Barriers to improved glycaemic control in pump therapy

The cornerstone of treatment for people with type 1 diabetes is the use of insulin therapy to attain an HbA_1c level of <7.5% (<58 mmol/mol) – this has been shown to achieve a significant reduction in the risk of developing complications (Diabetes Control and Complications Trial Research Group, 1993; NICE, 2009). 

In the author’s clinic, it was observed that many people with type 1 diabetes using insulin pump therapy had a mean HbA_1c level of ≥8% (≥64 mmol/mol), which had not improved over the years, despite the team’s best and continued efforts. In light of this, the following study was conducted to examine the barriers to improved glycaemic control in this population.

Methods
Eighty people with type 1 diabetes using insulin pump therapy with an HbA_1c level ≥8% (≥64 mmol/mol) were invited to participate in an informal group approach, where participants could discuss and find solutions to lowering their HbA_1c levels. Twenty-one people accepted and 17 participated in four, 1-hour focus groups. 

A semi-structured interview schedule was designed, but each group was given freedom to explore any issues that arose. Each focus group was recorded, transcribed and the emerging themes identified.

Emerging themes 
Expected and realistic HbA_1c levels
Participants were asked about their current HbA_1c level and what they were aiming for. Most specified that the optimum HbA_1c level was approximately 7% (53 mmol/mol), but they anticipated increased hypoglycaemia at this level. 

Participants felt that pump therapy had helped them lead a normal life, but they acknowledged the hard work and effort needed to achieve and maintain good glycaemic control.

Fear of hypoglycaemia and feeling safe
Half of the participants reported intentionally running their blood glucose levels higher than advised because they were fearful of hypoglycaemic episodes and wanted to feel safe. The emotions expressed were of being scared and anxious. Two situations in particular that caused this anxiety were driving and working. 

Participants reported taking a pragmatic approach to managing their diabetes, choosing to settle at an HbA_1c level that suited them, rather than aiming for tight glycaemic control. This is summed up by the following quote from one participant:

“I am happy around 8 [HbA_1c percentage] – it suits me as a person and suits my lifestyle.”

Conclusion
The results suggest there is a gap between what clinicians and people with type 1 diabetes regard as the optimum HbA_1c level to aim for when using insulin pump therapy. Participants often made a pragmatic decision not to aim for tight glycaemic control because they wanted to feel safe from hypoglycaemia, free from restrictions and to incorporate diabetes into their everyday life. 

Retrospective data analysis over 3 years’ experience of pump therapy has shown that HbA_1c levels can continue to improve in the first 12 months but then remain constant (Kerr et al, 2008). By this time, quality-of-life has improved and pump management has been incorporated into normal daily life. It is important, therefore, to make every effort to reduce the HbA_1c levels in people with type 1 diabetes using insulin pump therapy during the first 12 months.