Barriers and facilitators to continuous glucose monitor use in type 1 diabetes: A biopsychosocial model of the adolescent experience

Abstract

Our study aims to understand the barriers and facilitators surrounding continuous glucose monitors (CGMs) in adolescents experiencing diabetes distress from type 1 diabetes through a biopsychosocial lens. We qualitatively analyzed interviews of 21 adolescents and coded their emotional experiences. Findings show that biologically, adolescents noted improved mood with healthier glucose ranges and future health prospects. Psychologically, adolescents preferred a sense of control over when to use, and take a break from, their CGM. Socially, they described mixed feelings surrounding how CGM use impacts relationships with friends, with family, and at school. The biopsychosocial framework captures the complexity and interplay among these factors, highlighting the desire for identity exploration, sense of belonging, and good health as important themes in adolescent diabetes management with a CGM. Clinicians can play a crucial role by bringing a biopsychosocial understanding of the CGM experience into care conversations for adolescents and families to consider.

Keywords

type 1 diabetes continuous glucose monitors adolescents biopsychosocial model emotional experience

Introduction

Type 1 diabetes, a common chronic disease in children (Lawrence et al., 2021; Torpy et al., 2010), requires lifelong management with insulin and lifestyle changes which significantly affect the social and psychological well-being of the individual and, subsequently, one’s participation in treatment and overall quality of life. The American Diabetes Association (ADA) has recognized that such psychosocial considerations are crucial to the management of diabetes and has put forth recommendations in a position statement specific to psychosocial care for people of all ages with diabetes in 2016 (Young-Hyman et al., 2016). While benefits to physical health are apparent, additional recognition of psychosocial considerations in management is particularly relevant for adolescents with type 1 diabetes because of the increased influence of psychosocial factors in this crucial developmental stage.

As we see increasing technological advances in the treatment of type 1 diabetes, it is important to adapt our psychosocial considerations accordingly. In recent times, more attention has been put on diabetes technologies such as continuous glucose monitors (CGMs), which are associated with improved glycemic outcomes and decreased hypoglycemia (Weinstein and Kahkoska, 2022). A CGM device consists of a sensor that continuously reads glucose levels which are wirelessly transmitted to a receiver or phone. CGMs offer real-time, continuous feedback to allow for insulin dosing, tracking of glucose trends, and reduced need for manual blood glucose checks with a glucometer. Across older populations, CGMs have been shown to improve hemoglobin A1C, reduce hypoglycemic episodes, and result in greater patient satisfaction (Laffel et al., 2020; Lin et al., 2021). In adolescents, CGM outcomes are less robust. In a 2018 randomized controlled trial, mean hemoglobin A1C decreased by 0.4% in adolescents and young adults using CGMs, compared to those using glucometers (Laffel et al., 2020). Another randomized controlled trial among patients with insulin pump therapy showed a 0.46% decrease in hemoglobin A1C in pediatric patients with a CGM compared to those without (Battelino et al., 2012). Other studies have shown no difference in hemoglobin A1C or the amount of time per day that glucose readings were within target range among children and adolescents using a CGM versus a blood glucose meter for monitoring (Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study Group, 2008), unlike the significant improvements seen in adults. The most likely explanation for these differences is less consistent CGM use among the adolescent population (Weinstein and Kahkoska, 2022). Adolescents are most likely to discontinue CGM use as compared to other age groups (Beck et al., 2009). Literature regarding adolescents’ daily biological, psychological, and social experiences with CGMs, while present, has its limitations and would be useful in exploring barriers and facilitators to consistent CGM use in this population.

The biopsychosocial model has been used in the literature to conceptualize the full burden of living with type 1 diabetes in everyday life (Kelly et al., 2024; Schwartz et al., 1991). The biopsychosocial model was developed by George Engel in 1977 (Engel, 2012) and has been considered the overarching framework for contemporary healthcare. It was created to address the limitations to the biomedical model, which was expensive and lacked attention to primary and secondary prevention, by expanding our view of the causal and perpetuating factors of illness to include psychological and social influences, and subsequently the scope of management beyond just what could be done in a hospital setting (Bolton and Gillett, 2019). The biopsychosocial model becomes particularly relevant in long-term conditions, including diabetes, and has been studied in this illness as far back as 1991. Schwartz et al. (1991) found that individuals with a greater number of stressful life events, decreased social support, and an external locus of control had poorer glycemic outcomes. More recently, Kelly et al. (2024) identified high rates of self-reported psychosocial burdens of diabetes including anxiety and depression, fear of low blood sugars, negative effects on self-esteem and loneliness, and a highly common desire among patients for their diabetes team to address psychosocial issues and mental well-being in their diabetes care.

A biopsychosocial model becomes even more pertinent in diabetes care of the adolescent. Biologically, adolescence is marked by the onset of puberty characterized by reproductive maturity and changes in physical characteristics; development of the limbic system to increase sensitivity to rewards, motivate risk-taking behavior, and elevate social status; and changes in cortical regions to strengthen abstract thinking abilities and problem-solving skills that help prepare the adolescent for adulthood (National Academies of Sciences Engineering and Medicine, 2019). Salient psychological contributors unique to this age range include greater identity exploration, increased independence with decision-making, and larger susceptibility to peer influence with the desire to “fit in.” Social contributors include changing dependence on support systems, potential tensions among family relationships, and school and peer group considerations (National Academies of Sciences Engineering and Medicine, 2019; Young-Hyman et al., 2016).

Though they have not been brought under a single conceptual framework, substantial research has explored biological, psychological, and/or social benefits and burdens of CGM use among adolescents with type 1 diabetes, which we now summarize. The most frequently studied biological effects of CGMs are glycemic outcomes. As summarized earlier, while these outcomes are less robust than those of adults, results do generally show a benefit. Some studies argue that these biological outcomes are a more consistent finding in the literature than other psychological or social outcomes. In a systematic review and meta-analysis of CGM use in children and adolescents on glycemic outcomes and quality of life, the only certain findings were related to benefit with mean hemoglobin A1C, while subjective findings related to quality of life and user satisfaction were inconsistent. Even so, effect estimates of hemoglobin A1C were imprecise given the heterogeneity in results. Ratings for physical well-being were also higher than ratings for psychological well-being (Dorando et al., 2022). A more recent study of adolescents experiencing moderate levels of distress from type 1 diabetes management support these findings, where CGM use was associated with lower hemoglobin A1C, and effects on quality of life or family conflict were not seen (Straton et al., 2025). One study reports improved glycemic outcomes as the most common reason to use a CGM among adolescents, and most users believed it did (Ramchandani et al., 2011). Outside of measuring glycemic outcomes, CGM adherence in children and adolescents has also been positively linked to greater executive functioning skills (Farfel et al., 2020), and CGM nonadherence has been found to result from the development of contact dermatitis from diabetes devices among pediatric users (Passanisi et al., 2022).

Regarding psychological influences related to CGM use in adolescents, perceptions and attitudes toward technology is frequently cited as a factor. In one study of the adolescent experience of diabetes devices, the hassle of wearing devices, disliking the device on the body, and disliking how the device looks were the most common modifiable barriers to device use (Messer et al., 2020). Additional device-related concerns include difficulties with device adherence and mistrust of technology considering inaccurate readings (Meighan et al., 2025). Others report perceptions of the CGM as being intrusive into their lives (Ramchandani et al., 2011) and having negative perceptions of diabetes technology (Messer et al., 2020) as factors in discontinuation. A subset of literature dives more deeply into the psychology of adoption and use of technology and how this may influence uptake of diabetes devices (Gonder-Frederick et al., 2011, 2016). Outside of the technology aspects of the device itself, one study in adolescents and young adults found that worry of hypoglycemia was significantly decreased at 6 months among those who continued CGM use compared with those who had discontinued use (Lee et al., 2023). At a day-to-day level, Messer et al. (2022) found that morning perceptions of health, self-esteem, and motivation predicted improved diabetes outcomes for adolescents and young adults using CGMs for that day.

A few social factors have been mentioned in the literature as it relates to CGM use. Cost and insurance-related issues are common barriers (Ramchandani et al., 2011), with one study finding it the most common barrier to use (Messer et al., 2020), and another study finding that insurance-related barriers were more frequently reported as a barrier among Black and Latine youth compared to White youth (Meighan et al., 2025). One randomized controlled trial of 40 adolescents and young adults from diverse and marginalized backgrounds showed that virtual peer groups were found to have lowered hemoglobin A1C and increased CGM use, highlighting the importance of peer support in this population (Bisno et al., 2023). Family conflict has been studied, but not found, to be associated with CGM discontinuation (Messer et al., 2020; Straton et al., 2025). The ADA recommends assessing psychosocial issues and family stresses that can impact diabetes management, monitoring social adjustment (i.e., peer relationships and school performance) and diabetes-related distress, and allowing for developmentally appropriate family and personal involvement in decision making and routine management (Young-Hyman et al., 2016).

The burden of living with diabetes self-management, with its physical health sequelae, psychological impacts, and its social context often leads to significant emotional distress. This phenomenon is so well-studied that literature has coined its own term for it, diabetes distress (Dennick et al., 2017), and enough robust evidence exists to support its routine monitoring as part of ADA recommendations for psychosocial care (Young-Hyman et al., 2016). Adolescents are at an elevated risk of developing diabetes distress, with a prevalence of one-to two-thirds of adolescents with type 1 diabetes reported in the literature (Hagger et al., 2016; Hedge et al., 2023). Diabetes distress is one type of emotional experience that manifests from the intertwining of the biological, psychological, and social impacts of the disease. Broadly speaking, adolescents have greater emotional vulnerabilities, particularly relating to the emphasis on peer acceptance, growing autonomy and identity exploration, and the transitional nature of this period (Sanders, 2013). Emotions hold important information about what is going on within the individual, integrating biological, psychological, and social factors into a unique experience characterized by a feeling (Brackett, 2019). In other words, emotions, when identified and interpreted adequately, serve as an entryway into the biopsychosocial experiences individuals have of themselves and their environment. Having type 1 diabetes can generate feelings of isolation and powerlessness that stem from its biopsychosocial impacts on adolescents, potentially leading to disrupted patterns of treatment adherence (Buchberger et al., 2016; Hagger et al., 2016). The adolescent emotional experience becomes ever important to understanding the biopsychosocial model of barriers and facilitators to CGM use in adolescents with type 1 diabetes.

Our study aims to understand barriers and facilitators to CGM use in a population of adolescents with diabetes distress, particularly through the lens of the biopsychosocial model. This model has been used before among adolescents with type 1 diabetes using CGMs (Messer et al., 2022), though the overall literature that refers to this model is sparse for this subset of patients, let alone those specifically with emotional experiences such as diabetes distress. While studies exist that discuss biological and psychosocial outcomes, our study is unique in using this comprehensive lens to provide a single framework for these experiences. We use qualitative methods to explore adolescents’ emotional experiences and understand the underpinning biological, psychological, and social factors related to CGM use and discontinuation among adolescents. We hope results from this study will provide an expanded, holistic insight into the adolescent experience of CGMs that will inform future study and intervention.

Methods

Research design and methodology

We performed a secondary analysis on a dataset derived from a multi-site randomized controlled trial (funding period 2019–2023) of a positive psychology-based intervention to reduce diabetes distress in adolescents with type 1 diabetes. A subset analysis to this trial, from which data was used for this current study, applied a mixed methods approach to assess barriers and facilitators of adherence to CGM use in adolescents. Study aims for this subset analysis were to (1) define barriers to CGM use and reasons for CGM discontinuation in adolescents with type 1 diabetes, and (2) identify modifiable barriers to CGM use and describe how diabetes management may change during a “CGM break” (defined below). IRB approval was obtained through the Vanderbilt University Institutional Review Board. Interview guides, transcription, and data analysis were developed in conjunction with Vanderbilt University’s Qualitative Research Core Program. Data can be made available upon request.

Population

The inclusion criteria for the primary dataset was youth ages 13–17 recruited from the Vanderbilt Pediatrics Diabetes Clinic in Nashville, TN and the Children’s National Medical Center in Washington, DC. A focus group study for adolescents was initially planned after completion of the primary study’s intervention, however due to safety precautions under the COVID-19 pandemic, individual interviews were conducted instead. Inclusive of these adjustments, the dataset for this secondary analysis was ultimately of youth ages 14–19 (n = 21). Other eligibility criteria include having a diagnosis of type 1 diabetes for at least 12 months, reporting at least moderate diabetes distress on the Problem Areas in Diabetes Scale – Teen version (Weissberg-Benchell and Antisdel-Lomaglio, 2011), and the ability to speak and read English. Participants were excluded if they had serious health conditions that interfered with diabetes care. If participants were accompanied by a parent, the parent was welcome to participate in the interview, though parents were not explicitly invited to participate. Parents were present with two of the participants. It was intended for all participants to be current CGM users, however one participant had discontinued CGM use by the time of the interview. This participant’s transcript was still included in the study. 67% of participants had insulin pumps, devices that administer either continuous or bolus insulin, as an alternative to manual insulin injections. Informed consent was obtained from caregivers and participants older than 18 by the time of the interview, and assent obtained from participants younger than 18. Participant demographics are listed in Table 1.

Table 1.

Participant demographics.

	Mean (SD)	No. (%)
Age (years)	16.6 (1.4)
Age at type 1 diabetes diagnosis (years)	8.4 (3.3)
Age at start of CGM use (years)	13.1 (2.2)
Hemoglobin A1C at enrollment	8.7 (1.2)
Sex, male (%)		11 (52.4%)
Race
White		15 (71.4%)
Black		5 (23.8%)
Asian		1 (4.8%)
Household income
Less than $24,999		2 (9.5%)
$25,000-$49,999		4 (19.0%)
$50,000-$89,999		3 (14.3%)
$90,000-$149,999		5 (23.8%)
More than or equal to $150,000		7 (33.3%)

SD, standard deviation; CGM, continuous glucose monitor.

Procedure/Measures

Trained facilitators used a semi-structured approach to guide interviews. Questions included, “Why did you decide to get a sensor?”; “Did you ever take a “break” from your sensor?”; and, “How do these breaks make you feel?” Discontinued use of a CGM for reasons beyond the individual’s control (i.e., supply, device, or insurance issues) was termed a “forced break” in this study. Discontinued use of a CGM due to personal preference was termed a “voluntary break” (Supplemental Figure S1). Participants were compensated with a $30 gift card upon completion.

Analysis

In the primary dataset, two experienced qualitative coders used an iterative inductive-deductive approach (Fereday and Muir-Cochrane, 2006; Tjora, 2018) to independently code the same dataset after establishing inter-rater reliability, and discrepancies were reconciled. The codes related to participants’ emotions were filtered to comprise the dataset for this study. Emotion codes were thought to capture richer and more nuanced data on the adolescents’ unique, lived experience of barriers and facilitators that would not otherwise be captured from a direct response to an interview question, especially given this developmental age group’s heightened emotional salience. The contexts of these emotional experiences also helped elicit the most relevant factors to comprise the biopsychosocial model. Data were organized by the primary author (with prior qualitative coding experience) into the following: (1) the name of the emotion, (2) whether it was positive (facilitator) or negative (barrier), and (3) the context of the emotion. Any codes in doubt were discussed with a senior rater who is an expert in qualitative analysis.

An iterative inductive-deductive approach was used again with the resulting codes. Inductively, we sorted the quotes by coding category to identify higher-order themes and relationships between themes. Deductively, we were guided by the biopsychosocial framework (Engel, 2012). Resultant themes were organized into biological, psychological, or social factors, and were also broken down into subthemes in collaboration with all authors of the study. Names of specific technology devices were removed from quotes to maintain neutrality.

Results

A list of themes, subthemes, and emotions are shown in Table 2. Themes that emerged were organized into biological, psychological, or social factors. A fourth factor of themes, technological factors, was created, as it was thought to have unique attributes that were not adequately encompassed by the other categories. Themes were routine diabetes management, diabetes management during breaks, physical health (biological), forced breaks, voluntary breaks (psychological), friends, family, school (social), and device problems (technological). While themes are categorized into these four distinct factors, there is significant overlap of each theme among these factors, and the current discrete labeling of these factors in this manuscript is primarily for simplicity and ease of understanding. Quotes are shared throughout the text; a comprehensive list of quotes for each theme can be found in Supplemental Table S1.

Table 2.

Summary of themes, subthemes, associated emotions, and barriers/facilitators of adolescent CGM use.

Themes	Subthemes	Emotion (+/−)^a	Barrier/facilitator
Biological factors
Routine diabetes management	Simplicity	Content, thankful, relieved, liberated, happy, less worried (+)	Facilitator
	Less interference with daily life	Relieved, liberating (+)	Facilitator
	Constant feedback	Relieved, in control (+)	Facilitator
Management during breaks	BG fluctuations	Angry, annoyed, irritable, upset, labile, emotionally tired (−)	Barrier
Management during breaks	Returning to glucometer use	Annoyed, stressed, irritated (−)	Barrier
Physical health^b	Better health prospects	Thankful (+)	Facilitator
Physical health^b	Impacts on mood	Satisfied, thankful (+)	Facilitator
Psychological factors
Forced breaks	No choice/control	Afraid, anxious, angry, annoyed (−)	Barrier^c
	Disruption to daily life	Anxious, stressed, annoyed (−)	Barrier^c
	Response of loved ones	Annoyed (−), ambivalent (/), happy (+)	Both^c
	Positive coping	Accepting, appreciative, relieved (+)	Facilitator^c
Voluntary breaks	Mental break	Relieved, liberated, relaxed, in control (+)	Facilitator^c
	Break from physical discomfort	Indifferent (/), Relieved (+)	Facilitator^c
	Lack of negative consequences	Neutral (/)	N/A
Social factors
Friends	Freedom/less social disruption	Happy, liberated (+)	Facilitator
Family	Excessive help	Frustrated, upset, resentful (−)	Barrier
Family	Helping while allowing space	Happy, appreciative (+)	Facilitator
School^b	Device drawing attention in class	Anxious, annoyed, frustrated, helpless, embarrassed (−)	Barrier
School^b	Authority figures restricting use	Angry (−)	Barrier
Technological factors
Device problems	Connection issues (transient)	Annoyed, frustrated, confused (−) → relieved (+)	Barrier (transient)
	Questioning accuracy (Improved, or transient)	Frustrated, doubtful (−) → relieved, content (+)	Barrier (transient)
	Physical discomfort	Angry, frustrated, inconvenienced (−)	Barrier (+/− transient)
	Physical discomfort (anticipated, but not experienced)	Content, relieved (+)	Facilitator

^a(−) indicates negative emotion; (+) indicates positive emotion, (/) indicates neutral emotion.

^bReported by a single participant.

^cA barrier or facilitator to a forced or voluntary break theme was interpreted to mean that the corresponding subtheme was a barrier/facilitator to CGM use because of its potential to have a forced/voluntary break. CGM, continuous glucose monitor; BG, blood glucose.

Biological factors

Themes that emerged under biological factors were routine diabetes management, diabetes management during breaks, and physical health. Routine diabetes management using the CGM was perceived positively (facilitator). Its simplicity of use, having less interference with daily life, and constant feedback to track trends led to feeling relieved. With its simplicity and decreased interference with life, adolescents also reported feeling liberated and happy.

“I am happy that [my parents] put me on it, it's so much less of a hassle than having to prick my fingers all the time.” (18-year-old female, diagnosed at age 10, CGM since age 14)

“With the [CGM], I haven’t tried to take a break from it ‘cause it's just been so useful in just letting me live, I guess. Let me live a little more without having to stress as much…” (18-year-old female, diagnosed at age 6, CGM since age 11)

In contrast, diabetes management during breaks was an unpleasant experience (barrier). Returning to glucometer use made adolescents feel annoyed, stressed, and irritated: “It’s super annoying to check my blood sugar manually, so it just makes me want to check it even less.” (17-year-old female, diagnosed at age 12, CGM since age 15) The blood glucose fluctuations experienced during these breaks resulted in feelings of anger, annoyance, irritability, feeling upset, labile, and emotionally tired.

“Yeah. I’m definitely struggling more with lows and highs and because especially since they hit me out of nowhere and I can feel that it takes effect on my body, so it's really frustrating.” (17-year-old female, diagnosed at age 12, CGM since age 15)

“… I notice that his anxiety is higher when he doesn’t have it on because he gets frustrated with his blood sugars like going up and down and he feels like… I don't want to use this word but he kind of feels like crap, he's sleeping all the time, his stomach hurts, he doesn't want to eat when his blood sugars aren't in control. So he gets really frustrated a lot with his blood sugars being crazy and not being able to control them and his anxiety does definitely increase.” (Parent; participant: 16-year-old male, diagnosed at age 2, CGM since age 11)

One adolescent spoke directly to the biological impacts of their diabetes management with a CGM on their physical health. They felt satisfied and thankful that the CGM helped them maintain more stable blood sugars, which improved their mood and decreased the risk of health complications in the future (facilitator).

“It's basically a lifesaver, and it's going to help your body in the future. …And plus my mood changed a lot after getting sensors, because my sugar stayed down lower. And whenever you have high sugars, your hormones go up and you get upset easily. It's not changing you into a better person, exactly, but you're in a better mood, all the time. So it does change you a lot.” (17-year-old male, diagnosed at age 9, CGM since age 12)

Psychological factors

Themes that emerged under psychological factors were related to forced breaks and voluntary breaks. The adolescent experience of managing their diabetes when they were off their CGM, i.e., breaks, varied widely depending on whether the break was voluntary or forced. Forced breaks occurred due to supplier delays, sensor malfunction, problems with insurance, and the device being misplaced. Forced breaks were mostly met with negative emotions related to the lack of choice or control and the disruption to daily life, including feeling afraid, anxious, angry, stressed, and annoyed. These subthemes were considered a barrier to CGM use due to the potential for forced breaks to occur.

“It was frustrating because I have to suffer consequences for something that wasn't my fault. And it's making... It more of an inconvenience to my life because somebody didn't put in the paperwork on time or something.” (18-year-old female, diagnosed at age 6, CGM since age 11)

“The forced ones are worse than when I just want to take a break. …Because I don't have the choice. I have to be forced.” (16-year-old male, diagnosed at age 2, CGM since age 11)

“This just goes back to being, I don't check it as much as I usually would when on the CGM. I'm even more annoyed…” (17-year-old female, diagnosed at age 12, CGM since age 15)

Response of loved ones were met with varied emotions, from annoyed, to ambivalent, to happy.

“It turns into an argument because I feel like I know it more than like... I feel like I know when to do it and not but then my sugar goes high and then they're mad.” (16-year-old male, diagnosed at age 2, CGM since age 11)

“My friends are like yeah, she's got it, she's fine. Except for my best friend [name omitted] but that's because she's my best friend and she loves me a lot. But my parents definitely are a little bit more worried and make sure I'm doing it. But for the most part they leave me alone, which I enjoy.” (16-year-old male, diagnosed at age 6, CGM since age 14)

Some adolescents demonstrated positive coping with forced breaks, where they felt accepting, appreciative, and relieved, facilitating CGM use in spite of the negative consequences of forced breaks.

“One of the things, make the best of it. You're having your break now instead of when you take it off that same day.” (17-year-old female, diagnosed at age 9, CGM since age 10)

“I mean, I feel like it is good for my mental health because like I was even telling my mom that it can be kind of addicting, just like going back and forth to the [CGM] app, being like, oh my number's not perfect right now. And then like you overdose on insulin or like you underdose and things like that, where it does cause stress. Whereas if I'm just doing my [insulin pump], like not like it's bad or anything, but I'm like, okay, I know I'm okay. Like I'm alive. My numbers might not be perfect, but I feel okay. And stuff like that where I'm not constantly checking, oh, is this number like a couple numbers off or something like that.” (17-year-old female, diagnosed at age 10, CGM since age 15)

Voluntary breaks occurred due to adolescents wanting a break from the burdens of using the CGM. They provided a mental break, a break from physical discomfort, and for some, were taken simply because there were no perceived negative consequences to doing so. Voluntary breaks were met with either neutral (neither facilitator nor barrier) or positive emotions (facilitator). In taking a mental break, adolescents felt relieved, liberated, relaxed, and in control (facilitator).

“He's just more relaxed. He's not as anxious. And I think it's because if he knows if he's trending down, he can get it and be in control again.” (Parent; participant: 16-year-old male, diagnosed at age 2, CGM since age 11)

Interviewer: “So do you feel any different than you normally do when you take these sensor breaks?”

Participant: “Nope, except it's freedom.” (14-year-old female, diagnosed at age 10, CGM since age 12)

Those where a voluntary break removed a physical discomfort felt relieved or indifferent (facilitator or neither).

Interviewer: “Do you feel anything positive? Because you're saying that it's nice not to have something on your body.”

Participant: “I guess maybe a little bit, but I just don't really care like that. If that makes any sense? It's not something I've been negative or positive to.” (17-year-old female, diagnosed at age 9, CGM since age 10)

Interviewer: “Why do you sometimes choose to stop wearing the sensor?”

Participant: “Because after a while it can get pretty annoying. …It'll itch sometimes and just you can't reach it. …And with how clumsy I am, I'm always running into walls and it hurts when it hits the [CGM].” (14-year-old female, diagnosed at age 10, CGM since age 12)

Those who took a voluntary break due to lack of negative consequences felt neutral (neither).

“It doesn't really change. It's more or less it's just it's on me or off me, and it doesn't bother me. Well, it doesn't not [inaudible] doesn't bother me anymore. It doesn't affect how I think or how I feel.” (17-year-old male, diagnosed at age 8, CGM since age 15)

Social factors

Adolescents spoke of diabetes management with a CGM affecting their social experiences with friends, with family, and at school. Having less social disruption with friends compared to glucometer use caused adolescents to feel happy and liberated (facilitator).

“Freedom of the sensor in comparison to a test strip, it's much easier, especially when I'm going out to a dinner or something or if I'm hanging out with friends. Because, I have it hooked up to my phone because there's an app for it. And I quickly look at my phone and I'm like, 'Oh! I'm 107', and I put it back and I'm carrying on. I don't have to make the group stop and I don't have to hunch over a park bench doing it and get weird looks. I can just pull my phone out and be like, 'Oh. It's this. Okay. I can take this amount of insulin.' And it's much more convenient. Especially with someone who's deathly afraid of how people perceive them, it's much easier to do in public. And a lot less embarrassing. Embarrassed is the feeling that I got when I used to have to check it in public. It's just a lot more subtle.” (18-year-old female, diagnosed at age 10, CGM since age 14)

Impacts on family relationships were associated with frustration and resentment if family was perceived as offering help in excess (barrier), and happy and appreciative if family was perceived to strike a good balance between offering help and allowing autonomy (facilitator).

“And just for a while, I was very upset about [my parents] constantly spying on what I was doing. But the past year or so, they've stopped doing that because they trust me with it now. But for a while, I saw it as a punishment, but nowadays I'm like, ‘This is so much better.’” (18-year-old female, diagnosed at age 10, CGM since age 14)

One adolescent described her experience in school negatively (barrier); she felt angry when the principal restricted use, and anxious and annoyed when the device drew attention in class: “Oh, also, my [CGM] would always go off in class, and I’d get in trouble for it. …And that was frustrating because I would get in trouble, and I was like, I can’t help it.” (19-year-old female, diagnosed at age 4, discontinued CGM for 2 years).

Technological factors

Related to the physical device or technology itself, problems with using the CGM was initially met with negative emotions of annoyance, frustration, and doubt due to connection issues, questionable accuracy, and physical discomfort. These emotions were often transient, and as adolescents adjusted to the device, found solutions to these technical problems, or switched to a different brand of device, as shown in the succeeding quotes, their experience shifted more positively to relief and contentment (transient barrier).

Participant: “I didn't know that if you swipe out of it that it will lose connection. Like I just thought it's always on there. So for like a year I was losing connection and I was like, what is going on? And then someone from a [social media] group said, you can't swipe out of it. And I never knew that.”

Interviewer: “That's really annoying.”

Participant: “Yeah.” (17-year-old female, diagnosed at age 10, CGM since age 15)

“There have been a lot of times where it doesn't pick up the transmitter. The CGM device doesn't pick up a transmitter. I just end up waiting it out until it connects again, which sometimes can't be for hours, so that was quite annoying because then I had to end up using my manual. …I haven't been having that trouble as much recently.” (17-year-old female, diagnosed at age 12, CGM since age 15)

“The sensor is really uncomfortable, you have to change it every seven days. …It was just a problem and it was just really obnoxious and I wasn't paying attention because I hated it so much that I just wasn't paying attention to it at all. …So then we switched over to a [name of CGM brand] and I am loving it. It is so great.” (16-year-old female, diagnosed at age 6, CGM since age 14)

One adolescent commented on anticipating, but ultimately not experiencing the physical discomfort from the device, which was met with relief and contentment (facilitator).

“I think people's biggest fear, I know mine was, is having a new, unknown object on your body, per se, like, oh, how am I going to sleep with that? Or whatever. But you really don't feel it at all…. Depending on where you put it, you're not going to hit it on anything. You don't have to worry about it being there. But overall it's just a big game changer, and this, I don't know how to explain the difference, so much, but it is a huge difference in what it does.” (17-year-old male, diagnosed at age 9, CGM since age 12)

For some, the physical discomfort or technical difficulties with the CGM persisted (barrier).

Participant: “Well, usually it's more like a relief because I only take a break if it's starting to frustrate me. If the [CGM] starts to frustrate me.”

Interviewer: “And the frustration stems from the skin irritation.”

Participant: “Yes.” (15-year-old male, diagnosed at age 4, CGM since age 13)

“Right after you change it or put a new one in, in the 24 hours after that, or maybe just 12 or so, it can be quite inaccurate. It'll say that I'm having an emergency low blood sugar at 3:00 AM, and my mom comes into my room and then is like, “[inaudible], you're dying.” But then I'm like, “No, I'm not.” And then she's like, “Damn it.” …And it’s like, yeah, that’s frustrating.” (17-year-old male, diagnosed at age 12, CGM since age 13)

Discussion

In this study, we qualitatively capture the barriers and facilitators of adolescents’ experiences of living with type 1 diabetes using a CGM, conceptualized through a biopsychosocial framework. While other studies exist that explore barriers and facilitators of CGMs, they often explore only one or two factors of the biopsychosocial model; our study is novel in that it brings these various influences together into a single, comprehensive, evidence-based model of disease. We also uniquely apply a developmental lens by focusing on adolescents’ emotional experience to elicit these factors. We note how viewing the biopsychosocial framework in this way captures the complexity of the experience and brings to light the wide-reaching impacts that diabetes management with a CGM has on these individuals.

While the biopsychosocial framework speaks of biological, psychological, and social factors discretely, we find that there is heavy interplay among them. According to the literature, the decision to use a CGM is initially defined by a primarily biological goal: to improve glycemic outcomes (Ramchandani et al., 2011). Our study shows that use of the CGM meets psychological and social needs as well. Socially, it allows adolescents to go about their daily life and relieves the worry and frustration that comes with the encumbrances of glucometer use, which is particularly important in adolescence, a time marked by growing independence and identity exploration (Erikson, 1968). Psychologically, it offers a sense of control by providing constant feedback on glucose trends. Other literature has also spoken to the sense of empowerment adolescents may receive from taking responsibility in their diabetes management (Williams et al., 2023). These facilitators of CGM use become more apparent when compared to management during CGM breaks, which is generally perceived as a barrier. Blood glucose fluctuations on CGM breaks resulted in both direct biological effects on mood, as well as psychological effects of frustration due to the loss of control and independence.

While management during breaks was overall unpleasant, the psychological effect from whether the break was forced or voluntary influenced whether the CGM was perceived as a facilitator or barrier. This again points to the importance of the sense of control, specifically over access to the CGM, a unique recurring theme in the adolescent’s CGM experience. CGMs may be perceived, at least momentarily, as a threat to an adolescent’s identity, or their freedom to explore it; voluntarily taking a break from the CGM allows the adolescent to experience the sense of control and freedom to protect themselves from this threat. This may be one reason why adolescents are most likely to discontinue CGM use as compared to other age groups (Beck et al., 2009). Forced breaks were met with varied responses, which may be explained by the adolescent’s locus of control, a framework studied by Schwartz et al. (1991) in the context of diabetes management. Individuals with an external locus of control (i.e., those who depend on external events to influence their behavior) may be more likely to experience anxiety, stress, and annoyance that come with the forced loss of their CGM and the disruption to their daily routine. This poor coping may result in disrupted diabetes management and produce poor glycemic outcomes (biological factors), consistent with Schwartz’s findings, and the prospect of a forced break may be a barrier to CGM use. Those with an internal locus of control (i.e., those who take personal control over their behavior) may be more likely to engage in positive coping and improved glycemic outcomes, facilitating CGM use. We see from this study, therefore, that not all breaks are created equally – certain breaks, depending on the individual’s coping and whether the break was forced or voluntary, may be considered a therapeutic allowance or necessity to facilitate an adolescent’s optimal routine diabetes management.

Outside of the psychological impacts of forced breaks, socioenvironmental factors exert heavy influences on forced breaks, as these breaks were often a result of problems with insurance or supplier delays. Extant literature has discovered disparities in access to CGMs, where cost and insurance-related issues were found to be common barriers to access for Black and Latine youth compared to White youth (Meighan et al., 2025). These minority populations may be at elevated risk of experiencing forced breaks and the stresses that come with them. They may also be expected to take more voluntary breaks, if cost barriers prevented them from obtaining an updated sensor brand or version that might have less problems than older, less expensive versions. These socioenvironmental influences may lead these minority groups to have poorer glycemic outcomes.

Further considering social factors, the type of response of families and loved ones during both forced breaks and routine CGM use can produce starkly contrasting experiences in adolescents. Families and loved ones who have more critical or controlling responses tend to be barriers to CGM use and lead to feelings of annoyance, frustration, and resentment, whereas families and loved ones who offer a balance of independence and care facilitated CGM use and were met with more calming feelings of relief and appreciation. Interestingly, diabetes-specific support from parents that is perceived as “nagging” has been linked to poorer glycemic outcomes (Doe, 2018). This points to the importance of family interventions and psychoeducation in diabetes management of an adolescent using a CGM, which is considered a level A recommendation in the psychosocial care for youth and emerging adults by the American Diabetes Association (Young-Hyman et al., 2016).

Problems related to the device itself (i.e., connection issues, accuracy, and physical discomfort) were felt to be distinct enough to be placed into its own category of technological factors, in addition to the biopsychosocial model. These problems were generally perceived as frustrating initially; problems that weren’t resolved led to either voluntary breaks, positive coping, or were left unresolved. While our data does not allow us to draw causal conclusions on how one’s preconceived attitudes toward technology might influence how they cope with such device-related issues, these findings do strengthen the existing literature that has found these problems to be salient barriers to adolescent CGM use (Meighan et al., 2025; Messer et al., 2020). The influence of perceptions and attitudes toward diabetes technology on its uptake has been explored more extensively in the literature elsewhere (Gonder-Frederick et al., 2011, 2016). Because technology exerts significant biological, psychological, and social influences on an adolescent’s experience, expanding the biopsychosocial model to include a technological category may be a more comprehensive representation of the contributions of diabetes technology to the overall adolescent experience.

This biopsychosocial framework can be applied clinically. Clinicians can consider how biological factors of blood glucose trends may directly impact one’s mood, and how much importance adolescents may place on future health consequences of their diabetes. Clinicians can also appreciate and emphasize the psychological benefits of the CGM allowing for greater freedom and control, and at the same time validate and empathize with the adolescent in their reasons for taking voluntary breaks, even permitting them if it may facilitate improved outcomes. They can also understand how having a piece of technology on one’s body can be experienced as an intrusion to an adolescent’s sense of identity, then engage in shared decision making with the adolescent to consider if this disadvantage to its use is worth the advantages. Clinicians can be mindful of how some barriers and burdens to CGM use, such as insurance or cost, may result in disparities in access to CGMs, and provide resources and support accordingly. It is also important to consider and ask about the impact of CGM use in other aspects of the adolescent’s social life, including relationships with family, with friends, and at school. Clinicians can play a crucial role in the adolescent decision-making process by bringing into the conversation the biopsychosocial context of the adolescent CGM experience brought out by this study for their patients to consider. For those who struggle with more moderate to severe mental health issues, adolescents may need to seek additional support and treatment from an expert mental health provider.

This study has several limitations. The dataset was disrupted by the COVID-19 pandemic, which could have affected adolescents’ social and emotional experiences (Branje and Morris, 2021), and also resulted in an older adolescent/young adult population. Second, with the study being a secondary analysis only, the facilitator interview guide was less specific to inquiring of emotional experiences. Nevertheless, our results were rich with data that were both consistent with our clinical experience as well as the literature regarding adolescent experience of diabetes, which adds to the validity of our study. More than half of participants used insulin pumps as part of their diabetes management, which may or may not have affected the adolescent CGM experience, though studying the effects of insulin pump use was outside the scope of our study. Because of the small sample size, results should be interpreted accordingly and at this time are not generalizable to the typical adolescent CGM-using population.

Future areas of research can expand on this study. Findings can be more generalizable if repeated in a larger, multi-site population. Characteristics of effective clinician interactions with adolescents with type 1 diabetes using CGMs can be studied to better understand how clinicians can strengthen their therapeutic alliance with their patients and improve on skills of eliciting the biopsychosocial factors of adolescents’ experience. This may then lead to more informed ways to provide diabetes education and discuss management during CGM breaks. At the policy level, initiatives can be developed within insurance and device companies to prevent forced breaks by ensuring patients’ access to supplies are uninterrupted. Understanding experiences surrounding CGM use will be particularly important given the rapid changes in diabetes technology including automated insulin delivery systems that rely on input from CGMs to automate insulin delivery (National Institute of Diabetes and Digestive and Kidney Diseases, 2021).

In conclusion, our study highlights the biopsychosocial context of the adolescent’s experience in managing type 1 diabetes with a CGM, emphasizing how emotions interact with biological, psychological, and environmental factors to impede or enhance diabetes self-management behavior. The framework that we provide lays the groundwork for future studies to more deeply explore the adolescent experience of CGM use and breaks. In this way, clinicians and other patient advocates can be more informed allies to empower adolescents in their diabetes care.

Supplemental Material

Supplemental Material - Barriers and facilitators to continuous glucose monitor use in type 1 diabetes: A biopsychosocial model of the adolescent experience

Supplemental Material for Barriers and facilitators to continuous glucose monitor use in type 1 diabetes: A biopsychosocial model of the adolescent experience by Kimberly S. Hsiung, Karishma A. Datye, David G. Schlundt in Health Psychology Open.

Footnotes

ORCID iD

Kimberly S. Hsiung

Ethical considerations

IRB approval was obtained through the Vanderbilt University Institutional Review Board.

Consent to participate

Written informed consent was obtained from parents and caregivers, and assent obtained from participants younger than 18.

Author contributions

Kimberly S. Hsiung, MD, MS made significant contributions to the concept, design, acquisition, analysis, and interpretation of data; drafted the article as well as the final version for publication; and has agreed to be accountable for all aspects of the work and resolved any issues related to its accuracy or integrity. Karishma A. Datye, MD made significant contributions to the concept, acquisition, and interpretation of data; revised the article critically for important intellectual content; approved the final version for publication; and has agreed to be accountable for all aspects of the work and resolved any issues related to its accuracy or integrity. David G. Schlundt, PhD made significant contributions to the concept, design, analysis, and interpretation of data; revised the article critically for important intellectual content; approved the final version for publication; and has agreed to be accountable for all aspects of the work and resolved any issues related to its accuracy or integrity.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The Vanderbilt Institute for Clinical and Translational Research (VICTR) is funded by the National Center for Advancing Translational Sciences (NCATS) Clinical Translational Science Award (CTSA) Program, Award Number 5UL1TR002243-03.

Declaration of conflicting interests

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Karishma A. Datye, MD receives research funding through the National Institute of Diabetes and Digestive and Kidney Diseases and the American Diabetes Association. David G. Schlundt, PhD and Kimberly S. Hsiung, MD, MS declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.*

Supplemental Material

Supplemental material for this article is available online.

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