Multiple factors contribute, including Pubertal and insulin - induced weight gain Hormonal changes that decrease insulin sensitivity Psychosocial factors that lead to insulin nonadherence (eg, mood and anxiety disorders, hectic schedules, irregular meals, family conflict) Experimentation with cigarette, alcohol, and substance use Eating disorders that lead to insulin omission as a means of controlling weight For these reasons, some adolescents experience recurrent episodes of hyperglycemia, diabetic ketoacidosis, and hypoglycemia requiring emergency department visits and hospitalization.