Insulin Pumps: Strategies to Improve Blood Sugar Control

For parents of children with type 1 diabetes (T1D) and people with T1D, keeping blood sugar levels in range is a relentless pursuit. This journey is a challenging one; it constantly requires strategies and adjustments that don’t always yield the expected results.   

Over time, medical research has shown that certain glycemic control strategies can help to achieve blood sugar targets. For instance, a major study published in the 1990s was the first to observe that combining capillary blood sugar measurements with multiple daily injections of insulin helped to reach glycated hemoglobin (HbA1c) levels of 7.5% and under. Diabetes Canada currently recommends that HbA1c levels remain under 7.0% or 7.5%—depending on age—to prevent the onset or development of potential diabetes-related complications.   

Nowadays, the inflow and democratization of technology mean that a growing number of T1D patients use continuous glucose monitoring (CGM) systems or insulin pumps that, in most cases, lower the burden of blood sugar control, improve quality of life, reduce time spent in hypoglycemia and improve HbA1c levels. 

Although this sounds very good, there are strategies you can use to get the most out of these technologies. What are they? Are there any strategies that are more effective for improving blood sugar levels? 

Recently in Denmark, 770 adults with T1D who use an insulin pump participated in a study by answering questions online about how they use their pump. Their answers were then analyzed against their blood sugar levels. 

Self-adjusting pump settings

While insulin pumps allow better blood sugar control than multiple daily injections (MDI), the large number of settings and adjustments can be intimidating. However, the study showed that users who adjust their settings on their own in-between medical appointments have better HbA1c levels than those who don’t. 

The study didn’t involve any participant who used one of the new hybrid closed loop systems (Medtronic 670G and 770G and Tandem Control-IQ), which automatically adjust the basal rate and reduce the number of adjustments required from the user.

Other self-management tips

The study noted other self-management strategies, in addition to self-adjustment of pump settings, that were also associated with improved HbA1c:  

• No missed dose. Participants who said they never—or rarely—missed a dose before a meal or a snack were found to have a better HbA1c level than those who did. One strategy that can help to develop this habit is to set an alarm at mealtimes on your pump or your phone.
• Bolusing before a meal. Although it’s probably one of the hardest strategies to get used to, bolusing before a meal helps to reduce post-meal blood sugar spikes. This was demonstrated in the study, where participants who bolused 10–15 minutes before their meal had better HbA1c levels than those who bolused during or after their meal. 
• Regular change of infusion sets. Infusion sets are used for the subcutaneous administration of insulin. They include a catheter, tubing and a cartridge. Participants in the study who changed their infusion sets under the four-day mark did have better HbA1c levels than those who did so after 5–10 days. The Omnipod tubeless pump was not included in this finding, since the pod cannot be worn for more than three days. Current recommendations are to change infusion sets after 48–72 hours to avoid problems such as occlusions and lipodystrophy. 

Not-so-optimal strategies

While some strategies are clearly effective for improving HbA1c levels, others are not quite as beneficial, such as the following “advanced” insulin pump features:  

• Temporary basal rate. This option allows the user to increase or decrease their basal rate over a chosen period of time (e.g., when doing physical activity).
• Dual/square or extended bolus. This option allows the user to administer part of their insulin dose at the start of their meal and the remaining units over a chosen period of time (e.g., when eating a meal that is high in fat).
• Square bolus. This option allows the user to administer their insulin dose continuously over a chosen period of time (e.g., when eating a very long meal). 

These features may possibly not have a significant effect on HbA1c levels due to how difficult it is to find the right settings (e.g., time).

The results of the study suggest that insulin pump users must be proactive and sufficiently knowledgeable to adjust their settings on their own. Even hybrid closed loop systems that automatically adjust the basal rate according to blood sugar levels require the user to enter boluses (e.g., at mealtimes) and adjust certain settings (e.g., insulin-to-carb ratios, insulin sensitivity). And certain types of meals (e.g., higher in fat) can still affect blood sugar control (e.g., extended hyperglycemia).

As long as there is no cure for T1D, patients will need knowledge and confidence to take their diabetes management into their own hands. Healthcare professionals need to make sure they give their patients access to this knowledge and consider their needs to help them live better with T1D.