Missed
Mealtime Bolus Is Major Cause of Glucose Control
Problems in Insulin Pump Therapy
"Forgetting" was the most
frequently reported reason for missing boluses
sixty-seven percent of the time and,
discontinuing their pump during exercise was not
a factor in the rise in A1c.
Missed mealtime boluses appear to be the
major cause of suboptimal glucose control in
patients with type 1 diabetes who are using
insulin pump therapy, according to a recent
study.
The cross-sectional study, was completed by
Jonathon Burdick, BS, and colleagues from the
University of Colorado Health Sciences Center,
United States.
Forty-eight patients, between 7 and 20 years
old, who were using insulin pumps and glucose
meters that could be downloaded at the clinic
were admitted to the study. All had been using
the pumps for at least 6 months, had gone to
pump-training classes and received training on
calculation of mealtime insulin boluses. Either
the patients or their guardians (if 12 years old
or younger) were given a questionnaire to help
identify possible reasons for sub-optimal
control.
The only factor that was found to correlate
significantly with the HbA1c levels
was the number of missed mealtime boluses
(r=.41, P = .003). Thirty-five percent of
the patients missed less than 1 mealtime bolus
per week while the rest missed 1 or more. The
mean HbA1c level in the first group
was 8.0% compared with 8.8% for those 1 or more
missed boluses (P = .0001).
The mean number of physician-estimated missed
mealtime boluses per week was 2.1 versus 1.3
according to the self-reports (P = .052).
Although all age groups underestimated the
number of missed boluses per week, the 13 to
15-year-old age group had the highest level of
underestimation and the highest mean HbA1c
level (8.8%) of the 4 age groups.
Fifty-two percent of the participants said that
they discontinued their pump during exercise.
However, there were no significant differences
in HbA1c values related to stopping
the pump or bolusing before discontinuing the
insulin pump prior to exercise. The researchers
also saw no correlation between the amount of
time the pump was turned off and HbA1c
levels. The timing of the insulin boluses in
relation to meals (before only versus after
only) showed a non-significant trend toward
lower HbA1c levels among those who
bolused before the meal (P = .052).
When the researchers looked at the
questionnaires, "forgetting" was the
most frequently reported reason for missing
boluses (67%). Other cited concerns included
fear of hypoglycemia (6%), inconvenience of the
pump location (2%) and being too busy (8%).
Pediatrics. 2004. Mar. 113(3) e221-e224
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