The World Awake

The World
Awake
A global research report uncovering
the impact of nocturnal hypoglycaemia
on people with diabetes

“These findings suggest
a major education gap
in the area of nocturnal
hypoglycaemia. More
must be done to improve
the dialogue between
people with diabetes
and healthcare
professionals regarding
this serious obstacle to
treatment satisfaction
and wellbeing of
our patients.”
Foreword from
the International
Diabetes Federation
Nocturnal hypoglycaemia is a hidden problem within the diabetes community. Many
people with diabetes experience nocturnal hypoglycaemic events several times a month,
yet research has shown they are often underreported and may go unrecognised. These
night time events can have many implications for those with diabetes, impacting sleep
patterns, quality of life and diabetes self-management. Further, they can be an indicator
of poor glycaemic control and as a result, are a concern for those living with diabetes,
their families and the physicians who treat them.
The World Awake study aims to uncover more information not only on the impact of
having these events, but also worrying about these events, on those living with diabetes.
This report summarises the findings from the study and provides recommendations on
improving the dialogue between those with diabetes and their healthcare professional
to ensure optimal diabetes management.
The mission of the International Diabetes Federation (IDF) is to promote diabetes care,
prevention and a cure worldwide. Helping people with diabetes manage their nocturnal
hypoglycaemia is an important step towards improving their health and wellbeing, and
so we are delighted to lend our support to The World Awake campaign.
The IDF is an umbrella organisation of over
200 national diabetes associations in over 160
countries. It represents the interests of the
growing number of people with diabetes and
those at risk. The Federation has been leading
the global diabetes community since 1950. IDF’s
mission is to promote diabetes care, prevention
and a cure worldwide. www.idf.org
Professor Anthony Barnett, Emeritus Professor of Medicine
and Consultant Physician, University of Birmingham and
Heart of England NHS Foundation Trust, Birmingham, UK
The World Awake study was commissioned by Novo Nordisk A/S and supported by the International Diabetes Federation. Aequus Research
Ltd undertook the quantitative and qualitative research. This report was authored by Michael Gwilt, who was commissioned by Novo Nordisk
with contributions and approval from The International Diabetes Federation, Dr Richard Brice (GP with a Special Interest in Diabetes, Kent UK),
Professor Anthony Barnett (Consultant Physician and Emeritus Professor of Medicine, Birmingham UK), Red Health, and Novo Nordisk.
2 3

Contents
Executive summary
Executive summary 5
Introduction: The nocturnal hypoglycaemic challenge 7
Nocturnal hypoglycaemia and fear of nocturnal hypoglycaemia
are common in people treated with insulin for their diabetes 8
Frequency of nocturnal hypoglycaemic events 8
Worry about nocturnal hypoglycaemia 9
Having or worrying about nocturnal hypoglycaemia disturbs sleep 11
Impact of having a nocturnal hypoglycaemic event on sleep 11
Impact of worrying about having a nocturnal hypoglycaemic event on sleep 13
Worry about nocturnal hypoglycaemia changes
the way people manage their diabetes 14
Nocturnal hypoglycaemia – the ‘patient-physician consultation’ 17
Nocturnal hypoglycaemia is often not discussed with healthcare practitioners 17
Why are so many people with diabetes reluctant to discuss
nocturnal hypoglycaemia with their primary care physician? 18
Advice from GPs and PCPs on avoiding nocturnal hypoglycaemia 19
Key elements of ‘patient-physician consultations’ for diabetes care 20
Discussion 23
Recommendations for reducing the impact of nocturnal hypoglycaemia on 24
people with diabetes
Appendix: Background on The World Awake research study 25
References 27
The World Awake global research study
was developed to evaluate the impact
of self-treated nocturnal hypoglycaemic
events and the worry that they cause on
the lives of people with diabetes who are
insulin-treated. 1 How people with diabetes
interact with their healthcare practitioners
with regard to nocturnal hypoglycaemia
and its management was also examined.
The study was commissioned by Novo
Nordisk A/S and supported by the
International Diabetes Federation (IDF).
Diabetes is one of the most challenging
health problems in the 21st century. The
number of people with the condition is
increasing in every country worldwide.
People with Type 1 and Type 2 diabetes
who use insulin as part of their
treatment plan are exposed to the risk of
hypoglycaemia (commonly refered to as a
‘hypo’). Hypoglycaemia (abnormally low
blood glucose levels) is often associated
with insulin treatment and the type
and level of activity undertaken by the
individual. 2 Typical symptoms of mild
hypoglycaemia include dizziness, hunger/
thirst, shaking and sweating; more severe
events can cause confusion, disorientation,
coma and death. 3
Nocturnal hypoglycaemia – low blood
glucose events arising at night – has
attracted increasing interest in recent
years as an important source of
morbidity and even mortality in people
with diabetes who are insulin-treated.
Nocturnal hypoglycaemia can be a sign
of uncontrolled diabetes. Much attention
has focussed on severe events, such
as those requiring medical assistance.
However, it has been shown that nocturnal
hypoglycaemic events that people with
diabetes can manage themselves can also
impact quality of life, including quality and
amount of sleep, and the ability to drive
and function at work and home. 4
This study elicited quantitative data from
1,107 individuals using insulin for Type 1 or
Type 2 diabetes from Argentina, Canada,
France, India, Japan, Sweden and the UK,
and solicited qualitative insights into the
experiences of 210 of the participants. 1
All respondents were treated with insulin
and had experienced at least one nocturnal
hypoglycaemic event in the last 30 days.
The study was undertaken between July
and September 2013. 1
The study explored the impact of nocturnal
hypoglycaemia on sleep patterns,
successful diabetes management (selfmanagement
and through discourse with
their general practitioners (GPs) / primary
care physicians (PCPs) and other healthcare
professionals), and quality of life. 1
The study hypotheses were: 1
• Nocturnal hypoglycaemic events
are underreported by people with
diabetes
• People with diabetes may not
always speak to their physician
about these night time events
• Nocturnal hypoglycaemic events
and fear of these episodes have
more impact upon quality of life
than GPs/PCPs and other healthcare
professionals may realise
4 5

Summary of findings 1
• Self-treated nocturnal hypoglycaemia is common.
Overall respondents had experienced an average of three nocturnal hypoglycaemic
events in the previous 30 days a . Over a third of respondents (36%) estimated that they
had experienced between two and six events in the 30 days prior to being surveyed,
and 9% of respondents had experienced more than six nocturnal hypoglycaemic events
Introduction: The nocturnal
hypoglycaemic challenge
• People with diabetes worry about nocturnal hypoglycaemia. Over half (55%)
expressed moderate worry and 25% reported significant worry b
• Both the nocturnal hypoglycaemic events themselves and worrying about them
disrupted the sleep of people with diabetes. Symptoms of hypoglycaemia woke
people with diabetes frequently, often leaving them tired, irritable and less able than usual
to function the next day. Three quarters (75%) of those with diabetes reported marked
disturbance of sleep from worrying about nocturnal hypoglycaemia, with 19% reporting
severe sleep disturbance for this reason (score 8–10) c
• Worrying about nocturnal hypoglycaemia changed the way many people managed
their diabetes. 56% of respondents admitted to the worry causing a change in how
they manage their diabetes. Of these, 39% intentionally allowed their blood glucose to
elevate before bed, 39% reduced their insulin intake, 22% changed the timing of insulin
administration and 20% intentionally missed at least one insulin dose
• Many people with diabetes did not discuss their nocturnal hypoglycaemia with
their GP/PCP. Nearly half of all respondents (49%) discussed none of their nocturnal
hypoglycaemic events with their GP/PCP; only 13% discussed all of these events with their
GP/PCP. One in five (20%) did not discuss their nocturnal hypoglycaemic events with any
healthcare professional
• Respondents did not report these nocturnal events for a variety of reasons, most commonly
underestimation of the importance of nocturnal hypoglycaemia; 23% of respondents
who do not discuss any events with their GP/PCP noted that they did not mention the events
as they didn’t feel they were relevant or important enough. Responses to the qualitative
survey suggested that people with diabetes become familiar with nocturnal hypoglycaemia
and confident at managing events without bothering their GP/PCP
Based on the research findings Novo Nordisk A/S, supported by the IDF, will launch The
World Awake campaign to educate GPs/ PCPs about the impact of self-treated nocturnal
hypoglycaemia on people with diabetes by: 1
• Raising awareness of the physical and psychosocial impact of nocturnal hypoglycaemia
on those affected and their families
• Encouraging and driving proactive conversations about nocturnal hypoglycaemia,
its management and treatment
A second stage of the campaign will focus on driving awareness of, and understanding
about, the importance of these events among people with diabetes.
Key points:
• Hypoglycaemia is a major barrier
to the management of both Type 1
and Type 2 diabetes
• Nocturnal hypoglycaemia is
common and can have serious
consequences for people with
diabetes
Nocturnal hypoglycaemic events are
common in people with diabetes. These
events affect about half or more of adults
with Type 1 diabetes 5,6 and more than a
third with Type 2 diabetes. 7 Almost half of
hypoglycaemic events in all people with
diabetes occur at night. 8 Previous research
has shown that these events can pose
a particular problem for people with
diabetes, their families and those who treat
them for a number of reasons:
“Reducing the
frequency and
impact of nocturnal
hypoglycaemia is a
major unmet need
in insulin-treated
diabetes.”
Sir Michael Hirst, President of the
International Diabetes Federation
• Nocturnal hypoglycaemia does not
usually wake a sleeping person with
diabetes, so the low blood glucose can
go uncorrected 9
• Nocturnal hypoglycaemia reduces
quality of sleep and leaves people with
diabetes tired and feeling unwell the
following day, hence impacting upon
their ability to work productively and
perform routine tasks such as driving 4,10
• People with diabetes fear nocturnal
hypoglycaemia and often allow their
blood glucose to run high towards
bedtime, or change, reduce or even
miss insulin doses 4,10
• Nocturnal hypoglycaemia can be
a major worry for families 5,11,12
• Exercise during the preceding day
can increase the risk of nocturnal
hypoglycaemia, which is an important
barrier to persuading people with
diabetes treated with insulin to adopt
healthy lifestyles 13
a) The survey included respondents who had experienced at least one nocturnal hypoglycaemic event in the previous 30 days
b) Moderate/severe worry: rated 3–7/8–10 on a scale from 0 (no worry) to 10 (extreme distress/fear) c) Marked sleep disturbance:
score at least 3; severe sleep disturbance: score 8–10; 0=no impact on sleep, 10=severe insomnia
6 7

Nocturnal hypoglycaemia and
fear of nocturnal hypoglycaemia
are common in people treated
with insulin for their diabetes
Fig.2. Expressions of concern relating to nocturnal hypoglycaemia from the
qualitative survey 1
Less concerning Topic of discussion More concerning
Infrequent, predictable
Mild in impact
Night time low blood
sugar events
More frequent
Less predictable
Greater impact
Key points:
Some events may also go unrecognised. 9
Over two fifths of respondents (44%)
• 36% of respondents reported two believed that they may have experienced
or more self-treatable nocturnal more night time hypoglycaemic events
hypoglycaemic events within the than they realised, and a further 25%
30 days prior to being surveyed were unsure. 1 This finding was strongest in
India, where 64% felt that they may have
• Nocturnal hypoglycaemic events underestimated the number of nocturnal
can go unrecognised; 44% of hypoglycaemic events. 1
respondents believe they may
have experienced more events
than they realised
Fig.1. Average severity of worry about
daytime and night time hypoglycaemia
• 91% of respondents expressed at in the quantitative survey 1
least some degree of worry about
nocturnal hypoglycaemia (score Night time hypoglycaemia
≥1); 77% reported moderate or
significant worry
Frequency of nocturnal
hypoglycaemic events
This study included people with Type 1
or Type 2 diabetes who had experienced
at least one night time low blood glucose
event in the previous 30 days. 1 Over a
quater of respondents (27%) estimated Daytime hypoglycaemia
that they had experienced between two
and six events in the 30 days prior to
being surveyed, and 9% of respondents
had experienced more than six nocturnal
hypoglycaemic events. 1
Overall, about half of all hypoglycaemic
episodes occurred at night (42–56% of
events across our seven countries). 1
Significant
worry
Moderate
worry
Little or
no worry
Definitions according
to scale shown (out of 10):
Significant worry = 8–10
Moderate worry = 3–7
Little worry = 0–2
Results from quantitative
survey
Have experience with
hypos, know what to
expect, what to do
Have spouse/family
Have support
arrangements
Results from qualitative survey
Worry about nocturnal hypoglycaemia
In this study respondents worried about nocturnal hypoglycaemic events to about the
same extent as they did daytime events (Fig.1). 1 In total over three quarters (77%) of
respondents worried about having a nocturnal hypoglycaemic event that they could
treat themselves. 1
The qualitative survey showed that overall, irrespective of severity, nocturnal
hypoglycaemic events are worrying to some degree for most people with diabetes
(Fig.2). 1 More episodes of night time hypoglycaemia, less experience of managing them,
and a lower level of support available from family members were all associated with
greater worry about nocturnal hypoglycaemia in the qualitative study. 1 People with
diabetes feared “not being able to wake up or help oneself.” 1
Worrying about nocturnal hypoglycaemia can also impair family life. 1 About one-third
of respondents with a partner or children reported that night time hypoglycaemia had
a more than moderate impact on their relationships with a partner (34%, severe impact
for 18%) or children (30%, severe impact for 16%). d Respondents also reported a strong
emotional response to nocturnal hypoglycaemia in the qualitative survey, expressing
feelings such as: e1
• Fear of death (Argentina, Canada, Japan, UK)
• Anger at nocturnal hypoglycaemia and emptiness (France)
• Falling into a void (Argentina, UK)
Familiarity with low
blood sugar events
• Being trapped (Argentina, France, UK)
Availability of support
Less experience
with hypos
Do not know what to
expect, what to do
No spouse/family
able to help
No or limited support
arrangements
d) Rating of at least 6 (moderate) or 8 (severe) on a scale where 0=no impact and 10=severe impact.
e) Based on qualitative results. Respondents were asked if there was any particular kind of visual imagery that could
capture how they felt about actually having a night time low blood sugar event
8 9

“The number of
night time events
patients recognise
may be the tip of the
iceberg. Many people
with diabetes may
be nocturnal hypo
unaware. We must do
more to improve this.”
Having or worrying about
nocturnal hypoglycaemia
disturbs sleep
Key points:
• Waking up with symptoms
(sweating, feeling hot or cold,
shaking, tingling, light-headedness,
feeling unwell) were the most
common alarm signals for nocturnal
hypoglycaemia
• 47% did not record their nocturnal
hypoglycaemic event in any way
• 75% of those who worried reported
that worrying about nocturnal
hypoglycaemia also disturbed sleep
The most common symptoms were... 1
Sweats
Feeling
hot or cold
Shaking,
tingling
Lightheadedness
Impact of having a nocturnal
hypoglycaemic event on sleep
Also quite common were... 1
Two thirds (66%) of respondents were
aware that they had experienced a night
time hypoglycaemic event which they could
self-manage due to waking with symptoms
of not feeling well. 1
The qualitative survey provided an overview
of the key nocturnal hypoglycaemia
symptoms which caused respondents
to wake 1 .
Headache
‘Not feeling
right’
z z z
Thirst,
hunger
Fatigue
Dr Richard Brice, GP with a Special Interest in Diabetes, Kent, UK
10 11

Over two fifths of respondents (47%) did not in any way record any of the
nocturnal hypoglycaemic events which they could self-manage. 1
Of those respondents who did record the event, over half (59%) used a diary or
notepad by their bed. 1
Over half of those surveyed (58%) were aware that they had experienced a night-time
event because they measured their blood glucose on waking. 1 Over one in ten (15%) were
informed they had experienced an event by their partner, friend or housemate. 1
Impact of worrying about having a nocturnal hypoglycaemic
event on sleep
It was found that worrying about nocturnal hypoglycaemia also impaired sleep (Fig.3). 1
Of those respondents who worried about nocturnal hypoglycaemia, three quarters (75%)
noted that this worry adversely affected their sleep with 19% noting a severe impact
or insomnia. f,1
Fig.3. Effect of worrying about self-treatable night time hypoglycaemia on sleep
in the quantitative study of people with diabetes 1
Participants in the qualitative study provided insights into the experience of waking with
a nocturnal hypoglycaemic event: 1
“I sometimes have hypos and wake up, the only manifestation that wakes me
up is that I have the impression I peed on myself that is to say I am totally wet,
I sweat a lot and then I know I have a hypo. I still do a check up but I am rarely
wrong and then I have 0.45 or 0.5, so I get some glucose and go back to bed.”
Person with Type 2 diabetes, France
“You wake up in the night and you feel different so you know straight away that
your sugars may be low. You feel perhaps a little tingly in the legs, a little numb
in the mouth and a little bit light-headed and hot; sweaty hot; you feel
uncomfortably warm.”
Person with Type 2 diabetes, UK
Definitions based on a scale where 0=no impact on sleep and 10=severe impact or insomnia. Little impact
= score 0–2; moderate impact = score 3–7; severe impact = score 8–10. Results from quantitative survey
Impact of nocturnal hypoglycaemia on sleep
All subjects
UK
Sweden
Japan
India
France
More than half of respondents in the qualitative study reported reduced performance
the day after a nocturnal hypoglycaemic event, consistent with the above. 1 Worry about
nocturnal hypoglycaemic events moderately affected overall energy levels in all countries
(average ratings 3.9–6.5/10, on a scale of 0–10). 1
Canada
Argentina
0% 20% 40% 60% 80% 100%
Percentage of respondents who expressed worry about nocturnal hypoglycaemia
“I lose the motivation to be active, and I will tend to spend more time in bed…
even during the day. For whatever I do, for example, cooking a meal or doing
exercise, I can’t act on it spontaneously. I will be more sluggish compared to
other days. It takes more time.”
Person with Type 2 diabetes, Japan
Severe Moderate Little or none
Those who noted the highest impact of worry on sleep
(severe impact or insomnia, score of ≥8)
• Significantly more respondents in India (41%) vs. respondents in the other survey
countries
• Significantly more respondents with Type 2 vs. Type 1 diabetes (22% vs. 15%)
• Significantly more female vs. male respondents (24% vs. 13%)
f) Ratings of 2 or more and 8 or more where 0=no impact and 10=severe insomnia, respectively
12 13

Worry about nocturnal
hypoglycaemia changes
the way people manage
their diabetes
The changes in diabetes management varied across survey countries. 1 The top three
actions taken by respondents per country are shown in Fig.4.
Fig.4. The three most common actions taken to prevent nocturnal
hypoglycaemia in each country. 1
Argentina
(n=87)
Increased BGM frequency
Changed what I ate throughout the day
Intentionally allowed high glucose level
29%
64%
54%
Key points:
• 56% of those surveyed reported
taking actions to reduce their risk
of nocturnal hypoglycaemia
• Increased frequency of glucose
monitoring and changes to
diet were common strategies to
address worry about nocturnal
hypoglycaemia
• Respondents often changed their
insulin regimens, including
mistimed, reduced or omitted doses
More than half (56%) of respondents
who expressed worry about night time
hypoglycaemia reported that this worry
affected the way in which they managed
their diabetes (46–68% in individual
countries). 1
Worry
affected the
way they
managed their
diabetes
Worry did not
affect the way
they managed
their diabetes
Canada
(n=73)
France
(n=87)
India
(n=101)
Japan
(n=96)
Reduced my insulin dose
Intentionally allowed high glucose level
Changed what I ate throughout the day
Increased BGM frequency
Changed what I ate throughout the day
Reduced my insulin dose
Changed what I ate throughout the day
Increased BGM frequency
Reduced my insulin dose
Increased BGM frequency
Reduced my insulin dose
Intentionally allowed high glucose level
48%
45%
44%
46%
43%
32%
48%
35%
35%
49%
48%
41%
Overall, of those who changed their diabetes management: 1
Increased the frequency of blood
glucose monitoring (BGM)
49%
Sweden
(n=49)
Intentionally allowed high glucose level
Increased BGM frequency
Reduced my insulin dose
61%
59%
49%
Changed what they ate during
the day
Reduced their insulin intake
Intentionally allowed a high
glucose level before bed
42%
39%
39%
UK
(n=77)
Increased BGM frequency
Intentionally allowed high glucose level
Reduced my insulin dose
57%
49%
43%
Increased frequency of BGM could help to improve overall management of diabetes. 14 The
other actions described above, if taken unilaterally and without the support of a physician,
could impair the control of blood glucose, potentially increasing the likelihood of longterm
disabling complications. 15
Changed the timing of insulin
administration
Intentionally missed at least one
insulin dose
22%
20%
Further responses to the qualitative survey suggested that the worry about nocturnal
hypoglycaemia can lead to people with diabetes feeling self-critical: 1
“Annoying because: have I done anything
wrong? Should I have had that snack? Or why
didn’t I have that snack. If I had it would I have
stopped it? I’m trying to keep control of my
diabetes and it’s very difficult.”
“Why does this happen to me? Why can’t I look
after myself better? And often I know what I can
do and should do. So it feels unfair. I don’t sleep
well, I have a headache, I’m in a bad mood, but
at the same time I’m pleased that I wake up.”
Person with Type 1 diabetes, UK
Person with Type 2 diabetes, Sweden
14 15

“Fear of nocturnal
hypoglycaemia can
lead to poor treatment
satisfaction, poor
insulin adherence,
and ultimately poor
long-term outcomes
for patients. Physicians
and other healthcare
professionals must
regularly discuss
these events with
their patients.”
Nocturnal hypoglycaemia –
the ‘patient-physician
consultation’
Key points:
• People with diabetes often do not
discuss self-treated nocturnal
hypoglycaemic events with
healthcare practitioners;
- 49% of respondents discussed
none of their night time events
with their GP/PCP
- 20% of respondents did
not discuss their night time
events with any healthcare
professional
• The most common reason for not
discussing these events with their
GP/PCP was a feeling that it was
insufficiently important
• The most effective consultations
for those with diabetes were
where the physician proposed
practical and effective strategies
to mitigate the impact of nocturnal
hypoglycaemia that fitted with
the person’s specific needs and
limitations
Nocturnal hypoglycaemia is
often not discussed with
healthcare practitioners
Only about one respondent in seven
(13%, 2–24% across countries) discussed
all of their self-treated nocturnal
hypoglycaemia events with their GP/PCP
and almost half (49%, 18–82% across
countries) did not discuss any at all (Fig. 5). 1
Especially high proportions of people with
diabetes in Canada (56%), Japan (57%),
Sweden (82%) and the UK (64%) chose
not to discuss any nocturnal hypoglycaemic
events with their GP/PCP. 1
These findings did not differ according
to type of diabetes: only 10% of
respondents with Type 1 diabetes
and 16% of respondents with Type 2
diabetes discussed all of their nocturnal
hypoglycaemia events with their GP/PCP. 1
Only 23% of all respondents discussed all
of their nocturnal hypoglycaemia events
with their main diabetes specialist, with
lower figures for nurses, pharmacists or
other types of healthcare professional
(4–12%). 1
One in five (20%) respondents did not
discuss their nocturnal hypoglycaemic
events with any healthcare professional. 1
Professor Anthony Barnett, Emeritus Professor of Medicine
and Consultant Physician, University of Birmingham and Heart
of England NHS Foundation Trust, Birmingham, UK
16 17

Fig.5. What proportion of night-time hypoglycaemic
events do respondents discuss with their GP/PCP?
All
Some
None
The qualitative survey provided some insights into these findings: 1
“Well, my GP and my Endocrinologist share the same office so I am making the
uninformed assumption that they share the same information.”
Person with Type 2 diabetes, Canada
“It’s just part of the disease. I can handle it myself. You have to accept it, so I
don’t tend to say anything about it.”
Person with Type 1 diabetes, Sweden
Why are so many people with diabetes reluctant to discuss
nocturnal hypoglycaemia with their primary care physician?
Results from
quantitative survey 1
Advice from GPs and PCPs on avoiding nocturnal hypoglycaemia
According to respondents, GP/PCPs recommended a range of actions that people with
diabetes could take to minimise the possibility of nocturnal hypoglycaemia in the future
(Fig.7) 1 :
Respondents provided a range of reasons for not discussing any self-treated nocturnal
hypoglycaemic events with their GP or PCP (Fig.6). 1 Overall a lack of awareness or
understanding about the significance of nocturnal hypoglycaemic events among people
with diabetes may explain some of these findings, with nearly a quarter (23%) of
respondents who see their GP/PCP for diabetes stating that they didn’t feel these events
were relevant or important enough to mention. 1 Taken together, these findings suggest an
important need for greater understanding of managing nocturnal hypoglycaemia
effectively, on the part of both physicians and people with diabetes.
Fig.6. Reasons for not reporting nocturnal hypoglycaemic events to GPs/PCPs
Fig.7. What did your GP/PCP recommend?
Keep a diary of how often these events occur
Provide me with general information on how to avoid nocturnal events
Increase blood glucose monitoring
Advised me on how to self-manage these night time events
Eat sugar/a snack before going to bed
36%
33%
32%
30%
29%
Didn’t feel it was relevant/
important enough
23%
Change my evening or night time routines
Reduction in dose of my insulin
27%
22%
Feel my GP/PCP knows/
assumes
Feel like I waste my GP/
PCP’s time
10%
13%
Change the type of insulin I use
Did not recommend anything
Other or don’t know
15%
8%
5%
Forgot
6%
Didn’t have time during
the consultation
Concerned about the
consequences if I reported
I felt embarrassed
5%
5%
5%
Up to 15% of respondents felt that they had come away from the consultation with
no advice on how to better manage their nocturnal hypoglycaemia. 1 Canada had the
greatest number of respondents (15%) and Argentina the lowest (0%) who felt they
received no advice. 1
18 19

Key elements of ‘patient-physician consultations’
for diabetes care
According to respondents, the role of the GP/PCP varied in the different countries. 1 The
qualitative survey showed that in the UK, a healthcare professional typically raised the
question of hypoglycaemia with people with diabetes. 1 In other countries, people with
diabetes were more likely to instigate such discussions themselves, arising from general
discussions of their well being. 1 A review of a diary may occur, where used (see Fig. 7),
and hypoglycaemia may be discussed in the context of the person’s overall management
of blood glucose (insulin dosage/timings, diet etc). 1 People with diabetes were sensitive to
suggested solutions that fitted into the context of their personal situations. 1
People with diabetes pick up on emotional and practical aspects of their GP/PCP’s
approach (Box 1). 1 Being treated as a partner in the consultation, and not being patronised
or talked down to by the physician, was a common theme. 1 Those with diabetes are often
anxious about meeting the goals agreed with their physician and a requirement for
person-centred care is that healthcare professionals must adopt a non-judgemental
manner when dealing with people with diabetes. 16 Nevertheless, the person with diabetes
is looking for advice or interventions that will address specific problems successfully. 1
Box 1. Emotional and practical domains relating to a successful clinical
consultation, from the perspective of people with diabetes 1
A person with diabetes was typically satisfied with the consultation when: 1
• Questions were answered
• The physician’s recommendations improved their well being (“good results“)
• Recommendations were specific to the individual
• They saw the same healthcare practitioner at each visit, especially for hospital-based
personnel
Less satisfying consultations were characterised when: 1
• Recommendations were not new or seen as suitable for a given person
• Advice given was seen as being contradictory or variable advice between different
healthcare practitioners
“It was difficult at first because of the different views the dieticians have from
my own experience. The dietician may say that this one is alright and another
dietician will say that this one is not. I have to average the different advice
between the two dieticians to then decide what is best for me.”
Person with Type 2 diabetes, UK
Emotional
• Approachable, friendly, welcoming
- Good listener, pays attention
- Not too ‘business-like’
• Sympathetic and empathetic
- Not judgmental
- Not (unnecessarily) accusatory,
punishing
• Respectful manner
- Acknowledges expertise/
understanding of the condition
by the person with diabetes
- Not patronising
Results from qualitative survey
Practical
• Spends sufficient time
- Person with diabetes feels they
have had time to discuss issues/
concerns
• Knowledgeable, with
good communication
- Explains well
- Uses terms which person with
diabetes can understand
- Does not read advice off
the computer
• Provides practical (and successful)
solutions to specific problems
- Consistent with other HCPs’ advice
“We can see that nocturnal hypoglycaemia is an important issue for people with
diabetes where they require practical, personalised, high quality advice from
healthcare professionals to help mitigate the frequency and impact of these
episodes. This report gives useful insight into what people need from the doctors
they consult.”
Dr Richard Brice, GP with a Special Interest in Diabetes, Kent, UK
20 21

“GPs and primary care
physicians are ideally
placed to educate
patients on nocturnal
hypoglycaemia and
help them understand
the significance of
these events.”
Sir Michael Hirst, President of the International Diabetes Federation
Discussion
Having or worrying about nocturnal
hypoglycaemia, of a severity manageable
by those with diabetes themselves, were
common in a typical population of people
with Type 1 or Type 2 diabetes receiving
injections of insulin as part of their
therapeutic management in The World
Awake research study. 1
It was clear that both the nocturnal
hypoglycaemic events themselves and
worrying about them influenced the lives
of the people with diabetes in important
ways. 1 For example, having the
hypoglycaemic event frequently woke the
person with diabetes and/or their partner,
especially for men and people with Type 2
diabetes. Sleep disturbance from nocturnal
hypoglycaemia often left them tired and
feeling unwell the next day. 1 Worrying
about the event itself impaired sleep, and
in many cases prompted those with
diabetes to alter their diabetes
management, in particular by missing,
mistiming, or reducing doses of insulin. 1
These actions, if taken unilaterally and
without the support of a physician, could
impair the control of blood glucose and
thus increase the risk of long-term diabetic
complications. 15 Increasing the frequency of
glucose monitoring, on the other hand,
could be one potentially beneficial change
in overall diabetes self-management. 14
The World Awake study also shed light on
the nature of the consultation between the
person with diabetes and their physician. 1
There was no standard method for
reducing the frequency of nocturnal
hypoglycaemia, 1 which is unsurprising given
the complex nature of diabetes and the
need for individualised care. 17-19 However,
the study also showed that a substantial
proportion of people with diabetes were
unable or unwilling to discuss their
nocturnal hypoglycaemia with their GP/
PCP. 1 This barrier to communication came
about for a number of reasons, not least
that the people with diabetes themselves
underestimated the importance of
self-treated nocturnal hypoglycaemia. 1
Overall, a lack of awareness or
understanding about the significance of
nocturnal hypoglycaemic events among
people with diabetes may explain some
of these findings.
This reluctance to discuss nocturnal
hypoglycaemic events represents a serious
problem relating to the delivery of effective
diabetes care for many people with
diabetes. Fear of hypoglycaemia can lead
to poor treatment satisfaction. In turn, this
may promote loss of self-confidence
among people with diabetes and their
physicians. Poor adherence to therapy may
then lead to worsened glycaemic control,
with increased burden of disease (i.e.
likelihood of poor long-term outcomes
and diabetic complications). 15
Accordingly, physicians must work more
effectively with people with diabetes to
ensure that episodes of nocturnal
hypoglycaemia are explored fully.
According to our population, once a
problem with nocturnal hypoglycaemia has
been acknowledged, the GP/PCP needs to
communicate their knowledge of the
problem, and demonstrate their
commitment to providing practical and
effective strategies to mitigate the impact
of nocturnal hypoglycaemia that fit with
the person with diabetes’ specific needs
and limitations. 1
In conclusion, self-managed nocturnal
hypoglycaemia and the worry and fear
it engenders remain a major clinical
challenge in people with diabetes who
are insulin-treated. Increased
awareness and improved dialogue is
needed among people with diabetes
and the physicians who treat them in
order to reduce the substantial impact
of nocturnal hypoglycaemia on the
lives of people with diabetes.
22 23

Recommendations
for reducing the impact of
nocturnal hypoglycaemia
on people with diabetes
from Professor Anthony Barnett, Dr Richard Brice
and the International Diabetes Federation
Based on the findings from The World Awake research study, 1 the following suggestions
are recommended to improve the dialogue between people with diabetes and their
healthcare professional, aiding optimal diabetes management.
Appendix: Background
on The World Awake
research study 1
The global quantitative research was commissioned and funded by Novo Nordisk A/S and
conducted by Aequus Research Ltd amongst 1,107 adults (over 18 years old) with both
Type 1 and Type 2 diabetes between July and September 2013. All participants were
treated with insulin and had experienced a night time low blood glucose event in the 30
days prior to being surveyed. g
Interviews were conducted in seven countries (Fig.8):
1. Raise awareness among people with
diabetes and their families of the
seriousness of nocturnal hypoglycaemic
events.
All people with diabetes and their family
members should understand that even
self-treated nocturnal hypoglycaemia
can have serious consequences and
steps should be taken to manage and
reduce the incidence of these events.
2. Increase understanding among
healthcare professionals of the physical
and psychosocial impact that selftreated
nocturnal hypoglycaemic events
have on people with diabetes.
All physicians involved in the
management of diabetes should
understand that the impact of having
or the fear of having nocturnal
hypoglycaemia can be a real concern
for people living with diabetes and their
families, disturbing their sleep patterns,
quality of life and the way that they
manage their condition. Failure to
recognise the importance of nocturnal
hypoglycaemia with regards to diabetes
care can have serious therapeutic
implications. If people with diabetes are
dissatisfied with their treatment they
may not adhere well to it. Long-term
loss of glycaemic control would then
increase the likelihood of developing
complications of diabetes that reduce
the quality and duration of lives of
people with diabetes.
3. Encourage and improve proactive
discussion between people with
diabetes and their GP/PCP on the
topic of nocturnal hypoglycaemia.
People with diabetes should report
all nocturnal hypoglycaemic events
to their GP/PCP to allow their
management approaches to be
revised appropriately. Healthcare
professionals should help to prevent
night time events in people with
diabetes by providing practical and
effective strategies that fit with the
person’s specific needs and limitations.
These may include education and
empowerment, increased monitoring
and review of their insulin regimen.
Fig.8. Global reach of The World Awake study
Figures in brackets are the numbers of respondents in each country in the quantitative
survey. Thirty people with diabetes in each country contributed to the qualitative survey.
UK
(170)
Canada
Argentina
g) The survey only included respondents taking insulin
(170)
Sweden
France
(173)
(171)
(100)
India
(173)
Japan
(150)
24 25

• A quantitative survey based on 1,107 adult individuals using insulin to manage
their diabetes (536 with Type 1 diabetes and 571 with Type 2 diabetes). Each
respondent conducted a 20-minute online interview
• A qualitative survey conducted using interviews with 210 people with diabetes
(30 respondents from each country) who had participated in the quantitative study,
in order to gain further insight into the impact of hypoglycaemia. Each respondent
completed a 45-minute in-depth telephone interview
The participants included were typical of those seen in routine clinical practice in the
primary care setting:
83%
8%
9%
48% had Type 1 diabetes,
52% had Type 2 diabetes
The genders were equally
balanced overall – 46%
male vs. 54% female
54%
Most (83%) were aged 25–64 years;
8% were aged 18–24 years and 9%
were aged 65 years or over
Type 1 48%
46%
52% Type 2
• More people with Type 1 diabetes had been using insulin for more than 2 years
(76%) vs. for Type 2 diabetes (50%)
• Types of insulin used: basal (long-acting) only by 23%; bolus (short-acting mealtime
insulin) only in 16%; basal + bolus in 47% and premixed long- and short-acting insulin
in 14%
• More people with Type 1 diabetes (49%) used only insulin to manage their diabetes
compared with those with Type 2 diabetes (26%); 46% of each group said they were
also undertaking a lifestyle intervention (diet and exercise)
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