Blood Glucose Awareness Training
Research on strategies for spotting highs and lows
In an age of meters aplenty and continuous glucose monitors, the art of feeling out blood glucose levels may seem unnecessary. Yet, hypoglycemia (low blood glucose) and hyperglycemia (high blood glucose) are not relics of a past era. One study found that, over the course of a year, 7 percent of people with insulin-treated diabetes experienced a blood glucose low that required emergency assistance.
Identifying and treating lows are cornerstones of diabetes care, but some scientists think people shouldn't need to rely solely on technology for blood glucose intel. While testing is best, there are situations in which people can't check or don't think to test. That's why researchers have been quietly developing strategies that help people with diabetes use both internal and external cues to more accurately estimate their blood glucose levels. The results are promising, suggesting that blood glucose awareness training can help people react to dangerous glucose levels and reduce their risk of blood sugar emergencies. That may cut down on the physical toll blood glucose extremes take on the body and also on the rare car crashes caused by low blood glucose.
Under Your Skin
In the mid-1980s, Daniel Cox, PhD, ABPP, director of the Center for Behavioral Medicine Research at the University of Virginia, says he didn't know anything about diabetes. "What I had been doing before is called biofeedback," he adds, describing it as a "procedure where you give people info on what's going on under their skin." His focus then was on muscle-contraction headaches. Cox found that he could train people to recognize when they were tensing their head muscles; once they recognized that, they could unclench. The result: fewer headaches.
After attending a meeting with diabetes specialists, he began to wonder if people with type 1 diabetes could learn to estimate blood glucose by aligning their sensations with blood glucose readings from meters. What came next was a series of studies spanning decades that aimed to find the best way to train people to estimate their blood glucose levels and to prevent dangerous high and lows. In 2008, Cox published a study of the culmination of this research: an online blood glucose awareness training (BGAT) program.
The program (which is currently not available to the public) starts by asking users to plot their estimated blood glucose on a chart against measured blood glucose levels, so that they can see how close their estimates are. The next three units focus on external cues that affect blood glucose levels: food, physical activity, and insulin. For example, understanding how different foods affect blood glucose can help users estimate their numbers, says Cox. The program also trains people to take into account all forms of physical activity, including things such as walking a dog or raking leaves, and factor them into blood glucose estimates as well. The other important external factor is insulin. Because there are different types of insulin, says Cox, the program trains people to assess their risks for extreme blood glucoses based on their insulin regimen.
The second half of the blood glucose awareness training program attends to internal cues: physical, emotional, and cognitive symptoms that can point to a high or low. Clare Bradley, PhD, professor of health psychology at the University of London, began to study blood glucose awareness training from the emotional side at around the same time as Cox began his work. "I was pursuing mood states and blood glucose levels," she recalls. "What was clear from the work is that people vary enormously in terms of what feeling they have when they are having a high or low. You can't tell people what to expect—you can just give them the tools to figure it out."
Cox agrees that each person is likely to have a unique reaction to glucose highs and lows. "These changes are very idiosyncratic," he says. Bradley didn't have enormous success using mood cues alone to predict highs and lows, and believes Cox's approach of using internal and external factors together was key to his success.
This spring, Cox was continuing to recruit people with type 1 diabetes for a variation of blood glucose awareness training on diabetes and driving. This Web-based program can work even with people who believe they have lost the ability to sense lows (hypoglycemia unawareness), he says. "Our research has shown that people who think of themselves as hypoglycemia unaware can improve their awareness just as much as someone who is aware."
Deborah Caudill, 57, who lives in Ashland, Ky., is hypoglycemia unaware, she says, and a participant in the diabetes-and-driving study. She's had several close calls in her vehicle, although she's avoided collisions. "During the worst incident I remember, the road was visibly moving," she recalls. Before the program, Caudill hadn't come to grips with the hazards of driving while low. "I did not realize the danger I was putting others in, let alone myself," she says. The program taught her strategies that, even though she still can't recognize lows from physical symptoms, can keep her from driving while low. "Now I check my blood glucose all the time before I leave and check it frequently [during breaks while] driving," she says. "I think it helped me very much."
Time and again, studies have shown that blood glucose awareness training improved the accuracy of blood glucose estimates in people with type 1. Even more important, the program has consistently lowered the risk for driving mishaps, episodes of severe hypoglycemia, and fear of hypoglycemia. For example, a 2001 study found that the training reduced the risk for driving mishaps by 86 percent and the risk of severe hypoglycemia by 57 percent. Yet Cox admits the program isn't a cakewalk. "It's like playing tennis or the piano—when you first get started, it's pretty complex," says Cox, "but once you get good at it, it just flows."
Cox's program isn't the only game in town, though. Diabetes educators are experts at training people to avoid blood glucose extremes. In fact, that's one of their main jobs, according to Philip Cryer, MD, professor of endocrinology at the Washington University School of Medicine in St. Louis. He says educators can also teach people when to test, such as before driving a car and before exercise. "The key thing is training," he says, but adds that technology may help, too. Continuous glucose monitoring, Cryer says, "should allow people to recognize when their sugars are falling and when to do something about it."