2003). Also encouraging are studies from Norway showing that mass distribution of patient education materials (videotapes and brochures) reduced episodes of SH without compromising metabolic control in children with T1D. This randomized, controlled trial followed more than 200 pediatric patients over a 24-month period and found that episodes of SH were reduced from 45 to 24% in the experimental intervention group (Nordfeldt 2003, Norfeldt 2005a).
The successful results of these relatively simple interventions focusing on didactics suggest that inadequate patient education is an underrecognized but major risk factor for SH. The positive findings for several educational and behavioral interventions, combined with the difficulty of finding these for many patients, suggest that programs with demonstrated effectiveness at reducing SH risk are underimplemented in diabetes health care. Such programs are likely to be cost-effective because of the significant financial burden of hypoglycemia on the individual and the health care system (Brito-Sanfiel 2010). Given its impact on the quality of life, emotional well-being, and physical safety and health of people with diabetes, the problem of hypoglycemia has not received the attention it deserves, and the availability of interventions to reduce episodes is inadequate. Clearly, much more effort on several fronts, including research, clinical care, e-health efforts, and diabetes advocacy, needs to be directed at finding ways to implement effective interventions to address the problem of hypoglycemia in diabetes.
Recommendations for Care
1. Hypoglycemia is common in patients with both T1D and T2D, and patients should be assessed at each clinical encounter to determine whether this is a problem area for them. If there are problems, more detailed assessment should be conducted to determine whether or not referral is needed for patient education or other interventions, following the example of a comprehensive hypoglycemia interview provided by Cradock and Frier (2010). Often patients are reluctant to discuss SH episodes with health care professionals due to fears that their ability to engage in certain activities and/or occupations (e.g., driving, piloting airplanes) will be restricted (Davis 1997, DCCT Research Group 1997, Leese 2003, Workgroup on Hypoglycemia ADA 2005, Zammitt 2005).
2. FOH is common and should be periodically assessed in both patients and family members, including parents of children with diabetes, especially following distressing or traumatic episodes of SH. When patients present with chronically high BG levels, the possibility of very high FOH should be considered (Gonder-Frederick 1997b, Nordfeldt 2005b, Wild 2007, Barnard 2010).
3. During hypoglycemia assessments at clinic visits, potential problems in diabetes management behaviors related to episodes (e.g., missed meal, increased physical activity, variable work schedule that changes insulin dosing schedule) should be identified to guide patient counseling/education (Bognetti 1997, Workgroup on Hypoglycemia ADA 2005, Honkasalo 2011).
4. Individuals who exhibit risky behavior associated with increased episodes of hypoglycemia that are found to be associated with clinically significant emotional or cognitive problems will benefit from referral to a psychotherapist or counselor with expertise in diabetes management and behavioral intervention.
5. Beliefs about hypoglycemia and its treatment need to be assessed to identify attitudes and behaviors that increase risk. Some questions that may be helpful include: “How low does your BG need to be before you believe you need to raise it?” and “How low does your BG need to be before it affects your ability to think and function?”
6. When concerns regarding hyperglycemia appear to be contributing to increased hypoglycemic events, the practitioner might consider additional education sessions with a diabetes educator and modification of the care regimen that encourages more monitoring as well as compensatory strategies such as modification of the patient’s MNT.
7. Hypoglycemic awareness/detection should be assessed at each clinic visit given that hormonal counterregulation and symptom thresholds can change over time. Assess ability to recognize hypoglycemia in patients who do not report traditional hypoglycemic unawareness, because even these patients may fail to detect up to 50% of episodes. Ability to recognize hypoglycemia should also be assessed in pediatric patients as well as their parents, since research indicates that poor ability to identify low BG may be a risk factor for SH (Cox 1999, Cryer 2002, Workgroup on Hypoglycemia ADA 2005, Gonder-Frederick 2008).
8. Patients with comorbid psychiatric or cognitive problems, as well as those in lower-SES groups, may warrant closer monitoring for problems with SH given their higher risk level (Rewers 2002, Seligman 2010, Honkasalo 2011).
9. Ideally, all patients should receive comprehensive education on hypoglycemia, including its causes, its impact on cognitive functioning, and the need for immediate treatment. For the subset of patients who have recurrent problems with hypoglycemia, this education should be a continuing part of clinical care. Education regarding HAAF and the impact of frequent episodes of mild hypoglycemia on the ability to counterregulate and recognize warning symptoms should be provided, with care taken to present information in a manner that translates to behavior change strategies. Further, routine screening regarding incidence and identification may need to be accompanied by suggestions regarding accessible treatment resources (such as print or web-based information) when the practitioner is not able to provide these ongoing services.
10. Patients should be assessed for frequency of mild hypoglycemic events during clinic visits given that these can be a risk factor for HAAF and SH. Education regarding the impact of frequent mild hypoglycemia on symptoms and hormonal response should be provided to patients who have one or more weekly episodes, and the possibility of following a regimen aimed at avoiding these events to improve counterregulation should be discussed with the patient (Cranston 1994, Heller 2008).
11. CGM or SAP therapy should be considered for patients who have recurrent SH due to hypoglycemic unawareness, problems with nocturnal hypoglycemia, very high levels of FOH, or hypoglycemia that interferes with quality of life, and for those who live alone. Given the complexity of these technologies, patients considering using CGM or SAP therapy should receive comprehensive and systematic training from diabetes educators (Hermanides 2011, JDRF Research Group 2011).
12. Some of the strategies used in BGAT and BGATHome (e.g., BG Awareness Diaries) have been published previously for use by health care providers including psychologists, diabetes educators, nurses, and physicians (Cox 2006a) and can be suggested as intervention resources, especially when trained providers are not geographically available.
ACKNOWLEDGMENTS
This manuscript was supported in part by NIH/NIDDK Grants R01DK60039 and R21DK080896. The authors thank Karen Vajda and Kelli McFarling for their editorial assistance.
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