Diabetes Technologies in Ultra-Endurance Type 1 Diabetes: Qualitative Study

Background: Diabetes technologies—including continuous glucose monitoring (CGM), insulin pumps, and hybrid closed-loop systems—have profoundly transformed self-management in type 1 diabetes (T1D). While these technologies offer improved glycemic control and safety, their use in ultraendurance sports introduces specific cognitive, material, and organizational challenges that remain underexplored in digital health research. Objective: This study aimed to explore how adults living with T1D experience and use diabetes technologies in ultraendurance sports, with particular attention to tensions between autonomy, mental load, and vulnerability. Methods: We conducted semistructured interviews with 13 French-speaking adults with T1D who had completed at least one marathon or ultra-endurance event within the last 5 years and used ≥1 diabetes technology (CGM, pump, or hybrid closed loop). We adopted constructivist grounded theory (Charmaz), using iterative cycles of line-by-line and focused coding, constant comparison, and memo-writing to build and refine analytic categories. Sampling combined purposive strategies through associations and online communities with theoretical orientation (additional participants sought to elaborate emergent categories). Data collection ceased upon theoretical sufficiency, when further interviews no longer yielded substantively new insights for core categories. Two patient partners contributed to question framing, interim sense-checking, and manuscript review. Reporting followed the COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist. Results: Five interrelated categories described how athletes negotiated technology in practice: (1) From episodic control to continuous anticipation (reframing glucose management through real-time visibility); (2) Gains in safety and performance (perceived benefits and expanded possibilities); (3) Redistributed mental work (hyper-vigilance, logistics, device management); (4) Keeping things working when they break (fragility in extreme conditions, redundancy, improvisation, and experiential expertise); and (5) Making diabetes visible (technologies mediating identity, solidarity, and stigma). Across categories, participants articulated a tension between optimization-oriented performance and a user-constructed robustness—the capacity to maintain function under uncertainty through redundancy and adaptive know-how. Conclusions: In ultraendurance contexts, diabetes technologies act as both enablers and obligations: they open participation while shifting and sometimes intensifying cognitive and organizational work. A grounded account centered on robustness-in-use highlights practical implications for clinicians (pre-event routines, redundancy planning), designers (context-aware algorithms; improved physical durability), and policy makers (equitable access and exercise-specific education). These findings underscore the value of constructivist, practice-oriented inquiry to inform digital health tool design and support for people living with chronic illness.