If adults get the same level of education about blood sugar management there is only a tiny improvement in blood sugar control with a pump compared to a basal bolus injection regime.
The REPOSE trial was based in the UK with 315 participants across eight sites. Using small groups the patients were taught the DAFNE course, Dose Adjustment for Normal Eating. After the course the patients were randomised to either multiple daily injections which is standard UK management, or insulin pump use.
The organisers wanted to see how many people managed to get their hba1c below 7.5% after two years and what effects the regimes had on quality of life and hypoglycaemia.
Out of the original 315 patients, 260 finished the courses and entered the trial. There were small improvements in both groups for hba1c. The pump group got a 0.85% improvement in hba1c and the injectors got 0.42% improvement. This was not considered to be good enough to recommend pump provision, which is more expensive than pen injectors, to adults as a routine measure.
The pump group started with hba1s averaging around 9.5% and ended up around 8.7%. The injectors started with an average of 9.0% and ended up around 8.5%. In addition there was no particular difference in hypoglycaemia or psychosocial outcomes.
My comment: It is a pity that DAFNE is considered the gold standard educational tool for type one diabetics when the outcomes are so underwhelming. The main problems are that although carb counting is included, carbohydrate restriction is not. Insulin coverage of protein is not done and the seven unit rule is ignored. These are the main reasons that the outcomes are so poor. Structured education in person is expensive and time consuming for health care professionals. Why not grasp the nettle and actually teach people what they need to know to get normal blood sugars and not hba1cs of 8.5-8.7 which are certain to lead to diabetic complications?
Based on BMJ article BMJ 2017;356:j1285
Diabetes Diet 
Yes! Just like the trials that “prove” testing for Type 2s doesn’t work, or that low carb diets are no better than low fat, my first thought is that the trials were knobbled to produce the results they wanted it to produce.
Wasn’t there also one a while back that “proved” that Lantus and Levemir were no better than NPH? Results simply not found in the Real World.
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I also see the issue with the study. It gives us insight, without meaning.
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There is a belief out there that pumps will rescue diabetics out of poor control. Pump users get more education on meal to insulin matching, the dawn phenomenon, changing basals around illness and periods, and they are expected to cover protein with insulin. I have seen a difference of about 0.5% in other studies. But this study shows that with the same education you get very similar results. If the study had shown a clear benefit to pumps, it could have put more pressure on services to supply pumps. Of course what they need to do is supply low carb dietary education and precision meal insulin matching. This could still take years to become mainstream.
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I knew a girl with a pump, she was bright as a button and her mother was very far from stupid, but her A1c remained about 8.5%. This was entirely down to the fact they were not taught to drive it properly.
I recommended they contact an advisor from the pump importer and look at Type1Grit. Haven’t seen them recently, come to think, hopefully they have moved someplace where the doctors/nurses are more pump-savvy.
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I saw a chap recently who has a HbA1c of 12% on a pump. The lowest I’ve seen is 7.5%. Why don’t they just tell them to cut carbs and eat more fat?
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They genuinely believe you will instantly drop dead of a heart attack. 😦
The Opathy Sisters (as someone called them) dialysis and amputations are seen as a better alternative.
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Add in Blindness as another Opathy Sister. Good term!
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Retinopathy, neuropathy and of course myopathy among the medical staff 😦
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