Optimizing insulin delivery: assessment of three strategies in intensive diabetes management

Objective: To compare three intensive management strategies with respect to metabolic control (glycated haemoglobin, preprandial blood glucose, lipid profile, body weight, hypoglycaemic episodes) and psycho-social adaptation (quality of life, self-efficacy, stress and perceived complexity). Research Design and Methods: Fifteen adults with type 1 diabetes completed this 1-year, randomized, prospective, cross-over study. The three treatment strategies were categorized according to flexibility with insulin self-adj ustments as follows: Simplified (SIMP) = meal plan based on food exchanges with no self-adjustments of insulin for food, exercise and stress; Qualitat ive (QUAL) = meal plan based on food exchanges with qualitative adjustment of insulin for food, exercise and stress; Quantitative (QUANT) = meal plan using carbohydrate counting with quantitative adjustment of insulin for foo d and qualitative adjustment for exercise and stress. All three strategies allowed for adjustments of insulin for preprandial blood glucose and the op tion of adjusting diet for exercise. All subjects followed each strategy fo r 3.5 months. Subjects kept detailed log sheets where they recorded prepran dial blood glucose, insulin dosages, food intake, activity and stress level at least four times/day. The psycho-social aspects were determined with va lidated questionnaires that were completed before and after each strategy. Results: There were no statistically significant differences in metabolic c ontrol, quality of life and self-efficacy between the three strategies. The mean (+/- s.e.) for HbA(1) levels (normal < 8.5%) were: Baseline: 10.9 +/- 0.06 and End of SIMP = 9.7 +/- 0.03; QUAL = 9.5 +/- 0.04; QUANT = 10.2 +/- 0.04. Body weight and serum lipid levels did not change significantly. The frequency of severe hypoglycaemic episodes for the entire study was 20 epi sodes/100 patient-years. Perceived complexity of treatment strategy increas ed (p < 0.0001) from SIMP to QUANT (least to most flexible). Although the m ajority of subjects (n = 11) were following a strategy similar to SIMP prio r to entering the study, 12 subjects chose to continue with QUAL, three wit h QUANT and none with SIMP at the end of the study. Conclusions: These results indicate that a strategy that allows for flexibi lity of self-adjustments of insulin and is not very complex (such as QUAL) may be the strategy of choice for intensive management programmes.