A Psychoeducational Program to Restore Hypoglycemia Awareness: The DAFNE-HART Pilot Study

Abstract

OBJECTIVE To develop and pilot a novel intervention addressing motivational and cognitive barriers to avoiding hypoglycemia in people with type 1 diabetes and persistent impaired awareness of hypoglycemia (IAH) despite training in flexible insulin therapy. RESEARCH DESIGN AND METHODS A 6-week intervention using motivational interviewing and cognitive behavioral techniques was designed. Diabetes educators were trained and supported in its delivery to 23 people with IAH (Gold score ‡4). RESULTS Twelve months postcourse, hypoglycemia awareness had improved (P < 0.001). Median (range) rates of severe hypoglycemia (SH) fell from 3 (0-104) to 0 (0-3) per person per year (P < 0.0001) and moderate from 14 (0-100) to 0 (0-18) per person per 6 weeks (P < 0.001). Worry and behavior around hyperglycemia improved. HbA 1c was unchanged. CONCLUSIONS A pilot intervention targeting motivation and cognitions around hypoglycemia engaged patients with resistant IAH and recurrent SH and was associated with significant improvement, supporting the hypothesis that these factors underpin problematic hypoglycemia. Hypoglycemia and fear of hypoglycemia remain major barriers to achieving optimal glucose control and quality of life for people with type 1 diabetes. Structured education in flexible insulin therapy (e.g., the U.K.'s Dose Adjustment for Normal Eating [DAFNE]) and/or use of insulin pump therapy reduces severe hypoglycemia (SH) (1), but some continue to experience impaired awareness of hypoglycemia (IAH) with high rates of SH, their problematic hypoglycemia resistant to intervention. We hypothesized that many such people have motivational and cognitive barriers to hypoglycemia avoidance and resolution of IAH. We designed and piloted an intervention using motivational interviewing and cognitive behavioral theory targeting these barriers.

Interventions That Restore Awareness of Hypoglycemia in Adults With Type 1 Diabetes: A Systematic Review and Meta-analysis

“…There were 20 studies in this category: 8 in unselected populations with T1D (4,(21)(22)(23)(24)(25)(26)(27)) and 12 in participants with IAH at baseline (9,(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38). Eight studies (22,23,24,26,29,30,33,34) were long-term, durations ranging between 1 and 3 years.…”

“…Twelve studies in people with IAH were small: between 5 and 30 people in 11 studies (9,(28)(29)(30)(32)(33)(34)(35)(36)(37)(38), although 1 study had .100 people (31). Followup was 3-12 months, with longer-term follow-up data of 18 months (29) and 3 years (33) was available for two studies.…”

“…Four of 12 studies with baseline IAH used a psychoeducational approach to restore awareness (28)(29)(30)(31). BGAT, based on work by Cox et al (40), focuses on increasing self-awareness of personal cues for hypoglycemia.…”

Recovery of Hypoglycemia Awareness in Long-standing Type 1 Diabetes: A Multicenter 2 × 2 Factorial Randomized Controlled Trial Comparing Insulin Pump With Multiple Daily Injections and Continuous With Conventional Glucose Self-monitoring (HypoCOMPaSS)

“…A nonsignificant trend toward improved HbA 1c in those with higher levels at baseline was observed, in keeping with our pilot study findings. Greater regression to the mean may have been predicted, and absence of evidence for this suggests that the biopsychobehavioral determinants of each participant's personal target glucose may be relatively unaffected by conventional educational and medical interventions, perhaps indicating the need for more profound cognitive/motivational psychotherapeutic approaches (26).…”

Improving management of type 1 diabetes in the UK: the Dose Adjustment For Normal Eating (DAFNE) programme as a research test-bed. A mixed-method analysis of the barriers to and facilitators of successful diabetes self-management, a health economic analysis, a cluster randomised controlled trial of different models of delivery of an educational intervention and the potential of insulin pumps and additional educator input to improve outcomes

“…[Note added in revision: since we submitted the final report, 12-month data (beyond the scope of the work described in this chapter) have been reported. 140 ] …”