Sleep disorders, electronic device use, and family support: looking for a link in type 1 diabetic adolescents regarding their glycemic control

Sleep disorders, electronic device use, and family support: looking for a link in type 1 diabetic adolescents regarding their glycemic control | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Sleep disorders, electronic device use, and family support: looking for a link in type 1 diabetic adolescents regarding their glycemic control Mahdi Falah Tafti, Niki Talebian, Pourya Shokri, Soolmaz Shabani-Derakhshan, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4863380/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Sleep is a key element in adolescent health and affects glycemic control in diabetic patients. Electronic device use and family support are contributing factors to sleep characteristics and glycemic management in type 1 diabetes (T1D) patients. This study aims to evaluate the influence of electronic device use and family support on sleep disorders and identify possible effects on glycemic control in T1D adolescents. Methods This cross-sectional study was conducted on T1D adolescents who attended the diabetes clinic at Besat Hospital, Hamadan, Iran, from February 2021 to February 2022. Valid Persian versions of the Pittsburgh Sleep Quality Index (PSQI) and Perceived Social Support from Family (PSS-Fa) questionnaires were employed to measure sleep quality and family support. A valid self-report questionnaire was used to obtain data on time spent on screen-based sedentary behaviors, including TV, video games, and the Internet. The demographic characteristics and hemoglobin A1C (HbA1c) and fasting blood sugar levels of the patients were obtained during the follow-up sessions. Statistical analysis was performed using SPSS 21. Kruskal-Wallis and Dunn’s tests were applied to compare different sleep disorder groups in terms of quantitative variables. Spearman’s correlation test examined the association of PSS-Fa scores and quantitative variables. Results We recruited 171 patients with a mean age of 12.48 ± 1.75 years. Nine patients (5.3%) had no/mild sleep disorders, 75 (43.9%) had moderate sleep disorders, and 87 (50.9%) had severe sleep disorders. No association was found between sleep disorders and HbA1c ( P = 0.476). among electronic devices, only watching TV was associated with sleep disorders ( P = 0.023). PSS-Fa scores were significantly lower in adolescents with severe sleep disorders compared with no/mild ( P = 0.026) and moderate ( P = 0.029) sleep disorder groups. PSS-Fa scores were positively correlated with the number of annual visits ( P = 0.033; r = 0.164) and negatively correlated with the time since diabetes diagnosis ( P = 0.003; r = -0.229) and the HbA1c level ( P < 0.001; r = -0.271). Conclusions A supportive family can contribute not only to better sleep outcomes but also to more desirable glycemic management in T1D adolescents. Digital devices might deteriorate sleep quality but the pattern of this effect needs further investigation. Insulin-dependent diabetes mellitus Sleep disorder Screen time Adolescents Children Family support Figures Figure 1 Introduction Type 1 diabetes (T1D) is characterized by autoimmune T-cell mediated destruction of beta cells in the pancreas. However, after decades of investigation, the definitive etiology of T1D has not been determined ( 1 ). The estimated prevalence of T1D is approximately 8.4 million worldwide, and 18% of patients are children and adolescents younger than twenty ( 2 ). The Global burden of disease reports indicates that the overall trends in the incidence, prevalence, morbidity, and mortality of T1D have increased globally over the past decades ( 1 ). Adolescent T1D patients are at greater risk of poor glycemic control and severe adverse outcomes ( 3 ). Lifestyle characteristics including sleep quality, sedentary behaviors, and family support contribute to T1D children’s and adolescents’ health and glycemic status ( 3 – 6 ). Sleep disorders are more prevalent among patients with T1D than among nondiabetic individuals ( 7 ). Approximately 77% of adolescents with T1D have insufficient sleep ( 3 ). Regarding the potential association between sleep and glycemic control, recent research has recommended improving the quality and duration of sleep as standard medical care for diabetic patients ( 7 , 8 ). Nevertheless, the majority of available evidence originates from studies on patients with type 2 diabetes, and not much is known about T1D patients ( 7 ). The duration of sleep was discovered to be significantly shorter among children and adolescents with T1D than among their healthy peers ( 9 ). A recent meta-analysis in 2023 reported an insignificant decline in hemoglobin A1c (HbA1c) levels in T1D patients with longer sleep durations ( 10 ). In addition to glycemic control, sleep disturbances might cause further difficulties for adolescents with T1D including adverse academic outcomes and neurocognitive and behavioral impairments ( 7 , 11 ). Furthermore, both short sleep duration and poor sleep quality worsen diabetes management and adherence to medications in T1D teens ( 7 , 11 ). Glycemic control and sleep seem to have a bidirectional and complex relationship in T1D patients, although the available research findings are conflicting ( 9 , 10 ) Sedentary behavior is a dominant feature among children and adolescents ( 12 ). Sedentary activities, including the use of electronic devices (e.g., television, smartphones, and game consoles) have become increasingly widespread in recent decades ( 13 ). This rising pattern of electronic device use has been paralleled by a shorter sleep duration in adolescents ( 14 ). A large population study revealed a dose-response association between sleep deficiency and the use of electronic devices in adolescents ( 13 ). Children and youths with T1D tend to experience a more sedentary lifestyle associated with higher HbA1c levels ( 4 ). However, the available literature has not clearly identified the association between the time spent using each screen-based device and sleep disorders in adolescents with T1D. The family environment plays a key role in sleep disorders in adolescents despite the developmental and biological factors that substantially affect sleep ( 15 ). Family members’ support and involvement enhance diabetes management and the glycemic profile in adolescents with T1D ( 6 ). The link between sleep quality and perceived family support is highly unknown in T1D children and youths. To the best of our knowledge, this is the first original research aimed at assessing the influence of family support and the use of screen-based devices on sleep quality alongside the potential effects on glycemic management in a large population of T1D adolescents. Methods Study design This cross-sectional study was carried out at the Pediatric Diabetes and Endocrinology Clinic of Besat Hospital, Hamadan, Iran, from February 2021 to February 2022. Adolescents with T1D aged 11–17 years were enrolled in the study. The convenience sampling method was used. Inclusion criteria were the following: definite diagnosis of insulin-dependent diabetes mellitus for more than one year; age of 11 to 17; and patient consent for participation in the study. The adolescents were excluded if they took any medication that affects sleep cycles (e.g., antiepileptics and antihistamines), had a history of other chronic diseases or developmental disorders (e.g., attention-deficit hyperactivity disorder and autism), did not attend the follow-up sessions at least two times a year, did not have HbA1c report, or if patients intended to quit the study. Measurements A standard integrated questionnaire was designed to obtain data on patients’ demographic and clinical laboratory characteristics, sleep quality, family support, and time spent using electronic devices. Demographic and clinical laboratory data The data on participants’ age, time since T1D diagnosis, and number of annual visits were obtained from patients’ parents and medical records. The laboratory test results of the patients were checked for HbA1c and fasting blood sugar (FBS) levels. The results of the FBS test were not included if the patient had experienced nocturnal hypoglycemia or had not fasted for at least 8 hours over the night before the test. Sleep quality and quantity Patients’ sleep quality was examined via the Pittsburgh Sleep Quality Index (PSQI). This questionnaire comprises 19 questions assessing 7 components of sleep including daytime dysfunction, habitual sleep efficiency, sleep duration, sleep latency, sleep disturbances, subjective sleep quality, and use of sleep medications. The score of each component can vary from 0 to 3, which is interpreted as follows: a score of 0 for not occurring in the previous month; a score of 1 for less than one time per week; a score of 2 for up to two times per week; and a score of 3 for more than twice per week. The sum of all these scores represents an overall score for sleep quality. A score of more than five suggests poor sleep quality ( 16 ). We employed a valid version of the PSQI in Persian from previous research with assessed and approved validity and reliability ( 17 ). Patients were categorized according to their total PSQI score into three groups: no/mild sleep disorder (score of 0–8), moderate sleep disorder (score of 9–11), and severe sleep disorder (score of 12–21) ( 18 ). These groups were evaluated to identify possible associations between sleep disorders and both the time spent on electronic devices and the PSS-Fa score. Afterwards, the participants self-reported their sleep quality (very poor, poor, good, or very good) over the previous month. Family support The family support score was assessed via the Perceived Social Support from Family (PSS-Fa) questionnaire from a previous study by Procidano et al. ( 19 ). This questionnaire has 20 questions in which each question is scored from 0 (for “No” and “I don’t know”) to 1 (for “Yes”) and a higher total score reflects a better level of perceived support from family members. We used the validated Persian version of the PSS-Fa from a published study ( 20 ). Electronic device use The time spent on each specific electronic device was assessed via a questionnaire consisting of 3 items as follows: 1) “How many hours do you spend on the Internet (e.g., tablet, social media, mobile phone, personal computer) each day?”; 2) “How many hours do you spend playing video games daily?”; and 3) “How many hours of TV do you watch each day?”. These items were extracted from the Health Behavior in School-aged Children questionnaire, section of the health behaviors related to physical activity ( 21 ). Statistics The data were analyzed via SPSS 21. We described the quantitative variables as the means ± standard deviations (SDs). The distribution patterns of the quantitative variables were assessed via the Kolmogorov-Smirnoff test. Owing to a nonparametric pattern of distribution, the time spent using electronic devices, PSS-Fa scores, and HbA1c values were evaluated to discover probable significant differences between various groups of sleep disorders via the Kruskal-Wallis test. Dunn’s adjustment was performed for post hoc analysis as the nonparametric multiple comparison test. The associations between the PSS-Fa score and quantitative variables were evaluated via Spearman’s correlation test. A statistically significant difference was considered as a P -value of less than 0.05. Ethics This study was derived from the doctoral thesis of a medical student. The current study was approved by the Ethics Committee of Hamadan University of Medical Sciences [IR.UMSHA.REC.1400.719]. Participants’ parents were informed thoroughly about the objectives of this study and signed consent was obtained from them prior to their participation. The participants were assured that they had the right to cease their participation. Study protocols were defined in a way that does not impose additional financial burdens on the participants. Results Descriptive results Among the 171 included adolescents with type 1 diabetes (T1D), 78 (45.6%) were males and 93 (54.4%) were females. The mean ± SD age of the participants was 12.48 ± 1.75 with a range of 11–17 years. The mean time since T1D diagnosis was 5.89 ± 2.88 years. The patients attended follow-up sessions at the endocrinology and diabetes clinic a mean of 2.78 ± 1.23 times annually. The mean values for HbA1c, FBS, and random blood sugar were 9.32 ± 1.97, 140.08 ± 45.24, and 202.89 ± 56.31, respectively. PSQI results revealed that 87 patients (50.9%) had severe sleep disorders, 75 (43.9%) had moderate sleep disorders, and 9 patients (5.3%) had no/mild sleep disorders. In terms of self-reported sleep quality, 8 (4.7%) patients had very poor sleep, 31 (18.1%) had poor sleep, 88 (51.5%) had good sleep, and the remaining 44 (25.7%) had very good sleep. The mean PSS-Fa score was 12.26 ± 3.98. Figure 1 shows the frequency histogram of the PSS-Fa results. The mean hours of use of electronic devices were as follows: 3.08 ± 1.96 for TV; 2.39 ± 1.57 for video games; and 4.29 ± 2.32 for social media and the Internet. HbA1c and sleep disorders No associations were found between HbA1c values and various groups of sleep disorders on the basis of overall PSQI scores ( P = 0.476) (Table 1 ) or self-reported levels of sleep quality ( P = 0.453). Table 1 Comparison of digital device use, family support score, and Hb A1c level between various groups of sleep disorders Variables No/mild sleep disorder (n = 9) Moderate sleep disorder (n = 75) Severe sleep disorder (n = 87) Total population (n = 171) P- value Mean ± SD Range (min-max) Watching TV (hours) 2.67 ± 2.12 2.74 ± 1.92 3.41 ± 1.94 3.08 ± 1.96 0.5–10 0.023 * Video games (hours) 1.67 ± 0.82 2.53 ± 1.57 2.37 ± 1.62 2.39 ± 1.57 0–9 0.375 Social media and the Internet (hours) 2.81 ± 1.51 4.24 ± 2.12 4.51 ± 2.54 4.29 ± 2.32 0.5–12 0.148 PSS-Fa scores 14.89 ± 2.36 13.01 ± 3.50 11.33 ± 4.26 12.26 ± 3.98 1–20 0.004* HbA1c (%) 9.43 ± 2.24 9.10 ± 1.89 9.48 ± 2.02 9.32 ± 1.97 5.17–11.85 0.476 * Statistically significant P- values Sedentary behavior and sleep disorders Table 1 compares the time spent on specific sedentary activities, family support scores, and HbA1c values between various groups of sleep disorders. The time spent on TV was significantly different across different groups of patients with sleep disorders ( P = 0.023). Dunn’s test was applied to make pairwise comparisons which showed a significant difference between the patients with no/mild and severe sleep disorders ( P = 0.011). Nonetheless, no considerable difference was found between the severe and moderate sleep disorder groups ( P = 0.121) or between the moderate and no/mild sleep disorder groups ( P = 0.731) regarding the hours spent watching TV (Table 2 ). The time spent on video games and the Internet was not related to the incidence of sleep problems (Table 1 ). Table 2 Pairwise comparison of different sleep disorder groups regarding quantitative variables. Dunn’s test was performed for multiple comparisons. Different groups of sleep disorder No/mild Moderate Severe No/mild Watching TV P = 0.731 P = 0.011 * Family support scores P = 0.488 P = 0.026 * Moderate Watching TV P = 0.731 P = 0.121 Family support scores P = 0.488 P = 0.029 * Severe Watching TV P = 0.011 * P = 0.121 Family support scores P = 0.026 * P = 0.029 * * Statistically significant P- values Family support and sleep disorders The PSS-Fa scores differed significantly across the sleep disorder groups ( P = 0.004). Applying Dunn’s correction for multiple comparisons revealed that patients with severe sleep disorders had significantly lower PSS-Fa scores compared with patients with moderate ( P = 0.029) and no/mild ( P = 0.026) sleep disorders (Table 2 ). Family support and quantitative variables We found that the PSS-Fa score was significantly correlated with the HbA1c level ( P < 0.001, r = − 0.271), time since T1D diagnosis ( P = 0.003, r = -0.229), and number of annual visits ( P = 0.033, r = 0.164). However, there were no associations between family support and patient age ( P = 0.169), FBS ( P = 0.235), or random blood sugar ( P = 0.315) (Table 3 ). Table 3 Correlation of PSS-Fa scores of T1D adolescents with quantitative variables. Quantitative variables P- value r Age 0.169 -0.106 Time since T1D diagnosis 0.003 * − .0229 Number of annual visits 0.033 * 0.164 Hb A1C < 0.001 * -0.271 Fasting blood sugar 0.235 -0.088 Random blood sugar 0.315 -0.077 * Statistically significant P- values Discussion The findings of the current study suggested that both the family support scores and the amount of time spent watching TV are related to sleep disorders. However, sleep quality was not associated with the HbA1c level or the time spent on either video games or the Internet. Family support scores were negatively correlated with HbA1c levels and the time since T1D diagnosis. Patients with higher family support scores attended follow-up sessions more frequently. The current body of evidence suggests that sleep and glycemic control have a bidirectional connection; poor glycemic control causes sleep problems and sleep problems interfere with glucose homeostasis ( 7 , 9 – 11 ). According to two meta-analyses, the direct effect of sleep characteristics on glycemic management in T1D adolescents and children is not well established ( 9 , 10 ). Bahadur et al. compared sleep and behavior problems between T1D children and non-diabetic controls. They reported that T1D children had a shorter sleep time and experienced more daytime sleepiness compared with their control group. However, this study found no association between sleep parameters and glycemic control ( 22 ). Alder et al. also discovered no significant association between HbA1c levels and sleep in T1D children and adolescents ( 23 ). Similarly, our results indicated that HbA1c values do not significantly vary between different sleep disorder groups. On the other hand, numerous studies stated that poor sleep negatively affects glycemic control in T1D patients. A systematic review in 2021 demonstrated that poor sleep quality and irregular sleep patterns were related to higher HbA1c and suboptimal T1D self-care measurements ( 3 ). Moreover, both short and long sleep duration were linked to poor self-management behaviors ( 10 ), impaired adherence to glucose monitoring, and uncontrolled HbA1c levels ( 3 ). Berk et al. followed 61 T1D patients in the 6–16 age group for one year. They reported higher HbA1c values in patients with higher sleep disorders ( P = 0.02) ( 24 ). Frye et al. discovered that shorter sleep duration is linked with an elevated HbA1c level and poor diabetes self-care behaviors. However, additional analysis revealed that the relationship between HbA1c and sleep duration was mediated by self-measurement of blood glucose ( 25 ). These findings underline the mediating impact of self-management activities on the interaction between sleep and glycemic control of T1D youths. In fact, enhanced sleep could be accompanied by improved self-management behaviors which subsequently contribute to better glycemic control ( 3 , 10 ). However, our study did not identify any significant link between glycemic control and sleep. Digital device use adversely affects sleep characteristics in children and adolescents ( 26 ). A study in 2010 found that the average overall time spent on screen devices was approximately 3.5 hours for male and 2.5 hours for female youths with T1D ( 27 ). The participants of our study spent approximately three times more hours a day on electronic devices. This may point out the increasing trend of electronic media use among children and adolescents. Huert-Uribe et al. performed a meta-analysis to evaluate physical activity and sedentary behavior in adolescents with T1D. This study discovered that T1D adolescents are more sedentary compared with healthy peers ( 4 ). This could be related to the fear of hypoglycemia and lack of both motivation and time in T1D patients ( 28 ). Sedentary behaviors, including screen use, have been linked to higher values of HbA1c ( 5 ). These findings highlight the concerning impact of sedentary activities on glycemic control in youth with T1D which contributes to serious complications. Thus, it seems crucial to reverse sedentary behaviors and increase physical activity among adolescents with T1D to improve their cardiovascular profile and overall health ( 4 ). To address this issue, diabetes caregivers should focus on decreasing the duration of screen use as a leading contributor to a sedentary lifestyle. The American Diabetes Association emphasizes reducing sedentary activities, such as watching TV and using computer, to the greatest extent and taking breaks frequently by engaging in simple physical exercises (e.g., walking and standing). These feasible interventions may improve the glycemic status of diabetic patients ( 29 ). A randomized controlled trial study of T1D adults revealed that PSQI scores decreased significantly (21.4%; P- value < 0.001) after 6 weeks of increased physical activity ( 28 ). In a similar study on T1D children, sleep habits improved in patients with regular physical activity ( 30 ). A study of 45 T1D teenagers revealed a negative correlation between the time spent on sedentary activities and sleep duration ( P < 0.01; r = -0.64) ( 31 ). Compared with these findings, the results of our study suggested that individuals who spent more time watching TV tended to experience more sleep disorders. Similarly, a published study illustrated that the duration of nocturnal sleep was notably shorter in teens who spent over 2 hours watching TV or had late bedtimes ( 32 ). Sleep disorders such as late bedtime could be associated with more sedentary behaviors in adolescents with T1D which may lead to uncontrolled blood glucose levels ( 25 ). These findings highlight the impact of a sedentary lifestyle on T1D patients’ quality of life, particularly their sleep quality. A meta-analysis revealed that greater sedentary behavior, with the exception of screen time spent completing homework, was associated with worse HbA1c levels in T1D youths. Personality traits related to engaging in schoolwork are accompanied by promoted self-care behaviors and better glycemic control, which could explain this finding ( 10 ). Calella et al. investigated the physical activity and lifestyle of T1D adolescents in Italy. They found a positive association between overall screen time (TV, the Internet, and video games) and HbA1c levels. This study also indicated that adolescents with T1D spent approximately eight hours on screen-based devices daily and that their level of physical activity was lower than the minimum standard recommendations ( 12 ). Similarly, the participants in our study had a mean overall screen time of approximately 9 hours daily. These findings highlight the necessity of improving healthcare measures for T1D adolescents to modify sedentary habits and enhance physical activity to achieve optimum glycemic control. Family members of younger pediatric T1D patients are responsible for monitoring the blood glucose levels and supervising the insulin injection ( 6 ). Adolescents are more vulnerable to glycemic deterioration after the gradual transition to self-management and parental involvement remains essential for desirable diabetes management ( 6 ). Perceived family social support enhances diabetes self-care measurements and self-efficacy in youths with T1D ( 33 ). A systematic review revealed that the involvement of parents in the management of diabetes enhances glycemic control in adolescents with T1D ( 6 ). Similarly, our results indicated that T1D adolescents with greater family support had lower HbA1c values and attended follow-up sessions at the diabetes clinic more frequently. This may highlight the significance of family support in promoting the adherence of T1D teens to their treatment. A previous study in Iran reported that perceived family support was not associated with the age of T1D patients. However, both HbA1c levels and T1D duration were not related to family support contrary to our study ( 34 ). A study of 150 T1D adolescents revealed that the involvement of parents in diabetes care declined significantly with increasing age ( P < 0.01) ( 35 ). Hanna et al. reported that older adolescents with T1D perceived lower levels of parental autonomy support ( P < 0.001) ( 36 ). AlHaidar et al . conducted a cross-sectional study to evaluate family support in T1D adolescents. They demonstrated that older adolescents perceived significantly lower levels of various family support elements. However, the time spent after the diagnosis of T1D and the HbA1c values were only correlated with family supervision ( r = -0.647; P = 0.012) and critical situation support ( r = 0.335; P = 0.017), respectively ( 37 ). These findings highlight the inconsistency of data on the link between family support and T1D adolescents’ characteristics and outcomes. A longitudinal study on T1D adolescents and their parents indicated that parental adherence and involvement declined significantly over time ( 38 ). Family support was negatively associated with time since T1D diagnosis in our study but not with teen’s age. Parental burnout might explain this contradiction. Parents of diabetic children tend to experience burnout and characterize it as feeling grief for losing a normal life or feeling powerless to manage diabetes ( 39 ). Some background factors, such as socioeconomic status and limited leisure time, aggravate parental burnout ( 40 ). Hence, it could be practical for diabetes clinicians to support parents psychologically. This subsequently contributes to enhanced family support and improved attitudes towards diabetes management among T1D adolescents. Although higher family support scores were associated with enhanced sleep quality in our results, the role of parental supervision in adolescents’ sleep health should be taken into consideration. According to Bergner et al. , caregivers of T1D adolescents take some strategies to improve the quality of their teens’ sleep. This study mentioned setting sleep curfews (e.g., early bedtime) and eliminating digital devices from teenagers’ bedrooms as the most common strategies ( 41 ). However, parental interventions should not lead to prebedtime arguments, since such conflicts deteriorate sleep quality in children and adolescents ( 42 ). Limitations The cross-sectional design and lack of a control group influence the generalizability of the current study and limit the interpretability of the results. The data on the time spent on sedentary behaviors were obtained through self-reports of patients and their parents, which might lead to misconclusion. The association between sleep quality and daily glycemic variability is unclear since HbA1c is not an accurate predictor. Further studies should consider implementing continuous glucose monitoring to address this issue. Conclusion Sleep plays a prominent role in adolescents’ health. Sleep disorders and their contributors, including screen device use and family support, are still under discussion in the diabetic youth population. Family support and involvement in diabetes management should be promoted in adolescents and the transition of diabetes-care responsibilities needs to be more cautious and organized. Moreover, parental supervision and timing seem crucial to monitor digital media use and sleep schedules in T1D adolescents given their unique supportive care needs. However, the interactions among sleep, digital device use, family support, and glycemic control in such patients needs further investigation to be thoroughly understood. Abbreviations Type 1 diabetes (T1D), Pittsburgh Sleep Quality Index (PSQI), Perceived Social Support from Family (PSS-Fa), Hemoglobin A1C (HbA1c), Statistical Package for the Social Sciences (SPSS), Standard Deviation (SD), and Fasting Blood Sugar (FBS). Declarations Ethics approval and consent to participate The current study was approved by the Ethics Committee of Hamadan University of Medical Sciences [IR.UMSHA.REC.1400.719]. After explaining the study's steps and objectives to the participants and their parents, their consent was obtained. This study was conducted in accordance with the Declaration of Helsinki. Consent for publication Not applicable. Competing interests All of the authors declare that they have no competing interests. Funding Not applicable. Author Contribution A.P. performed study design, project administration, editing the manuscript. Z.R. participated in project administration, data gathering, and editing the manuscript. N.T., M.F.T., P.S., S.S.D., S.K.H., and A.J. participated in sample preparation, data gathering, statistical analysis, and writing the initial draft. All of the authors have reviewed and confirmed the final manuscript. 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Physical activity and electronic media use in the SEARCH for diabetes in youth case-control study. Pediatrics. 2010;125(6):e1364–71. Alarcón-Gómez J, Chulvi-Medrano I, Martin-Rivera F, Calatayud J. Effect of High-Intensity Interval Training on Quality of Life, Sleep Quality, Exercise Motivation and Enjoyment in Sedentary People with Type 1 Diabetes Mellitus. Int J Environ Res Public Health. 2021;18(23). Committee ADAPP, Committee. ADAPP. 5. Facilitating behavior change and well-being to improve health outcomes: Standards of Medical Care in Diabetes—2022. Diabetes Care. 2022;45(Supplement1):S60–82. Amiri N, Karami K, Valizadeh F, Mokhayeri Y. The effect of exercise on sleep habits of children with type 1 diabetic: a randomized clinical trial. BMC Pediatr. 2024;24(1):283. de Lima VA, Mascarenhas LPG, Decimo JP, de Souza WC, Monteiro ALS, Lahart I et al. Physical activity levels of adolescents with type 1 diabetes physical activity in T1D. Pediatric exercise science. 2017;29(2):213–9. Okano S, Araki A, Kimura K, Fukuda I, Miyamoto A, Tanaka H. Questionnaire survey on sleep habits of 3-year-old children in Asahikawa City: Comparison between 2005 and 2020. Brain and Development; 2023. Villaécija J, Luque B, Castillo-Mayén R, Farhane-Medina NZ, Tabernero C. Influence of family social support and diabetes self-efficacy on the emotional wellbeing of children and adolescents with type 1 diabetes: A longitudinal study. Children. 2023;10(7):1196. A R ATAB, B DS. M, F M. The Relationship between perceived social support from family and diabetes control among patients with diabetes type 1 and type 2. J Diabetes Metab Disord. 2011. Hilliard ME, Mann KA, Peugh JL, Hood KK. How poorer quality of life in adolescence predicts subsequent type 1 diabetes management and control. Patient Educ Couns. 2013;91(1):120–5. Hanna KM, Dashiff CJ, Stump TE, Weaver MT. Parent-adolescent dyads: association of parental autonomy support and parent-adolescent shared diabetes care responsibility. Child Care Health Dev. 2013;39(5):695–702. AlHaidar AM, AlShehri NA, AlHussaini MA. Family Support and Its Association with Glycemic Control in Adolescents with Type 1 Diabetes Mellitus in Riyadh, Saudi Arabia. J Diabetes Res. 2020;2020:5151604. King PS, Berg CA, Butner J, Butler JM, Wiebe DJ. Longitudinal trajectories of parental involvement in Type 1 diabetes and adolescents’ adherence. Health Psychol. 2014;33(5):424. Abdoli S, Vora A, Smither B, Roach AD, Vora AC. I don't have the choice to burnout; experiences of parents of children with type 1 diabetes. Appl Nurs Res. 2020;54:151317. Lindström C, Åman J, Norberg AL. Parental burnout in relation to sociodemographic, psychosocial and personality factors as well as disease duration and glycaemic control in children with Type 1 diabetes mellitus. Acta Paediatr. 2011;100(7):1011–7. Bergner EM, Williams R, Hamburger ER, Lyttle M, Davis AC, Malow B, et al. Sleep in teens with type 1 diabetes: perspectives from adolescents and their caregivers. Diabetes Educ. 2018;44(6):541–8. Peltz JS, Rogge RD. The moderating role of parents' dysfunctional sleep-related beliefs among associations between adolescents' pre-bedtime conflict, sleep quality, and their mental health. J Clin Sleep Med. 2019;15(2):265–74. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4863380","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":337499975,"identity":"5908cda5-ea52-498a-a7ea-7504c1c35b5c","order_by":0,"name":"Mahdi Falah Tafti","email":"","orcid":"","institution":"Student Research Committee, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran","correspondingAuthor":false,"prefix":"","firstName":"Mahdi","middleName":"Falah","lastName":"Tafti","suffix":""},{"id":337499976,"identity":"92d58e5a-9cfb-4143-9f7d-445c4c16b8e5","order_by":1,"name":"Niki Talebian","email":"","orcid":"","institution":"Student Research Committee, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran","correspondingAuthor":false,"prefix":"","firstName":"Niki","middleName":"","lastName":"Talebian","suffix":""},{"id":337499977,"identity":"3a053367-ff48-4815-8362-0fbe4117a544","order_by":2,"name":"Pourya Shokri","email":"","orcid":"","institution":"Student Research Committee, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran","correspondingAuthor":false,"prefix":"","firstName":"Pourya","middleName":"","lastName":"Shokri","suffix":""},{"id":337499978,"identity":"20b957ed-87a3-4f38-bcc9-08dbe35ac41c","order_by":3,"name":"Soolmaz Shabani-Derakhshan","email":"","orcid":"","institution":"School of Public Health and Research Center for Health Sciences, Hamadan University of Medical Sciences, Hamadan","correspondingAuthor":false,"prefix":"","firstName":"Soolmaz","middleName":"","lastName":"Shabani-Derakhshan","suffix":""},{"id":337499979,"identity":"1f3dfa1c-3a11-4d1f-9a5f-16b99c07856a","order_by":4,"name":"Seyed Kaveh Hadeiy","email":"","orcid":"","institution":"School of Public Health and Research Center for Health Sciences, Hamadan University of Medical Sciences, Hamadan","correspondingAuthor":false,"prefix":"","firstName":"Seyed","middleName":"Kaveh","lastName":"Hadeiy","suffix":""},{"id":337499980,"identity":"9bf4e274-141c-4cb4-85ef-9d724b68a8ac","order_by":5,"name":"Alimohamad Jafari","email":"","orcid":"","institution":"School of Public Health and Research Center for Health Sciences, Hamadan University of Medical Sciences, Hamadan","correspondingAuthor":false,"prefix":"","firstName":"Alimohamad","middleName":"","lastName":"Jafari","suffix":""},{"id":337499981,"identity":"a55efe3e-1304-42cb-84ab-6a3dfa2da4ba","order_by":6,"name":"Azar Pirdehghan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+ElEQVRIiWNgGAWjYBAC+2YGBgnGBoYEBgbmww8+AEXY2AloMTgM18KWZjgDpIWZkJYDcC08BtI8ICGCWo7zPrzxcUdtHv/sHgNjm1/b5PmYGRg/fMzB5xd2Y8uZZ44XS9w5VvA4t++2YRszA7PkzG14bGFmY5PmbTuW2HAjeYNxbs9tRqAWNmZeQlr+ArXMv5FgIG3Zc9ueOC2MbTWJG26kGEgz/LidSIwWZsvetgOJG2+kpRn2NtxObmNmbMbvF/5jjDd+ttUlzruRfPjBjz+3bee3Nx/88BGPFig4DKEY28BkA0H1QFAHpf8Qo3gUjIJRMApGGgAAyRhUtZUr6OUAAAAASUVORK5CYII=","orcid":"","institution":"School of Public Health and Research Center for Health Sciences, Hamadan University of Medical Sciences, Hamadan","correspondingAuthor":true,"prefix":"","firstName":"Azar","middleName":"","lastName":"Pirdehghan","suffix":""},{"id":337499982,"identity":"573c7ec6-c2a2-4844-9edf-5a1ca50f025e","order_by":7,"name":"Zahra Razavi","email":"","orcid":"","institution":"Department of Pediatrics, Hamadan University of Medical Sciences, Hamadan","correspondingAuthor":false,"prefix":"","firstName":"Zahra","middleName":"","lastName":"Razavi","suffix":""}],"badges":[],"createdAt":"2024-08-05 16:22:40","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4863380/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4863380/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":64570075,"identity":"6758d63e-f480-46bd-a9d4-99124a41bcce","added_by":"auto","created_at":"2024-09-16 01:00:13","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":44473,"visible":true,"origin":"","legend":"\u003cp\u003eThe frequency histogram of the PSS-Fa scores.\u003c/p\u003e","description":"","filename":"figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4863380/v1/83aba36014df370a9dfe5271.jpg"},{"id":65049446,"identity":"2877d9a7-217e-439c-b268-1d219c64d7a7","added_by":"auto","created_at":"2024-09-23 05:37:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":653273,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4863380/v1/2afea5a6-3098-4c46-855e-0633545f51f4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Sleep disorders, electronic device use, and family support: looking for a link in type 1 diabetic adolescents regarding their glycemic control","fulltext":[{"header":"Introduction","content":"\u003cp\u003eType 1 diabetes (T1D) is characterized by autoimmune T-cell mediated destruction of beta cells in the pancreas. However, after decades of investigation, the definitive etiology of T1D has not been determined (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The estimated prevalence of T1D is approximately 8.4\u0026nbsp;million worldwide, and 18% of patients are children and adolescents younger than twenty (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The Global burden of disease reports indicates that the overall trends in the incidence, prevalence, morbidity, and mortality of T1D have increased globally over the past decades (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Adolescent T1D patients are at greater risk of poor glycemic control and severe adverse outcomes (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Lifestyle characteristics including sleep quality, sedentary behaviors, and family support contribute to T1D children\u0026rsquo;s and adolescents\u0026rsquo; health and glycemic status (\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSleep disorders are more prevalent among patients with T1D than among nondiabetic individuals (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Approximately 77% of adolescents with T1D have insufficient sleep (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Regarding the potential association between sleep and glycemic control, recent research has recommended improving the quality and duration of sleep as standard medical care for diabetic patients (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Nevertheless, the majority of available evidence originates from studies on patients with type 2 diabetes, and not much is known about T1D patients (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The duration of sleep was discovered to be significantly shorter among children and adolescents with T1D than among their healthy peers (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). A recent meta-analysis in 2023 reported an insignificant decline in hemoglobin A1c (HbA1c) levels in T1D patients with longer sleep durations (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). In addition to glycemic control, sleep disturbances might cause further difficulties for adolescents with T1D including adverse academic outcomes and neurocognitive and behavioral impairments (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Furthermore, both short sleep duration and poor sleep quality worsen diabetes management and adherence to medications in T1D teens (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Glycemic control and sleep seem to have a bidirectional and complex relationship in T1D patients, although the available research findings are conflicting (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eSedentary behavior is a dominant feature among children and adolescents (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Sedentary activities, including the use of electronic devices (e.g., television, smartphones, and game consoles) have become increasingly widespread in recent decades (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). This rising pattern of electronic device use has been paralleled by a shorter sleep duration in adolescents (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). A large population study revealed a dose-response association between sleep deficiency and the use of electronic devices in adolescents (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Children and youths with T1D tend to experience a more sedentary lifestyle associated with higher HbA1c levels (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). However, the available literature has not clearly identified the association between the time spent using each screen-based device and sleep disorders in adolescents with T1D.\u003c/p\u003e \u003cp\u003eThe family environment plays a key role in sleep disorders in adolescents despite the developmental and biological factors that substantially affect sleep (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Family members\u0026rsquo; support and involvement enhance diabetes management and the glycemic profile in adolescents with T1D (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The link between sleep quality and perceived family support is highly unknown in T1D children and youths.\u003c/p\u003e \u003cp\u003eTo the best of our knowledge, this is the first original research aimed at assessing the influence of family support and the use of screen-based devices on sleep quality alongside the potential effects on glycemic management in a large population of T1D adolescents.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis cross-sectional study was carried out at the Pediatric Diabetes and Endocrinology Clinic of Besat Hospital, Hamadan, Iran, from February 2021 to February 2022. Adolescents with T1D aged 11\u0026ndash;17 years were enrolled in the study. The convenience sampling method was used. Inclusion criteria were the following: definite diagnosis of insulin-dependent diabetes mellitus for more than one year; age of 11 to 17; and patient consent for participation in the study. The adolescents were excluded if they took any medication that affects sleep cycles (e.g., antiepileptics and antihistamines), had a history of other chronic diseases or developmental disorders (e.g., attention-deficit hyperactivity disorder and autism), did not attend the follow-up sessions at least two times a year, did not have HbA1c report, or if patients intended to quit the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eMeasurements\u003c/h2\u003e \u003cp\u003eA standard integrated questionnaire was designed to obtain data on patients\u0026rsquo; demographic and clinical laboratory characteristics, sleep quality, family support, and time spent using electronic devices.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eDemographic and clinical laboratory data\u003c/h2\u003e \u003cp\u003eThe data on participants\u0026rsquo; age, time since T1D diagnosis, and number of annual visits were obtained from patients\u0026rsquo; parents and medical records. The laboratory test results of the patients were checked for HbA1c and fasting blood sugar (FBS) levels. The results of the FBS test were not included if the patient had experienced nocturnal hypoglycemia or had not fasted for at least 8 hours over the night before the test.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003eSleep quality and quantity\u003c/h2\u003e \u003cp\u003ePatients\u0026rsquo; sleep quality was examined via the Pittsburgh Sleep Quality Index (PSQI). This questionnaire comprises 19 questions assessing 7 components of sleep including daytime dysfunction, habitual sleep efficiency, sleep duration, sleep latency, sleep disturbances, subjective sleep quality, and use of sleep medications. The score of each component can vary from 0 to 3, which is interpreted as follows: a score of 0 for not occurring in the previous month; a score of 1 for less than one time per week; a score of 2 for up to two times per week; and a score of 3 for more than twice per week. The sum of all these scores represents an overall score for sleep quality. A score of more than five suggests poor sleep quality (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). We employed a valid version of the PSQI in Persian from previous research with assessed and approved validity and reliability (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Patients were categorized according to their total PSQI score into three groups: no/mild sleep disorder (score of 0\u0026ndash;8), moderate sleep disorder (score of 9\u0026ndash;11), and severe sleep disorder (score of 12\u0026ndash;21) (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). These groups were evaluated to identify possible associations between sleep disorders and both the time spent on electronic devices and the PSS-Fa score.\u003c/p\u003e \u003cp\u003eAfterwards, the participants self-reported their sleep quality (very poor, poor, good, or very good) over the previous month.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003eFamily support\u003c/h2\u003e \u003cp\u003eThe family support score was assessed via the Perceived Social Support from Family (PSS-Fa) questionnaire from a previous study by Procidano \u003cem\u003eet al.\u003c/em\u003e (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). This questionnaire has 20 questions in which each question is scored from 0 (for \u0026ldquo;No\u0026rdquo; and \u0026ldquo;I don\u0026rsquo;t know\u0026rdquo;) to 1 (for \u0026ldquo;Yes\u0026rdquo;) and a higher total score reflects a better level of perceived support from family members. We used the validated Persian version of the PSS-Fa from a published study (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eElectronic device use\u003c/h2\u003e \u003cp\u003eThe time spent on each specific electronic device was assessed via a questionnaire consisting of 3 items as follows: 1) \u0026ldquo;How many hours do you spend on the Internet (e.g., tablet, social media, mobile phone, personal computer) each day?\u0026rdquo;; 2) \u0026ldquo;How many hours do you spend playing video games daily?\u0026rdquo;; and 3) \u0026ldquo;How many hours of TV do you watch each day?\u0026rdquo;. These items were extracted from the Health Behavior in School-aged Children questionnaire, section of the health behaviors related to physical activity (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistics\u003c/h2\u003e \u003cp\u003eThe data were analyzed via SPSS 21. We described the quantitative variables as the means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviations (SDs). The distribution patterns of the quantitative variables were assessed via the Kolmogorov-Smirnoff test. Owing to a nonparametric pattern of distribution, the time spent using electronic devices, PSS-Fa scores, and HbA1c values were evaluated to discover probable significant differences between various groups of sleep disorders via the Kruskal-Wallis test. Dunn\u0026rsquo;s adjustment was performed for post hoc analysis as the nonparametric multiple comparison test. The associations between the PSS-Fa score and quantitative variables were evaluated via Spearman\u0026rsquo;s correlation test. A statistically significant difference was considered as a \u003cem\u003eP\u003c/em\u003e-value of less than 0.05.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eEthics\u003c/h2\u003e \u003cp\u003eThis study was derived from the doctoral thesis of a medical student. The current study was approved by the Ethics Committee of Hamadan University of Medical Sciences [IR.UMSHA.REC.1400.719]. Participants\u0026rsquo; parents were informed thoroughly about the objectives of this study and signed consent was obtained from them prior to their participation. The participants were assured that they had the right to cease their participation. Study protocols were defined in a way that does not impose additional financial burdens on the participants.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eDescriptive results\u003c/h2\u003e \u003cp\u003eAmong the 171 included adolescents with type 1 diabetes (T1D), 78 (45.6%) were males and 93 (54.4%) were females. The mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD age of the participants was 12.48\u0026thinsp;\u0026plusmn;\u0026thinsp;1.75 with a range of 11\u0026ndash;17 years. The mean time since T1D diagnosis was 5.89\u0026thinsp;\u0026plusmn;\u0026thinsp;2.88 years. The patients attended follow-up sessions at the endocrinology and diabetes clinic a mean of 2.78\u0026thinsp;\u0026plusmn;\u0026thinsp;1.23 times annually. The mean values for HbA1c, FBS, and random blood sugar were 9.32\u0026thinsp;\u0026plusmn;\u0026thinsp;1.97, 140.08\u0026thinsp;\u0026plusmn;\u0026thinsp;45.24, and 202.89\u0026thinsp;\u0026plusmn;\u0026thinsp;56.31, respectively.\u003c/p\u003e \u003cp\u003ePSQI results revealed that 87 patients (50.9%) had severe sleep disorders, 75 (43.9%) had moderate sleep disorders, and 9 patients (5.3%) had no/mild sleep disorders. In terms of self-reported sleep quality, 8 (4.7%) patients had very poor sleep, 31 (18.1%) had poor sleep, 88 (51.5%) had good sleep, and the remaining 44 (25.7%) had very good sleep. The mean PSS-Fa score was 12.26\u0026thinsp;\u0026plusmn;\u0026thinsp;3.98. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the frequency histogram of the PSS-Fa results. The mean hours of use of electronic devices were as follows: 3.08\u0026thinsp;\u0026plusmn;\u0026thinsp;1.96 for TV; 2.39\u0026thinsp;\u0026plusmn;\u0026thinsp;1.57 for video games; and 4.29\u0026thinsp;\u0026plusmn;\u0026thinsp;2.32 for social media and the Internet.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eHbA1c and sleep disorders\u003c/h2\u003e \u003cp\u003eNo associations were found between HbA1c values and various groups of sleep disorders on the basis of overall PSQI scores (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.476) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) or self-reported levels of sleep quality (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.453).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of digital device use, family support score, and Hb A1c level between various groups of sleep disorders\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNo/mild sleep disorder\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;9)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eModerate sleep disorder\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;75)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSevere sleep disorder\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;87)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eTotal population\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;171)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP- value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRange (min-max)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWatching TV (hours)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.67\u0026thinsp;\u0026plusmn;\u0026thinsp;2.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.74\u0026thinsp;\u0026plusmn;\u0026thinsp;1.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.41\u0026thinsp;\u0026plusmn;\u0026thinsp;1.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.08\u0026thinsp;\u0026plusmn;\u0026thinsp;1.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.5\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.023\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVideo games (hours)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.67\u0026thinsp;\u0026plusmn;\u0026thinsp;0.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.53\u0026thinsp;\u0026plusmn;\u0026thinsp;1.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.37\u0026thinsp;\u0026plusmn;\u0026thinsp;1.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.39\u0026thinsp;\u0026plusmn;\u0026thinsp;1.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u0026ndash;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.375\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial media and the Internet (hours)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.81\u0026thinsp;\u0026plusmn;\u0026thinsp;1.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.24\u0026thinsp;\u0026plusmn;\u0026thinsp;2.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.51\u0026thinsp;\u0026plusmn;\u0026thinsp;2.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.29\u0026thinsp;\u0026plusmn;\u0026thinsp;2.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.5\u0026ndash;12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.148\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePSS-Fa scores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.89\u0026thinsp;\u0026plusmn;\u0026thinsp;2.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.01\u0026thinsp;\u0026plusmn;\u0026thinsp;3.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.33\u0026thinsp;\u0026plusmn;\u0026thinsp;4.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.26\u0026thinsp;\u0026plusmn;\u0026thinsp;3.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u0026ndash;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.004*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHbA1c (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.43\u0026thinsp;\u0026plusmn;\u0026thinsp;2.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.10\u0026thinsp;\u0026plusmn;\u0026thinsp;1.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.48\u0026thinsp;\u0026plusmn;\u0026thinsp;2.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9.32\u0026thinsp;\u0026plusmn;\u0026thinsp;1.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.17\u0026ndash;11.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.476\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e* Statistically significant \u003cem\u003eP-\u003c/em\u003e values\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eSedentary behavior and sleep disorders\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e compares the time spent on specific sedentary activities, family support scores, and HbA1c values between various groups of sleep disorders. The time spent on TV was significantly different across different groups of patients with sleep disorders (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.023). Dunn\u0026rsquo;s test was applied to make pairwise comparisons which showed a significant difference between the patients with no/mild and severe sleep disorders (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.011). Nonetheless, no considerable difference was found between the severe and moderate sleep disorder groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.121) or between the moderate and no/mild sleep disorder groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.731) regarding the hours spent watching TV (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The time spent on video games and the Internet was not related to the incidence of sleep problems (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePairwise comparison of different sleep disorder groups regarding quantitative variables. Dunn\u0026rsquo;s test was performed for multiple comparisons.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDifferent groups of sleep disorder\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo/mild\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSevere\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo/mild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWatching TV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.731\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.011\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily support scores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.488\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.026\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWatching TV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.731\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.121\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily support scores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.488\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.029\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWatching TV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.011\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.121\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily support scores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.026\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.029\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003csup\u003e*\u003c/sup\u003eStatistically significant \u003cem\u003eP-\u003c/em\u003e values\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eFamily support and sleep disorders\u003c/h2\u003e \u003cp\u003eThe PSS-Fa scores differed significantly across the sleep disorder groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.004). Applying Dunn\u0026rsquo;s correction for multiple comparisons revealed that patients with severe sleep disorders had significantly lower PSS-Fa scores compared with patients with moderate (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.029) and no/mild (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.026) sleep disorders (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eFamily support and quantitative variables\u003c/h2\u003e \u003cp\u003eWe found that the PSS-Fa score was significantly correlated with the HbA1c level (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, r\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.271), time since T1D diagnosis (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.003, r = -0.229), and number of annual visits (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.033, r\u0026thinsp;=\u0026thinsp;0.164). However, there were no associations between family support and patient age (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.169), FBS (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.235), or random blood sugar (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.315) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelation of PSS-Fa scores of T1D adolescents with quantitative variables.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuantitative variables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eP-\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003er\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.169\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.106\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime since T1D diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.003\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.0229\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of annual visits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.033\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.164\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHb A1C\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.271\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFasting blood sugar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.235\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.088\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRandom blood sugar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.315\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.077\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003csup\u003e*\u003c/sup\u003eStatistically significant \u003cem\u003eP-\u003c/em\u003e values\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings of the current study suggested that both the family support scores and the amount of time spent watching TV are related to sleep disorders. However, sleep quality was not associated with the HbA1c level or the time spent on either video games or the Internet. Family support scores were negatively correlated with HbA1c levels and the time since T1D diagnosis. Patients with higher family support scores attended follow-up sessions more frequently.\u003c/p\u003e \u003cp\u003eThe current body of evidence suggests that sleep and glycemic control have a bidirectional connection; poor glycemic control causes sleep problems and sleep problems interfere with glucose homeostasis (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). According to two meta-analyses, the direct effect of sleep characteristics on glycemic management in T1D adolescents and children is not well established (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Bahadur \u003cem\u003eet al.\u003c/em\u003e compared sleep and behavior problems between T1D children and non-diabetic controls. They reported that T1D children had a shorter sleep time and experienced more daytime sleepiness compared with their control group. However, this study found no association between sleep parameters and glycemic control (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Alder \u003cem\u003eet al.\u003c/em\u003e also discovered no significant association between HbA1c levels and sleep in T1D children and adolescents (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Similarly, our results indicated that HbA1c values do not significantly vary between different sleep disorder groups.\u003c/p\u003e \u003cp\u003eOn the other hand, numerous studies stated that poor sleep negatively affects glycemic control in T1D patients. A systematic review in 2021 demonstrated that poor sleep quality and irregular sleep patterns were related to higher HbA1c and suboptimal T1D self-care measurements (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Moreover, both short and long sleep duration were linked to poor self-management behaviors (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), impaired adherence to glucose monitoring, and uncontrolled HbA1c levels (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Berk \u003cem\u003eet al.\u003c/em\u003e followed 61 T1D patients in the 6\u0026ndash;16 age group for one year. They reported higher HbA1c values in patients with higher sleep disorders (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.02) (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Frye \u003cem\u003eet al.\u003c/em\u003e discovered that shorter sleep duration is linked with an elevated HbA1c level and poor diabetes self-care behaviors. However, additional analysis revealed that the relationship between HbA1c and sleep duration was mediated by self-measurement of blood glucose (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). These findings underline the mediating impact of self-management activities on the interaction between sleep and glycemic control of T1D youths. In fact, enhanced sleep could be accompanied by improved self-management behaviors which subsequently contribute to better glycemic control (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). However, our study did not identify any significant link between glycemic control and sleep.\u003c/p\u003e \u003cp\u003eDigital device use adversely affects sleep characteristics in children and adolescents (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). A study in 2010 found that the average overall time spent on screen devices was approximately 3.5 hours for male and 2.5 hours for female youths with T1D (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). The participants of our study spent approximately three times more hours a day on electronic devices. This may point out the increasing trend of electronic media use among children and adolescents. Huert-Uribe \u003cem\u003eet al.\u003c/em\u003e performed a meta-analysis to evaluate physical activity and sedentary behavior in adolescents with T1D. This study discovered that T1D adolescents are more sedentary compared with healthy peers (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). This could be related to the fear of hypoglycemia and lack of both motivation and time in T1D patients (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Sedentary behaviors, including screen use, have been linked to higher values of HbA1c (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). These findings highlight the concerning impact of sedentary activities on glycemic control in youth with T1D which contributes to serious complications. Thus, it seems crucial to reverse sedentary behaviors and increase physical activity among adolescents with T1D to improve their cardiovascular profile and overall health (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). To address this issue, diabetes caregivers should focus on decreasing the duration of screen use as a leading contributor to a sedentary lifestyle. The American Diabetes Association emphasizes reducing sedentary activities, such as watching TV and using computer, to the greatest extent and taking breaks frequently by engaging in simple physical exercises (e.g., walking and standing). These feasible interventions may improve the glycemic status of diabetic patients (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). A randomized controlled trial study of T1D adults revealed that PSQI scores decreased significantly (21.4%; \u003cem\u003eP-\u003c/em\u003evalue\u0026thinsp;\u0026lt;\u0026thinsp;0.001) after 6 weeks of increased physical activity (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). In a similar study on T1D children, sleep habits improved in patients with regular physical activity (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). A study of 45 T1D teenagers revealed a negative correlation between the time spent on sedentary activities and sleep duration (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01; \u003cem\u003er\u003c/em\u003e = -0.64) (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Compared with these findings, the results of our study suggested that individuals who spent more time watching TV tended to experience more sleep disorders. Similarly, a published study illustrated that the duration of nocturnal sleep was notably shorter in teens who spent over 2 hours watching TV or had late bedtimes (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Sleep disorders such as late bedtime could be associated with more sedentary behaviors in adolescents with T1D which may lead to uncontrolled blood glucose levels (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). These findings highlight the impact of a sedentary lifestyle on T1D patients\u0026rsquo; quality of life, particularly their sleep quality.\u003c/p\u003e \u003cp\u003eA meta-analysis revealed that greater sedentary behavior, with the exception of screen time spent completing homework, was associated with worse HbA1c levels in T1D youths. Personality traits related to engaging in schoolwork are accompanied by promoted self-care behaviors and better glycemic control, which could explain this finding (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Calella \u003cem\u003eet al.\u003c/em\u003e investigated the physical activity and lifestyle of T1D adolescents in Italy. They found a positive association between overall screen time (TV, the Internet, and video games) and HbA1c levels. This study also indicated that adolescents with T1D spent approximately eight hours on screen-based devices daily and that their level of physical activity was lower than the minimum standard recommendations (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Similarly, the participants in our study had a mean overall screen time of approximately 9 hours daily. These findings highlight the necessity of improving healthcare measures for T1D adolescents to modify sedentary habits and enhance physical activity to achieve optimum glycemic control.\u003c/p\u003e \u003cp\u003eFamily members of younger pediatric T1D patients are responsible for monitoring the blood glucose levels and supervising the insulin injection (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Adolescents are more vulnerable to glycemic deterioration after the gradual transition to self-management and parental involvement remains essential for desirable diabetes management (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Perceived family social support enhances diabetes self-care measurements and self-efficacy in youths with T1D (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). A systematic review revealed that the involvement of parents in the management of diabetes enhances glycemic control in adolescents with T1D (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Similarly, our results indicated that T1D adolescents with greater family support had lower HbA1c values and attended follow-up sessions at the diabetes clinic more frequently. This may highlight the significance of family support in promoting the adherence of T1D teens to their treatment.\u003c/p\u003e \u003cp\u003eA previous study in Iran reported that perceived family support was not associated with the age of T1D patients. However, both HbA1c levels and T1D duration were not related to family support contrary to our study (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). A study of 150 T1D adolescents revealed that the involvement of parents in diabetes care declined significantly with increasing age (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01) (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Hanna \u003cem\u003eet al.\u003c/em\u003e reported that older adolescents with T1D perceived lower levels of parental autonomy support (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). AlHaidar \u003cem\u003eet al\u003c/em\u003e. conducted a cross-sectional study to evaluate family support in T1D adolescents. They demonstrated that older adolescents perceived significantly lower levels of various family support elements. However, the time spent after the diagnosis of T1D and the HbA1c values were only correlated with family supervision (\u003cem\u003er\u003c/em\u003e = -0.647; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.012) and critical situation support (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.335; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.017), respectively (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). These findings highlight the inconsistency of data on the link between family support and T1D adolescents\u0026rsquo; characteristics and outcomes.\u003c/p\u003e \u003cp\u003eA longitudinal study on T1D adolescents and their parents indicated that parental adherence and involvement declined significantly over time (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Family support was negatively associated with time since T1D diagnosis in our study but not with teen\u0026rsquo;s age. Parental burnout might explain this contradiction. Parents of diabetic children tend to experience burnout and characterize it as feeling grief for losing a normal life or feeling powerless to manage diabetes (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Some background factors, such as socioeconomic status and limited leisure time, aggravate parental burnout (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Hence, it could be practical for diabetes clinicians to support parents psychologically. This subsequently contributes to enhanced family support and improved attitudes towards diabetes management among T1D adolescents.\u003c/p\u003e \u003cp\u003eAlthough higher family support scores were associated with enhanced sleep quality in our results, the role of parental supervision in adolescents\u0026rsquo; sleep health should be taken into consideration. According to Bergner \u003cem\u003eet al.\u003c/em\u003e, caregivers of T1D adolescents take some strategies to improve the quality of their teens\u0026rsquo; sleep. This study mentioned setting sleep curfews (e.g., early bedtime) and eliminating digital devices from teenagers\u0026rsquo; bedrooms as the most common strategies (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). However, parental interventions should not lead to prebedtime arguments, since such conflicts deteriorate sleep quality in children and adolescents (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe cross-sectional design and lack of a control group influence the generalizability of the current study and limit the interpretability of the results. The data on the time spent on sedentary behaviors were obtained through self-reports of patients and their parents, which might lead to misconclusion. The association between sleep quality and daily glycemic variability is unclear since HbA1c is not an accurate predictor. Further studies should consider implementing continuous glucose monitoring to address this issue.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eSleep plays a prominent role in adolescents\u0026rsquo; health. Sleep disorders and their contributors, including screen device use and family support, are still under discussion in the diabetic youth population. Family support and involvement in diabetes management should be promoted in adolescents and the transition of diabetes-care responsibilities needs to be more cautious and organized. Moreover, parental supervision and timing seem crucial to monitor digital media use and sleep schedules in T1D adolescents given their unique supportive care needs. However, the interactions among sleep, digital device use, family support, and glycemic control in such patients needs further investigation to be thoroughly understood.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eType 1 diabetes (T1D), Pittsburgh Sleep Quality Index (PSQI), Perceived Social Support from Family (PSS-Fa), Hemoglobin A1C (HbA1c), Statistical Package for the Social Sciences (SPSS), Standard Deviation (SD), and Fasting Blood Sugar (FBS).\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003eThe current study was approved by the Ethics Committee of Hamadan University of Medical Sciences [IR.UMSHA.REC.1400.719]. After explaining the study's steps and objectives to the participants and their parents, their consent was obtained. This study was conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eAll of the authors declare that they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eA.P. performed study design, project administration, editing the manuscript. Z.R. participated in project administration, data gathering, and editing the manuscript. N.T., M.F.T., P.S., S.S.D., S.K.H., and A.J. participated in sample preparation, data gathering, statistical analysis, and writing the initial draft. All of the authors have reviewed and confirmed the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgments\u003c/h2\u003e \u003cp\u003eThe authors appreciate the valuable support from the members of the Pediatric Diabetes and Endocrinology Clinic at Besat Hospital, Hamadan, Iran.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets produced and analyzed during this study are not publicly accessible due to the protection of patients' confidentiality. However, they can be obtained from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBlagov AV, Summerhill VI, Sukhorukov VN, Popov MA, Grechko AV, Orekhov AN. Type 1 diabetes mellitus: Inflammation, mitophagy, and mitochondrial function. Mitochondrion. 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGregory GA, Robinson TIG, Linklater SE, Wang F, Colagiuri S, de Beaufort C, et al. 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J Diabetes Metab Disord. 2011.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHilliard ME, Mann KA, Peugh JL, Hood KK. How poorer quality of life in adolescence predicts subsequent type 1 diabetes management and control. Patient Educ Couns. 2013;91(1):120\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHanna KM, Dashiff CJ, Stump TE, Weaver MT. Parent-adolescent dyads: association of parental autonomy support and parent-adolescent shared diabetes care responsibility. Child Care Health Dev. 2013;39(5):695\u0026ndash;702.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlHaidar AM, AlShehri NA, AlHussaini MA. Family Support and Its Association with Glycemic Control in Adolescents with Type 1 Diabetes Mellitus in Riyadh, Saudi Arabia. J Diabetes Res. 2020;2020:5151604.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKing PS, Berg CA, Butner J, Butler JM, Wiebe DJ. 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Diabetes Educ. 2018;44(6):541\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeltz JS, Rogge RD. The moderating role of parents' dysfunctional sleep-related beliefs among associations between adolescents' pre-bedtime conflict, sleep quality, and their mental health. J Clin Sleep Med. 2019;15(2):265\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Insulin-dependent diabetes mellitus, Sleep disorder, Screen time, Adolescents, Children, Family support","lastPublishedDoi":"10.21203/rs.3.rs-4863380/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4863380/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSleep is a key element in adolescent health and affects glycemic control in diabetic patients. Electronic device use and family support are contributing factors to sleep characteristics and glycemic management in type 1 diabetes (T1D) patients. This study aims to evaluate the influence of electronic device use and family support on sleep disorders and identify possible effects on glycemic control in T1D adolescents.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis cross-sectional study was conducted on T1D adolescents who attended the diabetes clinic at Besat Hospital, Hamadan, Iran, from February 2021 to February 2022. Valid Persian versions of the Pittsburgh Sleep Quality Index (PSQI) and Perceived Social Support from Family (PSS-Fa) questionnaires were employed to measure sleep quality and family support. A valid self-report questionnaire was used to obtain data on time spent on screen-based sedentary behaviors, including TV, video games, and the Internet. The demographic characteristics and hemoglobin A1C (HbA1c) and fasting blood sugar levels of the patients were obtained during the follow-up sessions. Statistical analysis was performed using SPSS 21. Kruskal-Wallis and Dunn\u0026rsquo;s tests were applied to compare different sleep disorder groups in terms of quantitative variables. Spearman\u0026rsquo;s correlation test examined the association of PSS-Fa scores and quantitative variables.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWe recruited 171 patients with a mean age of 12.48\u0026thinsp;\u0026plusmn;\u0026thinsp;1.75 years. Nine patients (5.3%) had no/mild sleep disorders, 75 (43.9%) had moderate sleep disorders, and 87 (50.9%) had severe sleep disorders. No association was found between sleep disorders and HbA1c (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.476). among electronic devices, only watching TV was associated with sleep disorders (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.023). PSS-Fa scores were significantly lower in adolescents with severe sleep disorders compared with no/mild (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.026) and moderate (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.029) sleep disorder groups. PSS-Fa scores were positively correlated with the number of annual visits (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.033; \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.164) and negatively correlated with the time since diabetes diagnosis (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.003; \u003cem\u003er\u003c/em\u003e = -0.229) and the HbA1c level (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; \u003cem\u003er\u003c/em\u003e = -0.271).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eA supportive family can contribute not only to better sleep outcomes but also to more desirable glycemic management in T1D adolescents. Digital devices might deteriorate sleep quality but the pattern of this effect needs further investigation.\u003c/p\u003e","manuscriptTitle":"Sleep disorders, electronic device use, and family support: looking for a link in type 1 diabetic adolescents regarding their glycemic control","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-16 01:00:08","doi":"10.21203/rs.3.rs-4863380/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"95fc1528-8493-413d-9f4f-64bcd6fb695d","owner":[],"postedDate":"September 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-09-23T05:29:37+00:00","versionOfRecord":[],"versionCreatedAt":"2024-09-16 01:00:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4863380","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4863380","identity":"rs-4863380","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}