206 Diabetes Mellitus
component on peaks in insulin action, carbohydrate metabo-
lism, and the impact of changes in physical activity and other
aspects of self-care on BG levels. Through educational mate-
rials and homework exercises, people are taught to identify
their unique sensitive and speci“c cues for hypoglycemia
using a BG diary in which they record symptoms, estimate
their BG level, then actually perform SMBG and record their
BG. Errors in estimation and unrecognized hypoglycemia are
identi“ed and discussed. Appropriate corrective actions for
treating hypoglycemia are also introduced. Cox and col-
leagues have recently revised their program (BGAT II) to
include updated information and more attention to external
cues for hypoglycemia (e.g., changes in self-care behaviors
that in”uence BG levels). BGAT and BGAT II have been
shown to increase BG estimation accuracy and decrease
episodes of hypoglycemia (e.g., Cox et al., 1995; ter Braak
et al., 2000) in persons with type 1 diabetes. Long-term
follow-up of patients who underwent BGAT training indi-
cated fewer automobile crashes and continued improvements
in glycemic control (Cox, Gonder-Frederick, Julian, &
Clarke, 1994). Booster sessions administered to persons who
previously underwent BGAT seem to improve detection of
low BG events (Cox et al., 1994). Importantly, these im-
provements occurred without decrements in metabolic con-
trol. For clinicians working with an individual patient with
repeated hypoglycemia or reduced awareness of hypo-
glycemia, Cox and colleagues (1996) have published very
useful and speci“c clinical recommendations for the preven-
tion of hypoglycemia, the recognition of low BG, and treat-
ing low BG. This chapter also provides a copy of the BG
diary, described previously, that the authors developed for the
BGAT program.
Severe Hypoglycemia
Given the dangers associated with severe hypoglycemia,
patients with such a history have been the focus of research
to identify the correlates of risk for severe hypoglycemic
episodes. Cox and colleagues have developed a biopsychobe-
havioral model of severe hypoglycemia (Cox et al., 1999;
Gonder-Frederick, Cox, Kovatchev, Schlundt, & Clarke,
1997) in which physiological, psychological, and behavioral
factors are taken into account. Cox et al. (1999), using this
model, identi“ed several dif ferences between those with and
without a history of severe hypoglycemia. Speci“cally, pa-
tients with a history of severe hypoglycemia engaged in more
risky and fewer preventative behaviors. They were less likely
to recognize neuroglycopenic symptoms as indicative of
hypoglycemia and engage in appropriate treatment of low
BG, even when aware of their BG level. Thus, interventions
that have a strong focus on such neuroglycopenic symptom
detection and appropriate behavioral responses to low BG
may be especially fruitful for reducing repeated severe hypo-
glycemic episodes in these patients.SummaryHypoglycemia is a common side effect of intensive diabetes
management. Importantly, it is associated with serious phys-
ical, behavioral, emotional, and social consequences. Thus,
persons must be able to prevent, detect, and effectively treat
hypoglycemic episodes. Randomized clinical investigations
of a systemic intervention with these targets developed by
Cox and colleagues at the University of Virginia (BGAT and
BGAT II) indicate that persons who participate in the inter-
vention program show improvements in various areas related
to hypoglycemia (e.g., decrease in episodes of hypoglycemia,
improvement in detection of low BG) without decrements in
metabolic control. Persons with severe hypoglycemia may
particularly bene“t from such treatment. Future research is
needed to expand such treatment to more heterogeneous
patient groups, identify which components of this package
intervention are the most effective in leading to the noted
improvements, and determine characteristics of individuals
that predict successful outcomes following such an interven-
tion program.Weight ManagementObesity is strongly related to type 2 diabetes, with as many
as 90% of those who develop type 2 diabetes being obese
(Wing, Marcus, Epstein, & Jawad, 1991). Independently,
obesity can lead to cardiovascular disease, hypertension,
hyperglycemia, hyperinsulinemia, dyslipidemia, and hyper-
triglyceridemia (Albu, Konnarides, & Pi-Sunyer, 1995). The
coexistence of obesity and diabetes heightens the risk for de-
veloping these associated medical conditions, hence increas-
ing morbidity and mortality (Wing, 1991).Benefits of Weight LossWeight loss continues to be the cornerstone of treatment for
obese individuals with type 2 diabetes (Wing, 1991). Because
type 2 diabetes accounts for the largest proportion of individ-
uals with diabetes, weight loss interventions continue to re-
ceive signi“cant empirical attention. Weight loss is associated
with multiple health bene“ts, including improved glycemic
control, increased insulin sensitivity, decreased risk of coro-
nary heart disease, reduction in medication utilization and
cost, and enhanced mood (Butler & Wing, 1995; Maggio &