Wearing a medical identification (Med ID) is recommended for people living with type 1 diabetes to assist diagnosis and treatment of medical emergencies (1). From two previous studies on Med ID usage among young individuals (ages 6–24 years old) living with type 1 diabetes, reported rates ranged from 7% (based on Med ID database subscription) to 60% (from a sample of 100 individuals) (2,3). The objective of this study was to compare characteristics of participants reporting wearing versus not wearing a Med ID, with use of data from the BEhaviors, Therapies, TEchnologies and Hypoglycemic Risk in Type 1 Diabetes (BETTER) registry (4).
Data reported were collected between February 2019 and September 2022 from 2,302 BETTER registry participants who had responded to the question, “Do you wear a medical ID (e.g., a MedicAlert bracelet)?” This study was approved by the Montreal Clinical Research Institute ethics board (no. 2024-1265), and all participants signed an electronic consent form. The data sets generated during or analyzed in the current study are available from the corresponding author on reasonable request.
We report results regarding sociodemographic characteristics, diabetes-related characteristics, and patient-reported outcome measures (Table 1). In terms of sociodemographic characteristics, 41.6% (n = 958 of 2,302) of the participants reported wearing a Med ID. This is likely an overestimate of real-world use because the BETTER registry is voluntary and can capture a more engaged and informed segment of the population with type 1 diabetes. Participants who reported wearing a Med ID were older (mean ± SD age 42.8 ± 16.9 vs. 39.4 ± 15.3 years; P < 0.001) and more likely to be women (45.2% of women vs. 35.7% of men; P < 0.001) versus those not wearing one. This could indicate a gender difference in the acceptability of medical jewelry, with women more inclined to wear it (2). We did not ask whether alternative strategies such as medical alert tattoos were used or might be preferred.
Study outcomes
| . | Med ID . | No Med ID . | P . |
|---|---|---|---|
| N | 958 | 1,344 | |
| Age (years) | 42.8 ± 16.9 | 39.4 ± 15.3* | <0.001 |
| Diabetes duration (years) | 22.1 ± 15.7 | 19.9 ± 14.6* | <0.001§ |
| Gendera | <0.001 | ||
| Men | 310 (35.7) | 559 (64.3) | |
| Women | 643 (45.2)† | 779 (54.8) | |
| Reported HbA1c ≤7.0% | 283 (39.6) | 365 (27.2) | 0.912 |
| Insulin pump use | 394 (41.1) | 475 (35.3)* | 0.005 |
| CGM use | 802 (83.7) | 1,070 (79.6)* | 0.013 |
| No. of level-1-H in the last 3 daysb | 1 [1–3] | 2 [1–3] | 0.644 |
| No. of level-2-H in the past monthc | 5 [2–10] | 5 [3–10]* | 0.047 |
| No. of level-3-H in the past yeard | 2 [1–3] | 2 [1–3] | 1.000 |
| Impaired awareness of hypoglycemiae | 124 (21.5) | 116 (16.5)* | 0.025 |
| Hypoglycemic Confidence Scale scoref | 3.21 ± 0.55 | 3.15 ± 0.58* | 0.047 |
| Hypoglycemia Fear Survey-II scoreg | 35.1 ± 18.3 | 34.2 ± 18.3 | 0.394 |
| Behavior subscale | 17.0 ± 8.6 | 16.3 ± 8.4 | 0.132 |
| Worry subscale | 18.1 ± 12.4 | 17.9 ± 12.3 | 0.791 |
| Diabetes Distress Scale scoreh | 2.17 ± 0.98 | 2.30 ± 0.95* | 0.014 |
| DSAS-1 scorei | 39.3 ± 15.7 | 41.2 ± 15.8 | 0.074 |
| Treated Differently subscale | 9.7 ± 4.9 | 9.4 ± 4.9 | 0.349 |
| Blame and Judgement subscale | 15.6 ± 7.2 | 16.2 ± 7.1 | 0.225 |
| Identity Concerns subscale | 14.0 ± 6.8 | 15.7 ± 7.3* | <0.001 |
| Items of the DSAS-1 | |||
| I feel worried about telling people I have type 1 diabetes in case they react negativelyj | 48 (5.3) | 85 (6.3) | 0.020 |
| To avoid negative reactions, I don’t tell people I have type 1 diabetesj | 49 (5.1) | 97 (7.2) | 0.002 |
| . | Med ID . | No Med ID . | P . |
|---|---|---|---|
| N | 958 | 1,344 | |
| Age (years) | 42.8 ± 16.9 | 39.4 ± 15.3* | <0.001 |
| Diabetes duration (years) | 22.1 ± 15.7 | 19.9 ± 14.6* | <0.001§ |
| Gendera | <0.001 | ||
| Men | 310 (35.7) | 559 (64.3) | |
| Women | 643 (45.2)† | 779 (54.8) | |
| Reported HbA1c ≤7.0% | 283 (39.6) | 365 (27.2) | 0.912 |
| Insulin pump use | 394 (41.1) | 475 (35.3)* | 0.005 |
| CGM use | 802 (83.7) | 1,070 (79.6)* | 0.013 |
| No. of level-1-H in the last 3 daysb | 1 [1–3] | 2 [1–3] | 0.644 |
| No. of level-2-H in the past monthc | 5 [2–10] | 5 [3–10]* | 0.047 |
| No. of level-3-H in the past yeard | 2 [1–3] | 2 [1–3] | 1.000 |
| Impaired awareness of hypoglycemiae | 124 (21.5) | 116 (16.5)* | 0.025 |
| Hypoglycemic Confidence Scale scoref | 3.21 ± 0.55 | 3.15 ± 0.58* | 0.047 |
| Hypoglycemia Fear Survey-II scoreg | 35.1 ± 18.3 | 34.2 ± 18.3 | 0.394 |
| Behavior subscale | 17.0 ± 8.6 | 16.3 ± 8.4 | 0.132 |
| Worry subscale | 18.1 ± 12.4 | 17.9 ± 12.3 | 0.791 |
| Diabetes Distress Scale scoreh | 2.17 ± 0.98 | 2.30 ± 0.95* | 0.014 |
| DSAS-1 scorei | 39.3 ± 15.7 | 41.2 ± 15.8 | 0.074 |
| Treated Differently subscale | 9.7 ± 4.9 | 9.4 ± 4.9 | 0.349 |
| Blame and Judgement subscale | 15.6 ± 7.2 | 16.2 ± 7.1 | 0.225 |
| Identity Concerns subscale | 14.0 ± 6.8 | 15.7 ± 7.3* | <0.001 |
| Items of the DSAS-1 | |||
| I feel worried about telling people I have type 1 diabetes in case they react negativelyj | 48 (5.3) | 85 (6.3) | 0.020 |
| To avoid negative reactions, I don’t tell people I have type 1 diabetesj | 49 (5.1) | 97 (7.2) | 0.002 |
Data are n (%), mean ± SD, or median [interquartile range]. Significance was calculated with χ2 or Fisher exact test with a Bonferroni correction for categorical outcomes and with linear models (with or without confounding factors) or with Mood median test for numerical variables. *Significantly different from the Med ID group. §Not statistically significant (P = 0.648) after adjustment for age. †Significantly different from male participants. aEleven participants answered “other,” “I prefer to not answer,” or “I don’t know” to the question on gender. bLevel-1-H, level 1 hypoglycemia events: glucose levels ≤4.0 mmol/L. cLevel-2-H, level 2 hypoglycemia events: glucose levels ≤3.0 mmol/L where the participant was able to self-treat. dLevel-3-H, level 3 hypoglycemia events: low glucose level requiring help from another person, use of glucagon, or hospitalization or involving loss of consciousness. eAwareness of hypoglycemia was evaluated with the Clarke questionnaire. The Clarke questionnaire is composed of eight questions, and a score ≥4 indicates impaired awareness of hypoglycemia. fThe Hypoglycemic Confidence Scale is a validated nine-item questionnaire and is used to examine participant’s confidence in managing hypoglycemia. Items are rated on a 4-point scale from 0 (not confident at all) to 3 (very confident) and averaged. Higher scores indicate more confidence. gThe Hypoglycemia Fear Survey-II (HFS-II) is a validated 33-item questionnaire used to quantify participant’s fear of hypoglycemia. Items are rated on a 5-point scale from 0 (never) to 4 (almost always). Higher scores indicate more fear of hypoglycemia. hThe Diabetes Distress Scale is a validated 17-item questionnaire. Items are rated on a 6-point scale from 1 (not a problem) to 6 (a very serious problem) and averaged. Higher scores indicate more distress. iThe DSAS-1 is a validated 19-item questionnaire with a total score and three subscale scores (treated differently, blame and judgment, identity concerns). Items are rated on a 5-item scale from 1 (strongly disagree) to 5 (strongly agree). Higher scores indicate more perceived stigma. jData correspond to participants who answered with agree or strongly agree with this item.
For diabetes-related characteristics, the proportion of participants using an insulin pump and/or a continuous glucose monitoring (CGM) system was greater in the Med ID group (41.1% and 83.7%, respectively) than in the no Med ID group (35.3% and 79.6%) (P < 0.05). Less use of Med ID among people not using technology may be due to underlying concerns about having visible signs of type 1 diabetes. Conversely, individuals using diabetes technology may perceive Med ID use as redundant, since their technology devices (e.g., CGM) should be sufficient to communicate their diabetes status (2). Although impaired awareness of hypoglycemia was more common (21.5% vs. 16.5%; P < 0.05) in the Med ID group, there was no significant difference in the frequency of hypoglycemic episodes, at any severity level. People living with type 1 diabetes at high risk for level 3 hypoglycemia should be primarily targeted by education efforts about the importance of wearing a Med ID.
Results on patient-reported outcomes measures are as follows: Participants wearing a Med ID had a higher hypoglycemia confidence score (mean ± SD 3.21 ± 0.55) and a lower diabetes distress score (2.17 ± 0.98) than those not wearing one (3.15 ± 0.58 and 2.30 ± 0.95, respectively) (P < 0.05), suggesting higher confidence in diabetes management. Mean score was higher for participants not wearing a Med ID on the Identity Concerns subscale of the Type 1 Diabetes Stigma Assessment Scale (DSAS-1) (15.7 ± 7.3 vs. 14.0 ± 6.8; P < 0.001). Additionally, we found that a greater proportion of participants not wearing a Med ID agreed that they feel worried about telling people they have type 1 diabetes (6.3%) and do not tell people they have type 1 diabetes (7.2%) in comparison with their counterparts wearing a Med ID (5.3% and 5.1%) (P < 0.05). These results may help explain our observation of less technology use among participants who did not wear a Med ID. Together, these results suggest that confidence in diabetes management and willingness to disclose their medical condition may influence whether some people living with type 1 diabetes will wear a Med ID, which is not surprising considering how common diabetes stigma is (5). We could hypothesize that a certain degree of diabetes acceptance is needed to wear a Med ID; however, the clinical relevance of this is unclear, since the differences, though statistically significant, were small.
Rapid recognition of the presence of type 1 diabetes is crucial in a health emergency. In situations where patients are unable to communicate their diabetes status or self-manage their glucose levels, the presence of a Med ID may be lifesaving. The use of Med ID, however, is far from universal, and efforts to successfully increase its uptake will require more detailed understanding of the needs, wishes, and perceptions of people living with type 1 diabetes and barriers to its use.
Article Information
Acknowledgments. The authors thank participants and patient partners for their involvement in the BETTER project.
Funding and Duality of Interest. The BETTER registry is supported by grants from the Canadian Institutes of Health Research (grant JT1-157204), Breakthrough T1D Canada (3-SRA-2024-1523-M-N), and Diabète Québec and supported through nonrestrictive grants from Eli Lilly Canada, Novo Nordisk Canada, and Sanofi Canada and a donation from Dexcom Canada. The authors declare the following financial interests/personal relationships, which may be considered as potential competing interests: V.M. received purchase fees from Eli Lilly (artificial pancreas). A.S.B. is a Fonds de recherche du Québec en Santé Research Scholar; holds research grants from the Canadian Institutes of Health Research, Breakthrough T1D, Société Francophone du Diabète, and Diabète Québec; and has received speaker fees from Dexcom. P.A.S. has received grants from Breakthrough T1D, Canadian Institutes of Health Research, and Brain Canada and consulting or personal fees from Abbott, Bayer, Dexcom, Eli Lilly, GSK, Insulet, Novo Nordisk, Sanofi, Vertex Pharmaceuticals, and Ypsomed. He served previously as board chair for Diabetes Canada and is a co-lead for Diabetes Action Canada Innovations in Type 1 Diabetes Goal Group. He holds the Charles A. Allard Chair in Diabetes Research. L.A.H. holds a funded intercenter internship of the CardioMetabolic Health, Diabetes and Obesity Research Network. R.R.L. reports 1) research grants, Diabetes Canada, AstraZeneca, Eli Lilly, Cystic Fibrosis Canada, Canadian Institutes of Health Research, Fondation Francophone pour la Recherce sur le diabète, Janssen, Breakthrough T1D, Merck, National Institutes of Health, Novo Nordisk, Société Francophone du Diabète, Sanofi, and Vertex Pharmaceuticals; 2) consulting/advisory panel, Abbott, AstraZeneca, Bayer, Boehringer Ingelheim, Dexcom, Eli Lilly, HLS Therapeutics, Institut national d'excellence en santé et services sociaux, Insulet, Janssen, Medtronic, Merck, Novo Nordisk, Pfizer, and Sanofi; 3) honoraria for conferences, Abbott, AstraZeneca, Boehringer Ingelheim, CPD Network, Dexcom, Canadian Medical & Surgical Knowledge Translation Research Group, Eli Lilly, Janssen, Medtronic, Merck, Novo Nordisk, Sanofi, Tandem Diabetes Care, and Vertex Pharmaceuticals; 4) consumable gift (in kind), Eli Lilly, and Medtronic; 5) unrestricted grants for clinical and educational activities, Abbott, Eli Lilly, Medtronic, Merck, Novo Nordisk, and Sanofi; 6) patent: T2D risk biomarkers, catheter life; and 7) purchase fees, Eli Lilly (artificial pancreas). No other potential conflicts of interest relevant to this article were reported.
Author Contributions. V.M. designed the study and wrote the manuscript. A.S.B. designed the study and reviewed and edited the manuscript. P.A.S., L.A.H., M.L., and B.K. reviewed and edited the manuscript. C.G. performed statistical analysis. R.R.L. designed the study and reviewed and edited the manuscript. R.R.L. is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Handling Editors. The journal editors responsible for overseeing the review of the manuscript were John B. Buse and Stephanie L. Fitzpatrick.
