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'you can be stupid and be ok on a pump, but it's better if you're smart.'

by joseph alexiou

this past july, the new england journalof medicine released a study showingthat people with type 1 diabetes-themetabolic disease with high levels ofblood sugar caused by the body's inabilityto produce insulin-were able to moreeffectively reduce their levels of bloodsugar using insulin pumps than thetraditional self-injection method.

according to the report, authoredby richard m. bergdenstal, williamv. tamborlane, andrew ahmannand others, the level of glycatedhemoglobin-the scientific name of theblood sugar test often called the a1c bymost diabetics and endocrinologists-in

485 patients aged 7 to 70 was reducedon average from 8.3 percent to 7.5, amuch more acceptable level. twenty-sevenpercent of pump-therapy patientswere able to reduce their a1c to under7 percent, which is essentially the holygrail of acceptable sugar levels for type 1patients. only 10 percent of self-injectingpatients could achieve this.

so why is it, with 700,000 new yorkersaffected by diabetes, we don't hear moreabout the use of insulin pumps versustraditional injection methods? are thepumps not as effective as studies claim, orare we only now starting to benefit fromthe efficacy of these marvels of modernmedical technology?"the technology, in general forpatients with diabetes, has improveddramatically in the last 10 years," said dr.joel zonszein, a director of the clinicaldiabetes center at the albert einsteincollege of medicine-a division of

montefiore medical center in the bronx."but i always say that the pump will beonly as good as the person who's usingit. patients think, 'ok i get a pump, anautomatic pilot.' but really, they are verylabor intensive."

insulin pumps are small electronicdevices made up of a syringe and a motor-drivenscrewdriver. the patient attachesthe pump to a catheter, which he or shehas inserted into his or her skin using aneedle, allowing a continuous deliveryof fast-acting insulin. this plastic tubingmust be changed everythree days, but the constantstream of insulin allowsfor patients to easily adjusttheir level of intake for mealportions, exercise and otherfactors that longer-termself-injection insulin makemore complicated. and the amount ofneedle sticks, which is usually three to fiveinjections daily by patients who use thetraditional method, are much reduced.

while diabetes experts like dr.zonszein and dr. daniel lorber, anassociate professor at the weill-cornellmedical and an instructor at the newyork hospital in flushing, queens, agreethat there are advantages to using theinsulin pumps, "there's no such thing

as treatment without negatives," saiddr. lorber in a recent phone interview."pumps take work, they require logic andbrain power-you can be stupid and beok on a pump, but it's better if you'resmart."

according to dr. lorber, using thepump also requires patient training,which has more of a learning curve andcan take at least a full day of trainingfrom a practice educator in the mostsophisticated of diabetes medicalpractices. beyond the training, thereare two serious negatives for pump use:the risk of infection from improperlysanitized catheters; and mechanical pumpfailure-a patient who stops receiving theconstant stream of fast-acting insulin canquickly develop complications of diabeticketoacidosis, an affliction of diabetics withsymptoms including falling into a coma.

other cons of pumps include thecost-an extra $10,000 a year, which isoften covered by insurance, but also the emotional and psychological weight ofbeing attached to a machine. the size ofpumps has certainly been reduced sincethey were introduced in the early 1990s,but "there's an emotional response andresistance on being machine dependent,"said dr. lorber, who, in the face of all thenegatives, sees them as minimal risks. "if ihad type 1 diabetes i'd be on a pump in ahot minute."

dr. zonszein is more cautious in hisview of the pump, and believes that theeffectiveness of the treatment is mostlya result of the patient's efforts, and lessthe technology. he sees the extra cost, nosmall number, to be a lot to pay for whathe believes is "not such a big increasein efficiency." unlike the findings inthe study cited above, dr. zonszein'spatients-80 percent of whom use apump-are rarely able to reduce theira1c below 7 percent, regardless of themethod they use for insulin delivery.

ultimately, according to dr. zonszein,the best way to treat diabetes is to mimicthe deficient human system as best aspossible: a mechanical pancreas implantedin the pelvic region, secreting insulindirectly into the central venal system.this kind of technology has been underdevelopment as long as insulin pumps,but an effective version is years away fromcompletion.

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