A Psychoeducational Program to Restore Hypoglycemia Awareness: The DAFNE-HART Pilot Study
Nicole de Zoysa
2
Helen Rogers
1
Marietta Stadler
2
Carla Gianfrancesco
0
Susan Beveridge
0
Emma Britneff
2
Pratik Choudhary
2
Jackie Elliott
3
Simon Heller
3
Stephanie A. Amiel
2
0
Sheffield Teaching Hospitals NHS Trust, Northern General Hospital
,
Sheffield, U.K
1
King's College Hospital NHS Foundation Trust
,
London, U.K
2
Diabetes Research Group, King's College London
,
London, U.K
3
Sheffield University School of Medicine, Academic Unit of Diabetes, Endocrinology, and Metabolism, School of Medicine and Biomedical Sciences
,
Sheffield, U.K
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).
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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.
Diabetes Care 2014;37:863866 | DOI: 10.2337/dc13-1245
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.
RESEARCH DESIGN AND METHODS
An intervention, teaching aids,
curriculum, and manual
(DAFNEHypoglycemia Awareness Restoration
Training [DAFNE-HART]) were designed
by a clinical psychologist, doctors,
educators, and patient representatives.
It revised relevant sections from DAFNE
and interventions targeting problematic
hypoglycemia (2,3). Participants were
taught to look for hypoglycemia cues
and consider their own causes and
consequences of IAH and how to reduce
hypoglycemia exposure. The
educational material was presented
within a motivational interviewing
framework to support behavior change
and minimize resistance. Cognitive
behavioral techniques were used to
identify and restructure unhelpful
thoughts such as needing to soldier on
through episodes, underestimating the
consequences of hypoglycemia, and
worrying excessively about intermittent
hyperglycemia. In three weekly full-day
group sessions, theories about
hypoglycemia and awareness were
reviewed, the concept of a body scan
(a structured guide to find subjective
cues to blood glucose concentration)
was taught, insulin action was revised,
and theories linking thoughts with
behavior were explored, supporting
patients to recognize and challenge
their own cognitions around
hypoglycemia. Homework used home
glucose monitoring to test the learning
and, during weeks 4 and 5, try newly
learned skills/strategies, with scheduled
individual face-to-face and telephone
support. A final full-day group session
focused on relapse prevention.
Twenty-four people (12 male) with type
1 diabetes, using DAFNE principles for
insulin self-adjustment, with persistent
IAH assessed clinically and scoring $4
on the Gold score, in which patients
rate their awareness of hypoglycemia
from 1 (I am always aware of my
hypoglycemia) to 7 (I am never aware
of my hypoglycemia) (4), were
recruited. Hypoglycemia experience,
including self-report of SH
(hypoglycemia [,63 mg/dL/3.5 mmol/L]
that could not be self-treated,
requiring assistance), over the
preceding 12 months and moderate
hypoglycemia (,63 mg/dL/3.5 mmol/L,
self-treated but disrupting daily activity)
over the last 6 weeks, hypoglycemia
awareness and burden (Gold, Clarke,
and Ryan scores) (46), and mood and
self-care behaviors around glucose
control were documented by
questionnaires, including the Hospital
Anxiety and Depression Scale (HADS)
(7), the Problem Areas In Diabetes
(PAID) Questionnaire (8), the
Hypoglycemia Fear Survey II (9), and the
Hyperglycemia Avoidance Score
(courtesy of L. Gonder-Frederick,
University of Virginia, Charlottesville,
VA), and glycated hemoglobin (HbA1c)
was measured. At baseline and 3
months postcourse, up to 6 days
continuous glucose monitoring (CGM)
(Medtronic, Inc.) was performed.
Participants were reassessed 12 months
postcourse.
Five DAFNE educators (specialist nurses
and dietitians) were trained in the
curriculum and relevant psychologic (...truncated)