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Attitudinal barriers play a crucial role in severe hypoglycaemia

13th April 2023

People’s beliefs about hypoglycaemia were explored as part of the HypoCOMPaSS trial, which aimed to help those with impaired awareness reduce their rate of severe hypos. The findings, reported in a recent issue of Diabetologia, reveal that psycho-educational intervention can change attitudes and outcomes for the better. Dr Susan Aldridge reports. 

Impaired awareness of hypoglycaemia (IAH), which is a reduced ability to detect the onset of the symptoms of a hypo, affects around 20% of people with type 1 diabetes and is associated with a three- to six-fold increased risk of severe hypoglycaemia. It has also been shown that people with IAH may be reluctant to adjust their treatment regimens in order to avoid hypoglycaemia. 

The use of diabetes technology and diabetes education may go some way towards restoring hypoglycaemia awareness, but are not a complete solution. Research has suggested that cognitive, behavioural and emotional barriers exist that may prevent people with IAH from responding appropriately, even when they recognise a hypo. Addressing these barriers may improve outcomes. 

The 19-item Attitudes to Awareness of Hypoglycaemia (A2A) questionnaire defines the three main attitudinal barriers that may prevent individuals from taking steps to avoid hypoglycaemia and improve their awareness. These are ‘hyperglycaemia avoidance prioritised’, ‘asymptomatic hypoglycaemia normalised’ and ‘hypoglycaemia concern minimised’.

In the HypoCOMPaSS randomised controlled trial, participants with type 1 diabetes and IAH were allocated to insulin pump therapy or multiple daily injections and self-monitoring of blood glucose alone or with added real-time continuous glucose monitoring. Prior to randomisation, all 96 participants received the ‘my hypo compass’ structured psycho-educational intervention in small groups or individually. 

The goal of the intervention was to encourage reflection on personalised factors associated with dangerous hypoglycaemia, leading to the formulation of individualised plans to prevent further such events, without increasing exposure to high glucose. They also received enhanced support throughout the 24-week trial. The trial was associated with improved hypoglycaemia awareness and a 90% reduction in the rate of severe hypos at 24 weeks, along with a 5 mmol/mol reduction in HbA1c. 

In the current study, Professor Stephanie Amiel of the Diabetes Research Group at King’s College London, Professor James Shaw of the Translational and Clinical Research Group, Newcastle University, and colleagues elsewhere have assessed the A2A attitudinal barriers before, at 24 weeks and 24 months after the HypoCOMPaSS trial. They used the findings to see whether barriers at baseline and/or changes from baseline at 24 weeks had an impact on incomplete response to the programme, which was defined as reporting at least one further severe hypo during the 24-month follow-up. 

My hypo compass and A2A

The ‘my hypo compass’ psycho-educational programme consists of linking hypoglycaemia avoidance prompts around the four compass points North, East, South and West, as follows: Now; No delay (never delay hypoglycaemia treatment); Establish Your Extra Risks (and times when risk is highest); Scan for Subtle Symptoms (of hypoglycaemia); be Wary even While asleep (through watchful detection and active prevention of hypoglycaemia even when asleep).

Meanwhile, Part 1 of the A2A questionnaire asks participants to rate their perceived ability, concern and motivation to restore hypoglycaemia awareness on a five-point scale, ranging from low to high. Part 2 includes 12 statements regarding hypoglycaemia and its avoidance with responses on a four-point scale, where 0 is ‘not at all true’ and 3 is ‘very true’. These can relate to the three attitudinal barriers mentioned above. 

The barrier ‘hyperglycaemia avoidance prioritised’ assesses the importance to that person of avoiding high glucose rather than low glucose. This resonates with the statements ‘good diabetes control is mainly about avoiding high glucose levels’ and ‘I get frustrated/worried when I see high glucose readings’. 

The barrier ‘asymptomatic hypoglycaemia normalised’ refers to the tendency to ‘keep calm and carry on’ when they have hypoglycaemia, with statements like ‘I don’t need to treat a hypo unless I have symptoms’ and ‘there are no serious consequences to leaving mild hypos untreated’. 

Finally, the factor ‘hypoglycaemia concern minimised’ assesses the degree to which someone might underestimate the consequences of a hypo, as reflected by statements like ‘someone will always be around to sort me out if I go low’ or ‘I don’t get worried very easily about hypos.’ 

Participants were scored on each of the three groups of statements and the highest was used to define their personal predominant attitudinal barrier. At the end of the study, participants were divided into three groups. Responders were those with absence of severe hypos during follow-up after the intervention, while incomplete responders had one or more severe hypos during this time. The third ‘indeterminate’ group were those that could not be classified as either responders or non-responders because of incomplete data. 

Of the 64 participants for whom data were available, 62.5% were complete responders over the 24 months and 37.5% were incomplete responders. So how did attitudinal barriers influence the likelihood of a good response to the psycho-educational intervention consisting of ‘my hypo compass’ and ongoing support? 

‘Hyperglycaemia avoidance prioritised’

In Part 1 of A2A, 74% expressed high levels of concern about their IAH and 83% said they were highly motivated to regain awareness, responding ‘a lot’ or ‘extremely’ to this question. Similarly, 83% responded ‘a lot’ or ‘extremely’ to the question about their motivation to regain awareness. Despite this, ‘hyperglycaemia avoidance prioritised’ was the predominant attitudinal barrier for 84% of this group. But attitudes can change – there was a significant reduction in scores for this attitudinal barrier from baseline to 24 weeks and this was sustained at 24 months. 

A recent study, also monitored with A2A, also found significant reduction in the ‘hyperglycaemia avoidance prioritised’ barrier with HARPdoc (Hypoglycaemia Awareness Restoration programme for adults with type 1 diabetes and problematic hypoglycaemia), comparable to the findings of the current study. That both interventions led to sustained reductions in severe hypoglycaemia suggests that the magnitude of the change of attitude with education is clinically meaningful.

The reduced over-prioritisation of hyperglycaemia after the HypoCOMPaSS intervention was mirrored by significantly reduced ‘worry’ about high glucose, reduced ‘low blood glucose preference’, less ‘avoidance of glucose extremes’ and a lower drive to take ‘immediate’ action for high glucose, as reported by participants on the validated Hyperglycaemia Avoidance Scale. 

Addressing this drive to avoid high glucose at all costs is key to both ‘my hypo compass’ and the intensified support from healthcare professionals over the trial period. The goal was not to change beliefs that high glucose is to be avoided, but to provide tools that would allow for avoidance of hypoglycaemia without an increase in high glucose. This was reflected by a mean eight-unit reduction in insulin dose and a reduction of HbA1c at 24 months, with improved hypoglycaemia awareness and reduction of severe hypo frequency.  

‘Asymptomatic hypoglycaemia normalised’ 

Only 5.5% of participants had ‘asymptomatic hypoglycaemia normalised’ as their predominant attitudinal barrier. The ’my hypo compass’ intervention emphasised the ‘unacceptability’ of any glucose reading < 4 mmol/l – symptomatic or not – with its ‘being Watchful’ and ‘acting Now, without delay’ advice. 

Also, insulin dose reductions were negotiated with participants to address levels < 4 mmol/l. Although the score for ‘asymptomatic hypoglycaemia normalised’ was lower at 24 weeks, this was not sustained as there was no significant difference from the baseline score at 24 months. This suggests that the impact of ‘my hypo compass’ and ongoing support were limited in this group. Indeed, those with the highest scores for this attitude at baseline and the least reduction in score at 24 weeks were more likely to have ongoing severe hypoglycaemia. So ongoing review of ‘asymptomatic hypoglycaemia minimised’ might be needed, with top-up educational input and further monitoring with A2A. 

Hypoglycaemia concern minimised’ 

‘Hypoglycaemia concern minimised’ was the predominant attitudinal barrier among 6% of participants and scores were not affected by the HypoCOMPaSS intervention. There was, surprisingly perhaps, an association between a lower score on this tendency at baseline and ongoing severe hypoglycaemia, but this matches the authors’ previous findings – that those continuing to experience severe hypos were the ones with highest fear of hypoglycaemia at baseline and study end. This supports the conclusion that those with the most problematic hypoglycaemia are indeed appropriately concerned, but may also be over-accepting of asymptomatic hypoglycaemia and too enthusiastic about treating hyperglycaemia. 

The way forward

The HypoCOMPaSS trial was actually designed to compare insulin delivery and glucose self-monitoring modalities, with all participants receiving the psycho-educational intervention and intensified healthcare professional support, so the impact of ‘my hypo compass’ as a standalone intervention has not been determined. 

And causality cannot be attributed to the various associations reported above, as there was no control arm that did not receive ‘my hypo compass’. However, a previous study, mentioned above, showed that the HARPdoc psycho-educational intervention also changes A2A scores, suggesting that ‘my hypo compass’ may well account for the reductions in severe hypoglycaemia seen in the current study. 

These findings underline the importance of including an educational component when introducing new diabetes technologies to individuals with problematic hypoglycaemia. There is no evidence for restored hypoglycaemia awareness in trials of technology without a psycho-educational component.

There is also ongoing occurrence of significant hypoglycaemia, even on hybrid closed-loop therapy. This seems to be driven by inappropriate pre-meal and corrective bolusing, possibly associated with over-prioritisation of hyperglycaemia avoidance. A further randomised controlled trial is planned to look at the impact of ‘my hypo compass’ in comparison with standard care in individuals with recurrent severe hypoglycaemia who are embarking on hybrid closed-loop therapy. 

The strengths of this study lie in its recruitment of adults with type 1 diabetes and IAH. It provided equivalent psycho-education, support and attention from healthcare professionals and therapeutic targets for all, regardless of their mode of insulin delivery and glucose monitoring, with detailed follow-up for 18 months after return to standard care. 

The ‘my hypo compass’ intervention can be delivered by a single trained facilitator in a one-to-one session or a two-hour group session, with just one telephone follow-up four weeks later, so should be achievable within the limits of current healthcare resources. The multimodal HypoCOMPaSS trial has shown the feasibility and utility of implementing this alongside medical optimisation of self-management, supported by diabetes technology.

This study adds to the growing interest in providing tools that assess not just hypoglycaemia risk in an individual, but to characterise that risk in more detail. The A2A questionnaire with its unique focus on hypoglycaemia cognitions can help do this and so personalise the pathway towards eliminating severe hypos. 

The predominant attitudinal barrier identified here was ‘hyperglycaemia avoidance prioritised’ among those with IAH and severe hypoglycaemia. This can be addressed with a practical intervention. It also suggests that resistance to change with the other two attitudinal barriers might underlie the failure of such interventions to achieve complete success. Formal assessment of cognitive barriers limiting successful hypoglycaemia avoidance, using A2A, might lead to deeper understanding of individual concerns and needs. 

The study also provides further evidence for the HypoCOMPaSS holistic approach and support for including ‘my hypo compass’ as an easy-to-deliver psycho-educational intervention in future trials and clinical programmes aimed at sustained avoidance of severe hypoglycaemia. 

To read this paper, go to: Sepúlveda E, Jacob P, Poínhos R, Carvalho D, Vicente SG, Smith EL, Shaw JAM, Speight J, Choudhard P, de Zoysa N, Amiel SA on behalf of the HypoCOMPaSS Study Group. Changes in attitudes to awareness of hypoglycaemia during a hypoglycaemia awareness restoration programme are associated with avoidance of further severe hypoglycaemia episodes within 24 months: the A2A in HypoCOMPaSS study. Diabetologia online 20 December 2022.

Any opinions expressed in this article are the responsibility of the EASD e-Learning Programme Director, Dr Eleanor D Kennedy.