Biopsychobehavioral model of severe hypoglycemia. II. Understanding the risk of severe hypoglycemia.

Cox, Daniel J.; Gonder-Frederick, L; Kovatchev, Boris; Young-Hyman, Deborah Lee; Donner, Tom; Julian, Diana M; Clarke, William L.

doi:10.2337/diacare.22.12.2018

Cited by 39 publications

(21 citation statements)

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“…Exploratory analyses of individual differences for both type 1 diabetes studies indicated a mild relationship between greater routine exposures to hyperglycemia, as reflected by the percentage of SMBG readings Ͼ15 mmol/l, HbA 1c , and more cognitive tests affected by hyperglycemia. This is consistent with the results of studies demonstrating that greater exposure to hypoglycemia is associated with greater cognitive impairments during hypoglycemia (16) and is inconsistent with adaptive theories speculating that individuals may accommodate to extreme blood glucose levels.…”

Section: Individual Effects Of Hyperglycemiasupporting

confidence: 73%

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Relationships Between Hyperglycemia and Cognitive Performance Among Adults With Type 1 and Type 2 Diabetes

et al. 2005

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OBJECTIVE -Hyperglycemia is a common event among patients with type 1 and type 2 diabetes. While the cognitive-motor slowing associated with hypoglycemia is well documented, the acute effects of hyperglycemia have not been studied extensively, despite patients' reports of negative effects. This study prospectively and objectively assessed the effects of hyperglycemia on cognitive-motor functioning in subjects' natural environment.RESEARCH DESIGN AND METHODS -Study 1 investigated 105 adults with type 1 diabetes (mean age 37 years and mean duration of diabetes 20 years), study 2 investigated 36 adults with type 2 diabetes (mean age 50 years and mean duration of diabetes 10 years), and study 3 investigated 91 adults with type 1 diabetes (mean age 39 years and mean duration of diabetes 20 years). Subjects used a hand-held computer for 70 trials over 4 weeks, which required them to complete various cognitive-motor tasks and then measure and enter their current blood glucose reading.RESULTS -Hyperglycemia (blood glucose Ͼ15 mmol/l) was associated with slowing of all cognitive performance tests (P Ͻ 0.02) and an increased number of mental subtraction errors for both type 1 and type 2 diabetic subjects. The effects of hyperglycemia were highly individualized, impacting ϳ50% of the subjects.CONCLUSIONS -Acute hyperglycemia is not a benign event for many individuals with diabetes, but it is associated with mild cognitive dysfunction. Diabetes Care 28:71-77, 2005P atients with diabetes often report acute and transient cognitive disruptions associated with hyperglycemia. The impact of such effects could influence quality of life and daily functioning, as well as indicate cues to aid patients in better recognizing the presence of hyperglycemia. Holmes et al. (1) reported significant slowing of visual reaction time during a hospital clamp study at a blood glucose level of 16.7 mmol/l but were unable to replicate this subsequently using an auditory reaction-time task (2). Davis et al. (3) reported that blood glucose in the 20-to 30-mmol/l range was associated with a 9.5% reduction in type 1 diabetic children's performance IQ. Performance IQ was worsened in 67% of the children studied. Summerfield et al. (4) used a hyperinsulinic glucose clamp to test cognitive functioning at 14.5 and 16 mmol/l in adults with type 2 diabetes. During hyperglycemia, significant disruptions occurred in the performance of complex tests of cognitive functioning, such as four-choice reaction time. However, other investigators (5,6) were unable to detect decay in cognitive-motor performance on selected neuropsychological tests during hyperglycemia.Contrary to hypoglycemia and its associated neuroglycopenia, a major barrier to the investigation of the effects of hyperglycemia on cognitive-motor performance is the absence of a clear physiological mechanism that explains how hyperglycemia negatively influences brain functioning. However, research suggests several possible mechanisms (6).

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Section: Individual Effects Of Hyperglycemiasupporting

confidence: 73%

“…Third, the blood glucose readings entered into the HHC were compared with memory meter data to ensure accuracy of the SMBG results. We have used these procedures extensively in our investigations of hypoglycemia (12,16,17).…”

Section: Study 1 Subjectsmentioning

confidence: 99%

Relationships Between Hyperglycemia and Cognitive Performance Among Adults With Type 1 and Type 2 Diabetes

et al. 2005

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“…However, this is a complex process involving several steps, some of which are probably enhanced by education and mental preparation (12). One factor of great importance is how rapidly and to what degree cognitive dysfunction develops during hypoglycemia.…”

Section: Ethicsmentioning

confidence: 99%

“…During events of severe hypoglycemia, insulin-treated patients suffer from cerebral glucose deficiency. The capacity to maintain cognitive function during hypoglycemia is a crucial link in a complex chain of prerequisites to ensure that severe hypoglycemia is prevented by appropriate treatment of the initial hypoglycemia (12).…”

mentioning

confidence: 99%

Serum ACE Predicts Severe Hypoglycemia in Children and Adolescents With Type 1 Diabetes

Nordfeldt

Samuelsson

2003

Diabetes Care

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OBJECTIVE -To investigate whether risk of severe hypoglycemia is related to serum (S) ACE level during intensive treatment in type 1 diabetic children. (1.0), and the HbA 1c year mean was 4.7-10.2% (6.8). HbA 1c , insulin doses, and events of severe hypoglycemia (needing assistance from another person) were prospectively registered at regular visits, scheduled quarterly. S-ACE was determined once. RESEARCH DESIGN AND METHODSRESULTS -Severe hypoglycemia was correlated to S-ACE (r ϭ 0.22, 95% CI 0.01-0.41, P ϭ 0.0093). The square root of severe hypoglycemia was correlated to S-ACE (r ϭ 0.27, 95% CI 0.06 -0.45, P ϭ 0.0093). Patients with S-ACE at the median level or above (n ϭ 44) reported a mean of 3.0 yearly events of severe hypoglycemia compared with 0.5 events in patients with S-ACE lower than the median (n ϭ 42) (P ϭ 0.0079). Of the patients with an S-ACE at the median level or above, 27 (61%) reported severe hypoglycemia, compared with 17 (40%) patients with an S-ACE lower than the median (P ϭ 0.0527). Insulin dose, HbA 1c , age, onset age, duration, C-peptide, and sex did not differ between these two groups. S-ACE was negatively correlated with age (r ϭ Ϫ0.27, 95% CI Ϫ0.46 to 0.07, P ϭ 0.0265) but not with HbA 1c , duration, or blood pressure.CONCLUSIONS -The elevated rate of severe hypoglycemia among patients with higher S-ACE suggests, among other factors, that a genetic determinant for severe hypoglycemia exists. Further evaluation is needed before the clinical usefulness of this test can be elucidated. Diabetes Care 26:274 -278, 2003

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“…Education should include paying attention to the risks of high daily amounts of insulin. Pregestational educational intervention, e.g., with BG awareness training (BGAT) programs (29), may be helpful to reduce the high risk of SH associated with type 1 diabetic pregnancy.…”

Section: Sequelae Of Shmentioning

confidence: 99%

Risk Indicators Predictive for Severe Hypoglycemia During the First Trimester of Type 1 Diabetic Pregnancy

et al. 2002

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OBJECTIVES -To investigate the frequency of severe hypoglycemia (SH) and hypoglycemic coma during the first trimester of type 1 diabetic pregnancy and in the 4 months before gestation and to identify risk indicators predicting first trimester SH in a nonselected nationwide cohort of pregnant women with type 1 diabetes.RESEARCH DESIGN AND METHODS -We conducted a longitudinal cohort survey in 278 pregnant type 1 diabetic women using questionnaires at inclusion and at 17 weeks of gestation, addressing the frequencies of SH (i.e., external help required) and hypoglycemic coma, general characteristics, hypoglycemia awareness, blood glucose symptom threshold, and the Hypoglycemia Fear Survey.RESULTS -The occurrence of SH (including hypoglycemic coma) rose from 0.9 Ϯ 2.4 episodes per 4 months before gestation to 2.6 Ϯ 6.3 episodes during the first trimester (P Ͻ 0.001), including an increase in episodes of coma from 0.3 Ϯ 1.3 to 0.7 Ϯ 3.7 (P ϭ 0.03). The proportion of women affected by SH rose from 25 to 41% (P Ͻ 0.001). First-trimester SH was independently related to a history of SH before gestation (odds ratio CONCLUSIONS -In type 1 diabetic pregnancy, the risk of SH is increased already before pregnancy and rises further during the first trimester. A history of SH before gestation, longer duration of diabetes, an HbA 1c level Յ6.5%, and a higher total daily insulin dose were risk indicators predictive for SH during the first trimester. Further research should aim to elucidate how the benefits of strict glycemic control balance with the markedly increased risk of SH early in pregnancy.[ Diabetes Care 25:554 -559, 2002

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Biopsychobehavioral model of severe hypoglycemia. II. Understanding the risk of severe hypoglycemia.

Cited by 39 publications

References 0 publications

Relationships Between Hyperglycemia and Cognitive Performance Among Adults With Type 1 and Type 2 Diabetes

Relationships Between Hyperglycemia and Cognitive Performance Among Adults With Type 1 and Type 2 Diabetes

Serum ACE Predicts Severe Hypoglycemia in Children and Adolescents With Type 1 Diabetes

Risk Indicators Predictive for Severe Hypoglycemia During the First Trimester of Type 1 Diabetic Pregnancy

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