Blood Glucose Awareness Training

An Introduction to the Research

and Use of Neuroglycopenic Cues

John Zrebiec, MSW, CDE

Joslin Diabetes Center

BGAT-What is it?

• Recognition, prediction & prevention

of extreme blood glucose

• Active & personalized learning experiences

• Usually group format

Who Is BGAT For?

Adults Taking Insulin

• Frequent hypoglycemic episodes• Hypoglycemic unaware• Too afraid or lack a fear of hypoglycemia• Frequent motor vehicle accidents or violations• Family conflict due to BG• Trouble at work due to BG• Attempting intensive insulin therapy• Pursuing pregnancy

BGAT History

• NIH funded research for past 25 years• 15 US and international studies• Translated into 5 languages• Hypoglycemia, Anticipation, Treatment and Training (HAATT)• www.healthsystem.virginia.edu/bmc/ bgathome • BGAT for Parents

Reduction of Risk for Severe Hypoglycemia through Psychobehavioral Intervention

Linda Gonder Frederick, PhD, Daniel Cox,

Phd, Boris Kovatchev, PhD, William Clark,

MD and John Zrebiec, MSW

• University of Virginia, Charlottesville

• Joslin Diabetes Center, Boston

Effects of BG on Cognitive Function in School-Aged Children with T1DM:

A Field Study

Linda Gonder-Frederick PhD, John Zrebiec MSW,* Andrea Bauchowitz PhD, Daniel Cox PhD, Lee

Ritterband PhD, Jarim Lee BA,* Boris Kovatchev PhD, and

William Clarke MD

University of Virginia

and

*Joslin Diabetes Center, Harvard Medical School

Research supported by NIH R01DK60039 and Abbott Diabetes Care, Inc.

Within-Subject Results

• Question: How many children show a clinically significant deterioration in performance with mild hypoglycemia?

• Clinically significant defined as: Performance on the math task more than one SD poorer on > 50% of trials during mild hypoglycemia as compared to euglycemia.

• Result: 17% of children

BG Detection in School-Aged Children with T1DM and their Parents

Linda Gonder-Frederick, Ph.D.

John Zrebiec, M.A.*

Daniel Cox, Ph.D.

Boris Kovatchev, Ph.D.

Lee Ritterband, Ph.D.

William Clarke, M.D.

University of Virginia

*Joslin Diabetes Center at Harvard University

Research supported by NIH R01 DK 060039 and Abbott Diabetes Care, Inc.

EGA ResultsBG < 70 mg/dl (4.0 mmol/L) (n = 263)

0

5

10

15

20

25

30

35

40

Zone A Zone B Zone C Zone D Zone E

ChildrenParents

EGA ResultsBG < 50 mg/dl (3.0 mmol/L) (n = 65)

0

5

10

15

20

25

30

35

40

45

50

Zone A Zone D Zone E

ChildrenParents

EGA ResultsBG > 250 mg/dl (14 mmol/L) (n = 705)

0

10

20

30

40

50

60

Zone A Zone B Zone C Zone D Zone E

ChildrenParents

Conclusions

• School-aged children with T1DM and their parents show poor ability to recognize hypo- and hyperglycemia.

• Failure to detect extreme BG levels occurs as often or more often than accurate detection.

• Children and Parents are far more likely than adults to mistake low BG for high, and vice versa.

BGAT Patient Benefits

• Improves detection of extreme BG • Reduces occurrence of extreme BGs • Preserves Counter-Regulatory Response during intensive insulin treatment• Reduces sequeli of extreme BG 1. DKA 2. Severe hypoglycemia 3. Motor vehicle accidents & violations

BGAT PATIENT BENEFITS

Average Accuracy

Before 45%

After 75%

Most Accurate: Trained in Internal and External Cues

BGAT Patient Benefits

• Improves driving decisions

81% choose not to drive when low

• Million miles driven:

7 accidents BGAT

29 accidents non-diabetic

• Swerve first, then slow down

BGAT Patient Benefits

• Psychological benefits–Improves knowledge about diabetes

–Reduces fear of hypoglycemia

–Reduces depression

–Reduces family conflict

–Improves quality of life

Benefits for Physicians and Diabetes Educators

• Saves professional time dealing with hypoglycemia prevention

• Reduces emergency telephone calls• Reduces time spent with anxious family

members• Improves BG control• Educates patients about how to recognize

and treat extreme BG

Risk Factors Associated with Hypoglycemia

•Male

•Long Duration of Diabetes

•History of Severe Hypoglycemia

•History of Recurrent Mild Hypoglycemia

•Going to sleep with BG <100

Most Common Causes of Hypoglycemia

  1. Taking Too Much Insulin

2. Delaying Eating

3. Delaying Treating

Most Common Symptoms of Hypoglycemia

• Trembling

• Pounding Heart

• Difficulty Concentrating

• Uncoordination

• Only 50% report these symptoms• 50% report non-specific symptoms• Only 50% actually recognize symptoms

Research Findings

• 50% lows occur while asleep• Average episode of nocturnal

hypoglycemia lasts 86 minutes• 50% higher risk for next 24 hours • 25% higher risk for next 48 hours• Autonomic symptoms are significantly

depressed for next 72 hours

 

NeuroglycopeniaThinking & Performance Cues

• BG primary fuel of brain

• Brain sputters with low fuel

• Neuroglycopenia disrupts thinking and coordination

Things To Look For

• Informal performance cues–fine motor–gross motor

• Formal performance cues–fine motor –gross motor

Common Informal Mental Performance Cues

• Following directions

• Doing simple arithmetic

• Making change

• Following conversations

• Thinking of the correct word

• Having difficulty reading

• Having difficulty concentrating

Informal Gross Motor Performance Cues

• Walking quickly and turning

• Walking

• Climbing stairs

• Standing up

• Bending over at your waist

• Dancing

Informal Fine Motor Performance Cues

• Writing a check or addressing an envelope

• Hammering a nail or turning a screw

• Unlocking a door

• Typing

• Tying a knot, shoelace, or tie

Formal Performance Cues

• Doing a tongue twister

• Mental subtraction by 3’s

• Thinking of words that begin with a certain letter of the alphabet

• Flipping a dime

Other Common Neuroglycopenic Symptoms

• Fuzzy thinking• Slight confusion• Trouble talking• Uncoordinated• Dizzy or lightheaded• Unusual fatigue or sleepiness• Visual problems• Feeling “heavy” in arms or legs

Hypoglycemia and Driving

• Mid 50’s disrupts driving

• Accidents 3x more common among T1DM

• For every accident there are 5 episodes of severe hypoglycemia

• Judgment to drive is poor

Driving Performance Cues

• Difficulty steering in a straight line• Driving slower than usual to

compensate for bad driving• Difficulty finding your way• Running stop signs or red lights• Tailgating• Stopping too soon before a stop line or

a parked car• Other drivers honking at you

Best Driving Cues

• Trembling

• Incoordination

• Blurred vision

Rules of the Road

• If you think you might be low, CHECK BG before starting the car

• If you are low while driving, STOP immediately

• TREAT immediately

• WAIT to continue driving until BG rises

Good News about Driving

• BGAT improves judgement when not to drive

• Judgement to drive significantly correlates with crash record

• BGAT reduces crashes and motor vehicle violations

Date Time BG Cues, Internal and External Est Actual Zones Causes, BG<70>180

Daily Diary

Daily Diary sample

Date Time BG Cues, Internal and External Est Actual Zones Causes, BG<70>180 6/22 7:30a Feel funny, headache in forehead, kind of sleepy, worked hard

raking leaves 49 41 A Usual food and

insulin, but more exercise than usual

BG Diary / Summary Sheet Low BG / High BG

Cues Average

BG

Frequency Consistency

BG Diary / Summary Sheet Analysis

1. Find every actual low BG 2. List each individual and different cue3. List BG values occurring with each cue4. Find the average

ExampleSymptom / Average BG Irritable 53+66+64+61+49= 293 / 5 = 58

BG Diary / Summary Sheet Analysis

5. List the frequency of each cue

6. Find consistency: divide frequency by

total number of low BG entries

Example

Symptom / Avg BG / Frequency / Consistency

Irritable 58 10 10/20 = 50%