Severe hypoglycaemia and its association with psychological well-being in Australian adults with type 1 diabetes attending specialist tertiary clinics

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Abstract

Aim

To investigate severe hypoglycaemia (SH) in adults with type 1 diabetes and its associations with impaired awareness of hypoglycaemia (IAH), clinical, psychological and socio-demographic factors.

Methods

Attendees of three specialist diabetes clinics in Melbourne, Australia completed questions about frequency of SH in the past six months; impaired awareness of hypoglycaemia (Gold score); and measures of general emotional well-being (WHO-5), diabetes-specific positive well-being (subscale of W-BQ28), diabetes-related distress (PAID) and fear of hypoglycaemia (HFS).

Results

Of 422 participants (mean ± SD age 37.5 ± 15.0 years; 54% women), 78 (18.5%) reported at least one SH event and 86 (20.5%) had IAH. SH and IAH frequencies were similar at all clinics. In total, 194 SH events were reported, with 10 people experiencing 40% of events. Compared with those without SH, participants with SH had longer diabetes duration, were younger at diabetes onset and more likely to have IAH (p < 0.01). Those with SH had greater fear of hypoglycaemia and diabetes-related distress, poorer general emotional well-being, and lower diabetes-specific positive well-being, (p < 0.01). There were no associations with age, gender, insulin regimen or HbA1c.

Conclusions

This study has identified that SH and IAH in Australian adults with type 1 diabetes exist at similar levels to those reported in US and European research. SH was significantly associated with IAH and fear of hypoglycaemia.

Assessment of hypoglycaemia, IAH and psychological well-being as part of a routine diabetes clinic visit was well accepted by attendees and enabled identification of those who may benefit from medical, educational or therapeutic interventions.

Introduction

Severe hypoglycaemia (SH), requiring external assistance for recovery, is a common, feared and challenging complication of type 1 diabetes. It can result in collapse without warning, seizures, coma or death. Recurrent SH poses a significant challenge in terms of risk to personal safety, loss of personal control and independence, quality of life and mood changes [1]. Over time the awareness of hypoglycaemic symptoms diminishes which increases the annual risk of SH sixfold [2]. In unselected populations, between 30% and 40% of adults with type 1 diabetes have at least one SH event per year [2], [3], [4] depending on the definition and method of assessment of SH, and duration of diabetes. In a large Australian survey conducted in 2011, 20% of adults with type 1 diabetes reported having had at least one SH event in the past six months [5]. Adults who have diabetes for >15 years experienced higher rates of SH than those with diabetes for <5 years (22% versus 46%) [6].

Over the past decade, a significant decrease has been observed in the rates of SH in an Australian cohort of children and adolescents with type 1 diabetes [7], which may relate to the greater use of continuous subcutaneous insulin infusion (CSII) and modern insulins. Such data are unavailable for Australian adults. Internationally, studies conducted during the past decade have shown no change in the frequency of hypoglycaemia in adults with diabetes [2]. Today, as it was a decade ago, SH and fear thereof, remains the greatest barrier to achieving optimum glycaemic control [8].

The unpleasant symptoms and consequences of hypoglycaemic episodes can lead to fear of hypoglycaemia and impaired quality of life, for the person with diabetes [9], [10] as well as for their relatives [11]. A consistent association has been reported between fear of hypoglycaemia and the frequency of (severe] hypoglycaemic events [10], [12]. Experiencing one SH event has been shown to have an immediate negative impact on mood (increased fear of hypoglycaemia) and behaviour (reduction of insulin dose), which complicates improvement of clinical outcomes [10], [13]. Despite these findings, fear of hypoglycaemia frequently remains unrecognised [2].

The frequency of SH and impaired awareness of hypoglycaemia (IAH) in unselected clinic samples of adults with type 1 diabetes in Australia is unknown, nor has the psychological impact of SH been studied. Therefore, our aim was to examine self-reported prevalence of hypoglycaemia in a population of Australian adults with type 1 diabetes attending one of three specialist diabetes clinics; and to explore its associations with IAH, clinical, psychological and socio-demographic factors [14].

Section snippets

Setting and participants

Participants were recruited from three metropolitan specialist clinics: Royal Melbourne Hospital (site 1), St Vincent's Public Hospital (site 2), Baker IDI Heart and Diabetes Institute (site 3). In general, adults with type 1 diabetes attend these clinics on a quarterly basis, so data were collected over 8 to 12 weeks to capture people attending for routine appointments and to minimise risk of duplication. Data collections took place between October and December 2011 (site 1), and between

Participants

Of the 502 eligible adults invited to take part, 444 (88.4%) gave consent and completed the survey. An additional 22 questionnaires were discarded due to missing data, providing an overall response rate of 422 (84.1%). The majority (91.0%) completed the questionnaire in the waiting room, with 9.0% completing it at home (e.g. experiencing hypoglycaemia in the clinic). Socio-demographic and clinical characteristics of the total sample and by SH are summarised in Table 1. HbA1c had been assessed

Discussion

Our findings demonstrate that completion of a detailed hypoglycaemia and well-being assessment tool was both feasible and acceptable to patients during a routine clinic visit, resulting in a response rate of 88.4%. In three unselected clinic populations, with a combined sample of over 400 adults with type 1 diabetes, one in five participants reported at least one SH episode in the past six months, an average of one SH event per year per person. This annual rate falls within the range of 1.0 to

Conclusion

This study has shown that it is feasible and acceptable to invite clinic attendees to complete a questionnaire about hypoglycaemic events, IAH and psychological well-being. For routine clinical practice, we recommend a brief, standardised IAH and SH assessment (such as the items used here), which will take no more than 5 minutes to complete.

One in five Australian adults with type 1 diabetes experienced a SH event in the past six months, which was associated with impaired hypoglycaemic awareness,

Conflict of interest statement

The authors declare they have no conflict of interest.

Acknowledgements

We thank Elizabeth Maclean for data collection at Baker IDI, Daniel Calandro for data collection assistance at SVH, Lucy Morrish for data collection assistance at RMH, and Laura Smith and Anna Scovelle for biomedical data input and quality control of the survey data. We thank the participants for their contribution to this project. We also thank Diabetes Australia–Vic and Deakin University for their financial support.

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