Aims. To explore how changes in insulin regimen are associated with estimated adiposity over time among youths and young adults with type 1 diabetes and whether any associations differ according to sex. Materials and Methods. Longitudinal data were analyzed from youths and young adults with type 1 diabetes in the SEARCH for Diabetes in Youth study. Participants were classified according to insulin regimen categorized as exclusive pump (“pump only”), exclusive injections (“injections only”), injection-pump transition (“injections-pump”), or pump-injection transition (“pump-injections”) for each follow-up visit completed. Estimated body fat percentage (eBFP) was calculated using validated equations. Sex-specific, linear mixed effects models examined the relationship between the insulin regimen group and change in eBFP during follow-up, adjusted for baseline eBFP, baseline insulin regimen, time-varying insulin dose, sociodemographic factors, and baseline HbA1c (≥9.0% vs. <9.0%). Results. The final sample included 284 females and 304 males, of whom 80% were non-Hispanic white with mean diagnosis age of
12.7
±
2.4
years. In fully adjusted models for females, exclusive pump use over the study duration was associated with significantly greater increases in eBFP compared to exclusive use of injections (
difference
in
rate
of
change
=
0.023
%
increase per month,
95
%
CI
=
0.01
, 0.04). Injection-to-pump transitions and pump-to-injection transitions were also associated with greater increases in eBFP compared to exclusive use of injections (
difference
in
rate
of
change
=
0.02
%
,
95
%
CI
=
0.004
, 0.03, and 0.02%;
95
%
CI
=
0.0001
, 0.04, respectively). There was no relationship between the insulin regimen and eBFP among males. Conclusions. Among females with type 1 diabetes, exclusive and partial pump use may have the unintended consequence of increasing adiposity over time compared to exclusive use of injections, independent of insulin dose.