Wednesday, September 10, 2008

Trials Show BGAT Delivered Online a Success! But Don't Celebrate Just Yet ...

Blood Glucose Awareness Training (also known as "BGAT") is, perhaps, one of the most important pieces of diabetes education that miraculously, an overwhelming majority of certified diabetes educators (CDEs) have never even heard of. It should be required education, but sadly, is not and in my personal experience, many CDEs have never even heard of the program.

Now I must admit, when I was diagnosed at age 7 back in 1976, there was no such thing as a "CDE" and truthfully, I have never viewed that "certification" as having any particular value. My reason is not without merit. But my core theme today is not about CDEs or their ignorance about BGAT (even though I think that's inexcusable), but it pertains to Blood Glucose Awareness Training. There is a detailed review of BGAT which can be found in the Diabetes Care archives (see here for the article).

What is BGAT?

Well, if you suffer from impaired hypoglycemia awareness, then this training could quite literally save your life!

Last year, I hosted an online chat with Linda Gonder-Frederick, and as I recall, the number of participants was far greater than expected. This suggests to me that this is an area of tremendous interest that professional organizations like the American Association of Diabetes Educators (AADE) are closing their eyes and ears to.

When I recently asked Linda about BGAT-Home, the online version of the program which could potentially bring this valuable training to people all over. She responded by writing:

"Okay ... the internet version of BGAT. We are in the final stages of testing it and will be presenting our results at this year's ADA meeting. We have a website where people can go to put their names if they are interested in being notified as soon as we are 'up and running.' It has taken us a long time. My computer savvy colleague said that he needs to update it, and he will get to it this week. But you can enter your name now."

This past August, the diabetes journal Diabetes Care reported on the trial result for BGAT-Home. In the new study, researchers looked at whether an online program in "blood glucose awareness training" could help type 1 diabetics better manage their disease.

The program, now dubbed "BGAThome", is an adaptation of well-studied program that uses group sessions to teach people with diabetes (particularly those with type 1) tactics for predicting and preventing blood sugar ups-and-downs.

The Internet version of the program is designed to allow patients to improve their diabetes management from the privacy of their own home, Dr. Daniel Cox, the lead researcher on the study, told Reuters Health. The authors note that BGAT was converted for web-based delivery. They note that the internet allows BGAT delivery to be dynamic, engaging, convenient, and personalized. Efficacy was evaluated using a 2 (BGAThome, n=20, vs. control, n=20) x 2 (pre/post) design. They conclude that BGAThome was judged as useful and easy to use, was completed by 94% of the participants, and resulted in significant clinical improvements (P<0.05). So here's the deal:

In a follow-up conversation I had with Linda Gonder-Frederick, she told me that they were actually having a conference call with the ADA to discuss the possible role they might play in making BGATHome available nationwide. The crux of the matter is that they need financial backing to update and upgrade the system so that it can "handle" large numbers of users. These are really issues that are largely technical in nature, and the ADA certainly should be able to pony up the cash and expertise needed to address their concerns, and they may very well do so. But I responded to Linda that if those conversations were not fruitful, we may be able to get support from JDRF or another organization. But I also said that I would try to raise attention to the issue -- and that was NOT contingent on ADA support (which may or may not be forthcoming, I don't know yet).

Interestingly, yesterday, Close Concerns featured a posting about new men's health education campaign to help bridge the gap and reach men with diabetes. Their goal is to provide tools and resources to take a "modern" approach to managing diabetes in every day life. They closed with a note indicating they were excited about "ADA's take-charge stance on reaching out and closing the information gap" for men. But they also indicated that they hope the ADA continues to be proactive and help others – particularly those falling through the cracks of diabetes care (young adult and transition support anyone?? Pregnancy? Elderly?). I responded by asking about this particular program. My feeling is that issues such as erectile dysfunction don't need as much attention as hypoglycemia unawareness, but that hasn't stopped the ADA from giving that a higher priority.

This is a personal diatribe for me, namely that I think the ADA and various other diabetes establishment organizations, including the American Association of Diabetes Educators (AADE) have a very poor track record on this issue, and it's time to stop and address a more serious issue that today, patients tend to be "blamed" for, even though the science shows that patients are not to blame for it? This is an issue patients with type 1 diabetes in particular have not done enough complaining about, but they need to be aware of the facts, first, and sadly, many are not.

The Science Is By No Means "Clear" on this issue, so let me set the record straight:

#1 Patients With Diabetes Cannot Be "Blamed" for Hypoglycemia Unawareness

#2 Patients With Diabetes May Not Be Able to "Restore" their Symptoms, Even With Vigilant Avoidance of Hypoglycemia for a Period of Time

#3 The Medical Establishment has a Very Poor Track Record on this Particular Issue

#4 There ARE programs which may be able to help, but they badly need financial assistance!

#5 Many patients, especially those I have encountered in the online world, are mis-informed on this particular issue, so caveat emptor: let the buyer beware!

#6 The 2 programs DiabetesTalkFest has hosted on this particular topic were among the best-attended programs hosted, and Linda Gonder-Frederick remains one of the most popular guests ever hosted!

Listed below are some relevant links which may be of interest which ARE factually reliable, so yes, you may rely on this information:

Blood Glucose Awareness Training (BGAT-2)
An overview of blood glucose awareness training (BGAT) has been shown to help improve awareness of blood glucose (BG) fluctuations among adults with type 1 diabetes. This study investigates the long-term (12-month) benefits of BGAT-2.

An online version of Blood Glucose Awareness Training developed by the University of Virginia Diabetes Research Team in Behavioral Medicine.


Scott K. Johnson said...

I've always been interested in the BGAT training - I think it would a very valuable thing for many of us to do!

Thanks for bringing it (and the funding issues - frustrating!) back to our attention.

Kelly Close said...

hi Scott, thanks so much for this. I had no idea about it and I'd love to do it. AND we definitely do think the hypo-unaware need help - I'm affected personally by it way more than I'd like. In our blog, we weren't trying to call out every group that's being left behind, because goodness knows there are too many, but thanks so much for your (as always) insightful, thoughtful take. And I'm going to go check out BGAT ...!

tmana said...

"My feeling is that issues such as erectile dysfunction don't need as much attention as hypoglycemia unawareness..."

You said a mouthful and then some! (I am fed up to death with the overload of ED-drug TV commercials and penile-enhancement TV commercials during prime time viewing hours!!!!) I'd lay wager that if you asked an average five-year-old what the primary effect of diabetes was, he'd answer "ED" (in five-year-old language, of course). Despite popular opinion to the contrary, orgasm is not a necessary aspect of life. Blood glucose awareness... is.

type1emt said...

I am a graduate of BGAT-it really got me in touch with both my hypo AND hyper symptoms. The usual, the not so usual.It's been several years so I've forgotten most of it(no way to review) but I'm glad this will soon be more wildly available.

Anonymous said...

Blood glucose monitoring is a very inexact “science” . . . starting with the patient who performs the test, the error allowed by the FDA and meter companies as meter “standards”, and the drug insulin, which has unique pharmacokinetics and pharmacodynamics for each patient.

Sampling error and the results gained by each patient can easily lead to inherent error. For example, patients taking an insulin-analog which is supposed to peak in one and a half to two hours may find that it actually peaks in one hour or two hours. Those results for individual patients may vary considerably, day-to-day. The science behind testing is to take enough tests within the activity period to predict the release curve for any given set of conditions. This would mean that a diabetic, using a fast/sharp-peaking insulin would probably be wise to check bG 6-8 times during any given 2-1/2 hour period. Initially, this insulin resides in a depot, and the release is influenced by size of shot, location of shot, pre-shot activity, nature of food ingested, emotional state and any number of things going on within the biologic system at that time (e.g., disease,drug interaction, etc.).

A single bG check—for example, taken immediately before getting into a car to drive—documents your bG only for ‘a moment in time.’ This bG does not tell you whether your bG is on the rise or falling dramatically. Neither does it tell you what your bG will be 15 minutes, 30 minutes, or 1 hour later.

The peak of any fast-acting insulin can reduce the bG level more than 100 mg/dl during its activity period. Maintaining bG levels with today’s tight-control paradigm provides inherent danger for all diabetic patients using fast-acting insulins. The reason the ADA, JDRF and many doctors provide leniency in today’s diet for high-carb meals is not to satisfy the need for ‘normalcy’ with other Americans; it’s to provide insurance that the diabetic can cover these fast-acting analogs. I think we ALL would be astounded at the number of diabetics who experience hypoglycemia unawareness. I expect many consumed their “last meal” based on a bG that only reflect a moment in time—and tragically, it was the wrong moment.

We NEED our responsible, charitable organizations to get behind (support) the production/marketing of a non-invasive, continuous bG monitor that will be more reflective and provide accurate bG information corresponding to insulin-release data.

Linda Gonder-Frederick said...

Hi Scott - Ran into your blog. An update - we are meeting next week with a group from ADA. Get in touch with me after that to see if there are any promising updates. Best, Linda

Clare Venus, PhD, RN, CDE said...

Hello Scott,
I came across your`blog when I was looking for some additional BGAT information. I am a clinical psychologist and CDE and I specialize in working with individuals who are, among other things, doing poorly with their diabetes self-care. Linda Gonder-Frederick very kindly sent me her BGAT program last year. It would be wonderful to see the BGAT program online but I also think that many individuals with severe hypoglycemia and other problems desperately need face to face interventions and support.
CDEs generally do not deliver these kinds of programs in part I think because AADE has emphasized the systematic teaching of the 7 self-care behaviors over more interactive and psychologically-oriented approaches.
I look forward to reading more from your blog.

Anonymous said...

I see this discussion ended in 2008. Whatever happened to online BGAT? I still have patients who need training.