October 21, 2022
A collaborative study between Michigan Medicine Departments of Internal Medicine and Family Medicine, and the University of Kentucky College of Medicine, suggests that people’s beliefs about hypoglycemia play an important role in their hypoglycemia outcomes, even when they are using advanced diabetes technologies.
An individual’s blood glucose level can vary throughout the day and is dependent on many factors. For many people, the body can keep the glucose level to stay within the normal range. However, people who have diabetes can experience their blood glucose level going too high (known as “hyperglycemia”) or too low (known as “hypoglycemia”). Both conditions can cause devastating complications, and possibly even death, if not treated in an appropriate amount of time. As a result, people with diabetes have to be aware of their blood glucose level regularly throughout the day and night, so that they can adjust their food intake, physical activity, and/or medication based on their blood glucose level to bring it back within the normal range.
Continuous glucose monitoring systems (CGMs) were developed to help people with diabetes better monitor and manage their blood glucose levels. CGMs constantly track an individual’s glucose level and let people know their level at any given moment by looking at the monitor. An alarm can be set to let the person know if their glucose level goes too high or too low. CGMs can also work with insulin pumps, an insulin delivery device, to create a “hybrid closed-loop system”, which tests a person’s glucose level and automatically adjusts the insulin doses to help bring their level back into the targeted range.
However, despite these advancements in diabetes technology, dangerous hypoglycemia (including “level 2 hypoglycemia” - when a person’s glucose level is less than 54 mg/dL - and “severe hypoglycemia” - when a person is unable to function because of mental or physical changes due to hypoglycemia and needs help from another person to treat hypoglycemia) continues to occur in individuals with type 1 diabetes. Health care providers and researchers have been questioning why dangerous hypoglycemia is still happening with the use of these advanced diabetes technologies.
Yu Kuei Alex Lin, MD, Clinical Assistant Professor in the Department of Internal Medicine Division of Metabolism, Endocrinology, and Diabetes; Melissa DeJonckheere, PhD, Research Assistant Professor in the Department of Family Medicine; and colleagues set out to evaluate the relationship between the beliefs around hypoglycemia and their impact on the development of hypoglycemia in individuals with type 1 diabetes.
The researchers surveyed 289 adults with type 1 diabetes who were using CGMs at University of Michigan Health. Participant demographics and severe hypoglycemia history and CGM hypoglycemia data were collected. Participants also rated a series of statements about hypoglycemia to report their beliefs around hypoglycemia.
The study results, published in Diabetes Care, showed that participants who expressed beliefs downplaying the seriousness of hypoglycemia or prioritizing the care of hyperglycemia over hypoglycemia were more likely to develop dangerous hypoglycemia.
Learn more about the study from Dr. Alex Lin
What prompted you to conduct this study?
Advanced diabetes technologies, such as continuous glucose monitors, provide people living with diabetes the glucose information necessary for managing and preventing hypoglycemia. However, in the clinic, we still observe that some people continue to develop dangerous hypoglycemia despite using these state-of-the-art technologies. At the end of the day, humans use these technologies and human factors are still important. We therefore hypothesized that people’s beliefs about hypoglycemia would affect their decision making and behaviors around hypoglycemia self-management, and thereby their hypoglycemia outcomes.
What is the significance of the study’s findings?
Our study demonstrates that how people think of hypoglycemia plays an important role in their hypoglycemia outcomes, even when they are using the most advanced diabetes technologies currently available. These findings help us understand that we should work with people with diabetes to better calibrate their perceived risks of hypoglycemia and hyperglycemia, so they can better manage their hypoglycemia and prevent dangerous hypoglycemia from happening.
What can health care providers do to help patients who downplay the seriousness of hypoglycemia?
Traditional diabetes education may not sufficiently address this problem. Recent research from Dr. Stephanie Amiel and colleagues in the United Kingdom have demonstrated that combined psychological and educational interventions including techniques such as motivational interviewing and cognitive behavioral therapy will help address this resilient problem. We are also working to develop a program that specifically targets people who are using advanced diabetes technologies to better support this population.
What are the next steps?
Prior research on psychological barriers to hypoglycemia self-management has mostly focused on people who are not using advanced diabetes technologies. We are conducting studies to rigorously evaluate this population to identify barriers that are unique to this population, so we can better handle them in the future.
Additional authors of the study include:
- Iulia Dobrin; Kara Mizokami-Stout, MD; and Rodica Pop-Busui, MD, PhD (Department of Internal Medicine)
- Caroline R. Richardson, MD; Michael D. Fetters, MD, MPH, MA; and James E. Aikens, PhD (Department of Family Medicine)
- Wen Ye, PhD (Department of Biostatistics)
- Simon J. Fisher, MD, PhD (University of Kentucky College of Medicine)