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

Diabetes Care, Mar 2014

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.

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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). - 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)


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Nicole de Zoysa, Helen Rogers, Marietta Stadler, Carla Gianfrancesco, Susan Beveridge, Emma Britneff, Pratik Choudhary, Jackie Elliott, Simon Heller, Stephanie A. Amiel. A Psychoeducational Program to Restore Hypoglycemia Awareness: The DAFNE-HART Pilot Study, Diabetes Care, 2014, pp. 863-866, 37/3, DOI: 10.2337/dc13-1245