Despite New CGM Technology, Human Behavior Contributes to Hypoglycemia


Data from a new study indicates human behavior and decision-making could be hampering the ability of new diabetes technologies to reduce hypoglycemic events in patients with type 1 diabetes.

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Although new technologies have demonstrated their potential to improve diabetes management, behaviors and beliefs may contribute to their lack of benefit on reducing hypoglycemia in some patients, according to a new study.

A cross-sectional study of nearly 300 patients, data from the study indicates severe and level 2 hypoglycemia continue to occur in patients with type 1 diabetes and high hypoglycemia risks despite considerable advances in technology.

“The current study provides evidence that human behaviors continue to affect hypoglycemia outcomes in individuals with type 1 diabetes despite the implementation of advanced diabetes technologies,” wrote study author Yu Kuei Lin, Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan Medical School.

Recent evidence has shown that behavioral counterregulatory mechanisms associated with cognitive and environmental determinants of hypoglycemia self-management play key roles in recovery from hypoglycemia in those with T1D. Other barriers to hypoglycemia self-management in individuals with T1D included emotional, action planning, educational, and social factors.

New technologies including continuous glucose monitoring systems (CGMs) and closed-loop insulin pumps have become the standard of care for individuals with T1D.

The cross-sectional study conducted from January - April 2021 involved a self-report survey, collection of demographic and diabetes-related data through review of electronic medical records (EMRs), and collection of CGM data from EMRs or participants.

The survey assessed the duration of diabetes and CGM use, insulin pump use and features, close-loop features, and the development of severe hypoglycemia in the past 6 months. They assessed hypoglycemia awareness status through the Gold questionnaire (1 [always aware] to 7 [never aware]) in a Ukert-type scale.

Following exclusions for participants using CGMs less than 6 months, a total of 289 participants with recent CGM data were included in the analyses for severe hypoglycemia assessment and 257 participants were included in analyses for CGM glucose assessment.

Data show 100 participants (34.6%) had either experienced severe hypoglycemia or presented with significant level 2 hypoglycemia and 9 participants (3.5%) had both severe hypoglycemia experience and significant level 2 hypoglycemia presentation.

They observed a total of 74 (25.6%) of the 289 individuals reported experiencing at least one episode of severe hypoglycemia in the past 6 months. Those with severe hypoglycemia had higher HbA1c and average CGM glucose levels, Gold scores, and glycemic variabilities.

Further, a total of 172 individuals (66.9%) were found to have spent time in level 2 hypoglycemia and 35 (13.6%) were found to have presented with significant level 2 hypoglycemia.

Those presenting with significant level 2 hypoglycemia were older, had lower HbA1c, and average CGM glucose levels, higher Gold scores, spent more time in hypoglycemia, had higher glycemic variabilities, and were more likely to turn off the hypoglycemia alarm

Additionally, reporting beliefs are prioritizing hyperglycemia avoidance was associated with severe hypoglycemia development (P <.001), while having beliefs of minimal concerns for hypoglycemia was associated with spending ‡1% of time in level 2 hypoglycemia (P = .038).

“To reduce the burden of hypoglycemia, our findings suggest that diabetes health care providers would need to address patient preconceived notions regarding prioritizing hyperglycemia avoidance and minimizing hypoglycemia concerns beyond prescribing CGMs and insulin pumps and providing basic training,” investigators wrote.

The study, “Beliefs Around Hypoglycemia and Their Impacts on Hypoglycemia Outcomes in Individuals with Type 1 Diabetes and High Risks for Hypoglycemia Despite Using Advanced Diabetes Technologies,” was published in Diabetes Care.

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