Blood Glucose Awareness Training

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Blood Glucose Awareness Training

• An Introduction to the Research
• and Use of Neuroglycopenic Cues
• John Zrebiec, MSW, CDE
• Joslin Diabetes Center

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BGAT-What is it?

• Recognition, prediction prevention
• of extreme blood glucose
• Active personalized learning experiences
• Usually group format

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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

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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

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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

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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.

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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 gt 50 of
  trials during mild hypoglycemia as compared to
  euglycemia.
• Result 17 of children

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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.

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EGA ResultsBG lt 70 mg/dl (4.0 mmol/L) (n 263)
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EGA ResultsBG lt 50 mg/dl (3.0 mmol/L) (n 65)
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EGA ResultsBG gt 250 mg/dl (14 mmol/L) (n 705)
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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.

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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

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BGAT PATIENT BENEFITS

• Average Accuracy
• Before 45
• After 75
• Most Accurate Trained in Internal and External
  Cues

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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

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BGAT Patient Benefits

• Psychological benefits
• Improves knowledge about diabetes
• Reduces fear of hypoglycemia
• Reduces depression
• Reduces family conflict
• Improves quality of life

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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

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Risk Factors Associated with Hypoglycemia

• Male
• Long Duration of Diabetes
• History of Severe Hypoglycemia
• History of Recurrent Mild Hypoglycemia
• Going to sleep with BG lt100

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Most Common Causes of Hypoglycemia

•   1. Taking Too Much Insulin
• 2. Delaying Eating
• 3. Delaying Treating

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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

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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
•  

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NeuroglycopeniaThinking Performance Cues

• BG primary fuel of brain
• Brain sputters with low fuel
• Neuroglycopenia disrupts thinking and coordination

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Things To Look For

• Informal performance cues
• fine motor
• gross motor
• Formal performance cues
• fine motor
• gross motor

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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

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Informal Gross Motor Performance Cues

• Walking quickly and turning
• Walking
• Climbing stairs
• Standing up
• Bending over at your waist
• Dancing

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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

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Formal Performance Cues

• Doing a tongue twister
• Mental subtraction by 3s
• Thinking of words that begin with a certain
  letter of the alphabet
• Flipping a dime

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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

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Hypoglycemia and Driving

• Mid 50s disrupts driving
• Accidents 3x more common among T1DM
• For every accident there are 5 episodes of severe
  hypoglycemia
• Judgment to drive is poor

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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

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Best Driving Cues

• Trembling
• Incoordination
• Blurred vision

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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

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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

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Daily Diary
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Daily Diary sample
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BG Diary / Summary Sheet Low BG / High BG
Cues Average BG Frequency Consistency



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BG Diary / Summary Sheet Analysis

• 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 5366646149 293 / 5 58

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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