Pdf hypoglycemia

Six-Month Evaluation of a Diabetes
Self-Awareness Intervention
Cheri Ann Hernandez, PhD, RN, CDE;
Margaret R. Hume, MScN, RN, CDE;
N. Wilson Rodger, MD, FRCPC, CDE
The purpose of this pilot study was to evalu-
ate the effectiveness of a self-awareness in-
tervention in promoting increased awareness
of body cues associated with various levels of
glycemia and in enhancing well-being in per-
sons with Type 1 diabetes and hypoglycemia
unawareness. Study results indicated that
participants could identify more cues of nor-
mal blood glucose; experienced fewer blood
glucose levels below 3.5 mmol/L, fewer hypo-
glycemia unawareness-related events, and im-
proved glycemia; but reported lower diabetes
quality of life. The self-awareness interven-
tion represents an innovative theory-based
approach for helping clients with Type 1
diabetes and hypoglycemia unawareness to
achieve positive health outcomes. v
Hypoglycemia unawareness (HU), the inability
to detect symptoms of hypoglycemia, has be-
come a serious problem in Type 1 diabetes.
Hypoglycemia unawareness is a commonly
reported phenomenon that frequently results in
undetected episodes of hypoglycemia, which can
have devastating consequences, such as seizures,
brain damage, and even death.1
In addition to
negative physical effects, there are psychological
and social ramifications, all of which have a
profound detrimental impact on quality of life of
individuals and their family members.
Several causal factors for HU have been
suggested: a change from porcine insulin to
human insulin,2
frequent hypoglycemia,3
long-
standing diabetes,4
autonomic neuropathy,5
and
intensive insulin therapy.3
It has been estimated
that as many as 50% of those with longstanding
Type 1 diabetes have HU and that this results in a
five times greater risk of severe episodes of
hypoglycemia.4
The inability of clients to recog-
nize symptoms or to identify symptoms as being
an indication of hypoglycemia is a key determi-
nant of the frequency of severe hypoglycemia.6
The current move toward intensive insulin
therapy to promote improved diabetes control
has been found to increase the incidence of
serious hypoglycemic episodes,6 – 9
and many
studies report that intensification of diabetes
control results in diminished symptoms of
hypoglycemia.6,8
One report of the Diabetes
Control and Complications Trial (DCCT) indi-
cated that warning signs or symptoms of hypo-
glycemia occurred but went unrecognized by
subjects in 51% of the hypoglycemic episodes
that occurred during waking hours.9
There are no known educational interven-
tions targeting this problem, even though HU
affects a large percentage of the Type 1 diabetes
population and thus has major implications
for healthcare delivery and expenditures, as well
as for client physical health and quality of life
issues. Clinicians have tried to manage HU by
counseling clients to maintain blood glucose at
higher levels than usually recommended.1
How-
ever, this increased glycemia puts clients at risk
for microvascular complications7
and possibly
macrovascular complications. Clinicians have
tried other treatment strategies, such as changes
in insulin regimen, more insulin self-adjustment,
and diary keeping to prevent episodes of hypo-
glycemia in these clients. The impact of these
strategies remains unstudied. Researchers have
tried to increase awareness of blood glucose cues
in individuals with Type 1 diabetes through
blood glucose awareness training10 – 13
and self-
awareness education,14
although these interven-
tions have not specifically targeted persons with
hypoglycemia unawareness. The current study
was a pilot test of a new educational intervention
designed to help patients with Type 1 diabetes
and HU to learn to become more self-aware and
to detect important body cues for varying levels
of glycemia.
Review of the Literature
Researchers have suggested that clients should
learn to recognize the individual symptoms that
Outcomes Management v 2003 v Vol. 7 v No. 4148
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

are the most reliable indicators of hypoglyce-
mia6,15,16
or hyperglycemia15,16
for him or her.
Several recent studies have indicated that indi-
viduals can be taught to become sensitive to
blood glucose levels.10 – 14
External cues, such as
timing, amount, and type of food, exercise, and
insulin are important in symptom detection.12
Subjects who identified more symptoms of
hypoglycemia were able to recognize more of
their hypoglycemic episodes than were those
with fewer symptoms.17
When both internal and
external cues are used, accuracy increases.10
There is evidence that a variety of self-tests
can increase sensitivity to hypoglycemia.12
Family
members or close friends may be able to detect
subtle cues of hypoglycemia before the individ-
ual recognizes it.16
Subjects with Type 1 diabetes
but without HU were able to detect additional
body cues, circumstances, and strategies for de-
tecting low, normal, and high blood glucose
levels after participating in a self-awareness inter-
vention operationalized using the collaborative
alliance educational method.14
Clarke and asso-
ciates1
studied subjects with Type 1 diabetes for a
6-month period and found individuals who had
HU had symptoms that went undetected. There-
fore, it was suggested that these individuals might
benefit from interventions designed to teach
them to recognize all of their potential early
warning symptoms.1
All of these studies point to
the need to develop and test interventions to
address this escalating health problem.
Purpose
The purpose of this pilot research was to evaluate
the effectiveness of a self-awareness intervention
(SAI), an intervention designed to increase self-
awareness of salient body cues, in (1) promoting
increased awareness of body cues/symptoms
associated with various levels of glycemia and
(2) enhancing the well-being of adults with Type
1 diabetes and HU. Specifically, this study was
designed to determine if the SAI would be
successful in improving the number of cues
recognized for varying levels of glycemia (hypo-
glycemia, hyperglycemia, and euglycemia); in
reducing the number of HU-related incidents
(episodes of hypoglycemia requiring treatment
intervention by another person, visits to the
emergency room, hypoglycemia-related driving
incidents, and meter results below 3.5 mmol/L
without symptoms); in promoting increased
levels of integration and diabetes quality of life;
and in improving hemoglobin A1c levels.
This study is part of an ongoing longer-term
intervention study. The research questions were:
(1) What is the effect of an SAI program on the
number of body cues identified for different
levels of glycemia? (2) What is the effect of an SAI
program on the number of HU-related incidents?
(3) What is the effect of an SAI program on
perceptions of integration? (4) What is the effect
of an SAI program on perceptions of diabetes
quality of life? and (5) What is the effect of an SAI
program on metabolic control? In addition, the
evaluation of the intervention included a two-
part learning assessment and program evaluation
by an expert in program evaluation who was
external to the research project.
Conceptual Framework
Hernandez’18
1991 theory of integration was
the theoretical framework within which this study
was undertaken. The theory of integration origi-
nated from a grounded theory study of individuals
with Type 1 diabetes. A three-phase process of
integration was derived from data collected in
interviews, papers, and self-report journals.
The having diabetes phase begins when
diabetes is diagnosed; this phase is characterized
by a lack of knowledge about the disease or a
piecemeal type of knowledge, seeming disinterest
in diabetes, and varying degrees of commitment
toward diabetes management. The focus is on
living life as a normal individual. Some individuals
remain in this first phase even after many years of
living with diabetes.18 – 20
The having diabetes
phase ends at the turning point, when some life
event upsets the person’s complacency and forces
a reassessment of life with diabetes. During this
second phase, the person starts to take an interest
in learning about diabetes and in being involved in
all aspects of the diabetes regimen. The last phase,
the science of one, a personalized science of living
with diabetes, is a gradual progression out of the
second phase. In this phase, the person strives to
understand diabetes and continues to focus on
living but not to the detriment of physiologic
control.18
It is during the third phase that the integration
of the personal and diabetic selves occurs most
noticeably and thoroughly. The personal self is the
person as he/she existed before the diagnosis of
diabetes. The diabetic self refers to the new entity
that emerges, and must be contended with, upon
diabetes diagnosis. The integration occurs as the
individual learns to tune in to his/her own body
and to use the knowledge acquired through this
process. The complex and comprehensive nature
of the self-awareness work that occurs in the
science of one phase was delineated through
focus research methodology.21
The individuals in Hernandez’ original
study18,22
and later studies by Hernandez20
and
Six-Month
Evaluation of a
Diabetes
Self-Awareness
Intervention v
Outcomes Management v 2003 v Vol. 7 v No. 4 149

Bradish19
did not comply with the regimen set by
health professionals but were in excellent glyce-
mic control, as judged by their glycated hemo-
globin levels. By tuning in to body sensations and
cues, they integrated diabetes successfully into
their lives without it being the major focus of
living. They had become experts in their own
particular diabetes and were able to use this ability
to achieve excellent glycemic control. When asked
their preferences regarding healthcare professio-
nals, participants described give-and-take rela-
tionships in which there was equality in the areas
of participation, power, and acknowledgment of
expertise, that is, collaborative alliances.
Given that clients with diabetes are experts in
their particular diabetes, while health professio-
nals are experts in the general science of diabetes,
a collaborative alliance would be the most realistic
and most productive type of relationship in terms
of diabetes education and for health promotion.21 –
23
Therefore, the collaborative alliance educational
method, a practice model that is consistent with
the theory of integration, was the method used in
the current study.
Method
Sample and Setting
A convenience sample of 29 adults with Type 1
diabetes and HU who had diabetes for at least
5 years was recruited during a 5-month period
through five endocrinologists’ offices. The re-
search nurse recruited these 29 adults from an
original group of 50 subjects; 10 did not fit the
study criteria for type of diabetes or existence
of HU, and the remaining declined to participate.
The sample was divided into two groups for
the intervention sessions–one evening and one
morning group because a class size of more
than 15 would have been prohibitive in terms
of allowing each person adequate participation
in the group discussion and other activities of
the SAI.
Subjects had HU diagnosed by their endo-
crinologists, but the diagnosis was verified by the
research nurse using the eight-item hypoglyce-
mic awareness survey.1
All SAI sessions were
held in a classroom of the university in the
vicinity of most subjects’ homes.
Self-Awareness Intervention
To be consistent with the theory of integration,
the SAI was operationalized using a collaborative
alliance education method in which teaching and
learning about self-awareness occurred through
the development of collaborative alliance rela-
tionships with the group facilitators and each
other. A collaborative alliance relationship is a
relationship between the client and the educator
in which the interaction is characterized by
mutual trust and respect and reciprocity in the
areas of participation, power, and acknowledg-
ment of expertise.18
The collaborative alliance
education method involved the client as an active
and self-determining being who is an expert
in his or her own diabetes, and who participates
in content delivery and in choosing education
content, methods, sequencing, strategies, and
content delivery.24
This type of classroom climate
is also consistent with the principles of adult
education.
The SAI consisted of eight sessions spaced
at 2-week intervals. The primary facilitator was
experienced in development of a collaborative
alliance educational climate and was the prim-
ary facilitator for previous research using this
method.14
During the first session the partic-
ipants were introduced to the concept of self
awareness through the video, ‘‘Becoming Self
Aware: Cuing up to Body Listening,’’ developed
during previous SAI research.14
They were given
an SAI manual that provided information about
self-awareness and included possible classroom
(group and individual) and homework activities
as well as self-learning logs and other forms
on which to document their experiences and
progress through the SAI. Consistent with the
collaborative alliance teaching method, broad
topic areas (eg, hypoglycemia) were identified
as themes for each session, but the sequencing,
time spent, activities completed under these
topic areas, and inclusion of other topics were
co-determined by subjects based on their needs,
interests, and preferences.
Self-monitoring of blood glucose levels, to
objectively validate the occurrence of low, high,
and normal blood glucose, was a technique
used frequently throughout the intervention and
homework activities. Several homework assign-
ments involved family member input because of
their potential ability to identify additional symp-
toms and circumstances associated with different
levels of glycemia. However, to be congruent
with the collaborative alliance educational meth-
od, homework exercises were not assigned nor
were they mandatory; rather, subjects were en-
couraged to do the ones that would be of most
benefit to them.
Instrumentation
The study questionnaire contained demographic
items, The Diabetes Questionnaire25
to measure
integration, the Diabetes Quality of Life26
instru-
ment to measure diabetes quality of life, and
several questions to determine the number of HU-
related incidents (hypoglycemic episodes requiring
Six-Month
Evaluation of a
Diabetes
Self-Awareness
Intervention v

assistance, hospitalizations, driving incidents, me-
ter readings below 3.5 mmol/L without hypo-
glycemic cues) that had occurred during the
previous 6 months.
Integration. Integration was defined as ‘‘an on-
going process in which the two selves (diabetic
and personal) more fully merge to create an
individual who is healthy, both mentally and
physically. This unification of the selves is
manifested in the person’s ways of thinking,
being, and acting (including verbalization).’’25
Integration was measured by the total score
on The Diabetes Questionnaire (TDQ),25
a 15-
item questionnaire with 6-point Likert response
format ranging from 1 (strongly disagree) to 6
(strongly agree). This questionnaire was shown
to be valid (content, construct) and reliable (test-
retest, internal consistency) when pilot tested on
224 clients with Type 1 and Type 2 diabetes.
Reliability estimates were Pearson’s r = .75 for
test-retest reliability, and Cronbach’s alpha .84
for internal consistency of the total scale and .77
and .80 for the Psychoemotional Adjustment
and Somatic Sensitivity subscales, respectively.25
In the current study, internal consistency was
a = .80 at before intervention and a = .85
6 months after intervention.
Diabetes Quality of Life. Diabetes quality of life was
measured by the total score on the Diabetes
Quality-of-Life (DQOL) scale,26
a 46-item in-
strument with a 5-point Likert response format.
There are four subscales: satisfaction, impact,
diabetes worry, and social/vocational worry.
The ratings for the subscales are: from 1 (very
satisfied) to 5 (very dissatisfied) for satisfaction
and from 1 (no impact and never worried) to
5 (always impacted and always worried) for
the impact and worry scales. Higher scores
indicate lower quality of life. This instrument was
shown to be valid (content and con-
current validity), stable (Pearson’s r = .92) and
internally consistent (a = .92) when tested on 192
adults and adolescents with diabetes.26
In this
study, internal consistency was a = .89 before
interventionanda =.836monthsafterintervention.
Metabolic Control. The average glycemic control
was assessed by the hemoglobin A1c (HbA1c)
using the high-pressure liquid chromatography
(HPLC), a method that is the acknowledged
gold standard for glycated hemoglobin de-
termination.27
The normal reference range for
HbA1c was 0.43 to 0.61. The number of HU-related
incidents was another indicator of metabolic
control. HU-related incidents included epi-
sodes of hypoglycemia that required treatment
assistance from another individual, visits to the
emergency room, driving infractions or accidents
associated with hypoglycemia, and number of
times that a meter blood glucose test result was
below 3.5 mmol/L without warning symptoms
being detected.
Data Collection and Analysis
The study received ethical clearance from the
university Research Ethics Board. The research
nurse explained the study to subjects over the
telephone, and a written, informed consent was
obtained at the beginning of the initial SAI
session. Baseline measures of all study variables
were taken at the beginning of the first SAI
session, and measures were repeated at 6 months
after intervention. In addition, the accuracy of
subjects’ blood glucose meters was assessed by
having subjects perform a blood glucose test with
their own meters at the same time as a random
blood glucose was drawn. This quality control
procedure was necessary because it was essential
for subjects to have an accurate, objective method
of assessing or verifying the blood glucose status
(low, normal, or high) so that body cues/sen-
sations associated with these states could be
reliably detected or confirmed.
An external consultant completed a two-part
learning assessment and program evaluation at
the final (eighth) SAI session and 6 months later.
Data for the learning assessment and program
evaluation were obtained via individual ques-
tionnaires as well as a 1-hour focus group session
on each of these two occasions. The focus group
sessions were audiotaped and transcribed verba-
tim to ensure that all data were captured
accurately.
SPSS version 8 software was used to perform
all statistical analyses. Using unpaired t tests, no
differences were found between the treatment
groups in demographic characteristics (age, gen-
der, diabetes duration, height, weight, race,
marital status, educational level, employment
status, income, or living arrangements); thus, data
from both intervention groups were combined for
the subsequent analyses. Paired t tests were used
to determine if there were differences between
pre- and post-intervention levels of number of
body/cues detected for high, low, and normal
blood glucose, number of HU-related incidents,
and between pre- and post-intervention levels of
integration, diabetes quality of life, and HbA1c.
Results
Twenty-five subjects completed the intervention
(12 male, 13 female). Four subjects dropped out
Six-Month
Evaluation of a
Diabetes
Self-Awareness
Intervention v

of the study: a man because of personal illness, a
woman because of illness of her daughter, one
man with work scheduling difficulties, and one
woman who reported having learned enough to
detect her hypoglycemic episodes. Subjects were
between the ages of 24 and 73 years (mean =
50.52, SD = 14.63) and had diabetes for 7 to 45
years (mean = 23.76, SD = 11.04). All participants
were Caucasian. Sixty percent were married, 24%
were single, 12% were divorced, and 4% were
widowed. Most (44%) lived with a spouse or
companion, and an additional 24% lived with
their spouse and children. Twenty percent lived
alone, and the remainder was divided equally
between living with parents, children, or in other
arrangements.
Most (60%) participants reported having a
college or university education, whereas the
remainder had completed high school (28%) or
had some high school (12%). Forty percent were
employed full-time, 28% were retired, and the
remainder was divided equally into the catego-
ries of part-time workers, full-time homemakers,
and unemployed. Participants’ annual household
incomes (Canadian dollars) ranged from $15,000
to $130,000, with a median income of $42,500.
Fifty percent of the participants reported annual
household incomes greater than $40,000. Partic-
ipants attended from five to eight of the eight SAI
classes, with a median attendance of seven classes.
The results of the number of cues reported
for the varying levels of glycemia, number of
HU-related events, and hemoglobin A1c levels
are presented in Table 1. The number of cues
detected for hypoglycemia and hyperglycemia
was not increased significantly, but subjects
could identify more cues for normal blood
glucose (P < .05). There were fewer meter read-
ings below 3.5 mmol/L without warning (P < .05)
but not fewer driving incidents, hospitalizations,
Six-Month
Evaluation of a
Diabetes
Self-Awareness
Intervention v
Table 1
Physiological Measures at Six-Month Follow-Up
Measure Range Mean SD t Sig.
Symptoms of Glycemia
Low
Baseline 0–7 3.43 1.93 0.72 .479
Six-month follow-up 1–10 3.17 1.95
High
Baseline 0–5 1.78 1.59 À0.79 .436
Normal
Baseline 0–0 0.00 0.00 À2.66** .015
Total Symptoms:
Baseline 1–10 4.64 2.84 À1.49 .152
HU-Related Events
Required Assistance
Baseline 0–52 13.33 17.40 0.76 .454
Hospitalizations
Baseline 0–10 0.76 2.19 1.26 .227
Driving Incidents
Baseline 0–2 0.29 0.72 1.07 .296
Blood Glucose <3.5 mmol/L
Baseline 0–50 16.70 15.87 2.75** .013
Total HU-Related Events
Baseline 3–77 30.50 23.66 2.05* .055
Hemoglobin A1c
Baseline .067–.125 0.0886 .015 1.88* .074
Six-month follow-up .064–.122 0.0856 .014
* P < .10
** P < .05
*** P < .001

or hypoglycemic episodes requiring assistance.
However, if a more lenient alpha (P < .10) were
used, given the small sample size, there were
fewer total HU-related incidents. Hemoglobin A1c
levels decreased, but this was not significant,
except with a more lenient alpha (P < .10). The
results of changes in levels of integration and
diabetes quality of life are presented in Table 2.
Levels of integration did not increase signifi-
cantly. Diabetes quality of life decreased signifi-
cantly (P < .001).
An extensive learning assessment and pro-
gram evaluation were performed by an external
consultant using a combination of focus group
method and individual questionnaires. The
results provided information about the strengths
and weaknesses of the SAI, as well as subject
confidence in, satisfaction with, and frequency of
use of the various components of the SAI.
SAI Effectiveness
Subjects rated the overall effectiveness of the SAI,
using a 5-point scale, as 3.77 at the eighth SAI
session and as 3.96 at the 6-month postinterven-
tion session. They reported that all but one of
their personal learning objectives were partly,
fully, or more than met. The most effective
program elements were listed as the size of the
group, learning from others in the group, the
group facilitators, collaborative alliance environ-
ment, large group discussions, time of sessions,
frequency of sessions, number of sessions, and
small working groups (all rated above 3.5 on a
5-point scale). Program elements rated below
3 were the homework activities and the SAI
video. The elements of the program that partic-
ipants liked the most were meeting/sharing with
others, openness of discussions, and learning
from others. Elements of the program liked the
least were the repetition and homework.
Subjects’ reports of their experiences pro-
vided evidence that the nurse facilitators did
promote a collaborative alliance educational en-
vironment: Almost all personal learning goals
had been at least partially met, and SAI aspects
that they reported liking the most were meeting/
sharing with others, openness of discussions, and
learning from others. In addition, some program
elements that were rated as most effective were
learning from others in the group, the group
facilitators, collaborative alliance environment,
and large group discussions. Subjects reported
having confidence in developing a collaborative
alliance with health professionals.
Subject Confidence
Seventy-three percent of the subjects rated their
overall confidence level at 7 or higher on a
10-point scale (mean = 7.2). They expressed the
most confidence in the following areas: treat a
low, identify circumstances causing highs, treat
a high, reduce the number of HU-related inci-
dents, overall confidence in managing diabetes
and HU, get help from family or friends, and
develop a collaborative alliance with health pro-
fessionals (rated above 7 on a 10-point scale).
Least confidence was reported in three areas:
detect cues for normals, detect cues for highs,
and keep blood sugar within the target range.
Subject Satisfaction
Subjects rated their satisfaction with the various
SAI activities on a 5-point scale. Most satisfaction
was shown with: treat a low, identify circum-
stances that cause highs (rated at 4 or more).
Least satisfaction was expressed with the fol-
lowing: recognize cues for normals, keep blood
sugar within the target range, recognize cues
for lows, and recognize cues for highs (rated
below 3.5).
Frequency of Use of SAI Activities
Subjects indicated how frequently they used the
SAI activities. The most frequently used activities
included: identify circumstances that cause highs,
identify the circumstances that cause lows, treat a
low, prevent lows, and treat a high (rated at 4 or
more on a 5-point scale). Least frequently used
activities were: recognize cues for normals, keep
blood sugar within target range, and get help
from family and friends (all rated below 3.5 on a
5-point scale).
Discussion
This research represented a novel educational
approach, a self-awareness intervention to deal
Six-Month
Evaluation of a
Diabetes
Self-Awareness
Intervention v
Table 2
Psychosocial Measures at
Six-Month Follow-Up
Measure Mean SD t Sig.
Diabetes Quality of Lifey
Baseline 90.75 19.04 À7.76*** .000
Six-month
follow-up
127.96 22.90
Integration
Baseline 75.30 7.81 À0.76 .456
Six-month
follow-up
76.51 8.71
*** P < .001
yDQOL is scored so that a high score
reflects greater dissatisfaction.

with HU in adults with Type 1 diabetes. After
only 6 months, this theory-based approach
demonstrated the ability to promote several
positive physiologic health outcomes. Although
a significant increase in the number of cues
identified for hypoglycemia was not found, there
were fewer meter readings below 3.5 mmol/L
without warning signs and a tendency toward
fewer HU-related episodes overall, which is an
indication that self-awareness did increase in
study subjects. This enhanced self-awareness
may have the potential for future physiologic or
psychological benefits and decreased healthcare
expenditures. As shown in Table 1, most of the
HU-related incidents were rare at baseline. Thus,
it might have been unrealistic to expect that there
would be a significant decrease in these individ-
ual types of HU-related events within a 6-month
period. Glycemic control did improve, as shown
by the decrease in hemoglobin A1c levels dur-
ing the 6 months after the SAI. These findings
are consistent with the theory of integration, in
which improved self-awareness leads to better
glycemic control.
Some caution should be exercised in inter-
preting these results given that the researchers
did not have control over the other aspects of
subjects’ diabetes healthcare. In addition, a larger
sample size might have increased the signifi-
cance of some of the findings. However, a longer
test of the intervention is warranted to monitor
these outcomes. Another possibility is to incor-
porate an SAI booster session into future research
designs to determine the impact on glycemic
control and other study outcomes.
Although subjects reported high levels of
confidence and satisfaction with the SAI acti-
vities, this did not translate into significant
increases on the study psychosocial instruments.
The nonsignificant increase in integration may
indicate that a larger sample size or a longer test
of the intervention was required. The reason for
a decrease in diabetes quality of life is unex-
plained. The SAI may have increased subjects’
awareness of the problems and risks of HU,
resulting in a reduction in reported diabetes
quality of life. An alternative explanation is that
this decrease might be an artifact of other events
in the subjects’ lives, rather than the influence
of the SAI. Subjects rated the effectiveness of the
SAI highly and expressed a great deal of sat-
isfaction with the SAI activities and confidence in
performing them, which is an indication that the
decrease in diabetes quality of life may have
been unrelated to the SAI.
The inclusion of qualitative data about quality
of life and preintervention measures of confi-
dence would have been useful to help explain
changes in the rating of quality of life over
time. Further research, using additional mea-
sures of quality of life, is indicated for a longer
period of time to confirm or disprove these
assertions.
A growing body of literature points to the
need to assist clients to become more sensitive to
the individual cues and symptoms arising from
their bodies. The ability to sense blood glucose
fluctuations is an important aspect in the self-
management of Type 1 diabetes.10
The inability
to detect symptoms of hypoglycemia places
the patient at risk for severe life-threatening
hypoglycemia.28
Severe and recurrent hypo-
glycemic episodes have been associated with
anxiety and decreased happiness,29
cognitive
dysfunction,15,30 – 35
motor deficits,15,31,34,35
damage
to the central nervous system,36
cardiovascu-
lar complications,36
and death,37
including acci-
dental death caused by motor vehicle or other
accidents. Clients often maintain blood glucose
at high levels to offset fear of hypoglycemia, but
the resulting chronic hyperglycemia puts them
at increased risk for chronic, and often debilitat-
ing complications, such as retinopathy, neuro-
pathy, and nephropathy.7
Another reason that self-awareness is such
an essential skill in diabetes is that clients often
intentionally omit one or more blood glucose
tests per day18
or may refuse to self-monitor. Self-
monitoring of blood glucose, through the finger-
prick method and use of a portable blood
glucose meter, reflects the blood glucose level
at the time tested, but hypoglycemia can occur
at almost any time during the day or night and
thus may go undetected, even in those who
are monitoring regularly. Therefore, enhancing
the self-awareness ability to identify and detect
symptoms of hypoglycemia, euglycemia, and
hyperglycemia is an important adjunct to blood
glucose monitoring and warrants additional
research using the SAI.
The current study demonstrated that an SAI
is effective in helping individuals with Type 1
diabetes and HU to become more effective at
detecting and interpreting their personal body
cues and using this information to achieve better
metabolic control. More research is needed to
determine the long-term effectiveness of the
SAI and to redesign it for use in conventional
diabetes education programs if its long-term
effectiveness is confirmed.
Acknowledgments
This research was funded by the Canadian
Diabetes Association Grant for Applied Research
in Diabetes Education Management and Care.
The authors thank Arthur Kidd, MD, FRCPC,
Windsor, Ontario, for his advice and assistance
Six-Month
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with the design and implementation of the subject
recruitment strategy, and Kathryn D. Lafreniere,
PhD, Associate Professor, Psychology Depart-
ment, University of Windsor, for her statistical
assistance and advice regarding publication.
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Accepted for publication March 22, 2003.
Cheri Ann Hernandez, PhD, RN, CDE, is
Associate Professor, Faculty of Nursing, University
of Windsor, Windsor, Ontario, Canada.
Margaret R. Hume, MScN, RN, CDE, is Clinical
Nurse Specialist, Endocrinology, University Health
Network, Toronto, Ontario, Canada.
N. Wilson Rodger, MD, FRCPC, CDE, is Professor
in the Division of Endocrinology, Department of
Medicine, The University of Western Ontario, London,
Ontario, Canada.
Address correspondence to Cheri Ann Hernandez,
RN, PhD, CDE, Associate Professor Faculty of
Nursing, University of Windsor, 401 Sunset Avenue,
Windsor, Ontario N9B 3P4 Canada (e-mail:
cherih@uwindsor.ca).
Six-Month
Evaluation of a
Diabetes
Self-Awareness
Intervention v

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