Effect of Education on Impaired Hypoglycemia Awareness and Glycemic Variability in Children and Adolescents with Type 1 Diabetes Mellitus

Günay Demir, Samim Özen, Hafize Çetin, Şükran Darcan, Damla Gökşen, Günay Demir, Samim Özen, Hafize Çetin, Şükran Darcan, Damla Gökşen

Abstract

Objective: The aim of this study was to determine the prevalence of impaired hypoglycemia awareness (IHA) in children and adolescents with type 1 diabetes mellitus using a professional continuous glucose monitoring (CGM) system and to show the effect of structured education on glycemic variability (GV) in children and adolescents with IHA.

Methods: Forty type 1 diabetic children and adolescents with a diabetes duration of at least five years were eligible for inclusion in this prospective, quantitative study. All subjects were asked about their history of being aware of the symptoms of hypoglycemia using a questionnaire. Professional CGM was conducted in all of the patients for six days. The frequency of IHA detected by comparison of CGM and logbook reports were analyzed. Patients with identified IHA underwent a structured training program. After three months, CGM was re-applied to patients with IHA.

Results: The study was completed by 37 diabetic children and adolescents. After the initial CGM, nine patients (24.3%) were found to have had episodes of IHA. Area under the curve (AUC) for hypoglycemia and number of low excursions were; 1.81±0.95 and 8.33±3.60 for the IHA group at the beginning of the study. AUC for hypoglycemia was 0.43±0.47 after three months of structured education the IHA patients (p=0.01). Coefficient of variation which shows primary GV decreased significantly although unstable at the end of education in IHA patients (p=0.03).

Conclusion: CGM is a valuable tool to diagnose IHA. IHA, GV and time in range can be improved by education-based intervention.

Keywords: Continuous glucose monitoring; education; impaired hypoglycemia awareness; glycemic variability; type 1 diabetes; children.

Figures

Figure 1
Figure 1
Percentage change in area under the curve (mg/dL x day) after education for impaired hypoglycemia awareness *p

Figure 2

Change in coefficient of variation…

Figure 2

Change in coefficient of variation after education for impaired hypoglycemia awareness *p=0.03, CV:…

Figure 2
Change in coefficient of variation after education for impaired hypoglycemia awareness *p=0.03, CV: coefficient of variation
Figure 2
Figure 2
Change in coefficient of variation after education for impaired hypoglycemia awareness *p=0.03, CV: coefficient of variation

References

    1. Alberti KG, Zimmet PZ. Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: diagnosis and classification of diabetes mellitus provisional report of a WHO consultation. Diabet Med. 1998;15:539–553.
    1. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2007;30(Suppl 1):S42–S47.
    1. Ly TT, Maahs DM, Rewers A, Dunger D, Oduwole A, Jones TW; International Society for Pediatric and Adolescent Diabetes. ISPAD Clinical practice Consensus Guidelines-Hypoglycemia: Assessment and management of hypoglycemia in children and adolescents with diabetes. Pediatric Diabetes. 2014;15(Suppl 20):180–192.
    1. Danne T, Nimri R, Battelino T, Bergenstal RM, Close KL, DeVries JH, Garg S, Heinemann L, Hirsch I, Amiel SA, Beck R, Bosi E, Buckingham B, Cobelli C, Dassau E, Doyle FJ, Heller S, Hovorka R, Jia W, Jones T, Kordonouri O, Kovatchev B, Kowalski A, Laffel L, Maahs D, Murphy HR, Nørgaard K, Parkin CG, Renard E, Saboo B, Scharf M, Tamborlane WV, Weinzimer SA, Phillip M. International consensus on use of continuous glucose monitoring. Diabetes Care. 2017;40:1631–1640.
    1. Vurallı D, Kandemir N. İçinde: Cinaz P ve ark. Tip 1 diyabetes mellitus. Çocuk Endokrinolojisi. Nobel Tıp Kitabevi, Ankara, 2014:399–452.
    1. Reno CM, Litvin M, Clark AL, Fisher SJ. Defective counter-regulation and hypoglycemia unawareness in diabetes: Mechanisms and emerging treatments. Endocrinol Metab Clin North Am. 2013;42:15–38.
    1. Olsen SE, Asvold BO, Frier BM, Aune SE, Hansen LI, Bjørgaas MR. Hypoglycemia symptoms and impaired awareness of hypoglycemia in adults with Type 1 diabetes: the association with diabetes duration. Diabet Med. 2014;10:1210–1217.
    1. Gravelling AJ, Noyes KJ, Allerhand MH, Wright RJ, Bath LE, Deary IJ, Frier BM. Prevalence of impaired awareness of hypoglycemia and identification of predictive symptoms in children and adolescents with type 1 diabetes. Pediatric Diabetes. 2014;15:206–213.
    1. Martín-Timón I, Del Cañizo-Gómez FJ. Mechanisms of hypoglycemia unawareness and implications in diabetic patients. World J Diabetes. 2015;6:912–926.
    1. Ly TT, Hewitt J, Davey RJ, Lim EM, Davis EA, Jones TW. Improving epinefrine responses in hypoglycemia unawareness with real time continuous glucose monitoring in adolescents with type 1 diabetes. Diabetes Care. 2011;34:50–52.
    1. Hepburn DA, Deary IJ, Macleod KM, Frier BM. Structural equation modeling of symptoms, awareness and fear of hypoglycemia, and personality in patients with insulin-treated diabetes. Diabetes Care. 1994;17:1273–1280.
    1. No authors listed. Epidemiology of severe hypoglycemia in the diabetes control and complications trial. The DCCT Research Group. A J Med. 1991;90:450–459.
    1. Cryer PE, Binder C, Bolli GB, Cherrington AD, Gale EA, Gerich JE, Sherwin RS. Hypoglycemia in IDDM. Diabetes. 1989;38:1193–1199.
    1. Pramming S, Thorsteeinsson B, Bendtson I, Binder C. Symptomatic hypoglycemia in 411 type 1 diabetic patients. Diabet Med. 1991;8:217–222.
    1. Gold AE, Macleod KM, Frier BM. Frequencyof severe hypoglycemia in patients with type 1 diabetes with impaired awareness of hypoglycemia. Diabetes Care. 1994;17:697–703.
    1. Ly TT, Gallego PH, Davis EA, Jones TW. Impaired awareness of hypoglycemia in a population-based sample of children and adolescents with type 1 diabetes. Diabetes Care. 2009;32:1802–1806.
    1. Davis SN, Shavers C, Costa F. Gender-related differences in counter-regulatory responses to antecedent hypoglycemia in normal humans. J Clin Endocrinol Metab. 2000;85:2148–2157.
    1. Pedersen-Bjergaard U, Pramming S, Heller SR, Wallace TM, Rasmussen AK, Jørgensen HV, Matthews DR, Hougaard P, Thorsteinsson B. Severe hypoglycemia in 1076 adult patients with type 1 diabetes: influence of risk markers and selection. Diabetes Metab Res Rev. 2004;20:479–486.
    1. Geddes J, Schopman JE, Zammitt NN, Frier BM. Prevalence of impaired awareness of hypoglycemia in adults with Type 1 diabetes. Diabet Med. 2008;25:501–504.
    1. Graveling AJ, Frier BM. Impaired awareness of hypolycemia: a review. Diabetes Metab. 2010;36:64–74.
    1. Dagogo-Jack S, Rattarasarn C, Cryer PE. Reversal of hypoglycemia unawareness, but not defective glucose counterregulation, in IDDM. Diabetes. 1994;43:1426–1434.
    1. Gimenez M, Lara M, Conget I. Sustained efficacy of continuous subcutaneous insulin infusion in type 1 diabetes subjects with recurrent non-severe and hypoglycemia unawareness: a pilot study. Diabetes Technol Ther. 2010;12:517–521.
    1. Lucidi P, Porcellati F, Bolli GB, Fanelli CG. Prevention and Management of severe Hypoglycemia and Hypoglycemia Unawareness; Incorporating sensor Technology. Curr Diab Rep. 2018;18:83.
    1. Silverstein J, Klingensmith G, Copeland K, Plotnick L, Kaufman F, Laffel L, Deeb L, Grey M, Anderson B, Holzmeister LA, Clark N; American Diabetes Association. Care of children and adolescents with type 1 diabetes: a statement of the American Diabetes Association. Diabetes Care. 2005;28:186–212.
    1. Di Meglio LA, Acerini CL, Codner E, Craig ME, Hofer SE, Pillay K, Maahs DM. ISPAD Clinical Practice Consensus Guidelines 2018: Glycemic control targets and glucose monitoring for children, adolescents, and young adults with diabetes. Pediatric Diabetes. 2018;19(Suppl 27):105–114.
    1. Cengiz E, Xing D, Wong JC, Wolfsdorf JI, Haymond MW, Rewers A, Shanmugham S, Tamborlane WV, Willi SM, Seiple DL, Miller KM, DuBose SN, Beck RW; T1D Exchange Clinic Network. Severe hypoglycemia and diabetic ketoacidosis among youth with type 1 diabetes in T1D exchange clinic registry. Pediatr Diabetes. 2013;14:447–454.
    1. Hopkins D, Lawrence I, Mansell P, Thompson G, Amiel S, Campbell M, Heller S. Improved biomedical and psychological outcomes 1 year after structured education in flexible insulin therapy for people with type 1 diabetes. The U.K. DAFNE experience. Diabetes Care. 2012;35:1638–1642.
    1. Cryer PE, Fisher JN, Shamoon H. Hypoglycemia. Diabetes Care. 1994;17:734–755.
    1. Tan HK, Little SA, Leelarathna L, Walkinshaw E, Lubina-Solomon A, Hosking J, Speight J, Kerr D, Heller SR, Evans ML, Shaw JA, Flanagan D. Low-Blood Glucose Avoidance Training Improves Glycemic Variability in Adults With Type 1 Diabetes Complicated by Impaired Awareness of Hypoglycemia: HypoCOMPaSS Trial. Diabetes Care. 2016;39:56–58.
    1. Van Beers CA, DeVries JH, Kleijer SJ, Smits MM, Geelhoed-Duijvestijn PH, Kramer MH, Diamant M, Snoek FJ, Serné EH. Continuous glucose monitoring for patients with type 1 diabetes and impaired awareness of hypoglycaemia (IN CONTROL): a randomised, open-label, crossover trial. Lancet Diabetes Endocrinol. 2016;4:893–902.

Source: PubMed

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