA), a term describing an increase in engagement with self-care tasks just prior to a scheduled clinic appointment, across cohorts with multiple chronic conditions. In youth with type 1 diabetes (T1D), research also shows an increase in self-monitoring blood glucose frequency ahead of youths’ clinic visits. While studies show preliminary evidence for the occurrence of WCA in youth with T1D, no study has examined the effect of WCA and mealtime insulin dosing behaviors in youth with T1D. The frequency of mealtime insulin bolusing score (BOLUS) is an objective measure of mealtime insulin use in youth with T1D that could be vulnerable to WCA. To fill this gap in the literature and further our understanding of WCA in pediatric diabetes, we determined whether WCA also impacts BOLUS scores in youth with T1D.

Research design and methods We extracted insulin pump records and HbA1c levels from a clinical database for 459 youth with T1D (Mage=12.5±2.9 years). We calculated mean BOLUS scores for 6–5, 4–3, and 2–0 weeks prior to youths’ routine clinic visits. We used multilevel modeling to examine patterns of BOLUS scores prior to clinic visits and tested for age differences.

Results Multilevel modeling showed a significant increase in BOLUS scores in the weeks prior to youths’ clinic appointments (β=0.07, p<0.001). On average, adolescents had lower BOLUS scores than school-age children (β=−0.35, p<0.001). Post hoc analyses showed that adolescents consistently had lower BOLUS scores than children across assessments (p’s<0.001).

Conclusions Youth with T1D increase their mealtime insulin use prior to clinic appointments. The BOLUS may be a viable target for intervention to drive improved glycemic control. Whether increased tendency to WCA is associated with reduced risk of diabetic complications remains to be determined.

  • type 1
  • adolescents / children
  • insulin administration
  • adherence

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  • Contributors AM and SRP wrote the paper. SRP designed the research study. AEN analyzed the data. MAC helped design the research study and provided feedback on the paper.

  • Funding This research was supported in part by grant DK 100779 (to SRP) from the National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health.

  • Competing interests MAC is the chief medical officer for Glooko and reports personal fees from Eli Lilly and Medtronic, outside the submitted work.

  • Patient consent for publication Not required.

  • Ethics approval This study was approved by the Children’s Mercy Hospital Institutional Review Board (IRB number 11120355). Data collection and analyses were approved by the local institutional review board.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request.

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