Not too high, not too low
Deakin health researchers have participated in a project that will significantly reduce the likelihood of severe hypoglycaemic episodes for people with type 1 diabetes.
For many of these people and their families, the improved management procedures will be life changing.
Around 120,000 people in Australia live with type 1 diabetes and one in five experience at least one severe hypoglycaemic episode every year, with the incidence increasing the longer a person lives with the condition.
Severe ‘hypos’, as they are commonly known, are caused by low blood glucose (sugar) and can result in confusion, collapse, fitting and, in extreme cases, even sudden death. Exact causes are different for each person and each episode, but events are typically caused by too much insulin or physical activity, or too little food.
Severe hypoglycaemia can have a huge impact on the lives of people with type 1 diabetes and their families. Unpleasant symptoms and consequences of severe hypos can lead to fear of hypoglycaemia and reduce independence and spontaneity, which are both important for quality of life. Severe hypos also put pressure on family and friends, who need to provide assistance to help the person recover. Those who experience recurrent severe hypos are often prevented from driving and can face employment difficulties.
In the first few years after being diagnosed, people with type 1 diabetes will experience early warning signs of impending hypoglycaemia, such as sweating or shaking, which will give them time to eat or drink something sugary before they become incapacitated. But it has long been known that people who have type 1 diabetes for more than five years can start to lose these warning symptoms, placing them at very high risk of a hypo both when awake and while asleep.
Now, a multi-centre trial published in leading journal, Diabetes Care, has found that the vast majority of people with type 1 diabetes can regain their hypo warning signs and avoid these traumatic experiences – even after many years of insulin therapy.
The HypoCOMPaSS trial took place at five specialist centres in the UK, led by Professor James Shaw (University of Newcastle) and funded by Diabetes UK. The lead psychologist on the study was Deakin’s Chair of Behavioural and Social Research in Diabetes Professor Jane Speight, who is also the Foundation Director of The Australian Centre for Behavioural Research in Diabetes, a partnership for better health between Diabetes Australia – Victoria and Deakin University.
The trial involved 96 adults with type 1 diabetes from across the UK (Bournemouth, Cambridge, Newcastle, Plymouth, and Sheffield), who were asked to follow simple guidelines for adjusting their insulin doses to minimise low glucose levels and took part in a brief education session to provide them with a ‘hypo compass’. This provided a framework for preventing progression of mild hypos into dangerous events through a range of practical strategies remembered through the points of a compass.
The study also compared the impact of different approaches to insulin delivery (insulin pumps, versus multiple daily injections) and glucose monitoring (continuous glucose monitoring through censors under the skin, versus conventional finger-prick testing) on the avoidance of severe hypos.
Before the study, those who took part had been experiencing around ten severe hypos every year. However, during the six-month trial period, 80% of them experienced no further episodes.
This study has confirmed the need for access to best possible guidance and structured support for everyone with type 1 diabetes, to enable them to achieve optimal glucose levels (important for preventing long-term complications) without severe hypos in the short-term.
Professor Speight explained, “This level of health professional input has often been reserved for those using technologies, such as insulin pumps and continuous glucose sensors, but this study shows structured support works for most people – and could dramatically reduce the number of severe hypos experienced by people with type 1 diabetes – so it needs to be provided equally to all.
“For years, people with type 1 diabetes have been advised not to let their blood glucose levels get too high (to avoid long-term complications) and now we are also advising them not to get too low, so it’s a complicated message. But HypoCOMPaSS shows that with appropriate support and education, a safe and effective balance can be achieved in the vast majority of cases.
“These really exciting results were achieved without any worsening of participants’ average glucose levels (HbA1c), meaning that the participants did not increase their risk of long-term complications.”
The trial showed that equivalent biomedical benefits could be achieved using multiple daily injections or an insulin pump. Similarly, regular finger-prick glucose monitoring, including some night-time checks, was just as effective as real-time continuous glucose monitoring through a sensor placed under the skin every few days.
“The only difference between the technology arms was that satisfaction with treatment was particularly high in those randomised to the insulin pump. Fear of hypos reduced significantly for everyone. For many people and their families, prevention of severe hypos is life changing,” explained Professor Speight.
Professor Speight will be discussing these findings at an endocrinology conference in Sydney in July 2014. She and her team are working to ensure that better support is provided to Australians with type 1 diabetes and have submitted for an NHMRC project grant to further their hypoglycaemia research program.