Impact of Technology Introduction on Glycemic Control of People Living with Type 1 Diabetes in Belgium: An Observational, Real-World Study

Objective: To evaluate long-term trends in metabolic outcomes among people living with type 1 diabetes (T1D) within a nationwide structured care program in Belgium with full reimbursement of diabetes technologies. Methods: Repeated cross-sectional analyses were performed across three audit periods (2010–2011, 2017–2018, and 2023–2024). Outcomes included glycated hemoglobin (HbA1c), low-density lipoprotein (LDL) cholesterol, systolic blood pressure (SBP), and body mass index. Trends were analyzed using generalized estimating equations adjusted for age, sex, diabetes duration, insulin delivery, and glucose monitoring modalities. In 2023–2024, glycemic outcomes were compared across technology use, including hybrid closed-loop (HCL) therapy. Results: In adults, HbA1c decreased from 7.9% (62.8 mmol/mol) to 7.5% (58.5 mmol/mol, P < 0.001), with target attainment (<7%; <53 mmol/mol) increasing from 22.3% to 35.1%. In children and adolescents, HbA1c declined from 8.0% (63.5 mmol/mol) to 7.6% (59.0 mmol/mol, P < 0.01), and target attainment rose from 19.7% to 33.1% ( P < 0.001). Continuous glucose monitoring (CGM) exceeded 90% by 2023–2024, while insulin pump use reached 25% in adults and 47% in younger individuals. In adults, HCL therapy was associated with lower HbA1c (7.0%; 53.5 mmol/mol), higher time-in-range (73%), and lower time-below-range (1.5%) compared with other modalities ( P < 0.001). LDL cholesterol improved, with target attainment (<70 mg/dL; <1.8 mmol/L) increasing from 18.3% to 37.4% ( P < 0.001), and from 15.5% to 46.5% among those with cardiovascular disease (<55 mg/dL; <1.4 mmol/L, P < 0.001). SBP remained stable. Obesity prevalence increased in all age groups. Conclusions: Over 14 years, glycemic and lipid outcomes improved alongside near-universal CGM use and increasing adoption of HCL therapy. However, rising obesity and persistent smoking-related risks highlight the need for targeted prevention strategies. These real-world data confirm that benefits seen in clinical trials translate into durable population-level improvements and support integrated care models for implementing diabetes technology effectively.