2019

Managing hypoglycaemia in

diabetes: lessons from the USA and the

Netherlands

GAYLE RICHARDS

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Copyright © 31/03/2019 by Gayle Richards. The moral right of the author has been

asserted. The views and opinions expressed in this report and its content are those

of the author and not of the Winston Churchill Memorial Trust or its partners, which

have no responsibility or liability for any part of the report.

Front cover photograph of the first Diabetes Nurse Educators. This picture hangs in

the entrance to the Joslin Centre.

Acknowledgements

I wish to thank the Winston Churchill Memorial Trust for this Churchill

Fellowship which has enriched my life and hopefully the lives of people with

diabetes in the UK

Thanks go to those who helped me in all aspects of my Churchill Fellowship.

I am grateful to Northern Devon Healthcare NHS Trust who allowed me the

time to accomplish my travel and my colleagues for their support.

John Zrebiec and Marilyn Ritholz (from Joslin Centre, Boston, USA) were

extremely generous with their time; giving me the benefit of their extensive

knowledge and expertise.

I thank all the Diabetes Educators at Joslin Centre who gave me insight into

their practice.

In the Netherlands I appreciated the generosity of Marloes Hogenelst and

Frank Snoek in spending time with me and in encouraging me in my efforts to

improve the management of hypoglycaemia in UK.

Finally I thank all the people with diabetes who have helped me to appreciate

the impact of hypoglycaemia on their lives.

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Figure 1 Promotion that appeared in the North Devon Gazette.

About the author

I have worked as a Diabetes Specialist Nurse in the UK for over 30 years in four

different settings. In working with people with diabetes, my aim has always been to

empower individuals to live the best possible life through advice, providing

information and giving psychological support. I have supported people from

diagnosis right through to the unfortunate development of debilitating complications

both acute and chronic. I have always tried to look at more effective ways for

diabetes to be managed. Over the course of my career managing the problem of

severe hypoglycaemia (low blood glucose level) has remained a crucial component

of my clinical work. The Churchill Fellowship has enabled me to travel to the USA

and the Netherlands to look at programmes which can help people with diabetes

manage problem hypoglycaemia

List of contents

1. Executive summary p3

2. Introduction p5

3. Findings p11

4. Conclusion and recommendations p24

5. References and Bibliography p28

6. Appendices p29

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1. Executive summary

Hypoglycaemia is a significant complication of managing diabetes. The National

Institute of Health and Care Excellence (NICE) Guidelines for Type 1 diabetes in

adults: diagnosis and management (NG17) recommend that consideration should be

given to assisting access to the Blood Glucose Awareness Training (BGAT)

programme for adults with type 1 diabetes who are having recurrent episodes of

hypoglycaemia. In the UK this training is not available outside a small number of

specialist centres. The programme was originally developed in the USA and has

been adapted for use in other countries, in particular recently in the Netherlands.

In addition, there have been many developments in the field of technology which aim

to enable people with diabetes to better manage their condition and potentially

reduce the short and long term harmful effects.

The Winston Churchill Travel Fellowship application aimed to answer the following

questions:

• Is Blood Glucose Awareness Training (BGAT) an effective way to help people

with diabetes manage hypoglycaemia?

• Could a BGAT programme be delivered in the UK?

• What technological advances are currently in development and how might

they help people with diabetes?

Findings

BGAT programmes have consistently been shown to help people with diabetes,

particularly those with Type 1 diabetes but are now only delivered in a limited way in

the USA. It appears that programmes may cease to be run, especially at the Joslin

Centre. In contrast, the programme in the Netherlands (where it is termed

“HypoAware”) has been adapted to be delivered partly as a web-based programme

and has been shown to be successful. The centre at the Vrije Universiteit Medical

Centre (VUMC) in Amsterdam now uses a model where training in BGAT is provided

to health professionals from outside VUMC who can then deliver the programme in

their own centres.

There are many technological advances in managing diabetes, particularly in the

fields of monitoring glucose levels and the delivery of insulin, however many of these

developments will not be widely available in the UK in the immediate future.

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Recommendations

• Adaptation of the VUMC model of HypoAware in the UK to deliver group

training for people with diabetes with problem hypoglycaemia.

• Raising awareness amongst health professionals of the impact of Impaired

Awareness of Hypoglycaemia and the need to screen for this.

Implementation

• The development of a 2 day structured education programme for people with

diabetes is underway.

• Discussions with Bristol Community Health to pilot this programme have taken

place.

• Promotion of alternative strategies for managing hypoglycaemia has begun by

dissemination of my findings within clinical teams.

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2. Introduction

What is diabetes?

Diabetes is a chronic condition characterised by high levels of glucose (sugar) in the

blood (hyperglycaemia). This hyperglycaemia is caused by an absolute or relative

lack of insulin. Insulin is a hormone that enables the transfer of glucose from the

blood stream to all cells in the body so that it can be used as the main source of

energy. A deficiency in insulin means that glucose remains within the blood stream

and cannot be used by cells. This is hyperglycaemia and causes both short and long

term complications.

The main types of diabetes are: Type 1 where no insulin is produced at all and Type

2 where insulin is made but is not wholly effective due to insufficient quantities and

also to resistance which develops in the cell walls especially when people are

overweight.

Around the world the prevalence of both types of diabetes is rising. In the UK there

are almost 3.7 million people diagnosed with diabetes (2017 figures). About 90% of

people have Type 2 diabetes and this is often associated with being overweight. In

this case treatment concentrates on weight loss by lifestyle changes but medication

is often required. This can be tablets and types of injected therapy which can include

insulin. Type 1 diabetes and other rarer types of diabetes make up the remaining

10%. Type 1 diabetes develops more commonly in children and young people and

insulin is the only effective treatment. This is usually multiple daily injections or a

continuous infusion by an insulin pump.

Both types of diabetes can cause health problems. It is important to manage

diabetes well to prevent long term complications such as damage to the eyes,

kidneys and nerve endings. Life expectancy of people with diabetes remains

reduced due to an increased risk of strokes and heart attacks. Good management of

diabetes requires a daily regimen of medication, and adherence to healthy lifestyle

measures including diet and exercise. Monitoring of blood glucose levels is often

also required. Traditionally this involves obtaining a drop of blood by pricking the

finger which is then applied to a chemical strip. A meter uses the chemical change to

calculate the blood glucose level.

Quality of life can also be affected by short term complications of diabetes caused by

hyperglycaemia (leading to skin and other infections, slow healing, feeling thirsty and

lacking energy) and hypoglycaemia. Hypoglycaemia is the experience of a low blood

sugar and is a key side effect of insulin or certain oral medications.

When people have Type 1 diabetes, insulin must be injected at appropriate doses as

there is essentially no natural insulin produced. Managing Type 1 diabetes is actually

a delicate balancing act where the dose of insulin administered needs to avoid both

hypo and hyperglycaemia. This fine balance is affected by many variables including

the amount and type of food eaten, the amount and type of activity, mood, state of

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health and other medications. The individual with Type 1 diabetes needs to take

account of these variables to determine insulin doses. When the amount of insulin

administered is greater than the body’s requirements then hypoglycaemia can occur.

Why is hypoglycaemia a problem?

Hypoglycaemia is variously defined as a blood glucose level of below 4 or below 3.5

mmol/l and is categorised as mild or moderate when the individual can recognise

and treat the hypoglycaemia themselves. Severe hypoglycaemia requires assistance

from another person to ensure treatment is given to raise the blood glucose. This is

because the person with diabetes is confused, drowsy or (in rare cases)

unconscious.

It is difficult to accurately determine the incidence of hypoglycaemia in people with

Type 1 diabetes or insulin treated Type 2 diabetes. Differences are due in part to

variations in definitions. Severe hypoglycaemia is relatively simple to define as it

needs the assistance of another person whereas mild and moderate hypoglycaemia

are more complex. One study of self-reported non-severe hypoglycaemia in the UK

found 129.7 episodes per patient per year i.e. more than 2 per week. This figure is

similar to other studies in other developed countries.

Studies have variously reported rates of severe hypoglycaemia as 10% to 30% of

patients per year.

However measured it is indisputable that the impact of hypoglycaemia is significant.

The symptoms can be unpleasant and even frightening. This is due to the release of

adrenalin. People fear being thought of as drunk and can feel out of control and

dread doing something embarrassing. Andy Broomhead who has Type 1 diabetes

writes in his blog about three types of hypos being “inconvenient, awful and serious”

https://blogs.diabetes.org.uk/?p=7017

In my work as a Diabetes Specialist Nurse I have heard and seen the impact of

hypoglycaemia on the quality of life of people with Type 1 diabetes. It can be difficult

to live with the prospect of going hypo at work, while looking after children, when

driving or when alone.

Signs and Symptoms of hypoglycaemia

1. Adrenergic symptoms:

Trembling, pounding heart, sweating, clammy

skin

2. Neuroglycopenic symptoms:

Difficulty in concentrating, confusion, irritability,

drowsiness

3. Rarely, convulsions and coma can occur.

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For most people with diabetes, hypos are inconvenient and annoying but they do not

require assistance from anyone else to treat the low blood glucose level. The

symptoms are recognised as being an indication of a hypo and the individual takes

treatment.

The most effective treatment is rapidly absorbed carbohydrate such as sugary

drinks, sweets (e.g. jelly babies) or glucose tablets. In a severe hypo when the

individual cannot take treatment by mouth, injectable glucagon can be given. This is

a hormone which causes the release of glucose into the blood from stores in the

liver.

Symptoms of hypos in adults can vary in type and intensity. Factors which can lead

to the reduced perception of hypos include stress, alcohol, depression and certain

medications. However, the most significant factor is the duration of diabetes. It is

more common for people who have had diabetes, particularly Type 1 diabetes, for

many years to find that the symptoms of hypoglycaemia are greatly reduced or

absent. When this happens frequently it is termed Impaired Awareness of

Hypoglycaemia.

What is Impaired Awareness of Hypoglycaemia and how can it be managed?

Hypo unawareness or Impaired Awareness of Hypoglycaemia (IAH) are terms used

to describe the situation where individuals do not have sufficiently strong symptoms

(or “signals”) to recognise that their blood glucose is low. This is an ongoing issue

not an isolated event. This means that when experiencing a hypo, individuals can

appear to be drunk, confused or aggressive. In rare cases, convulsions, loss of

consciousness or coma can occur. Hypoglycaemic treatment will have to be given by

someone else. This can be problematic if the individual is resisting help or is too

drowsy to be given treatment by mouth. Injectable glucagon treatment may then be

needed. This can be given by a family member but often requires an emergency call

to paramedic services.

IAH can be devastating and often severely impacts on the quality of life of individuals

in whom it develops. In my work as a DSN the cases I remember are:

1. The man who lost consciousness walking home and was found lying in the

street by his friend who went to look for him

2. The mother who had a convulsion while at her child’s playgroup

3. The man who became violent and hit his wife when hypo

I have also been aware of several cases of car accidents including a driver who,

while hypo tragically killed a pedestrian.

IAH is therefore an incredibly important area to try to understand and better manage

and has been the focus of research for many years. It is estimated that IAH affects

20-25% people with Type 1 diabetes and 10% of people with Type 2 diabetes. These

figures have remained stable over time and seem to be consistent across different

countries.

Some research centres have looked for physiological and anatomical changes in the

brain which might explain why IAH might occur.

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Other work has explored ways to help people with hypo-unawareness. One of the

key areas is Blood Glucose Awareness Training.

What is Blood Glucose Awareness Training (BGAT)?

BGAT is a psycho-educational intervention designed to help individuals with Type 1

diabetes to better recognise their blood glucose levels from observing their

physiological state. By “tuning into” their physiological state it is proposed that

individuals can learn to better recognise hypo signals and reduce IAH.

Studies using BGAT date from the 1980’s. Initially the programmes aimed to improve

individuals’ ability to anticipate, detect, treat and prevent both very high and very low

blood glucose levels. The programme was developed in the USA by Daniel Cox and

Linda Gonder-Frederick. Several randomised controlled trials demonstrated the

benefits of the training. The training was delivered in the USA, Germany and the

Netherlands. To my knowledge no centre was routinely delivering such a programme

in the UK at that time.

However when the NICE guidelines for Management of Type 1 diabetes (NG17)

were published in the UK in 2015, my interest was aroused by guideline 1.3.7 which

states “Consider the Blood Glucose Awareness Training (BGAT) programme for

adults with type 1 diabetes who are having recurrent episodes of hypoglycaemia”

(2015, updated 2016)

I therefore started to investigate what is meant by BGAT and what the programme

involved. I contacted one of the leading experts on the management of IAH,

Professor Stephanie Amiel (from Kings College Hospital, London) who told me that

her team had completed a pilot study of a psycho-educational programme to restore

hypo awareness in individuals with IAH. She also told me that she was not aware of

any UK centres delivering a hypo-unawareness programme other than from her

research group. The programme at Kings College had received advice from Daniel

Cox and Linda Gonder-Frederick (who had developed BGAT in the USA) when

setting up their trial.

I realised that it was important to learn more about BGAT to explore whether such a

programme could be of benefit to people with diabetes in the UK. I therefore applied

for the Winston Churchill Travel Fellowship to look at the programmes that are

delivered in the USA and in the Netherlands. The key aim was to evaluate those

programmes and if appropriate, to develop a similar programme in the UK.

Technology

An additional aspect of my Churchill Fellowship was to explore how technology is

supporting people in the management of their diabetes. One of the more obvious

forms of technology, insulin pumps were first used in the UK in the 1970’s and were

mechanical devices that delivered insulin continuously through a needle inserted just

under the skin. They fell out of favour in the UK as they were cumbersome, intrusive

and somewhat unreliable. Over time, technological advances led to smaller and

more accurate pumps. They have now become a mainstay method of managing

Type 1 diabetes in the UK.

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Even in a small centre like my own, approximately 12% of adults with Type 1

diabetes use an insulin pump which is above the national average (National

Diabetes Insulin Pump Audit Report, 2013-15).

In order to deliver insulin appropriate to their body’s needs by an insulin pump or by

injections, people with Type 1 diabetes need to know the level of glucose in their

blood. In the 1980’s meters which measured capillary blood glucose (taken as a drop

of blood from the finger) became available and are now widespread as the means for

people to self-test. Unfortunately testing is painful and messy so alternative methods

have been the source of much research. These have included watches which

measured skin glucose, attempts to measure glucose in saliva and continuous

glucose monitoring of the skin. The latter is now available in the UK although NHS

funding is variable. There are no NICE guidelines which enable this to be given

routinely to adults. Exceptional funding can be awarded in special circumstances.

These can be for individuals with significant problems with IAH.

In an additional step, continuous glucose monitoring has then been used alongside

insulin pumps and further to coordinate together in a closed loop system (the

“artificial pancreas”). In addition, smart phones using applications (apps) have

encouraged the integration of glucose monitoring, activity tracking and insulin

delivery.

Progress in this field is so rapid that it can be difficult to keep up to date. I wanted to

ensure that I had an understanding of current developments and being awarded the

Churchill Fellowship gave me the opportunity to learn more and therefore be a

resource for other UK health professionals and for people with diabetes.

Objectives of my Churchill Fellowship

1. To visit centres in the USA and the Netherlands where Blood Glucose

Awareness Training is delivered as a group or individual intervention.

2. To use that experience to evaluate the benefits of BGAT and explore if this

could be delivered in the UK.

3. If a BGAT programme is appropriate for the UK the aim would be to then

develop such a programme for people with Type1 diabetes and/or health

professionals.

4. To learn more about emerging technology for the management of diabetes.

5. To use that experience in my clinical practice and disseminate more widely.

Planning my Churchill Fellowship

From academic searches I was able to ascertain that BGAT originated with

Professor Daniel Cox at the University of Virginia, Charlottesville, USA and my

original plan was to visit him there. After contacting him via email, Professor Cox

explained that he had retired from working in this field and suggested other names

that I should contact. Following up on these leads I was able to make contact with

John Zrebiec and Marilyn Ritholz at the Joslin Diabetes Centre in Boston, USA.

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This had a secondary interest for me as in all my career in diabetes, the Joslin

Diabetes Centre had been identified as a centre of innovation and excellence in

diabetes management, especially education. Therefore the opportunity to visit the

Joslin Diabetes Centre would enable me to speak to leading experts in BGAT and

also be able to see diabetes education in a world-leading centre.

A potential visitor to the Joslin Diabetes Centre must join their visitor programme.

There is a cost involved and a need to prove immunisation status. An individual

programme is then developed for the visitor. For me this meant that I would be able

to sit in on Certified Diabetes Educator clinics, group education sessions and

seminars as well as talk with John Zrebiec and Marilyn Ritholz.

After internet searches to look at technological developments I realised that there are

incredibly diverse companies, research institutes and academic centres involved with

this. These ranged from small biotechnology companies to Google. To link these into

a simple itinerary would be impossible. I realised that the most effective way to learn

more in this area would be to attend the American Diabetes Association (ADA)

Annual Congress. This is the largest diabetes conference in the world and current

and future research topics would be presented in a single meeting. I had not had the

opportunity to attend this meeting previously so this was a great privilege. In the year

of my Churchill Fellowship it was to be held in San Diego. I was able to co-ordinate

my visit to the Joslin Diabetes Centre immediately after attending the ADA Congress.

As the American insurance-based health system is very different to that of the UK it

was important to see BGAT delivered in a different health system. The most recent

publications on the benefits of such a programme have come from Professor Frank

Snoek’s group in the Netherlands. I was able to arrange to spend time at the VU

University Medical Centre where Professor Snoek is based and to speak to his team

who deliver their programme and had worked on the research that has been

published.

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3. Findings

I will present my findings under the headings of technology, hypoglycaemia

management and clinical care.

Findings in the field of technology from ADA annual congress and the Joslin

Diabetes Centre.

Many of the technology sessions at ADA Congress were devoted to variations of the

Artificial Pancreas (AP). This technology is predominantly used in Type 1 diabetes

and aims to replicate the action of the normal pancreas. In the closed loop system

insulin is released according to changes in the glucose levels detected by a

continuous sensing system. This system is often perceived as a Holy Grail by people

with Type 1 diabetes. I was interested to hear that this is by no means perfect. For

example, during exercise the system cannot respond fast enough to drops in the

glucose levels. Some systems incorporate as many as 9 different measures to try to

achieve better stability. These would be sensing such aspects as heart rate, body

temperature, accelerator and galvanic skin response. The further development

incorporates “dual hormone” technology into the AP. An infusion of glucagon is

released to counterbalance the insulin. After listening to talks from different research

centres about the benefits and drawbacks of different systems I realised that the key

aspect which leads to the greatest accuracy is the mathematical algorithm.

Figure 2 The dual hormone AP

Another fascinating area was the developments in insulin therapy. Insulin was

identified by Banting and Best in the early 1920’s. Insulin therapy has remained

pretty much the same since then. Insulin is administered subcutaneously either

through a single injection or continuously through a pump. Unless a closed loop

system is used (as above), doses are determined by the individuals themselves.

Advances have led to insulin with varying duration and strength and much work has

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been devoted to improving the intra-variability of action to give consistency in the

way insulin works. The exciting development is that of “smart” insulin. This insulin

reacts automatically to changing blood glucose levels which it identifies. Various

companies are developing slightly different approaches to smart insulin, however,

one way in which smart insulin works is by using a molecule called a ‘binding

element’. When blood glucose is low, the binding element attaches to the insulin and

prevents it from working. Conversely, as blood glucose levels rise, the glucose

molecules free the insulin from the binding element. This, in turn, allows the insulin to

lower blood glucose levels back into balance. It was impossible to tell when this

technology might be freely available. However I have discovered that since attending

the ADA Congress one of the large pharmaceutical companies working in this area

has announced that it has abandoned its research.

Perhaps more realistic are options to improve the absorption of insulin such as an

Insupad, which warms the injection site, and the use of microneedles in a patch

form. Some of this work has been on-going for many years and it was good to hear

of the challenges faced by researchers first hand.

I had been hoping to hear news of such innovations as contact lenses which are able

to sense glucose levels but there were no presentations regarding this technology at

the Congress. I have since read that Novartis and Google X who were working

together have abandoned attempts to take this concept forward.

Much of what I heard described the barriers and challenges in harnessing

technology to improve the lives of people with diabetes. It was incredibly useful for

me to understand these in order to explain to patients and colleagues in the UK. I

think that it can appear that funding constraints in the NHS prevent the adoption of

new technology and it is good to explain that there are other limitations.

This was especially true when I sat in on the Certified Diabetes Educator clinics at

the Joslin Diabetes Centre. An insulin pump company (Medtronic) has released a

closed loop insulin pump and glucose monitoring system into general clinics. I was

able to talk with patients at the Joslin Centre who have been using this technology.

Their experience was variable. Some of the patients found it very beneficial however

there were others who found that they did not have the stability of blood glucose

levels that they expected. From my learning at the ADA Congress I was able to

understand that the limitations would be those associated with the algorithm set up

to deliver insulin according to glucose levels. I was able to see that the speed with

which changes in glucose levels lead to appropriate changes in insulin delivery

depends on mathematics rather than engineering.

One of the Certified Diabetes Educators herself has Type 1 diabetes and had been

part of the phase 3 trial of the dual hormone pump (with insulin and glucagon). She

had found that this system gave her near perfect stable blood glucose levels

although she did say that she doesn’t do any formal exercise. At the ADA Congress

limitations of this system when the individual does exercise were described. The

delivery of glucagon (which raises glucose level) is currently not fast enough to keep

pace with the drop in glucose levels which occurs during and after exercise.

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Understanding these limitations enabled me to see how this technology is not the

perfect solution that it might first appear.

Another fascinating aspect of the use of technology in diabetes is that of the attitude

of people with diabetes themselves. Marilyn Ritholz who is a behavioural scientist at

the Joslin Centre explained her research to me. In work published in 2008 and 2010

Marilyn questioned whether technology is appropriate for everyone. Her research

identified issues of patients’ resistance to technology including body image,

frustrations about the limitations, finding change difficult and how starting a new

technology could bring back emotions similar to those from diagnosis. She also

identified aspects which could help people successfully adapt to technology. These

include good decision making, good mathematical/logical thinking, being flexible and

open to new experiences. It was apparent that it was important that the individual is

emotionally stable at the time of change to new technology. I found this very

interesting. In my experience these factors are rarely taken into account in clinical

practice and in fact technology can be introduced as a “last resort” when patients

may feel vulnerable. In other work (in 2007) Marilyn demonstrated that people who

don’t get benefits from insulin pump therapy had previously perceived that it was a

“magic pill” but instead found that it was too much work and also described a fear of

technology. Marilyn’s more recent work in 2014 looked at the impact of Continuous

Glucose Monitoring on marital relationships. This is particularly important as the new

generation of sensors (such as the Dexcom Follow) can transmit data of glucose

levels to family/carers even when they are away from the person with diabetes. This

can bring challenges into a relationship if this has not been discussed prior to

starting to use the sensor. Marilyn’s work found tensions when people with diabetes

resisted assistance from their partner. This is an important aspect when introducing

technology. I do not feel that clinicians are sufficiently aware of this and I am keen to

promote these considerations in clinical practice in the UK.

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Findings regarding Hypoglycaemia from the ADA Congress.

Figure 3 The impressive San Diego conference centre

As the main purpose of my Fellowship was to learn more about BGAT, a programme

to assist in hypoglycaemia it was important to learn as much as possible about

current ideas about hypoglycaemia, especially in Type 1 diabetes. Professor Frank

Snoek had presented his research into an online BGAT programme at the ADA

Congress in 2016. However, there were no presentations covering BGAT when I

attended in 2017.

There were however other presentations dealing with hypoglycaemia. One of the

sessions I attended was entitled “Prevention and Treatment of Hypoglycaemia”.

Researchers from around the world have attempted to understand the physiological

mechanisms that underlie hypoglycaemia and to develop more effective treatments.

One of the exciting developments is nasal glucagon. Glucagon is the opposing

hormone to insulin – it is naturally released from the pancreas at times of low blood

glucose level and stimulates the liver to release glucose into the blood stream. It is

thought that individuals who have had Type 1 diabetes for some time have

decreased ability to raise blood glucose in this way. As glucagon is a hormone like

insulin it is degraded when taken by mouth. It is given by injection either by a family

member or paramedics at times of severe hypoglycaemia. The presentation from

Elizabeth Seaquist from University of Minnesota demonstrated that nasal glucagon

was effective in raising blood glucose and was much easier to administer than when

injected.

Another presentation from Stacey Anderson from the University of Virginia compared

the various technology systems (e.g. closed loop insulin pumps) and found that the

closed loop system appeared to reduce hypoglycaemia more effectively compared to

a sensor and pump combination.

Of particular relevance to the objectives of my Churchill Fellowship were other

sessions which looked at the phenomenon of Impaired Awareness of Hypoglycaemia

and ways to manage this. Potentially helpful strategies presented included research

15

from the University of Utah using a group of medications called tricyclic

antidepressants. A research group from Copenhagen argued that in their research

severe hypoglycaemia was linked to a genotype, hypo unawareness was not.

The other aspect which I find thought provoking was the fact that many researchers

use a self-reported scale to measure hypoglycaemia unawareness. The most

commonly used are the Gold or Clarke scales. I have not used these and in my

experience using scales to measure IAH is not common in clinical practice in the UK,

however the NICE guideline 17 (2015) recommends clinicians in diabetes services

“Use the Gold score or Clarke score to quantify awareness of hypoglycaemia in

adults with type 1 diabetes, checking that the questionnaire items have been

answered correctly” (1.10.2).

I feel that many diabetes health professionals are not sufficiently aware of this

recommendation and do not feel confident about which scale to use. It is likely that

IAH is not being recognised appropriately and therefore support is not being offered.

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Findings regarding hypoglycaemia from the visit to the Joslin Diabetes Centre

Figure 4 Standing in the atrium at the Joslin Centre.

I was able to spend several sessions with John Zrebiec from the Behavioural

Science unit at the Joslin centre. John’s work on Blood Glucose Awareness Training

has spanned many years. As I visited, John was in the last weeks before retirement

so I felt very privileged to hear about his work.

John worked with Daniel Cox and Linda Gonder-Frederick on the original

randomised controlled trial of BGAT in 1980’s.

This programme came about after 14 years of research at University of Virginia and

as described above was designed to help individuals anticipate changes in blood

glucose levels (both high and low), recognise symptoms and effectively treat those

with extreme blood glucose levels.

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John explained that over 25 years in his practice, this had evolved into a

Hypoglycaemia Awareness, Anticipation and Treatment Training (HAATT) or

Hypoglycaemia Prevention Programme. This enabled a focus on hypoglycaemia

only. The delivery of the programme has also changed over time. Now the training at

the Joslin Centre is a full day workshop and is aimed at people with diabetes who

are having problematic hypoglycaemia either because of diminished awareness,

frequency or fear of hypoglycaemia. Unfortunately due to his imminent retirement, I

was not able to see the workshop in practice; however John was able to talk me

through the ethos, content and method of delivery. There is an education component

where the patients’ knowledge of hypoglycaemia is discussed. Any

misunderstandings are explored and corrected. Participants are encouraged to talk

about their experience of hypoglycaemia. Strategies for linking the subjective

symptoms of hypoglycaemia with the objective blood glucose levels are introduced.

John discussed various cues to low blood glucose levels which were new to me and

which I found very interesting.

In an insurance based health system such as the USA, blood glucose monitoring

equipment can be restricted but even in the UK where it is supplied through the NHS

people with diabetes might be reluctant to test even when their blood glucose might

be low. People describe the test as painful (more so than injections), messy and

demoralising. Anything which helps people to identify potential blood glucose levels

without testing can be beneficial.

I could see that these were potentially really useful tools for use in clinical practice.

Helping people to use these strategies improves their recognition that they have a

low blood glucose level even without testing their blood glucose. However, patients

must learn to link these cues to low blood glucose levels and this requires practice.

I could also see that these strategies would fit into a mindfulness approach which is

very topical at the moment.

Cues to help identify low blood glucose levels from the Joslin programme

Informal mental performance – following directions, following conversations,

thinking of the correct word, doing simple arithmetic.

Informal gross motor performance- walking quickly and turning, bending over

at the waist, climbing stairs, standing up

Informal fine motor performance- addressing an envelope, hammering a nail,

unlocking a door, typing, tying a shoelace.

Formal mental performance- subtracting 3 from 100, tongue twisters, thinking

of words beginning with a certain letter of the alphabet.

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Examples of driving performance cues are driving slower than necessary and

tailgating or stopping too far away from a stop line or from a car in front.

John explained that BGAT had also led to improved driving safety. It is difficult to get

accurate figures for the UK but one survey of drivers with insulin-treated diabetes

suggested that 13% had experienced hypoglycaemia while driving during the

preceding year and nearly 60% did not test their blood glucose before driving as

advised by DVLA. I had not considered the potential benefits of BGAT to improve

driving safety before discussing this with John and felt this should be an important

part of the evaluation of any programme

John explained the ethos of BGAT and in particular the importance of the patient

diary. The patient who is participating in the programme needs to keep a diary of

blood glucose levels and link these to symptoms. There needs to be at least 20 low

BG levels before a level of consistency in symptoms can be reached. His research

has shown that in patients who have reduced awareness at the start of the

programme only 75% of hypos will be identified even when the patient has 3 or 4

symptoms. Participating patients must therefore agree to test their blood glucose

level as part of the programme.

With John’s retirement it seems possible the BGAT programme will no longer be

delivered at the Joslin Centre. We spent some time discussing why this is the case

and why the programme is not delivered in the UK. The behavioural scientists feel

that increased reliance on the use of technology particularly continuous glucose

monitoring has led to a belief that this will reduce the frequency of hypoglycaemia

and especially problem hypoglycaemia. The use of continuous glucose monitoring is

very common at the Joslin Centre. While this monitoring is not widespread in the UK,

a system termed “flash” monitoring developed as a Freestyle Libre has been

launched in the UK and is discussed below.

I was interested in the interaction between the behavioural science department and

the diabetes clinicians. When asked, the Certified Diabetes Educators were not

aware of Marilyn Ritholz’s research looking at why technology doesn’t work for

everyone. I observed several clinic and group sessions where patients were

introduced to new technology or were reviewed with existing technology. In several

cases I could see that individuals were struggling with the concept of how to manage

insulin pumps or continuous glucose monitoring. This was either in a practical way

as some of this technology is complex or they appeared uncertain how it would

benefit them.

In the UK, since my visit to the Joslin centre, the Freestyle Libre has become

available on NHS prescription under certain criteria. The Freestyle Libre system is a

“flash” continuous glucose monitoring system. The sensor is a fine plastic cannula

which sits in the skin and continually measures glucose levels. The person with

diabetes can read the level at any time by scanning the sensor with a device

provided. A smart phone can also read the scanner if the appropriate app is

downloaded.

19

Figure 5 The Freestyle Libre in use

Interestingly there is not an expectation that this alone will reduce the frequency of

hypoglycaemia or improve quality of life for those with reduced awareness of

hypoglycaemia. This is because there is insufficient evidence that it would achieve

these goals.

My perception therefore is that it is unlikely that technology will be the answer to the

problem of hypoglycaemia. One of my identified objectives in visiting the Joslin

Centre and speaking with John was to gain an understanding of the value of BGAT

and to consider whether such an approach could work and be useful in the UK.

Overall my feeling was that there were many components that could be incorporated

into my clinical practice in the UK.

I was disappointed not to see the BGAT programme in action and somewhat

saddened to think that it may disappear from the Joslin Centre programme and the

USA completely. I was therefore keen to visit the Netherlands where a programme is

being delivered.

Findings from the Hypo awareness programme at VUMC, Amsterdam

As mentioned above, Professor Frank Snoek presented the results of a version of

BGAT developed in the Netherlands at the ADA Annual Congress in 2016.

“HypoAware” was designed at the VU University Medical Centre and was shortened

from the original programme to three workshops of 2.5 hours each alongside two

online modules. Results were presented from a cluster-randomised trial at eight

outpatient centres in the Netherlands. Patients with both Type 1 and Type 2 diabetes

received usual diabetes care or usual care plus the HypoAware programme. The

results of the trial were published in 2016.

Attending the HypoAware programme resulted in fewer severe hypoglycaemic

episodes, significantly improved hypoglycaemia awareness and less hypo distress

compared to those who received usual care alone.

I was very keen to see this programme and was particularly interested in the online

component.

20

I arranged to visit the Diabetes Psychology Research (DPR) group of Diabetes

Mentaal of the VU University Medical Center in Amsterdam. I had hoped to see one

of the “Hypobeurst “(HypoAware) workshops, however these are delivered in Dutch

and it would not have been appropriate for this to be interpreted for me while it was

running. As an alternative I spent a day meeting with the professionals who have

developed and delivered this programme as part of the randomised controlled trial.

In particular I was able to spend time with Dr Marloes Hogenelst. Marloes was one of

the researchers in the original trial and has now developed a training programme for

health professionals to act as facilitators for the HypoAware programme sessions.

Marloes talked me through the patient workshops that have been standardised for

those facilitators to deliver across the Netherlands. Having spent time with John

Zrebiec I was able to see that the core aspects have come from the original BGAT

programme. In particular, stressing the importance of keeping a diary to link actual

blood glucose levels to the symptoms of hypoglycaemia however subtle these might

be.

A crucial component is the mapping of measured blood glucose levels against the

patients’ assessment of what they think their blood glucose level is on a chart. I

thought this visual representation was an extremely useful tool that I could imagine

would work well.

21

This is represented as:

Misleading signal, hypo/ hyper. Your BG was opposite to the estimate

Missed signals, estimated normal but actually BG too high/low

Misleading signal, actually normal BG

Reliable signal- correct estimation of BG

Participants map their estimation of their blood glucose against their actual blood

glucose levels. The aim is to achieve as many plots as possible in the green area on

the diagram. That helps the participants to learn to recognise symptoms that match

their low blood glucose levels.

There are three group workshops each lasting approximately 2.5 hours. The first

introduces the concepts and sets goals for the participants. Homework is set with the

aim that the participants will keep the glucose testing diary to bring to the second

session. Analysis of the diary is a large component of the second session.

One of the online modules is completed prior to the first workshop which provides

the baseline assessment. Between the sessions participants are encouraged to

complete the further online module which is designed to reinforce learning from the

workshops and to support the homework for participants. This appears to be a cost

effective way of supporting participants once the online modules have been set up.

The third workshop is for people with diabetes together with a friend/partner/family

member/work colleague. John Zrebiec had talked with me about the importance of

involving significant others in the therapeutic work in hypoglycaemia management.

John often worked with couples in his clinics and described tragic situations where

marriages were put under considerable stress through the partner’s problem hypos.

When hypoglycaemic, people can become irritable and even aggressive, sometimes

violently. I myself have worked with a couple where the wife has left the marriage on

several occasions having been physically abused by her husband when he is

hypoglycaemic.

I was very interested in this third session involving partners. In the past I have

worked on a research project where a group workshop for partners/friends was

delivered. In that case, people with diabetes were not included. Participants were

able to talk about their fears and anxieties freely. Much of these were around

hypoglycaemia.

22

This workshop appeared to be incredibly useful however it has been difficult to

secure long term funding for such a group. This appears to be because the

individuals are technically not seen as the patient. A recent online survey by

Diabetes UK found that 77% of carers said they sometimes or often felt down in

mood because of their family member’s diabetes.

It was therefore really encouraging to see this aspect included in the VUMC

programme. This third session looked at how support by a significant other can be

made as effective as possible. This echoed Marilyn Ritholz’s work that I had heard

about at the Joslin Centre. People with diabetes are individuals and have different

thoughts about how much and what type of help and support they need in managing

their diabetes and in particular their hypoglycaemia. It is important that their

partner/friends offer support in the most beneficial way for that individual.

During the session the partner is asked to rate their helping strategy on a scale.

Independently the person with diabetes is asked to rate what level of support they

feel they need. The two scores are then compared. Any discordance is then

managed by the facilitator. I could imagine that this would be a very useful and

enlightening exercise.

The three sessions and the online modules make up the HypoAware programme

that is now being rolled out to other centres in Holland by trained facilitators. I was

given a copy of the facilitators’ manual in Dutch.

The randomised controlled trial demonstrated clear benefits although it is not known

whether these are sustained long term. Education programmes inevitably require

follow up maintenance sessions to reinforce knowledge and behaviour change so it

is likely this would be the case for HypoAware.

In addition to hearing about the programme I was privileged to meet with Professor

Frank Snoek. Professor Snoek has been a hugely important figure in the psychology

of diabetes and his book “Psychology in Diabetes Care” written with T. Chas Skinner

had been an important part of my clinical practice and teaching. Professor Snoek

had worked alongside American researchers at the Joslin Centre on early BGAT

programmes. He had then developed the HypoAware programme for Dutch diabetes

care. He encouraged me to look at introducing a UK-appropriate programme into

general care. Initiatives in place are in specialist centres such as that at Kings

College Hospital. Professor Snoek was supportive of the idea that techniques used

in the programmes can benefit patients in any diabetes service. I know from my own

experience and that of my colleagues that supporting individuals with diabetes and

IAH can be very difficult. Programmes based on BGAT are a different way of working

and enable alternative strategies.

23

Findings from the experience of diabetes clinical care

While at the Joslin Centre I was able to sit in on various Certified Diabetes Educator

(CDE) clinic settings, both group and one-to-one. These were usually training

sessions on the use of technology. I was able to compare these with clinical practice

in the UK.

Group education at the Joslin Centre appears to be delivered in a more formal way

than I am used to. Patients sat in a boardroom setting, behind tables. The CDEs

appeared to deliver the session through a formal PowerPoint presentation or used a

formal teaching method. This is somewhat different to the UK where principles of

adult learning are encouraged with active participation (problem solving, using

previous experience etc.). Diabetes education in the UK follows NICE QS6: Diabetes

in adults. Quality statement 1 – structured education (published in 2011).

In one-to-one clinics at the Joslin Centre I was surprised to see that the CDEs did

not have their own case load and there appeared to be only limited continuity of

care. Patients were booked to see the CDE that was available at the time of the

appointment and follow ups were booked in a similar way. CDEs in the USA are not

prescribers whereas Diabetes Specialist Nurses in the UK are encouraged to be

prescribers. At the Joslin Centre patients have been seen by a physician and a

treatment plan decided before the appointment with the CDE. In the UK, experienced

DSN’s are autonomous practitioners and can take direct referrals. I was surprised to

see these differences and reassured that UK diabetes care does not appear to be at

all inferior.

I did feel that the American CDEs were more confident in technology as it is more

widespread in the USA. The proportion of patients using insulin pumps or continuous

glucose monitoring is much higher, particularly at a renowned centre like the Joslin

Centre. This made me question my attitudes to such technology and how I discuss it

with the patients in my service. Since my visit I feel more confident in explaining the

benefits of pump therapy. I have also been able to talk knowledgably about the

Medtronic 670G which will be launched in general clinics in the UK in spring 2019.

The pump makes 24-25 alterations in a 24 hour period and over time “learns”

patterns of blood glucose levels. Patients at the Joslin Centre reinforced what I had

learnt about the problems in exercise/activity and limitations of the algorithm at the

ADA Congress and this has made me more confident in discussions with patients

and colleagues.

I also met with a Diabetes Nurse while at VUMC and found that the Netherlands and

the UK had many areas of practice in common. The level of usage of technology

(pumps and continuous glucose sensing) and service structure and delivery were

very similar. This would be expected as the health service provision is comparable,

unlike the American system.

24

4. Conclusion and recommendations

The key elements from my Churchill Fellowship are:

Recommendations

1. All health professionals working in diabetes should be aware of the limitations

of technology and the importance of taking psychological factors into account

in discussions about technology with people with diabetes.

2. Health professionals working in diabetes should be aware of the impact of IAH

on quality of life.

3. Diabetes services should routinely use a scale to assess IAH.

4. On balance, I feel that a UK-appropriate version of the BGAT and HypoAware

programmes could be useful and should be available to people with IAH.

5. It will be beneficial for all health professionals supporting people with diabetes

(especially those with IAH) to be familiar with and be able to use specific

techniques from those programmes.

1. Important learning about possible technological advances for the

future management of diabetes. This includes a better

understanding of the benefits and limitations of the closed loop

insulin pumps that are about to be launched in the UK.

2. An appreciation of how BGAT evolved and a better understanding

of the value and limitations of this training.

3. The importance of raising awareness of IAH and the need to

assess people with Type 1 diabetes and Type 2 diabetes on

insulin to better identify the problem.

4. The benefits of supporting individuals who have IAH and how

best to do this.

25

Implementation

1. Technology.

I have been much more confident in my discussions about new technology

both with patients in my clinic and with colleagues. In my clinical practice I feel

I am now able to give patients a much clearer understanding of what

technology is available to them now and time scales for further developments.

I published articles in the Journal of Diabetes in which I explored the need for

Diabetes Specialist Nurses to be aware of technological advances but also to

be conscious of the limitations e.g. when talking to patients about the next

wave of “closed loop” pumps.

One of the manufacturers of a next generation pump which has recently

launched in the UK has been appreciative of my input into their promotion

following my experience at the Joslin Centre.

2. Impaired Awareness of Hypoglycaemia.

I have continued to research and improve my knowledge of IAH.

I presented at the Southwest Diabetes Specialist Nurse Symposium in 2017.

This symposium is for DSNs working in the Southwest. I had considered that

knowledge of IAH might be high in DSNs as they have the most on-going

contact with patients with diabetes. However, a 2016 survey found that 60%

of DSNs are retiring between 2016 and 2026. This means that there are

relatively inexperienced DSNs who may be aware of IAH but have limited

skills and knowledge in how to manage it.

I have continued to promote the benefits of assessing IAH using a validated

scale such as the Gold score or the Clark Hypoglycaemic Awareness Survey.

The value of screening for IAH has recently been shown by a Scottish study

published in 2018 which screened people with diabetes for IAH and showed

that impaired awareness of hypoglycaemia in patients who are attended by an

ambulance service clinician due to a severe hypoglycaemic event is more

than double that which is found in those who did not require an ambulance for

hypoglycaemia. This group’s recommendation is that the Gold assessment

should be incorporated into an ambulance clinician’s assessment of patients

who have had a severe hypoglycaemic emergency where appropriate. This

would screen for IAH and potentially reduce the risk of further ambulance

calls.

3. Progress towards a UK programme for support managing hypoglycaemia

similar to that of HypoAware.

I am able to use the resources which John Zrebiec gave me and also the

facilitators’ manual for the HypoAware programme. I was able to find a native

26

Dutch speaker and the Churchill Fellowship paid for the manual to be

translated from Dutch into English.

Using these excellent resources I have begun to set up a programme and

have developed a 2 day course aimed at people who have IAH.

Online modules proved to be too difficult to set up, particularly as I do not

have expertise in this area.

In developing the programme I was also aware that the VUMC group had

since published data showing that the HypoAware programme was not cost

effective compared to usual care. I am therefore mindful of the need to pilot

the programme and to establish appropriate evaluation.

I have agreed to pilot the programme with Bristol Community Health over the

next 12 months.

4. While the benefits of a UK programme remain uncertain, I firmly believe in the

benefits of using techniques such as those used by John Zrebiec and in Hypo

Aware within clinical practice. I explained some of these techniques in the

presentation to the Southwest DSN Symposium and have had very positive

responses from those that have tried them.

In my own clinical practice I have found them very useful.

An example is a patient whom I have supported in my clinic for 5 years. We had

identified that fear of hypos was severely impacting her quality of life and her ability

to manage her diabetes at a healthy level. Jane (not her real name) was too fearful

of drops in her blood glucose levels to walk her dog without testing her blood glucose

many times. I had made various suggestions over the time that I had known her but

nothing had helped.

Following my conversations with John Zrebiec I was able to talk Jane through some

of the cues to low blood glucose levels (as above). Jane identified that she could use

the technique of thinking of words beginning with the same letter. Jane tried this out

when her blood glucose was normal so that she could establish a “normal”

expectation of how her brain would work when not hypo. She was then able to

recognise when there was a difference if her blood glucose were to be low. After

practising this for some time, Jane was able to walk her dog without testing her blood

glucose frequently. If she became anxious about being hypo, she performed the

mental cue test which reassured her that her blood glucose was not too low. I would

not have been able to suggest this help if I had not visited the Joslin Centre.

27

Personal achievements.

Being awarded the Winston Churchill Travel Fellowship was an amazing privilege

and an important part of my own personal and professional development.

I had not previously travelled on my own to such an extent as this. It was a new

experience to book my own travel arrangements and my first experience of Airbnb.

The whole experience was a great boost to my self-confidence and has changed my

view of myself for the better. I appreciated the fact that I was part of a network of

others who were travelling through the Churchill Fellowship. I was able to meet with

another 2017 traveller in a bar in Boston where we encouraged each other with our

endeavours.

I also set up a blog which was new learning for me and helped promote my findings:

https://gaylerichards.wordpress.com/

I work for a small NHS Trust and being awarded the Churchill Fellowship was an

important boost for the organisation at a time of turbulence.

An article about being awarded the Fellowship was published in the North Devon

Journal:

https://www.northdevongazette.co.uk/news/woolacombe-nurse-wins-top-travel-grant-

to-help-people-with-diabetes-1-4976283

I am at the latter stage of my career and I did not think that further opportunities to

widen my horizons would occur. The Churchill Fellowship has enabled me to

accomplish things that I would not have anticipated. Highlights have included

attending the ADA Congress for the first time, visiting the world renowned Joslin

Centre and meeting people who have influenced my clinical practice in their writing.

The experience of my travel has given me renewed enthusiasm for my work, set me

new challenges and encouraged me to nurture the next generation of Diabetes

health professionals.

28

5. References and Bibliography.

1. NICE Guideline NG17. Type 1 diabetes in adults: diagnosis and management.

2015 (updated 2016)

2. NHS Digital (2018) Quality and Outcomes Framework 2017–18

digital.nhs.uk/data-andinformation/publications/statistical/quality-and-

outcomes-framework-achievement-prevalence-andexceptions-data/2017-18

3. Kidmealem L Zekarias and Elizabeth R Seaquist. Hypoglycaemia in Diabetes:

Epidemiology, Impact, Prevention and Treatment. SM Group. 2017.

4. Cox DJ, Gonder-Frederick L, Polonsky W, Schlundt D, Kovatchev B, et al.

Blood glucose awareness training (BGAT-2): long-term benefits. Diabetes

care. 2001; 24: 637-642.

5. Cox DJ et al. Blood Glucose Awareness Training. What is it? Where is it? And

where is it going? Diabetes Spectrum. 2006. 19(1). 43-49.

6. NHS Digital. National Diabetes Audit - Insulin Pump Report 2016-17. July

2018.

7. Ritholz, M. Is Continuous Glucose Monitoring for Everyone? Consideration of

Psychosocial Factors. Diabetes Spectrum, 2008 21(4)..287-289.

8. Ritholz, MD, Beste M, Edwards SS, Beverly EA, Atakov-Castillo A, Wolpert

HA. Impact of Continuous Glucose Monitoring on diabetes management and

marital relationships of adults with Type 1 diabetes and their spouses. Diabet.

Med. 2013 Jul 2.

9. Ritholz MD, Smaldone A, Lee J, Castillo A, Wolpert H, Weinger K. Perceptions

of psychosocial factors and the insulin pump. Diabetes Care. 2007; 30(3): 549-

554.

10. Graveling AJ et al. Hypoglycaemia and driving in people with insulin‐treated

diabetes: adherence to recommendations for avoidance. Diabetic Medicine.

2004. 21(9) 1014-1019

11. Boyle PJ and Zrebiec J. Management of diabetes-related hypoglycaemia.

Southern Medical Journal. 2007. 100 (2) 183-194

12. Rondags SM et al. Effectiveness of HypoAware, a Brief Partly Web-Based

Psychoeducational Intervention for Adults With Type 1 and Insulin-Treated

Type 2 Diabetes and Problematic Hypoglycemia: A Cluster Randomized

Controlled Trial. Diabetes Care 2016. 39 (2) 2190-2196

13. Diabetes UK. Three quarters of carers for people with diabetes experience

emotional or mental health problems. Nov 2018.

14. NICE Quality standard 6. Diabetes in Adults. 2011 (updated 2016)

15. Duncan EAS, Fitzpatrick D, Ikegwuonu T, et al. Role and prevalence of

impaired awareness of hypoglycaemia in ambulance service attendances to

people who have had a severe hypoglycaemic emergency: a mixed-methods

study

BMJ Open 2018;

29

5. Appendices.

Appendix 1- publications regarding my Winston Churchill Travel Fellowship

https://www.diabetesonthenet.com/resources/details/my-plan-bring-blood-glucose-

awareness-training-uk

https://www.diabetesonthenet.com/resources/details/77th-american-diabetes-

association-meeting-i-learnt

https://www.diabetesonthenet.com/journals/issue/552/article-details/visit-joslin-

diabetes-center-i-learnt

30

Appendix 2

Proposed plan for pilot structured education programme for people with Impaired

Awareness of Hypoglycaemia

Aims

1. Participants will understand the causes and most appropriate treatment of

hypoglycaemia

2. Participants will learn to better recognise hypoglycaemia

3. Participants will learn to netter predict and prevent hypoglycaemia

4. Participants will have reduced anxiety regarding hypoglycaemia

Structure

The course will consist of 2 sessions of 2 hours to allow participants to maintain a

diary to relate blood glucose levels to symptoms of hypoglycaemia between

sessions. The course will be facilitated in a way that allows participants to engage in

active learning and learn from each other’s experience.

Content

Session 1

What is hypoglycaemia? Explore the lived experience of hypoglycaemia. Explore

causes of hypoglycaemia and what signals do people occur.

What is Impaired Awareness of Hypoglycaemia and why does it occur?

Look at the 4-step model of “solving a hypo”

Step Reasons Solutions

Are there signs of a hypo?

Hypo-unawareness BG monitoring Paying more attention to signs involving the brain Trying to predict times that a hypo might occur

Do you notice the signs? Too busy or distracted Not expecting a hypo at that time

Learning to pay attention to the signs Learning to predict

Do you assume the signs are caused by something other than a hypo?

Temperature of the room, bright lights, alcohol, too much coffee Confusing a hypo with hyperglycaemia

Learning to predict and interpret signs

Do you respond appropriately to signs of a hypo?

Postpone action (embarrassed, too busy or want to finish something) Inappropriate treatment

Learn to act promptly Learn to treat appropriately.

31

Give the participants diary sheets and guidelines for completion as homework.

Session 2

Ask participants for feedback on their experiences since the first session.

An analysis of the blood glucose diaries will be facilitated.

Use the estimation guide to plot participants’ actual blood glucose levels against their

estimation

Misleading signal, hypo/ hyper. Your BG was

opposite to the estimate

Missed signals –estimated normal but actually

BG too high/low

Misleading signal, actually normal BG

Reliable signal- correct estimation of BG

Participants are then encouraged to look where the majority of their plots lie.

Interpretation of the colour zones

Green zone: You have correctly estimated your BG. The signals you felt were a good

predictor of a low or high BG. These may be your reliable signals. From now on, try to

pay attention to these signals.

Yellow zone: You thought your BG was too low or too high, but your BG was normal.

The signals you felt were not good predictors. From now on, take care not to pay

attention to these signals.

Orange zone: You thought your BG was normal, but your BG was too low or too high.

You have not felt any signals. Maybe you can still recognize subtle signals afterwards?

If you really do not feel anything, measuring blood glucose more often or checking

your external factors may help.

Red zone: You thought your BG was too low while it was too high (or the other way

around). You muddle up the signals of a hypo and a hyper

32

The end of the session will focus on what has been learnt and setting goals for the

future.

It will be important to feedback the learning and goals to other health professionals

involved in the participants’ care. The participants should be encouraged to talk with

others (including health professionals, family, friends and work colleagues) about the

way hypoglycaemia affects their lives and what changes they will make as a result of

the programme.

Evaluation

It will be important to assess before and after the programme. If practical, this should

include follow-up several months after the programme.

Suggested evaluation tools could include:

1. HbA1c measurements

2. Assessment of frequency of hypoglycaemia

3. Assessment of IAH by Gold and Clark scores

4. Assessments of Anxiety and Depression.