The role of structured education in the management of hypoglycaemia

Abstract

The role of intensive glycaemic control in preventing microvascular disease in diabetes is well established. Iatrogenic hypoglycaemia is, however, a major barrier to effective treatment. Hypoglycaemia is associated with a significant level of morbidity and, despite pharmacological and technological therapeutic advances, reported rates of severe hypoglycaemia in clinical practice have not fallen over the last 20 years. This suggests that human factors are of major relevance and that ensuring the effective self-management of diabetes is an important strategy for the reduction of hypoglycaemic risk. Most of the evidence for the impact of this strategy on hypoglycaemia risk is confined to adults with type 1 diabetes although, in this review, we also cite studies that have specifically addressed this in type 2 diabetes. There are relatively few adequately powered RCTs that have rigorously evaluated the effectiveness of structured education and training programmes on hypoglycaemia; however, the available data suggest a subsequent reduction in severe hypoglycaemia rates of around 50%, a rate reduction that is comparable with that observed following technological interventions. Furthermore, longitudinal observational cohorts support these data, showing similar reductions in rates of hypoglycaemia following structured education. Those who continue to experience recurrent hypoglycaemia and impaired awareness of hypoglycaemia despite education and training in diabetes self-management may benefit from technological interventions and/or interventions that specifically address psychological factors that contribute to hypoglycaemia risk; however, there is urgent need for further research in this area. In the meantime, structured education for effective self-management of diabetes should be part of routine therapy for all those with type 1 diabetes.

Keywords: Hypoglycaemia; Review; Structured education; Type 1 diabetes; Type 2 diabetes.

Fig. 1

Evaluation of the efficacy of teaching flexible, intensive insulin therapy as part of a structured training course on glycaemic control and severe hypoglycaemia rates in 9583 individuals with type 1 diabetes between 1992 and 2004. Participants underwent 20 h of training as inpatients and were advised to measure blood glucose before main meals and at bedtime. Insulin was adjusted to actual blood glucose level and intended carbohydrate intake. Red circles, 1 year prior to intervention; green triangles, 1 year after intervention [28]. To convert values for HbA_1c in DCCT % into mmol/mol, subtract 2.15 and multiply by 10.929. Adapted from [28] with permission of Springer-Verlag