Rethinking hypo awareness in the era of diabetes technology

Rethinking hypo awareness in the era of diabetes technology

ACBRD

UK review highlights the importance of asking the right questions when assessing awareness of hypos, despite technological advances

By Dr Uffe Søholm

Low blood glucose (also called hypoglycaemia or hypos) is a common side effect of insulin treatment in diabetes. Hypos cause unpleasant and, in some cases, dangerous symptoms. For example, reduced focus, weakness, dizziness, shaking. Over time, it can become harder to notice or feel hypo symptoms. This is known as impaired awareness of hypoglycaemia. Without the usual warning symptoms, people may not treat their hypos in time, putting them at greater risk of a severe hypo. Severe hypoglycaemia is where they need help from someone else to recover. Research shows that awareness can be improved with the right support.

Researchers in the UK have looked at how common impaired awareness and severe hypoglycaemia are, and how diabetes technology may help to identify those at risk. To do this, they reviewed published research articles. They found:

    • Overall, the number of people with type 1 diabetes with impaired awareness of hypos is going down. As is the incidence of severe hypos.
    • About 15-18% of people with type 1 diabetes have impaired awareness. For people with insulin-treated type 2 diabetes, around 10-24% have impaired awareness.
    • In the last year, 6-20% of people with type 1 diabetes had a severe hypo. For people with type 2 diabetes, 1-32% had experienced severe hypos.
    • People using continuous glucose monitors (CGM) may be less likely to experience severe hypos.

CGM alarms warn people about low blood glucose, sometimes even before they feel any symptoms. This “technological awareness” can help prevent severe hypos. But it also makes it harder to know if someone truly feels and recognises their own hypos.  

Despite advances in treatment and technology, researchers state that severe hypos remain a major problem for people with diabetes. Particularly for those with impaired awareness. Identifying those with impaired awareness is key to providing support and reducing their risk.

The paper highlighted some questionnaires that can be used to check for hypo awareness. These include the Gold Score, Clarke Score, Pedersen-Bjergaard Score, DAFNE tool, HypoA-Q Impaired Awareness Subscale, and the HYPO score. These questionnaires vary in their length and focus. Some older questionnaires may need rewording to show the difference between real symptom awareness and technological awareness. Only the HypoA-Q meets regulatory standards.

Researchers suggest combining different tools for risk assessment is the best way forward. This could include using questionnaires together with CGM data and clinical discussion. This more complete approach could help better spot who is at risk and guide safer, more effective diabetes care.

Researchers at ACBRD are currently part of the US-led CLEAR study that is working to learn more about impaired awareness and how to restore it.

Want to learn more about research into hypos? Check out our past blogs.

Reference

Berry SA, Liarakos AL, Koutroukas V, Choudhary P, Wilmot EG, Iqbal A. The challenge of assessing impaired awareness of hypoglycaemia in diabetes in the era of continuous glucose monitoring: A narrative review of evidence and translation into clinical practice. Diabetes Obes Metab. 2025 May;27(5):2363-2376. doi: 10.1111/dom.16284. Epub 2025 Feb 25. PMID: 39996361.

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