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
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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
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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 SchoolAged 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 Results
BG < 70 mg/dl (4.0 mmol/L) (n = 263)
40
35
30
25
Children
Parents
20
15
10
5
0
Zone A
Zone B
Zone C
Zone D
Zone E
EGA Results
BG < 50 mg/dl (3.0 mmol/L) (n = 65)
50
45
40
35
30
Children
Parents
25
20
15
10
5
0
Zone A
Zone D
Zone E
EGA Results
BG > 250 mg/dl (14 mmol/L) (n = 705)
60
50
40
Children
Parents
30
20
10
0
Zone A
Zone B
Zone C
Zone D
Zone E
Conclusions
• School-aged children with T1DM and their
parents show poor ability to recognize hypoand 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
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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
Neuroglycopenia
Thinking & 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
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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
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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
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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
Daily Diary
Date
Time
BG Cues, Internal and External
Est
Actual
Zones
Causes, BG<70>180
Daily Diary
sample
Date
6/22
Time
7:30a
BG Cues, Internal and External
Feel funny, headache in forehead, kind of sleepy, worked hard
raking leaves
Est
49
Actual
41
Zones
A
Causes, BG<70>180
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.
2.
3.
4.
Find every actual low BG
List each individual and different cue
List BG values occurring with each cue
Find the average
Example
Symptom / 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%