BGAT - Blood Glucose Awareness Training

by scott strumello

Hypoglycemia is the most significant risk of insulin therapy, representing the thin line between safety and peril. Any injection or bolus can be miscalculated and result in a severe low, in some cases without warning or even awareness.

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Some doctors estimate that as many as 10%-20% of all patients with type 1 diabetes have some degree of hypoglycemic unawareness. Many overlapping factors can contribute, and even with their best efforts, patients find that the number of variables to consider when dosing insulin leaves too much room for error. Personally, I struggle with an inability to sense lows, often times until it’s too late to treat myself.

So what is a person who has hypoglycemic unawareness to do?

A number of years ago, researchers at the University of Virginia Health Sciences Center (with funding from the National Institutes of Health) developed an excellent program they dubbed Blood Glucose Awareness Training (known by the acronym ‘BGAT’). A psychoeducational program, BGAT is designed to improve patients’ detection and interpretation of relevant blood glucose (BG) symptoms and to point out other cues to help them avoid severe hypoglycemia.

The BGAT program was developed by several diabetes experts, including Dr. William Polonsky of the Behavioral Diabetes Institute (and author of “Diabetes Burnout”). The program involves group sessions in which individuals meet with a trainer who leads them through an eight-chapter manual. The group setting is valuable, for often times patients can learn from one another. In the program itself, patients are not blamed for their inability to sense lows, which can happen in other settings. Rather, they’re taught how to identify and/or recognize new hypoglycemia cues, which are often subtle.

The nature of these cues vary from person to person. If you spend a lot of time behind a computer (like me), you may notice a change in your typing speed or an increase in the frequency of typos. A carpenter might learn that dropping nails is a good indicator of hypoglycemia. A student might notice that he or she reads much more slowly when blood glucose gets low.

The program recommends monitoring "performance cues" by asking three questions:

1. Is this task taking more effort than usual?

2. Am I doing this task more slowly than usual?

3. Am I making more errors than usual?

Using these, they help participants to identify their own "cues". I have certainly noticed an increase in typos associated with my hypoglycemia, although I have to admit, I find it frustrating that these so-called “symptoms” for hypoglycemia can differ each time!

I attended BGAT training at the Joslin Diabetes Center in Boston and found it to be the single most valuable lesson in diabetes education I’ve ever received. The staff insisted on talking with you and not at you, as is often the case with diabetes education group settings. They shrugged off all their titles and established a personal rapport from the outset. Importantly, they were very willing to acknowledge the limitations of current diabetes treatments, and they always wanted to help patients work around the challenges they face in their diabetes management. The main challenge is that so much of diabetes education follows textbook definitions, yet so much of the patient experience doesn't fit so neatly into these rigid textbook categories. BGAT is intended for those who already know the basics of diabetes care, so its focus is not teaching the basic tripod upon which diabetes education and self-care is built (food, exercise and insulin), but instead putting those things into relevant context with real-life situations. In other words, it teaches you how to know what your carbohydrate utilization actually is, what the effects of physical activity (and how to determine this) could have to enable you to better anticipate when your blood glucose might go high or low. In fact the whole reason BGAT was created was to eliminate the parts of standard diabetes training that did not work so well. For example BGAT establishes the level of diabetes education of the participants and is modified to reduce the risk that some people get bored and tune out because they are already familiar with the topic being discussed.

The small group setting (about eight to ten people per staff member) allowed great openness between participants. For example, one girl (she was only 18 or so) was recently involved in her third motor-vehicle accident during the past five years due to lows, and her doctor essentially forced her to attend (probably because he was asked to sign a DMV affidavit saying she was fit to drive). Another was an older gentleman who had type 1 diabetes for 54 years and whose wife was upset because of his severe lows. Most people I attended with had insulin pumps – although clinical evidence suggests that insulin pumps do reduce lows, we can certainly say pumps are no magic solution. At lunch, some attendees reflected on having diabetes as a kid; others recalled using Clinitest test tubes used for urine testing, while the older gentleman told us how he used to boil his glass syringes and sharpened the needles on something similar to a stone-based knife sharpener. The youngest participant in the group was amazed at how good she had it!.

Awareness of, and accessibility to, the BGAT program remains a key challenge. Even among diabetes educators who are familiar with the program, many aren’t trained to teach it or they do not have the materials. For now, Joslin is the only site that offers the program. The next class will be held February 27, 2009 at the Joslin Diabetes Center, and if you are in the Boston area around that time, I’d suggest giving it a try. The program costs $95, and you can register by calling (617) 732-2594. In addition, the developers of BGAT are hoping to release an online version, called bgathome, in collaboration with the American Diabetes Association - but funding remains a problem.