Comprehensive Approaches to Addressing Hypoglycemia
By Natalie Sainz
At ATTD 2022, several researchers presented on projects aimed at understanding and addressing the impact of hypoglycemia. While diabetes technology is helpful and effective, it can only go so far. Read about other approaches in minimizing the harm that hypoglycemia can cause.
Why are we still talking about hypoglycemia 100 years after the first insulin injection? Dr. Stephanie Amiel of Guy’s Hospital School of Medicine in London, England posed this question during an ATTD 2022 Conference session on hypoglycemia.
Hypoglycemia, defined as a glucose value below 70 mg/dL, can be extremely dangerous to people with diabetes if they do not address it. When someone does not treat low glucose levels, they can experience severe hypoglycemia, in which glucose levels are so low that mental or physical functioning is impaired and the person requires assistance.
Even in an era of increased diabetes technology use, many people with type 1 diabetes are at high risk of severe hypoglycemia, according to Amiel. In fact, just 10% of people with type 1 diabetes contribute to 70% of hypoglycemia episodes.
Amiel said that perhaps even more of an issue is impaired awareness of hypoglycemia (IAH), which is when someone is not aware that their blood glucose is too low. IAH is a real threat to people with diabetes. Unfortunately, many of those at high risk of severe hypoglycemia have a low level of concern for this serious condition.
In addition to the harmful physiological effects of hypoglycemia, people with diabetes and IAH also “carry an excess burden of mental health issues,” Amiel said, describing studies that showed that people with IAH also reported higher scores for anxiety and depression.
Although new technology, primarily continuous glucose monitors (CGM), has drastically changed how hypoglycemia, especially severe hypoglycemia, affects people with diabetes, more work remains to be done. Diabetes technology alone may not be enough to address hypoglycemia and IAH. “Cognitive and psychological approaches may be needed to help achieve the better outcomes modern management of insulin therapy can offer,” Amiel said.
Even the knowledge that one might be at risk for hypoglycemia can cause overwhelming anxiety and affect their diabetes management, said Dr. William Polonsky, president and co-founder of the Behavioral Diabetes Institute in San Diego, California, one of the panelists. “The impact of hypoglycemia is not just how many people we know who have it, but also the people who are really fearful of hypoglycemia,” he said.
Polonsky explained that some people are so fearful of experiencing low blood sugar that they go through excessive, and potentially harmful, measures to avoid it as much as possible. In fact, 46% of people with type 1 diabetes and 26% of people with type 2 diabetes experience “elevated fear of hypoglycemia,” he said.
This fear can lead to unhealthy behaviors in diabetes management. For example, people may underdose prandial insulin at meals, constantly snack, and significantly limit one’s activities, all to avoid any possible lows.
“It’s about a loss of confidence in one’s body,” said Polonsky. “It’s about helping people regain their confidence.”
Polonsky explained two strategies for addressing hypoglycemia and the anxiety that can come with it:
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Help people with diabetes be safe. This can be done through better use of available medications, use of diabetes technology (such as continuous glucose monitors or CGM), addressing IAH, getting better at identifying key symptoms, being prepared to treat, and identifying times of extra risk.
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Help people with diabetes feel safe. This is especially critical for people who have excessive worry around hypoglycemia. Healthcare providers can do this by helping their patients start on CGM, clarifying any symptoms, and educate them on how hypoglycemia makes their body feel.
Another attempt to “address unhelpful health beliefs in improving awareness of hypoglycemia and preventing severe hypoglycemia,” Amiel explained, was the hypoglycemia awareness restoration program for adults with type 1 diabetes and problematic hypoglycemia despite optimized self-care (called the HARPdoc trial).
The HARPdoc clinical trial was led by Amiel and focused on understanding and addressing the emotional stress behind hypoglycemia so that people with diabetes feel prepared when they do experience lows. The program developed for the trial uses cognitive behavioral therapy and motivational interviewing to influence people’s feelings, thoughts, and behavior regarding hypoglycemia. Indeed, results showed HARPdoc successfully and significantly reduced diabetes distress, anxiety, and depression.
The panelists said that much about hypoglycemia is still unknown, which contributes to the lack of awareness on how to effectively treat and reduce its occurrence.
Dr. Pratik Choudhary of the University of Leicester referred to this as the “hypo knowledge gap” and explained that wider use of CGM has identified a large number of hypoglycemia episodes without symptoms. Additionally, the impact of asymptomatic hypoglycemia is not clear, and the impact of different “depths” and “durations” of hypoglycemia has not been studied.
Because of the amount of information needed to further understand and address hypoglycemia, projects like HypoResolve and HypoMETRICS explore the impact of hypoglycemia in people with diabetes, according to Choudhary.
HypoResolve is a European research project that entails database analyses, studies, metrics, and financial costs of hypoglycemia. It ultimately aims to reduce the burden and consequences of hypoglycemia.
HypoMETRICS is an app that records a person’s hypoglycemia episodes and evaluates its impact on daily functioning. People with diabetes can record their glucose levels as well as their symptoms and describe how it impacted them. The app assesses this impact of hypoglycemia on a person’s daily functioning.
According to Choudhary, HypoMETRICS will “provide a ‘data-driven’ definition of sensor detected hypoglycemia with optimized precision to identify patient reported hypoglycemia,” adding that it will also provide “detailed data on the different impact of different ‘types’ of hypoglycemia.”
Addressing hypoglycemia successfully requires a comprehensive approach. Studies and projects such as HARPdoc, HypoResolve, and HypoMETRICS aim to improve our understanding of hypoglycemia and its effects on people with diabetes.
