L E A D E R S
BGAT, BINGO or BASH –
What’s in a name?
Hypoglycaemia is the most important complication of insulin and methodology behind BGAT lends itself to the skills and
treatment. Although rates of severe hypoglycaemia are thought to expertise of diabetes specialist nurses, who are invariably involved
increase exponentially as HBA1c levels fall towards the non-diabetic in dealing with the physical and psychological consequences of
range,1 recent evidence suggests that when intensive insulin therapy severe hypoglycaemia.
takes place within a structured training programme, the frequency
The role of the diabetes specialist nurse (DSN) consists of
expert clinical practice, education, facilitation, innovation and
of very low blood glucose levels does not invariably increase.2
Early detection and avoidance of hypoglycaemia is the ‘Holy research. The DSN is particularly effective in the first three but
Grail’ for patients on insulin. Unfortunately, studies suggest that often less so in the last two. One of the reasons may be the over-
up to 25% of patients with long-standing type 1 diabetes have whelming workload, where DSNs are so busy firefighting there is
complete hypoglycaemia unawareness3 and locally we have found not the time to look at the causes of the fires and implement effec-
that 31% of insulin-treated individuals self-report a reduction in tive preventative methods.
intensity of warning symptoms irrespective of insulin regimen or
Programmes such as BGAT have huge implications in alloca-
formulation. Whilst there have been significant advances in detec- tion of time and resources but we believe priorities have to be
tion of hypoglycaemia using continuous glucose monitoring sys- made for such programmes in order to reduce the cost of severe
tems,4 the majority of at-risk individuals still rely on detecting hypoglycaemia to patients.
characteristic warning symptoms combined with traditional home
blood glucose monitoring. Unfortunately, there are errors related Joan Everett
to the performance of home blood glucose monitoring devices,5 Diabetes Specialist Nurse
which do not appear to be resolved by alternative site testing.6 For Dr David Kerr
some patients, the process of finger-stick testing can be painful, Consultant Physician
messy and troublesome as evidenced by the report that only 20% Royal Bournemouth Hospital, UK
of insulin treated patients appear to pick up enough blood glucose
monitoring strips for at least once daily testing.7
References
1. The DCCT Research Group. Hypoglycemia in the Diabetes Control and
Complications trial. Diabetes 1997; 46: 271–286.
Blood Glucose Awareness Training (BGAT) is an established
programme, originating from the USA, which teaches patients to
improve their accuracy in estimating the prevailing blood glucose
level. The technique involves recognition of external cues such as
food and alcohol and internal signals including physical symp-
toms and emotional well being.8 They are taught the nuances of
insulin kinetics and carbohydrate counting as well as the antici-
pated effects of exercise. BGAT is available on the Internet for use
ntr/centers/bmc/bgat/). There is a certified course and training
manual and the programme has been adapted for use in Holland
as BINGO (Bloedsuikers Inschatten no Gestructureered Oefenen)
and locally as BASH (Bournemouth Awareness of Symptoms of
Hypoglycaemia). The results are impressive, with improved accu-
racy in estimating blood glucose levels, detecting the onset of
hypoglycaemia and practical benefits including a fall in the num-
ber of road traffic violations and accidents for diabetic drivers.9,10
The program is now being developed to deal specifically with
patients with recurrent severe hypoglycaemia – Hypoglycaemia
Anticipation Awareness Treatment Training.11
2. Jorgens, V, Gruber M, Bott U, Muhlhaauser I, Berger M. Effective and safe translation
of intensified insulin therapy to general internal medicine. Diabetologia 1993; 36:
99–105.
3. Cryer PE. Symptoms of hypoglycemia, thresholds for their occurrence, and hypo-
glycemia unawareness. Endocrinol Metab Clin North Am 1999; 28: 495–500.
4. Kerr D. Continuous blood glucose monitoring: detection and prevention of hypogly-
caemia. Int J Clin Pract Suppl 2001; 123: 43–46.
5. Johnson RN, Baker JR. Analytical error of home glucose monitors: a comparison of
18 systems. Ann Clin Biochem 1999; 36: 72–79.
6. Jungheim K and Koschinsky T. Risky delay of hypoglycemia detection by glucose
monitoring at the arm. Diabetes Care 2001; 24: 1303–1304.
7. Evans JM, Newton RW, Ruta DA, MacDonald TM, Stevenson RJ, Morris AD.
Frequency of blood glucose monitoring in relation to glycaemic control: observational
study with diabetes database. BMJ 1999; 319: 83–86.
8. Cox DJ, Gonder-Frederick LA, Julian DM and Clarke WL. Long-term follow-up eval-
uation of blood glucose awareness training. Diabetes Care 1994; 17: 1–5.
9. Cox DJ, Gondor-Frederick L, Polonsky W et al. Blood glucose awareness training
(BGAT-2): long-term benefits. Diabetes Care 2001; 24: 637–642.
10.Cox D, Clarke W, Gondor-Frederick L, Kovatchev B. Driving mishaps and hypo-
glycemia: risk and prevention. Int J Clin Pract Suppl 2001; 123: 38–42.
11.Cox DJ, Kovatcheev BP, Gondor-Frederick L et al. Reducing vulnerability to driving
mishaps. Diabetes 2001; 50: A389.
Please see related review on diabetes and driving in the UK on
page 290.
Clearly BGAT is effective with a solid evidence base, yet within
the UK access to it at the present time is very limited. The theory
Reflections following the 2002 PCD
Europe Annual Conference
Based on an exclusive interview by Practical Diabetes International with the Chairman and two leading Executive Committee
members of Primary Care Diabetes Europe after the Annual Conference of PCD Europe in Stockholm on 10/11 May 2002 (see page
299 for a full conference report).
Pract Diab Int November/December 2002 Vol. 19 No. 9
Copyright © 2002 John Wiley & Sons, Ltd.
275
Tewari
