The thoughts associated with awareness of hypoglycaemia and recurrent severe hypoglycaemia

Researchers from King’s College London have explored the role of beliefs about low and high glucose levels in ~2000 adults with type 1 diabetes

By Sienna Russell-Green


Almost 100 years since insulin was discovered for use as a treatment for type 1 diabetes (T1D), a serious complication of insulin treatment remains: hypoglycaemia (low blood glucose). Research suggests that certain beliefs such as a lack of concern about hypoglycaemia, may act as barriers to an individual’s ability to prevent severe hypoglycaemia (SH). SH is defined as requiring assistance from another person to treat/manage it. The Attitudes to Awareness of Hypoglycaemia (A2A) questionnaire was developed based on qualitative research (interviews) about the beliefs of people with T1D with impaired awareness of hypoglycaemia (IAH) and experiencing recurrent severe hypoglycaemia (RSH). The A2A assesses the degree to which individuals endorse a range of modifiable attitudes or beliefs implicated in both IAH and RSH.

In a study published in Diabetes Care, a group of researchers from the US, UK and Australia aimed to investigate the prevalence of beliefs around hypo- and hyperglycaemia in adults with T1D with, and without, IAH and RSH in a large U.S. population. A cross-sectional, multicentre survey was emailed to participants, including the Gold Score (a single question assessing IAH) and the A2A questionnaire. Of the 1,978 respondents, most were women (62%). On average, they were 40±16 years of age and been living with T1D for 23±14 years.

Thirty-seven percent reported IAH, 16% RSH, and 9% both. Respondents with IAH or RSH expressed appropriate concern about low glucose levels, but those with IAH were more likely to prioritise concerns about high glucose levels than those with intact awareness (p = 0.002). Those with RSH were more likely (than those without RSH) to normalise low glucose levels experienced without symptoms (p=0.019). There was a trend towards prioritising concerns about high glucose levels (p=0.097), driven by those with both IAH and RSH. Those with RSH were more concerned about having IAH (p<0.001) and were more motivated to regain awareness (p<0.001).

These findings suggest that health beliefs about high and low glucose levels are associated with the development and/or maintenance of IAH and RSH in adults with T1D. Furthermore, this study addresses which of these beliefs may indicate higher risk of RSH: in particular, a lack of concern about asymptomatic hypoglycaemia (low glucose experienced without symptoms) in combination with a fear of high glucose levels. These beliefs may be modifiable. Thus, research is needed to engage people experiencing IAH and RSH in strategies to challenge and adapt their beliefs to help them avoid future hypoglycaemia. Such research is currently being led by the team at King’s College London.

If you enjoyed this blog, you can check out our other blogs on hypoglycaemia here.

You can also read a commentary by co-author Prof Jane Speight here.

Cook AJ, DuBose S, Smith EL, Wu M, Rickels MR, Speight J, deZoysa N, Amiel SA. Cognitions associated with hypoglycemia awareness status and severe hypoglycemia experience in adults with type 1 diabetes. Diabetes Care, 2019; 42(10): 1854-1864.