Internet Addiction Among Diabetic Adolescents and The Impact on Their Self Esteem

doi:10.21203/rs.3.rs-8093872/v1

Background

Compulsive Internet use has emerged as a contemporary addictive behavior. Our aim was to investigate the level of internet use and the psychological impact upon self-esteem among Egyptian adolescents with diabetes mellitus (DM) compared with healthy controls.

Objectives

This current study examined the relationships between Internet addiction symptoms, specific relational patterns, and self-esteem in diabetic adolescents.

Methods

Two hundred and fifty-five diabetic adolescents attending outpatient clinic of pediatric Diabetes clinic; El demerdash pediatric hospital -Ain Shams University; who are diagnosed with DM (type 1 &2) and equal number of healthy adolescents, age & sex matched was enrolled in the study. The Arabic version of the 20 items Young's Internet Addiction Test (IAT) and the translated Adolescent Self-Esteem Questionnaire (ASQ)was undergone by the adolescents.

Results

Total number of Two hundred and fifty-five diabetic adolescents (n = 255) where 164 females (64.3%) and 91 males (35.7%) participated in the study with mean age 14.2 ± 1.3 SD & Mean HbA1c (%) 6.5–12.2. Equal number of healthy adolescents where 160 females (62.7%) and 95 males (37.3%) participated in the study with mean age 14.4 ± 1.3 SD as control group.

Conclusion

Low self-esteem is a significant factor contributing to higher internet addiction scores among both diabetic adolescents and healthy controls. This problematic internet use poses a challenge for managing diabetes in adolescents with diabetes mellitus (DM). The negative impact of low self-esteem on their lifestyle likely exacerbates their internet use, making it a crucial area to address in diabetes management strategies.

Psychiatry

Psychology

Pediatrics

Adolescents

Internet addiction

self-esteem

questionnaire

diabetes mellitus

The development of type 1 diabetes is a life sentence to a difficult therapeutic regimen that is only partially effective in preventing acute and chronic complications (Devendra, et al 2004). It is well recognized that living with and self-managing type 1 diabetes, with and without complications, is psychologically challenging, impacting on emotional health and social functioning (Cox, et al 1992). There is also evidence that type 1 diabetes is associated with mild to moderate cognitive deficits, also called decrements, during childhood (Gaudieri, et al 2008).

Children and young people with diabetes are at a greater risk for emotional and behavioral problems. However, the psychological aspect of the disease is often missed with whole/most of the emphasis given on the strict maintenance of blood glucose (Naguib, et al 2009).

Self-esteem is the ability of individuals to perceive their value. Ackerman (2020) noted that self-esteem expert Rosenberg (1965) described self-esteem as one's attitude toward oneself. A common theme in the varied definition of self-esteem is self-respect. Self-esteem indicates the extent to which the individual believes himself or herself to have a positive outlook, the ability to be confident and to express one's own needs. Kenowitz et al. (2020) state that self-esteem is a factor in an individual's self-concept and is crucial in adolescents' evolution with independent identity development. Adolescence is a time of swift change physically, psychologically, and socially. Chronic illness has the potential to significantly impact growth and maturation through the transition of youth into adulthood (Ziegler, 2020).

The young person may battle a range of reactions and emotions regarding their condition, responses to others, and have concerns about going to school. In order to provide quality healthcare services to support and promote self-esteem in our young people, health professionals need to understand the social and personal ramifications of living with a long-term illness (Delamater et al., 2018).

The use of social media may offer one avenue to better meet the needs of adolescents with type 1 diabetes outside the ambulatory care setting (Hausmann et al., 2017). Social media is being used by a majority of adolescents, and many cite a preference for communication via social networking services (SNS). Of those using social media, approximately 90% of teens share that they are on the Web several times a day or almost constantly (Anderson et al., 2018).

The evolution of social media over the past decade now offers adolescents an array of potential benefits, including access to information, social support, and far-reaching communication tools that have the potential to facilitate diabetes management support outside of the ambulatory care setting. Specifically, the unique functions and features of different social media platforms provide youth a variety of perceived affordances (i.e., properties of different social media apps that can be recognized by users and that can contribute to their function) to support chronic disease management (Burgess et al., 2018).

For example, many adolescents with type 1 diabetes may believe that certain features of social media offer cognitive affordances, such as the ability to expand one’s learning about type 1 diabetes and how to improve self-care. Other adolescents may be drawn to features of certain social media platforms that offer social affordances, including a sense of belonging to a group related to diabetes, given the interactive nature of social media (Moreno et al., 2019).

These perceived affordances highlight the potential for social media to be used to provide Web-based diabetes education, peer support, and decision advice through real-time bidirectional communication in a digital environment (Gabarron et al., 2018).

Adolescents with diabetes, in particular, appear to be ideal candidates for chronic disease management support using social media, given their extensive use of technology as part of their daily diabetes management, including devices that monitor glucose and deliver insulin, diabetes-specific apps on smartphones, and internet-enabled education and support programs (Giani et al., 2015).

Everyday internet usage is particularly significant in the population of adolescents and young people. Besides numerous benefits, internet usage brings certain risks of addictive behavior (Černja et al., 2019). Internet addiction could be conceptualized as a maladaptive pattern of Internet use behavior which is associated with several psychological and social problems (Chou et al., 2005).

Such non-conventional addictive behaviors are still lacking a well-established nomenclature (Morahan-Martin, 2005) and definition (Chou et al., 2005). Although the term Internet addiction is widely used, synonyms such as Internet abuse, compulsive Internet use, and pathological Internet use are also commonly used (Fu et al., 2010).

An empirical study was conducted to explore the behavioral problems of misuse of the Internet using the term “Internet addiction.” Based on the DSM-IV-TR (American Psychiatric Association, 2000) criteria for pathological gambling, diagnostic criteria for Internet addiction were proposed as (1) preoccupation with the Internet; (2) need to spend increasing amounts of time online; (3) repeated but unsuccessful attempts to reduce Internet use; (4) suffering withdrawal symptoms from reduction of Internet use; (5) time management problems; (6) environmental distress from school, family, work, and friends; (7) deception of Internet time; and (8) mood modification through Internet use (Young, 1996a).

Comparative Cross-sectional study was conducted on two hundred fifty-two adolescents with type 1 diabetes & equal number of age and sex matched adolescents without diabetes as a control group to study the level of internet use and its impact on self-esteem in chronic diabetic adolescents. An ethical committee approval was done before the start of the study.

Inclusion criteria

Adolescents aged between 10–18 years of both sexes, adolescents attended the outpatient clinic regularly with their caregivers, and adolescent diagnosed with diabetes mellitus for more than 6 months with HBA1c level was ≥ 6.5% according to International Society for Pediatric and Adolescent Diabetes (ISPAD) guidelines for diabetes diagnosis criteria were included.

Exclusion criteria

Adolescents recently diagnosed with diabetes, Adolescents with other chronic medical condition (e.g. Epilepsy, bronchial asthma) and patient refused to participate in the research.

Translating adolescent self-esteem questionnaire (ASQ)

A 13-item measure of global self-esteem. The ASQ includes both negatively and positively worded items which are on a 5-point Likert scale. Item scores were summed, with positively worded items reverse coded, to determine an individual’s self-esteem score. A higher score reflects higher levels of self-esteem (Hafekost et al., 2017). This questionnaire was translated into Arabic, validity and reliability were done through a pilot study by candidate and supervisors. Validity expresses the degree to which a measurement measures what it purports to measure. Reliability refers to the degree to which the results obtained by a measurement and procedure can be replicated (Wong et al., 2012).

Detailed medical history including order of birth, number of siblings and socioeconomic background, duration of diabetes, glycemic control using average HbA1c levels in the last 9 months.

Arabic version of the 20 items Young's Internet Addiction Test (IAT): was undergone by the adolescents. The test consisted of 20 self-reported questions whose answers were scored on a 5- point Likert scale ranging from one point for the answer “rarely” to five points for the answer “always” (Hawi NS, 2013; Ibrahim, 2011).

Statistical analysis:

The collected data were coded, tabulated, and statistically analyzed using IBM SPSS statistics (Statistical Package for Social Sciences) software version 28.0, IBM Corp., Chicago, USA, 2021.

Quantitative data tested for normality using Kolmogorov-Smirnov test, then described as mean ± SD (standard deviation) as well as minimum and maximum of the range, and then compared using independent t-test (two independent groups) and ANOVA test (three independent groups), while Pearson test was used for correlations. Qualitative data described as number and percentage and then compared using Chi square test as well as Fisher’s Exact test for variables with small expected numbers. Linear regression model was used to find out independent factors affecting scores. ROC curve was used to evaluate the performance of different tests differentiate between certain groups. The level of significance was taken at p-value ≤ 0.050 was significant, otherwise was non-significant.

Self-esteem questionnaire scores were significantly lower among diabetic group. Low self-esteem was significantly more frequent among diabetes group as shown table 1.

Internet addiction test scores were significantly higher among diabetic group. Moderate and severe internet addiction were significantly more frequent among diabetic group as shown in table 2.

Diabetic group with low self-esteem had significant higher internet addiction score as well as more frequent moderate and severe internet addiction as shown in table 3.

Self-esteem questionnaire scores among diabetics group had significant negative correlations with Age, Duration, HbA1c, Attacks of hypoglycemia, Attacks of DKA and IAT. Self-esteem questionnaire scores among diabetic group had significant negative correlations with IAT score as shown in table 4.

Internet addiction test scores among diabetes group had significant positive correlations with Age, Duration, HbA1c, Attacks of hypoglycemia & Attacks of DKA. Self-Esteem Questionnaire scores among control group had significant positive correlations with BMI as shown in table 5.

The current study aimed to study the level of internet use and its impact on self-esteem in chronic diabetic adolescents. The Results of the present study revealed that Self-esteem questionnaire scores were significantly lower among diabetic adolescent(p < 0.001) with type 1 diabetes (29.4%) this goes in accordance with previous studies; (Kakleas et al.,2009), Young 2014 stated that T1DM can also increase the adolescent’s risk for psychiatric illness and can contribute to decreased self-esteem, conflict with family, peer difficulties, and poor coping with illness demands. As well as Mutlu et al., 2017 whose data revealed no difference in depression and anxiety levels, and self-esteem between adolescents with T1DM and healthy controls, indicating that these patients might adapt well to the disease. Moreover, Hards et al., 2023 reported that adolescents with T1D had comparable total self-esteem scores to healthy adolescents without a chronic illness and there were no significant differences in any self-evaluation domains.

In this study, Self-esteem questionnaire scores (ASQ) among diabetic adolescents had significant negative correlations with age, duration, HbA1c, attacks of hypoglycemia, attacks of DKA and IAT score. That’s to say, self-esteem tends to decrease with advancing age, prolonged duration of diabetes, elevated HbA1c levels, increased frequency of hypoglycemic episodes and diabetic ketoacidosis (DKA) attacks, and higher levels of internet addiction. Consistent with our results; Sivakumar and Fenn, 2023 whose study showed a strong, positive correlation between self-esteem and glucose management (HbA1c), dietary control, physical activity, health care-use, energy, positive well-being, and general well-being. All the dimensions of self-management, i.e., glucose management, dietary control, physical activity, and health care use, indicated a strong positive correlation with self-esteem. As self-esteem enhances a person’s diabetic self-management also strengthens and vice versa.

These results go in accordance with Banariu et al., 2021 documented that there are statistically significant correlations between glycemic variability and depression, (positive correlation) included its both patterns: anxiety (positive correlation) and low self-esteem (negative correlation) The highest glycemic variability was observed in people with low self-esteem.

The Current study was consistent with previous studies stating that people who experienced repeated attacks of diabetic ketoacidosis may be more likely to experience difficulties with depression, low self- esteem, anxiety and personality disturbances (Allcock et al., 2022). The results of previous study performed by Vlachioti and collegues 2010 agreed with present results regarding treatment duration which shows a slight negative effect on self-esteem.

In the current study, a positive correlation between high body mass index (BMI) percentiles & low self-esteem scores was reported and was in concordance with previous findings of Vlachioti et al., 2010 who found that BMI have a slight negative effect on self-esteem. Although BMI and treatment duration had a slight negative effect on self-esteem seemed to have a positive effect, the associations did not reach statistical significance.

In present study, age and BMI were significant independent factors that decreased self-esteem score (towards low self-esteem), while mean male sex was a significant independent factor that increased self-esteem score (toward normal self-esteem). This model could explain 31.9% of the variability of self-esteem score (ASQ) among control group. Similarly, Pazzaglia et al., 2020 examined gender-related difference in self-esteem; results confirmed that girls report a lower self-esteem than boys Also, Bachman et al., 2011 whose findings suggested that among most adolescents in the United States, with the notable exception of African Americans, females are somewhat less willing than males to provide highly positive self-evaluations, but their findings didn’t show any age-related differences.

Additionally, current results revealed that Internet addiction test scores were significantly higher among diabetic adolescents(P < 0.001); Moderate and severe internet addiction were significantly more frequent among them too (P#0.028). Ozturk & Ayaz-Alkaya S 2021 reported that adolescents with chronic diseases were 2.1 times more at risk for problematic internet usage. This result was taken to mean that families of adolescents with chronic diseases may adopt a protective approach, allowing adolescents to do whatever they want and use the internet as much as they want.

On the contrary; Daniilidou et al., 2019 results revealed that Adolescents with T1DM and especially those on an insulin pump exhibit normal Internet use compared to their healthy peers, taking into consideration the small sample that was enrolled in the study (35 diabetic adolescents & equal controls) and that their study support the hypothesis that excessive Internet use is associated to poorer glycemic control for adolescents with T1DM. But worth noting that current study included a larger sample compared to these previous studies besides different social levels.

Moreover, results demonstrated that among diabetic adolescents, younger ages have normal internet use scores, followed by mild, then moderate while older ages have significant severe internet addiction, the differences were statistically significant (P < 0.001*). Additionally, Male sex was least frequent in normal internet use, followed by mild, then moderate and most frequent in severe internet addiction, the differences were statistically significant (P#0.011*), that’s to say males had moderate to severe internet addiction. Internet addiction test scores (IAT) among diabetes group had significant positive correlations with age, duration, HbA1c, attacks of hypoglycemia & attacks of DKA.

Interestingly; Büyükyılmaz et al., 2023 results stated that there was a weak negative correlation between the duration of diabetes and internet addiction scores in children with diabetes (r = − 0.21, p = 0.021). In line with these results, Daniilidou et al., 2019 found that levels of HbA1c (either as recent values or as previous year’s average) were lower in the group demonstrating normal Internet use but without reaching statistical significance. Finally, IAT scores and HbA1c values as previous years’ average were linearly correlated with an association that was approaching significance (r = 0.315, p = 0.065).

Low self-esteem was least frequent with normal IA, followed by mild, then moderate and most frequent with severe IA, the differences were statistically significant(P < 0.001*). In line with precedent mentioned findings, Chen et al., 2020 pointed out that students with lower self-esteem are more likely to become addicted to the Internet. This result is the same as that of Fioravanti et al., 2012 who conducted an analysis of IA in adolescents and found that self-esteem was related to IA, as well as Kim and Davis 2009, who proposed that low self-esteem can predict problematic Internet use.

Low self-esteem is a significant factor contributing to higher internet addiction scores among both diabetic adolescents and healthy controls. This problematic internet use poses a challenge for managing diabetes in adolescents with diabetes mellitus (DM). The negative impact of low self-esteem on their lifestyle likely exacerbates their internet use, making it a crucial area to address in diabetes management strategies.

IAT, Internet Addiction Test; ASQ, Adolescent Self-Esteem Questionnaire.

A statement on participant consent

Ethics approval and consent to participate: A written informed consents were obtained from parents/care-givers of the subjects after explanation of the aim of the study and its benefits. According to the ethical committees of Faculty of Postgraduate Childhood studies -Department of Medical Studies for Children with national code (RHDIRB2020110401) registered in November 2020, Moreover, they were informed that the study could be used by authors for scientific publication for medical research purposes without disclosing their personal identities non invasive procedures were done on the patients. Data collected in the study were confidential and kept under secrecy of the researcher.

Consent for publication: Not applicable

Conflict of interest:

NIL.

Source of funding:

NIL.

Individual author's contribution:

Hala Adel Abd Elaziz Eraky: Whole work of the study.

Mona Medhat Reda: Continuous supervision on whole work and guidance of selection of cases and broad instructions.

Dina Youssef ElAlfy: Direct supervision on all of the work starting from choosing the title of the study and all through the study methods and results.

Rasha Adel Thabet: Direct supervision and close monitoring of cases.

Ackerman CE (2020) What is self-esteem? A psychologist explains. Posit Psychol. ;16
Allcock B, Stewart R, Jackson M (2022) Psychosocial factors associated with repeat diabetic ketoacidosis in people living with type 1 diabetes: A systematic review. Diabet Med 39(1):e14663
American Psychiatric Association (2000)
, Anderson Monica, and Jingjing Jiang. Teens, social media & technology 2018 Aug 31
Bachman JG, O'Malley PM, Freedman-Doan P, Trzesniewski KH, Donnellan MB (2011) Adolescent self-esteem: Differences by race/ethnicity, gender, and age. Self identity 10(4):445–473
Banariu GM, Tica I, Rus M, Stanca I, Onuc S, Neagoe G, Tica VI (2021) The relationship between depression, anxiety disorder and low self-esteem in regard to glycemic variability in diabetic patients. Acta Endocrinol (Bucharest) 17(4):486
Burgess J, Marwick A, Poell T (eds) (2018 Nov) The SAGE handbook of social media. Sage, p 20
Büyükyılmaz G, Toksoy Adıgüzel K, Koca SB (2023) Comparison of internet usage and internet addiction scores in healthy children and children with type 1 diabetes mellitus. J Pediatr Endocrinol Metab 36(5):435–440
Černja I, Vejmelka L, Rajter M (2019) Internet addiction test: Croatian preliminary study. BMC Psychiatry 19(1):388 Dec 5
Chen HC, Wang JY, Lin YL, Yang SY (2020) Association of internet addiction with family functionality, depression, self-efficacy and self-esteem among early adolescents. Int J Environ Res Public Health 17(23):8820
Chou C, Condron L, Belland JC (2005) A review of the research on Internet addiction. Educational Psychol Rev 17:363–388
Cox DJ, Gonder-Frederick L (1992) Major developments in behavioral diabetes research. J Consult Clin Psychol 60(4):628
Daniilidou K, Triantafyllou P, Resta M, Dimitriadou M, Christoforidis A (2019) Level of Internet use among Greek adolescents with type 1 diabetes. Int J Adolesc Med Health 31(1):20160140
Devendra D, Liu E, Eisenbarth GS (2004) Type 1 diabetes: recent developments. BMJ 328(7442):750–754
Delamater AM, de Wit M, McDarby V, Malik JA, Hilliard ME, Northam E, Acerini CL (2018) ISPAD Clinical Practice Consensus Guidelines 2018: Psychological care of children and adolescents with type 1 diabetes. Pediatr Diabetes. ;19
Fioravanti G, Dèttore D, Casale S (2012) Adolescent Internet addiction: testing the association between self-esteem, the perception of Internet attributes, and preference for online social interactions. Cyberpsychology Behav Social Netw 15(6):318–323
Fu KW, Chan WS, Wong PW, Yip PS (2010) Internet addiction: prevalence, discriminant validity and correlates among adolescents in Hong Kong. Br J Psychiatry 196(6):486–492
Gabarron E, Årsand E, Wynn R (2018) Social media use in interventions for diabetes: rapid evidence-based review. J Med Internet Res 20(8):e10303
Gaudieri PA, Chen R, Greer TF, Holmes CS (2008) Cognitive function in children with type 1 diabetes: a meta-analysis. Diabetes Care 31(9):1892–1897
Giani E, Scaramuzza AE, Zuccotti GV (2015) Impact of new technologies on diabetes care. World J diabetes 6(8):999
Hafekost K, de Boterhoven K, Lawrence D, Sawyer MG, Zubrick SR (2017) Validation of the Adolescent Self-Esteem Questionnaire: technical report. Perth, Australia: Telethon Kids Institute and the Graduate School of Education, The University of Western Australia
Hards E, Orchard F, Khalid S, D’souza C, Cohen F, Gowie E, Loades M (2023) Self-evaluation and depression in adolescents with a chronic illness: A systematic review. Clin Child Psychol Psychiatry 28(1):382–397
Hausmann JS, Touloumtzis C, White MT, Colbert JA, Gooding HC (2017) Adolescent and young adult use of social media for health and its implications. J Adolesc Health 60(6):714–719
Hawi NS (2013) Arabic validation of the Internet addiction test. Cyberpsychology. Behav Social Netw 16(3):200–204
Ibrahim I (2011) اختبار يونج لإدمان الإنترنت [Young’s Internet Addiction Test]. كراسة الأسئلة والتعليمات [Questionnaire booklets]. https://doi.org/10.13140/RG.2.2.18368.58881
Kakleas K, Kandyla B, Karayianni C, Karavanaki K (2009) Psychosocial problems in adolescents with type 1 diabetes mellitus. Diabetes Metab 35(5):339–350
Kenowitz JR, Hoogendoorn CJ, Commissariat PV, Gonzalez JS (2020) Diabetes-specific self‐esteem, self‐care and glycaemic control among adolescents with Type 1 diabetes. Diabet Med 37(5):760–767
Kim HK, Davis KE (2009) Toward a comprehensive theory of problematic Internet use: Evaluating the role of self-esteem, anxiety, flow, and the self-rated importance of Internet activities. Comput Hum Behav 25(2):490–500
, Morahan-Martin J (2005) Internet abuse. *Social Sci Comput Rev, *23(1),39–48
Moreno MA, Uhls YT (2019) Applying an affordances approach and a developmental lens to approach adolescent social media use. Digit health 5:2055207619826678
Mutlu EK, Mutlu C, Taşkıran HG, Özgen İT (2017) Relationship between physical activity level and depression, anxiety, quality of life, self-esteem, and HbA1c in adolescents with type 1 diabetes mellitus. Turkish J Physiotherapy Rehabilitation 28(2):38–46
Naguib JM, Kulinskaya E, Lomax CL, Garralda ME (2009) Neuro-cognitive performance in children with type 1 diabetes—a meta-analysis. J Pediatr Psychol 34(3):271–282
Ozturk FO, Ayaz-Alkaya S (2021) Internet addiction and psychosocial problems among adolescents during the COVID-19 pandemic: A cross-sectional study. Arch Psychiatr Nurs 35(6):595–601
Pazzaglia F, Moè A, Cipolletta S, Chia M, Galozzi P, Masiero S, Punzi L (2020) Multiple dimensions of self-esteem and their relationship with health in adolescence. Int J Environ Res Public Health 17(8):2616
Rosenberg M (1965) Rosenberg self-esteem scale (RSE). *Acceptance and Commitment Therapy Measures Package, ; 61. https://doi.org/10.1037/t01038-000
Sivakumar P, Fenn J (2023) The Mediating Role of Self-Esteem in the Relationship between Diabetic Self-Management and Well-Being among Diabetic Patients. Int J Indian Psychȯlogy. ;11(3)
Vlachioti E, Petsios K, Boutopoulou B, Chrisostomou A, Galanis P, Matziou V (2010) Assessment of self-reported self‐esteem in healthy and diabetic children and adolescents in Greece. J diabetes 2(2):104–111
Wong KL, Ong SF, Kuek TY (2012) Constructing a survey questionnaire to collect data on service quality of business academics. *European J Social Sci 29(2):209–222
Young KS (1996a) Internet addiction: The emergence of a new clinical disorder. Paper presented at the 104th annual meeting of the American Psychological Association, Toronto, Canada August
Ziegler D (2020) Psychological aspects of adolescent diabetes (Master's thesis). Kennesaw State University Digital Commons. https://digitalcommons.kennesaw.edu/nursmast_etd/11

Table (1): Comparison between diabetic and control groups regarding self-esteem (ASQ):

Variables		Diabetic group (Total=255)	Control group (Total=255)	p-value
Score	Mean±SD	23.0±9.0	25.9±7.5	^<0.001*
Score	Range	1.0–47.0	7.0–45.0	^<0.001*
Category (n, %)	Normal	180 (70.6%)	218 (85.5%)	#<0.001*
Category (n, %)	Low	75 (29.4%)	37 (14.5%)	#<0.001*

^Independent t-test. #Chi square test.

Table (2): Comparison between diabetic and control groups regarding internet addiction (IAT)

Variables		Diabetes group (Total=255)	Control group (Total=255)	p-value
Score	Mean±SD	47.2±16.6	41.7±13.6	^<0.001*
Score	Range	6.0–96.0	9.0–84.0	^<0.001*
Category (n, %)	Normal	39 (15.3%)	56 (22.0%)	#0.028*
	Mild	116 (45.5%)	124 (48.6%)
	Moderate	90 (35.3%)	72 (28.2%)
	Severe	10 (3.9%)	3 (1.2%)

^Independent t-test. #Chi square test.

Table (3): Comparison between self-esteem questionnaire scores (ASQ) among diabetic group regarding internet addiction (IAT)

Variables		Self-esteem		p-value
Variables		Normal (Total=180)	Low (Total=75)	p-value
Score		40.1±12.0	64.3±13.6	^<0.001*
Category (n, %)	Normal	39 (21.7%)	0 (0.0%)	#<0.001*
	Mild	104 (57.8%)	12 (16.0%)
	Moderate	37 (20.6%)	53 (70.7%)
	Severe	0 (0.0%)	10 (13.3%)

^Independent t-test. #Chi square test. *Significant.

Table (4): Correlations of self-esteem questionnaire scores (ASQ) among diabetics and control groups

Variables	Measures	Diabetes group (Total=255)	Control group (Total=255)
Age	r	-0.449	-0.426
Age	p-value	<0.001*	<0.001*
Order	r	0.057	-0.045
Order	p-value	0.364	0.477
Weight	r	-0.048	0.026
Weight	p-value	0.449	0.683
Height	r	0.030	0.040
Height	p-value	0.633	0.529
BMI	r	0.107	-0.379
BMI	p-value	0.089	<0.001*
Age of onset	r	0.059
Age of onset	p-value	0.349
Duration	r	-0.179
Duration	p-value	0.004*
HbA1c	r	-0.247
HbA1c	p-value	<0.001*
Attacks of hypoglycemia	r	-0.222
Attacks of hypoglycemia	p-value	<0.001*
Attacks of DKA	r	-0.199
Attacks of DKA	p-value	0.001*
IAT	r	-0.824	-0.750
IAT	p-value	<0.001*	<0.001*

r: Correlation coefficient. *Significant.

Table (5): Correlations of internet addiction scores (IAT) among diabetic and control groups

Variables	Measures	Diabetes group (Total=255)	Control group (Total=255)
Age	r	0.422	0.396
Age	p-value	<0.001*	<0.001*
Order	r	-0.024	0.085
Order	p-value	0.699	0.178
Weight	r	0.034	-0.042
Weight	p-value	0.593	0.502
Height	r	-0.052	-0.063
Height	p-value	0.406	0.313
BMI	r	-0.089	0.338
BMI	p-value	0.157	<0.001*
Age of onset	r	-0.037
Age of onset	p-value	0.561
Duration	r	0.149
Duration	p-value	0.017*
HbA1c	r	0.211
HbA1c	p-value	0.001*
Attacks of hypoglycemia	r	0.193
Attacks of hypoglycemia	p-value	0.002*
Attacks of DKA	r	0.168
Attacks of DKA	p-value	0.007*

r: Correlation coefficient. *Significant.

The authors declare no competing interests.

Internet Addiction Among Diabetic Adolescents and The Impact on Their Self Esteem

Status:

Version 1

Abstract

Background

Objectives

Methods

Results

Conclusion

Introduction

Patients and Methods

Statistical analysis:

Results

Discussion

Conclusion

Abbreviations

Declarations

References

Tables

Additional Declarations

Status:

Version 1