Scientific Online Resource System

Scripta Scientifica Medica

Advantages from “do-it-yourself” loops among children and adolescents in Varna’s Diabetes Center

Yuliya Bazdarska, Violeta Iotova, Vilhelm Mladenov, Veselin Boyadzhiev, Rositsa Stoycheva, Sonya Galcheva, Yana Bocheva


Introduction: In the last 5 years, the use of automatic insulin delivery systems has been increasing among patients with type 1 diabetes mellitus (T1DM). It has been shown that they improve metabolic control, decrease the time spent in hypoglycemia and the number of episodes of nocturnal hypoglycemia; increase the time spent in target and are feasible and safe.

Aim: Our aim is to evaluate the glycemic control in children/adolescents using do-it-yourself (DIY) regulatory unapproved insulin-delivery loops vs sensor-augmented pump therapy (SAP).

Materials and Methods: A total of 43 families with child/children with T1DM on pump treatment and continuous use of continuous glucose monitoring (CGM) were invited to participate in the study; 31 (72.1%) of the families accepted. The children were followed for 6 months, a total of 196 patient months.

Results: The study group consisted of 31 children with T1DM, 24 (77.4%) of them were on SAP, and 7 (22.6%) used DIY loops. No differences were observed in regard to age, duration of diabetes, and daily insulin dose between groups. Patients on DIY loops spent significantly more time in range (83.0 vs 68.8%, p=0.02), less time in hyperglycemia above 14 mmol/L (2.1 vs 8.6%, p=0.02). They had significantly better HbA1c at the 6th month (6.5 vs 7.2%, p=0.006) vs SAP patients for the follow-up period. No severe hypoglycemia and diabetic ketoacidosis (DKA) occurred. There were no gender differences between and within both groups.

Conclusion: DIY unregistered loop systems showed promising results for better metabolic control at least in terms of mean blood glucose levels (BGLs) and without increasing the risk of severe hypoglycemia and DKA. Further impact e. g. mean insulin dose, long-term efficacy, consumed fat/protein in the daily diets, etc., remains to be studied in future larger and longer studies.


T1DM, closed insulin-delivery loop, DIY, CGM, benefits

Full Text


NCT01464346, Available from:

Zhong A, Choudhary P, McMahon C, Agrawal P, Welsh J, Cordero T, et al. Effectiveness of automated insulin management features of the MiniMed® 640G Sensor-Augmented Insulin Pump Diabetes Technol Ther. 2016; 18(10):657-63. doi: 10.1089/dia.2016.0216.

Available from:

Available from:

Lifetime benefits and costs of intensive therapy as practiced in the diabetes control and complications trial. The Diabetes Control and Complications Trial Research Group. JAMA. 1996; 276(17):1409–15. doi: 10.1001/jama.1996.03540170053032.

Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) Research Group1, Nathan DM, Zinman B, Cleary PA, Backlund JY, Genuth S, et al. Modern-day clinical course of type 1 diabetes mellitus after 30 years’ duration: the diabetes control and complications trial/epidemiology of diabetes interventions and complications and Pittsburgh epidemiology of diabetes complications experience (1983-2005). Arch Intern Med. 2009; 169(14):1307-16. doi: 10.1001/archinternmed.2009.193.

Nordwall M, Abrahamsson M, Dhir M, Fredekison M, Ludvigsson J, Arngvist JH. Impact of HbA1c, followed from onset of type 1 diabetes, on the development of severe retinopathy and nephropathy: the VISS Study (Vascular Diabetic Complications in Southeast Sweden). Diabetes Care. 2015; 38(2):308–15. doi: 10.2337/dc14-1203.

Misso ML, Egberts KJ, Page M, O’Connor D, Shaw J. Continuous subcutaneous insulin infusion (CSII) versus multiple insulin injections for type 1 diabetes mellitus. Cochrane Database Syst Rev. 2010; 1:CD005103. doi: 10.1002/14651858.CD005103.pub2.

Karges B, Schwandt A, Heidtmann B, Schierloh U, Binder E, Schierloh U, et al. Association of insulin pump therapy vs insulin injection therapy with severe hypoglycemia, ketoacidosis, and glycemic control among children, adolescents, and young adults with type 1 diabetes. JAMA. 2017; 318(14):1358–66. doi: 10.1001/jama.2017.13994.

Miller MK, Foster NC, Beck RW, Bergenstal RM, DuBose SN, DiMeglio LA, et al. Current state of type 1 diabetes treatment in the U.S.: updated data from the T1D Exchange clinic registry. Diabetes Care. 2015; 38(6):971-8. doi: 10.2337/dc15-0078.

Foster NC, Beck RW, Miller KM, Clements MA, Rickels MR, DiMeglio LA, et al. State of type 1 diabetes management and outcomes from the T1D Exchange in 2016-2018. Diabetes Technol Ther. 2019; 21(2):66-72. doi: 10.1089/dia.2018.0384.

SWEET Benchmarking Report 01/01/2019 - 31/07/2019, Available from:

ISPAD Guideline 2018, Available from:

Weissberg-Benchell J, Antisdel-Lomaglio J. Diabetes-specific emotional distress among adolescents: feasibility, reliability, and validity of the problem areas in diabetes-teen version. Pediatr Diabetes. 2011; 12(4pt1):341-4. doi: 10.1111/j.1399-5448.2010.00720.x.

Hood KK, Beavers DP, Yi-Frazier J, Bell R, Dabelea D, Mckeown RE, et al. Psychosocial burden and glycemic control during the first 6 years of diabetes: results from the SEARCH for Diabetes in Youth study. J Adolesc Health. 2014; 55(4):498-504. doi: 10.1016/j.jadohealth.2014.03.011.

Buchberger B, Huppertz H, Krabbe L, Lux B, Mattivi JT, Siafarikas A. Symptoms of depression and anxiety in youth with type 1 diabetes: A systematic review and meta-analysis. Psychoneuroendocrinology. 2016; 70:70–84. doi: 10.1016/j.psyneuen.2016.04.019.

Cooper MN, Lin A, Alvares GA, de Klerk, NH, Jones, TW, Davis, EA. Psychiatric disorders during early adulthood in those with childhood onset type 1 diabetes: Rates and clinical risk factors from population-based follow-up. Pediatr Diabetes. 2017; 18(7):599-606. doi: 10.1111/pedi.12469.

Petersson C, Huus K, Enskär K, Hanberger L, Samulesson U, Åkesson K. Impact of type 1 diabetes on health-related quality of life among 8–18-year-old children. Compr Child Adolesc Nurs. 2016; 39(4):245–55. doi:10.1080/24694193.2016.1196265.

Sundberg F, Sand P, Forsander G. Health-related quality of life in preschool children with type 1 diabetes. Diabet Med. 2014; 32(1):116–9. doi: 10.1111/dme.12557.

Patterson CC, Harjutsalo V, Resenbauer J, Neu A, Cinek O, Skrivarhaug T, et al. Trends and cyclical variation in the incidence of childhood type 1 diabetes in 26 European centres in the 25 year period 1989-2013: a multicentre prospective registration study. Diabetologia. 2019; 62(3):408-17. doi: 10.1007/s00125-018-4763-3.

Weisman A, Bai JW, Cardinez M, Kramer CK, Perkins BA. Effect of artificial pancreas systems on glycaemic control in patients with type 1 diabetes: a systematic review and meta-analysis of outpatient randomised controlled trials. Lancet Diabetes Endocrinology. 2017; 5(7):501–12. doi: 10.1016/s2213-8587(17)30167-5.

Musolino G, Dovc K, Boughton CK, Tauschmann M, Allen JM, Nagl K, et al. Reduced burden of diabetes and improved quality of life: Experiences from unrestricted day-and-night hybrid closed-loop use in very young children with type 1 diabetes. Pediatr Diabetes. 2019; 20(6):794-9. doi: 10.1111/pedi.12872.

Lewis D. History and perspective on DIY closed looping. J Diabetes Sci Technol. 2019; 13(4):790-3. doi: 10.1177/1932296818808307.

OpenAPS. Open APS. 2015. Available at:

Lewis D, Leibrand S, #OpenAPS Community. Real-world use of Open Source Artificial Pancreas Systems. J Diabetes Sci Technol. 2016; 10(6):1411. doi:10.1177/1932296816665635.

Lewis DM, Swain RS, Donner TW. Improvements in A1C and time-in-range in DIY closed-loop (OpenAPS) users. Diabetes. 2018; 67(1):352-OR. doi: 10.2337/db18-352-OR.

Provenzano V, Guastamacchia E, Brancato D, Cappiello G, Maioli A, Mancini R, et al. Closing the loop with OpenAPS in people with type 1 diabetes-experience from Italy. Diabetes. 2018; 67(1):993-P. doi: 10.2337/db18-993-P.

Choi SB, Hong ES, Noh YH. Open artificial pancreas system reduced hypoglycemia and improved glycemic control in patients with type 1 diabetes. Diabetes. 2018; 67(1):964-P. doi: 10.2337/db18-964-P.

Battelino T, Danne T, Bergenstal RM, Amiel SA, Beck R, Biester T, et al. Clinical targets for continuous glucose monitoring data interpretation: recommendations From the International Consensus on Time in Range. Diabetes Care. 2019; 42(8):1593-603. doi: 10.2337/dci19-0028.

Bergenstal RM, Garg S, Weinzimer SA, Buckingham BA, Bode BW, Tamborlane WV, et al. Safety of a hybrid closed-loop insulin delivery system in patients with type 1 diabetes. JAMA. 2016; 316(13):1407–8. doi:10.1001/jama.2016.11708

Garg SK, Weinzimer SA, Tamborlane WV, Buckingham BA, Bode BW, Bailey TS, et al. Glucose outcomes with the in-home use of a hybrid closed-loop insulin delivery system in adolescents and adults with type 1 diabetes. Diabetes Technol Ther. 2017; 19(3):155-63. doi: 10.1089/dia.2016.0421.

Patton SR, Dolan LM, Henry R, Powers SW. Fear of hypoglycemia in parents of young children with type 1 diabetes mellitus. J Clin Psychol Med Settings. 2008; 15(3):252-9. doi: 10.1007/s10880-008-9123-x.

Gonder-Frederick LA, Fisher CD, Ritterband LM, Cox DJ, Hou L, DasGupta AA et al. Predictors of fear of hypoglycemia in adolescents with type 1 diabetes and their parents. Pediatr Diabetes. 2006; 7(4):215-22. doi: 10.1111/j.1399-5448.2006.00182.x.

Hovorka R, Kumareswaran K, Harris J, Allen JM, Elleri D, Xing D, et al. Overnight closed loop insulin delivery (artificial pancreas) in adults with type 1 diabetes: crossover randomised controlled studies. BMJ. 2011; 342:d1855. doi: 10.1136/bmj.d1855.

Ly TT, Keenan DB, Roy A, Han J, Grosman B, Cantwell M et al. Automated Overnight Closed-Loop Control Using a Proportional-Integral-Derivative Algorithm with Insulin Feedback in Children and Adolescents with Type 1 Diabetes at Diabetes Camp. Diabetes Technology & Therapeutics 2016; 18(6):377-384.

Phillip M, Battelino T, Atlas E, Kordonouri O, Bratina N, Miller S, et al. Nocturnal glucose control with an artificial pancreas at a diabetes camp. N Engl J Med. 2013; 368(9):824–33. doi: 10.1056/nejmoa1206881.

Del Favero S, Boscari F, Messori M, Rabbone I, Bonfanti R, Sabbion A, et al. Randomized summer camp crossover trial in 5- to 9-year-old children: outpatient wearable artificial pancreas is feasible and safe. Diabetes Care 2016; 39(7):1180–5. doi: 10.2337/dc15-2815.

Mauras N, Mazaika P, Buckingham B, Weinzimer S, White NH, Tsalikaian E, et al. Longitudinal assessment of neuroanatomical and cognitive differences in young children with type 1 diabetes: association with hyperglycemia. Diabetes. 2015; 64(5):1770-9. doi: 10.2337/db14-1445.

Rachmiel M, Cohen M, Heymen E, Lezinger M, Inbar D, Gilat S, et al. Hyperglycemia is associated with simultaneous alterations in electrical brain activity in youths with type 1 diabetes mellitus. Clin Neurophysiol. 2016; 127(2):1188-95. doi: 10.1016/j.clinph.2015.07.011.



About The Authors

Yuliya Bazdarska
Medical University of Varna

Department of Paediatrics, Faculty of Medicine

Violeta Iotova
Medical University of Varna

Department of Paediatrics, Faculty of Medicine

Vilhelm Mladenov
Medical University of Varna

Department of Paediatrics, Faculty of Medicine

Veselin Boyadzhiev
Medical University of Varna

Department of Paediatrics, Faculty of Medicine

Rositsa Stoycheva
Medical University of Varna

Sector of Pediatrics, St. Marina Diagnostic and Consultation Center

Sonya Galcheva
Medical University of Varna

Department of Paediatrics, Faculty of Medicine

Yana Bocheva
Medical University of Varna

Department of General Medicine and Clinical Laboratory, Faculty of Medicine

Font Size