When you have a hypoglycemic incident, does it usually catch you by surprise? Probably-hypoglycemic symptoms are not always easy to recognize. For example, you more than likely have had hypoglycemic episodes when you just did not feel as many warning symptoms as you usually do. You may also have had episodes when you felt symptoms, but thought they were caused by something other than your blood glucose. If symptoms can be so hard to recognize, what can you do to improve your ability to tell when your blood glucose is too high or too low?
This is where Blood Glucose Awareness Training (BGAT) comes into play. BGAT (pronounced “bee-gat”) was developed over the last 15 years by Linda A. Gonder-Frederick, PhD, and her colleagues Daniel Cox, PhD, and William Clarke, MD, at the University of Virginia. The purpose of BGAT is to teach patients how to better recognize blood glucose symptoms, avoid hypo- and hyperglycemic episodes, and treat themselves when blood glucose does get too low or too high. BGAT has been tested in numerous studies showing that it significantly improves patients’ symptom awareness and ability to reduce extremes in blood glucose levels.
Last year, Dr. Gonder-Frederick lectured at the 22nd Annual American Association of Diabetes Educators Meeting and Educational Program in Boston. Her focus at the meeting was on hypoglycemia, since it can occur suddenly-often when patients do not have their glucose meters with them-and needs to be treated immediately.
BGAT espouses the belief that “symptom perception is a skill” that can be developed. If a person doesn’t recognize his or her individual signs (or cues) of hypoglycemia, awareness can be enhanced. In fact, Gonder-Frederick says that diabetics who initially rate low on the symptom-awareness scale generally enjoy even greater improvement than patients who enter the program with high awareness. BGAT recognizes that people are all different.
“On average,” says Gonder-Frederick, “Patients with diabetes detect less than half of their symptoms-there’s lots of room for improvement.”
Surprisingly, Gonder-Frederick’s research group has found that some of the “classic” hypoglycemic symptoms, like hunger, are not necessarily reliable cues. This is because patients feel hungry when their blood glucose is normal, or even high, just as often as when their blood glucose is low. Symptoms like nervousness or mood changes can be unreliable cues for the same reason. Although hypoglycemia can cause mood changes, it doesn’t usually make happy people become sad, or vice versa. Instead, it tends to intensify already-existing emotions.
BGAT lasts eight weeks, with a 90-minute meeting each week. During the training, patients do exercises and self-experiments and test their knowledge with quizzes in their course workbook. The workbook includes chapters on “Internal Cues” (symptoms, problems with thinking and mood changes) and “External Cues” (insulin, food, and exercise).
One of the most important aspects of BGAT is the Blood Glucose Awareness Diary that patients keep throughout the course. To make a diary entry, patients first record all of the symptoms they are currently experiencing. Patients are taught to start at the top of their heads and work downward, taking note of all the sensations they are feeling, including their emotions and any problems they are having thinking clearly. They then write down what they think their blood glucose levels are and compare them with their actual levels. Doing this several times a day begins the process of helping patients identify their own best internal cues.
Another important aspect of BGAT is teaching patients to be more aware of their “Performance Cues.” These are changes in mental and motor abilities caused by hypoglycemia. Individual patients vary in how much hypoglycemia affects their performance.
Says Gonder-Frederick, “At 60 mg/dl, some people have trouble saying the Pledge of Allegiance, while others can say it easily at 45 mg/dl.”
In BGAT, patients learn to increase their awareness of their performance during routine tasks. For instance, a secretary might monitor his or her typing ability and notice if typing is slower or has more errors. A carpenter might learn that dropping nails is a good indicator of hypoglycemia. A student might notice that he or she reads much more slowly when blood glucose gets low.
To monitor performance cues of hypoglycemia, patients need to ask themselves three important questions:
- Is this task taking more effort than usual?
- Am I doing this task more slowly than usual?
- Am I making more errors than usual?
The first and second questions are the most important since humans tend to unconsciously compensate for impairments by exerting more effort and going more slowly. So, even when patients are not making more errors, they need to consider the time and energy they have to expend to do the task.
Symptoms of hyperglycemia are also covered in BGAT. In addition to the more traditional hyperglycemic symptoms like dry mouth, nausea, and fatigue, BGAT teaches patients to monitor themselves for changes in taste and pain perception. Even though there are many hyper-glycemic symptoms, “These are typically more subtle and occur more gradually than hypoglycemic symptoms,” says Gonder-Frederick.
In addition to internal cues, patients learn to use external cues-insulin, food, and physical activity-to predict and avoid blood glucose extremes. There has to be a balance between learning to recognize internal cues and using external cues. Recognizing internal cues won’t help patients during sleep, when most hypoglycemic episodes occur.
BGAT’s coursebook has three chapters on external cues. The chapter on insulin teaches patients how to “plot curves” of their own insulin action throughout the day. These curves show when their insulin is peaking in action-which can cause hypoglycemia-or waning in action-which can cause hyperglycemia.
In the food chapter, patients learn to monitor their carbohydrate intake. This improves their ability to predict how much their blood glucose is likely to rise after meals and snacks. Sometimes patients don’t realize how much their carbohydrate consumption varies from day to day, which may help explain swings in blood glucose levels.
Gonder-Frederick says that BGAT reduces the number of hypoglycemic and hyper-glycemic episodes, but does not necessarily improve overall metabolic control. Long-term follow-up studies show that after BGAT, patients have fewer automobile accidents and violations than patients who have not taken the course. Depression, feelings of helplessness, and fear of hypoglycemia can diminish as patients increase their sense of control.
While BGAT is “not for unmotivated patients,” it is increasing in popularity. The coursebook has been translated into Dutch and German, and recently physicians from Japan inquired about the program. Says Gonder-Frederick, “Patients need to open their ‘internal eyes.’ But, even though almost all patients find new glucose cues in BGAT, recognizing them isn’t enough. Patients have to change the way they think about blood glucose cues and learn to take the right action in response to them.”
Said William H. Polonsky, PhD, CDE of San Diego’s Sharp HealthCare Diabetes Management and Treatment Center, “We’re planning BGAT sessions for patients in California during 1996. Anyone who’d like more information can call (619) 965-5659.”
Healthcare professionals interested in BGAT training for themselves can call the University of Virginia at (804) 924-5316.