Spouse’s worries concerning diabetic partner’s possible hypoglycaemia

LETTERS

LETTERS

Diabetes—What’s in a Name?

The American Diabetes Association (ADA)new diagnostic criteria for the diagnosingof diabetes, recommending a fastingplasma glucose (FPG) value for peoplewithout clinical symptoms, provides amuch simpler method to diagnose dia-betes than the oral glucose tolerance test(OGTT) required by the World HealthOrganization (WHO).1 The ADA suggestthat the FPG is simpler, less expensive,more acceptable to patients and morereproducible but will result in fewerpeople being diagnosed with diabetes.We have examined all glucose tolerancetests performed at Bournemouth betweenJanuary and July 1997 and reclassifiedthem according to the ‘new’ ADA rec-ommendations.

Number of OGTT = 219Excluded because screened

for gestational diabetes = 95Total of OGTT analysed = 124(70 male; average age 64 years rangingfrom 46–82 years)

Results

Thus, 4 % would have their status changedfrom impaired glucose tolerance to ‘dia-betes’ but worryingly, 11 % of patientspreviously labelled as ‘diabetic’ wouldnow be re-classified as ‘not diabetic’ orhaving impaired fasting glucose (Table 1below). The concern is that these patientswould become part of the problem whichthe ADA sought to address, namely,several years of hyperglycaemia resultingin complications and ‘silent’ morbidityupon diagnosis. The HbAIc of all patientsnewly diagnosed with Type 2 diabetes atBournemouth was 10.4 % 6 3.9 (normalrange ,6.5 %) but the HbAIc of those

Table 1. Changes in diagnostic status from WHO criteria to ADA criteria (mean)

Number % FBS SD 2 h value SD WHO definition ADA definition(mmol l−1) (mmol l−1)

57 46 4.8 0.8 6.5 1.5 No diabetes No diabetes0.8 14 6.5 0.3 9.4 Impaired glucose tolerance Impaired fasting glucose9 7 5.6 0.3 9.8 2.1 Impaired glucose tolerance No diabetes5 4 7.8 0.7 9.5 1.2 Impaired glucose tolerance Diabetes3 2 5.7 0.2 12.9 0.2 Diabetes No diabetes11 9 6.6 0.4 14.1 2.0 Diabetes Impaired fasting glucose22 18 9.2 1.6 16.3 3.2 Diabetes Diabetes

619CCC 0742–3071/98/070619–04$17.50 1998 John Wiley & Sons, Ltd. DIABETIC MEDICINE, 1998; 15: 619–622

who would now be reclassified as nothaving diabetes was 6.3 % 6 1.1.

In Bournemouth there is a nurse-ledopen access system whereby newly diag-nosed Type 2 patients are seen within1 week of diagnosis. Data have beencollected on a group of 156 patients whoentered this programme in 1994 and havebeen followed up for 3 years. 16 % ofthese were diagnosed through OGTT. Ifthese were to be re-classified accordingto the ADA recommendations, 10 %would not be diagnosed as having dia-betes. Fortunately, only one patient outof this 10 % had complications of diabetesdetected at diagnosis and this person isalso the only one to require medicationto control his diabetes.

This is a small local sample but theconclusion based on this evidence sug-gests that the recommendation of theADA of using FPG in preference to OGTTwould reduce the numbers of individualswith diabetes but would not result inmissing the complications of diabetes atleast over a 3-year period.

D. Kerr, D.A. Cavan, J. EverettDiabetes and Endocrine Centre, RoyalBournemouth Hospital, Bournemouth,Dorset, BH7 7DW, UK

Reference

1. Harris MI, Eastman RC, Cowie CC,Flegal KM, Eberhardt MS. Comparisonof diabetes diagnostic categories inthe U.S. Population According to1997 American Diabetes Associationand 1980–1985 World HealthOrganization Diagnostic Criteria:Diabetes Care 1997; 20: 1859–1862.

Spouse’s Worries Concerning DiabeticPartner’s Possible Hypoglycaemia

Occurrence of severe hypoglycaemia1 iscommon2 and can have major negative

consequences, ranging from embarrass-ment to phobic fear3 to death.4 Clinicalexperience suggests these negative seque-lae affect both the patient and theirfamilies, including parents,5 spouses, andchildren. There has been only one studythat quantified this impact. Gonder-Fred-erick et al.6 studied an American samplevolunteering for a long-term clinical trial.7They found spouses of patients withfrequent severe hypoglycaemia had morefear of hypoglycaemia, more marital con-flict surrounding diabetes management,and more sleep disturbance while worry-ing about nocturnal hypoglycaemia thanspouses whose diabetic partner had nothad recent severe hypoglycaemia. Thecurrent data comes from another country(Switzerland), from patients who were notparticipating in a clinical trial.

Participants were emergency roompatients presenting for the treatment ofsevere hypoglycaemia at the UniversityHospital, Basel. All patients had Type 1diabetes mellitus, reported a mean of 6.1episodes of severe hypoglycaemia in theirlifetime, and a mean of 2.0 in the pastyear. Mean duration of diabetes was17.7 ± 11 years. Spouses were asked toparticipate in a home interview dealingwith ‘living with hypoglycaemia’; fiverefused. There were 38 husbands and 22wives, average age 43 ± 16 years. Duringa structured interview, spouses were askedthree questions concerning severe hypog-lycaemia (Table 1 overleaf).

This culturally different sample anddifferent data collection strategy revealedfindings similar to the American study:6the psychosocial impact of severe hypog-lycaemia goes beyond the patient experi-encing the event. While this survey didnot have a comparison group, it diddemonstrate that the possibility of a part-ner having severe hypoglycaemic hasmultiple implications. When the partneris late, for nearly 1/5 of the subjects thefirst concern was the possibility of asevere hypoglycaemic episode. Severehypoglycaemia was a source of concernor ‘consternation’ for 2/3 of the sample.Finally, for nearly 10 % of the spouses,

LETTERSTable 1. Questions asked of spouse and distribution of responses

1. What do you think when your partnerdoes not show up at an appointed time?

Sure that s/he is suffering from hypoglycaemia 17.3 %Concerned that something might have 60.3 %happened, e.g. accidentOther thoughts 22.4 %

2. What is your emotional reaction to severehypoglycaemia?

Consternation 67.3 %Keep relatively calm 31.7 %

3. Is the potential of a severe hypoglycaemia a familyburden?

Always 9.1 %Sometimes 47.3 %Never 41.8 %

the possibility of severe hypoglycaemiawas ‘always’ a burden.

Further research is needed to determinewhether some spouses and marriages aremore vulnerable to psychosocial problemssecondary to recurrent severe hypoglycae-mia. Clinical experience suggests that, forsome couples, such hypoglycaemia stresscan perpetuate problems with severehypoglycaemia. For example, spousalconcern about future severe hypoglyca-emic episodes can trigger attempts to takemore control over diabetes management,with more resistance to treatment assist-ance in patients.8 Couples who demon-strate such power struggles should bereferred for marital therapy to addressthese issues and improve their ability tocope with hypoglycaemia.

We would expect that spouses, likepatients,3 develop more fear of hypoglyca-emia the more traumatic its past conse-quences. Severe hypoglycaemia may havesimilar psychosocial ramifications for chil-dren who have discovered their diabeticparents stuporous or unconscious and inneed of emergency treatment. We believethat the psychosocial impact of hypoglyca-emia on family members deservesincreased clinical and empirical attention.

M. Stahl,1 W. Berger,1 H. Schaechinger,1D.J. Cox2

1Division of Endocrinology, Diabetologyand Clinical Nutrition, University ofBasel, Switzerland2Department of Psychiatric Medicine,University of Virginia Health SciencesCenter, Charlottesville, Virginia, USA

References

1. The Diabetes Control and Compli-cations Trial Research Group. Influ-

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ence of intensive diabetes treatmenton quality-of-life outcomes in TheDiabetes Control and ComplicationTrial. Diabetes Care 1996; 19: 195–203.

2. Gold AE, MacLeod KM, Frier BM.Frequency of severe hypoglycaemiain patients with Type 1 diabetes withimpaired awareness of hypoglycae-mia. Diabetes Care 1994; 17: 697–703.

3. Irvine A, Cox DJ, Gonder-FrederickLA. The fear of hypoglycaemia scale.In. Bradley C, ed., Handbook ofPsychology and Diabetes. Nether-lands: Harwood Academic Pub-lishers, 1994: 133–155.

4. Lorenz R, Siebert C, Cleary P, SantiagoJ, Heyse S, for the DCCT ResearchGroup. Epidemiology of severe hypo-glycaemia in the DCCT. Diabetes1988; 37: 3A.

5. Clarke WL, Gonder-Frederick LA,Miller S, Richardson T, Snyder A.Maternal fear of hypoglycaemia intheir children with insulin-dependentdiabetes mellitus. J Pediatr Encodcri-nol Metab 1998; 4: 189–194.

6. Gonder-Frederick LA, Cox DJ, Kovat-chev B, Julian D, Clarke W. Theimpact of severe hypoglycaemic epi-sodes in patients with IDDM onspouses’ psychosocial status andmarital relationships. Diabetes Care1997; 20: 1543–1546.

7. Cox DJ, Gonder-Frederick LA, Polon-sky W, Schlundt D, Julian D, ClarkeW. A multi-center evaluation of bloodglucose awareness training-II. Dia-betes Care 1995; 18: 523–528.

8. Polonsky WH. Besieged by the dia-betes police. Diabetes Forecast 1995;12: 21–26.

Panhypopituitarism, Neurosensory Deaf-ness and Noonan’s Syndrome in a Childof a Diabetic Mother: Role of MaternalHypoglycaemia during Pregnancy inInduction of Congenital Lesions

We describe a Type 1 diabetic patientwith severe and recurrent hypoglycaemicepisodes during her pregnancy who gavebirth to a child with severe lesions. Thepatient is a 28-year-old woman with Type1 diabetes mellitus diagnosed at the ageof 3 years. Her knowledge of diabeteswas good and, during the course of herdisease, glycated haemoglobin measure-ments have usually been within or closeto the reference levels. She never smoked.Her first two pregnancies and deliverieswere without complications.

At the beginning of her third pregnancyat the age of 27 years she had no signsof nephropathy, normal blood pressurelevels, and fundal photographs demon-strated only solitary dot haemorrhages.During the pregnancy she mesaured herblood glucose concentration 4–6 timesdaily. From the start of gestational week6 and to the end of week 11, 41 of 120registered blood glucose concentrationswere #4 mmol l−1 and 19 #2 mmol l−1.HbA1C levels from week 6 to week 16decreased from 6.3 % to 4.2 %, the lowerreference level in the non-diabetic rangein our laboratory. The levels were lowerthan in the previous two pregnancies. Shesuffered five hypoglycaemic comas, hadmarked tremor in connection with onehypoglycaemic episode and experiencedpronounced tiredness during 13 furtherhypoglycaemic episodes. After 38 weeksof pregnancy she gave birth to a femaleinfant with a weight of 3.250 kg, a lengthof 47 cm and head circumference of38 cm. The infant cried at once, and theApgar scores were 8, 8, 9, respectively.Her initial blood glucose concentrationwas low (1.4, 0.9, and 1.6 mmol−1) andthe hypoglycaemia lasted for 40 hours. Inaddition obstipation and gastric retentionwere found. Non-immunological icterusalso developed. Further investigationsrevealed panhypopituitarism in the infant.Computer tomography of the brain andpituitary demonstrated no pathologicalmorphology. l-Thyroxine, cortisol, andgrowth hormone replacement was startedat day 10 postnatally. Later she requiredhearing aids for congenital neurosensorydefects and spectacles because of myopia.At the age of 5 years, she has moderatepsycho-motor retardation and has beendiagnosed with Noonan’s syndrome.1 Thediagnosis is based on the findings of shortneck stature, hypertelorism, characteristicfacial changes, mild mental retardation,and peripheral pulmonary stenosis.

Noonan’s syndrome can occur spon-taneously, occasionally in associationwith pituitary hormonal deficiencies, and