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Hypoglycemia Awareness Program

Chapter 4

but attribute the sign down to another reason.
 
Chapter 5. Is the second group actually evidenced as being independent group and an independent cause from the first group? As opposed to being an overlapping group or the same cause?

The following groups of people have been identified at being at a higher risk of losing hypo awareness:
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    • Those who regularly have hypos over night
    • Those who go to sleep with blood glucose levels of 5.5 mmol/L or less

What's the basis for the implied recommendation not to go to sleep below 5.5 mmol/L? I'm really not comfortable with that advice. I would want to see a reference. None of the claims and advice in the Program are referenced. I think that's wrong. You are asking people to trust DCUK implicitly, as if it was a medical body. I don't even think we should trust medical bodies implicitly when it comes to our health and safety. We should expect, and get, references to evidence to back up medical claims being made.
 
Module 2 Lesson 1
I would add the signs to look for in the morning that show you might have had a hypo in the night
- bed linen wet with sweat
- unexpected / atypical high blood sugar
- feeling very physically tired
- feeling very hungry
- aching muscles - can indicate a fit
 
Module 2 Lesson 2

Ensure you test and have sufficient carbohydrate before going to bed after drinking.​

This is problematic. How much is 'sufficient'. Depending where the person is in the cycle of drinking, carbs at bedtime could prevent a hypo, or cause very high blood sugar in the morning. Do you just mean do a normal carb correction upward? What's the target BG? Or are you saying to always eat carbs before bed after drinking? If so, how many. I don't think this advice is very usable in the way it's written at the moment.
 
Module 2 Lesson 6 - hypos at work or school

Might want to put something in here about health and safety rights at work, Equality Act, who to talk to in a workplace if they are not making allowances for diabetic treatment for hypos and testing
 
Module 2 Lesson 9 - recognising a hypo

I would add

- aggressiveness
- disengaged, detached behaviour
 
Overall it's a pretty good online course and will be helpful to many people. Good job!
 
Here are 4 claimed causes of loss of hypo awareness (from the IDDT website) that you don't mention:

  • Intensive therapy with multi-daily insulin injections and aiming for near normal blood glucose levels, has been shown to cause a threefold increase in the risk of severe hypoglycaemia. This increased hypoglycaemia can therefore increase the risk of loss of warnings.
  • Neuropathy – damage to the autonomic nervous system is a complication of diabetes and this can cause loss of warning symptoms.
  • Changing insulin species can cause a loss or change in warning symptoms.
  • ‘Human’ insulin can cause loss of warnings of hypoglycaemia. This is often not readily admitted by many health professionals but since the early 1990s, Patient Information Leaflets in ‘human’ insulin packs have included a warning of that ‘human’ insulin can cause changed or loss of warnings of an impending hypo.
 
With me, consuming carbs before bedtime would cause a hypo.

And with the best will in the world (and not having been invited to complete the course, so I haven't seen what I am commenting on...) I no longer trust any internet information source that doesn't have good, recent, references - or that ties in with information I already have, that has been backed with good, recent, references.

I suspect that the lack of references would have made me stop reading very early.
 
At question 3 in the Evaluation Survey, there are two different wristband options with the identical description "Insulin Dependent Diabetic".
 
Here's the most recent paper (2013) I could find by Philip Cryer who is the academic czar of hypo unawareness.

http://digitalcommons.wustl.edu/cgi/viewcontent.cgi?article=3453&context=open_access_pubs

The summary is that the mechanism of hypoglycemia awareness is not known. But it is known to be caused by recent hypoglycemia, or recent exercise, or while asleep. What I still haven't found is the evidence to say hypo awareness is caused by periods of low blood sugar, independently of whether those low blood sugar periods are triggering hypo warnings (epinephrine). If not we can't rule out that hypo awareness is caused by habituation to repeatedly triggering warning signs (epinephrine) in a "boy who cried wolf" scenario. (unless this is the 'systemic mediator' scenario that Cryer does rule out).

Regardless, based on this article the HAP should add exercise as a temporary cause of reduced hypo awareness. We were taught this in DAFNE actually. And also point out that hypo warning responses are suppressed while we are asleep.
 
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