How does blood sugar control compare between pump users and insulin injecting adults?

insulin pump

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

Learning and Diabetes: A vicious circle

Learning and Diabetes

Rowan Hillsoncalculator

Practical Diabetes Nov/Dec 16

Only 32% of type one diabetics and 78% of type two diabetics are currently offered structural education in England. Even then, not all will attend. Will it have any positive long term effects for those who do? Many issues affect learning. This article discusses some of them.

Literacy and numeracy

In England in 2011, 15% of the population aged 16-65 had the learning that is expected of an eleven year old child. This is considered “functionally illiterate” by the National Literacy Trust.  Although they would not be able to pass an English GCE, they can read simple texts on familiar topics. More than 50,000 UK diabetics are at this basic level of reading ability.

Numeracy problems are higher with 24% of adults function at the same level as your average eleven year old. Testing diabetics shows that numeracy and literacy are linked and that blood sugar control is better in those with better numeracy and literacy. This is not surprising since so many tasks need these skills.

Weighing foods and estimating portion sizes


Converting between metric and imperial systems

Multiplying and dividing

Using decimals

Recognising and understanding fractions

Working with ratios, proportions and percentages


Arial 12 point font, upper and lower case, on white or off white backgrounds, using short words, short sentences and short paragraphs all improve readability.

Health Literacy

Health literacy includes reading, writing, numeracy, listening, speaking and understanding.

In the type two diabetes population, lower health literacy was significantly associated with less knowledge of diabetes, poorer glucose self- management, less exercise and more smoking.

In the USA people understood food labels better if they had higher income and education.  Overall 31% gave the wrong answer to food label questions. Many diabetics have problems with misinterpreting glucose meter readings, miscalculating carbohydrate intake and medication doses.

Lower scores were associated with being older, non-white, fewer years in education, lower income and lower literacy and numeracy scores.

When an internet based patient system was offered, those with limited health literacy were less likely to sign in and had more difficulty navigating the system.

Cognitive impairment

Alzheimer’s disease, vascular dementia and other cognitive impairments are more likely in diabetics particularly those with type two diabetes. A longer duration of diabetes and a younger age of onset were associated with cognitive impairment.


High blood sugars can cause poor concentration, tension, irritability, restlessness and agitation. In experiments, high blood sugar induced delayed information processing, poorer working memory, and impaired attention.

In five to eighteen year olds with new type one diabetes most neuropsychological tests showed considerable impairment.  One year post diagnosis, dominant hand reaction time was worse in those with poor glycaemic control.

Long term, type ones diagnosed before the age of 18 had five times the risk of cognitive impairment compared to their non- diabetic counterparts. Chronic hyperglycaemia increased the risk.


Most friends and relatives can recognise if someone well known to them has a low blood sugar, often faster than the individual. Cognitive performance drops at blood sugars of 2.6-3 in non- diabetic subjects.  In type one children, those who had recurrent severe hypoglycaemia had more impaired memory and learning.

Psychological issues

Both depression and anxiety can impair test performance. Both of these and other mental illnesses are more common in diabetics.

Sensory and motor problems

Visual impairment and deafness can make some learning methods difficult.


We all learn in different ways. A substantial proportion of the population has low literacy and numeracy. This impairs health literacy which impairs diabetes knowledge for self -care. Poor numeracy may worsen blood sugar control. Clearly written, easily readable information helps everyone. Having diabetes increases the risk of cognitive impairment both at diagnosis and long term. Both high and low blood sugars affect current ability to learn and may have long term adverse effects on cognition.

Before teaching diabetics it is worth having a think about any difficulties your patient could be having assimilating the learning. If so, how can you tailor your teaching to their needs?

The BBC has adult learning resources at



Diabetes structural education for children and their families: labour intensive, poorly attended, and no improvement in blood sugars


familyNICE want to see structural education for all new diabetics but particularly children and their families. Sadly the end results sometimes doesn’t seem to justify the effort put in. The wrong focus on eating lots of starch we wonder? Here is the abstract of one teams considerable efforts with the full paper here: :

Implementing a structured education program for children with diabetes: lessons learnt from an integrated process evaluation | BMJ Open Diabetes Research & Care <!– [if lt IE 10]><![endif]–>


Background There is recognition of an urgent need for clinic-based interventions for young people with type 1 diabetes mellitus that improve glycemic control and quality of life.

The Child and Adolescent Structured Competencies Approach to Diabetes Education (CASCADE) is a structured educational group program, using psychological techniques, delivered primarily by diabetes nurses.

Composed of four modules, it is designed for children with poor diabetic control and their parents. A mixed methods process evaluation, embedded within a cluster randomized control trial, aimed to assess the feasibility, acceptability, fidelity, and perceived impact of CASCADE.


Methods 28 pediatric diabetes clinics across England participated and 362 children aged 8–16 years, with type 1 diabetes and a mean glycosylated hemoglobin (HbA1c) of 8.5 or above, took part. The process evaluation used a wide range of research methods.


Results Of the 180 families in the intervention group, only 55 (30%) received the full program with 53% attending at least one module. Only 68% of possible groups were run.

Staff found organizing the groups burdensome in terms of arranging suitable dates/times and satisfactory group composition. Some staff also reported difficulties in mastering the psychological techniques.

Uptake, by families, was influenced by the number of groups run and by school, work and other commitments. Attendees described improved: family relationships; knowledge and understanding; confidence; motivation to manage the disease. The results of the trial showed that the intervention did not significantly improve HbA1c at 12 or 24 months.


Conclusions Clinic-based structured group education delivered by staff using psychological techniques had perceived benefits for parents and young people. Staff and families considered it a valuable intervention, yet uptake was poor and the burden on staff was high. Recommendations are made to inform issues related to organization, design, and delivery in order to potentially enhance the impact of CASCADE and future programs.

Current Controlled Trials ISRCTN52537669.

Key messages

  • The Child and Adolescent Structured Competencies Approach to Diabetes Education (CASCADE) structured education program is perceived by young people and parents who attend as having benefits but practical challenges associated with attendance result in low uptake.

  • Staff are positive about the potential of the program but organizational aspects are unacceptably burdensome.

  • CASCADE is potentially deliverable to families as part of routine care and could be a useful intervention. However, improvements in clinical and administrative support, staff training, program content, and service structures are required to ensure fidelity to the program and feasibility and acceptability to key stakeholders.

    1. Mary Sawtell1,
    2. Liz Jamieson2,
    3. Meg Wiggins3,
    4. Felicity Smith2,
    5. Anne Ingold3,
    6. Katrina Hargreaves3,
    7. Meena Khatwa3,
    8. Lucy Brooks4,
    9. Rebecca Thompson5,
    10. Deborah Christie5

    Author affiliations

    1. 1Social Science Research Unit, UCL Institute of Education, London, UK

    2. 2Department of Practice and Policy, UCL School of Pharmacy, London, UK

    3. 3Social Science Research Unit, Institute of Education, London, UK

    4. 4Medical Statistics Department, London School of Hygiene and Tropical Medicine, London, UK

    5. 5University College London Hospitals NHS Foundation Trust, London, UK
    1. Correspondence to Mary Sawtell;