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RE: [IPk] my response to the DAFNE trial published in the BMJ

My thought on the DAFNE article was that they chose to focus on a single
group - long term diabetics with moderate control.

My view is that the most beneficial point to apply DAFNE would be at the
point of "maximum leverage" - when new diabetics have recovered from the
shock of diagnosis and want to know how to manage their new condition, and
to instill good habits before bad habits have a chance to develop. I think
DAFNE is offered to this group in Northumberland.

I'm not sure if education gives sufficient attention to motivation - which I
now think is a VERY important factor in patient education. I would give it
as much attention as the technicalities and practicalities of injecting

I'd suggest that A1c's under 7 are achievable with MDI in *most* cases
(there are, of course, exceptions) - a pump increases that flexibility and
makes the process more straightforward and sensitive. The issues are
motivation and focus, willingness to change and put up with the
inconvenience, and (theoretical and self-)knowledge in most cases imho, but
also an acceptance of a higher A1c than is possible.

I have a slight concern that pump enthusiasts can over-egg the pump pudding
relative to MDI on some occasions, and that may cause some to see pumps as a
technological "great white hope". In due course that could cause a backlash.

<dons tin hat>

Who is planning a pump trial soon

> -----------------------------------------------------------------
> "adjusting carbohydrate and meal insulin only part of the problem"
> -----------------------------------------------------------------
> <!-- article ID: 325/7367/746 -->
> <P>  I have struggled with type 1 diabetes for 16 years and for the last 2
> of these have greatly benefitted from a pump.I was encouraged to read that
> some far thinking professionals are now doing what should have been
> uniformly taught to those with type 1 diabetes who are capable of
> undertaking such a program, for at least the last decade since the advent
> of "basal bolus" insulin regimens and home blood glucose monitoring.
> However the DAFNE study fails to mention the vital need for physiological
> basal insulin substitution in order to give good control while minimising
> hypos and allowing freedom with food. I am doubtful and envious that once
> or twice daily NPH will meet this need in many of those with diabetes.
> Part of this problem could be overcome by substituting the new long acting
> analogue glargine but many of us have widely varying basal insulin
> requirements which can only be met by a pump which can be programmed to
> give different rates each hour. Without this there would still be a need
> to eat large snacks at certain times of the day when insulin sensitivites
> are greater, or conversely spend times when sensitivity is less,
> hyperglycaemic to the detriment of HBa1c and future health.
> I believe that for some of us the pump is the only way to achieve
> satisfactory control. Perhaps I am being unrealistic in my dismay that
> people who are willing to monitor and inject intensively achieve only an
> average A1C in the mid 8s, rather than the 6s or 7s. The pump has allowed
> me to improve gradually from 9.6 to 6.6 % while retaining hypo awareness
> I believe, as a diabetic or to be politically correct, a person with
> diabetes, that we deserve the best.
> If I could not afford to pay I may well have had to have settled for
> second best
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help SUPPORT Insulin Pumpers http://www.insulin-pumpers.org/donate.shtml