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The brain and hypo unawareness

Project summary

Understanding cerebral responses to hypoglycaemia: a pathway to effective strategies to treat hypoglycaemia unawareness in Type 1 diabetes

Hypo unawareness affects 30-45% of people with Type 1 diabetes. Dr Pratik Choudhary will use advanced imaging techniques in people with hypo unawareness to find out if the brain activity that typifies this condition can be reversed by avoiding hypos.

Background to research

Unawareness of the symptoms of low blood glucose (hypo unawareness) affects 30-45% of people with Type 1 diabetes and causes a 3-6 fold increase in severe hypos that require support from another person. This in turn can have a significant impact on driving, employment, relationships and overall quality of life.

Studies have shown that hypo awareness can be restored by avoiding hypos, but this is difficult in practice and often unsustainable.  

During hypoglycaemia, people with hypo unawareness show changes in regional brain activation that suggest hypos cause less stress, anxiety and hunger, and are perceived as less unpleasant than in people who are hypo aware.

Accordingly, many people with hypo unawareness show low concern about their unawareness, and sometimes do not follow treatment recommendations designed to reduce hypos.

These findings might explain the challenges involved in restoring and sustaining hypo awareness, despite the use of advanced technologies such as insulin pumps and continuous glucose monitoring. It is unclear if these changes in brain function are reversible or if they represent a permanent vulnerability to hypo unawareness. 

Research aims

Dr Pratik Choudhary and his team at King’s College London will use advanced imaging techniques in people with Type 1 diabetes and hypo unawareness to study the brain activity that typifies this condition and find out if it can be reversed by avoiding hypos.

They will determine whether the characteristic brain responses of hypo unawareness are reversible or can at least be used to identify people for whom restoring awareness is particularly hard. 

The researchers will study regional brain responses to controlled hypos (with blood glucose levels of 2.6 mmol/l) in 10 people who are hypo aware and 30 people with hypo unawareness.

Over the next six months, those with hypo unawareness will undergo intensive therapy to rigorously avoid hypos. This approach will involve education, insulin pumps and continuous glucose monitoring and has been shown to restore hypo awareness in at least 50% of cases.

Participants’ will then be re-studied after six months to evaluate reversal of hypo unawareness, to look for the activation patterns involved, and for neurological and behavioural predictors of successful reversal.

Potential benefit to people with diabetes

This study will improve our understanding of the mechanisms involved in hypo unawareness and help determine which patients are likely to respond to treatments that are known to improve awareness. It will also help to identify potential new therapies for those who are not likely to respond to current treatments.

In the longer-term, findings from this study will contribute to the development of psychological and pharmacological interventions for hypo unawareness that could reduce the burden of this condition for people with diabetes.

This project has been adopted by:

Diabetes UK local groups: Bromley, Havering, Northampton, and Solihull

Organisations: Royal Eastbourne Golf Club, Supporting Kernows Young Diabetics, and Wadhurst Rotary Club
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