Diabetes Self-Management Blog

Would it help you to know your glucose level without checking, or to know where it’s going to be in an hour? Perhaps you can. In blood glucose awareness training (BGAT), people learn to sense and predict their levels, allowing better decisions about activities, food, and insulin.

Developed by Linda Gonder-Frederick, PhD, Daniel Cox, PhD, and William Clarke, MD, at the University of Virginia, BGAT helps people link their actual blood sugar levels to physical and mental sensations. Trainees write down their feelings and sensations, such as tiredness, hunger, mental fuzziness, or whatever they’re feeling. They estimate their glucose level. Then they test with a meter and compare the two results. Over time, people’s estimates get closer and closer to their real numbers, and they learn to predict how those numbers will move.

BGAT’s main goal is detecting and preventing lows, especially with an eye toward avoiding driving and other dangerous activities when there is a chance of going low. Blood glucose awareness may be a higher priority for people with Type 1 on insulin than for others, because they have more danger of going low. Everyone benefits from awareness, though. If you know you are running high, you can figure out what’s going on and get your situation under better control.

According to its developers, BGAT may reduce people’s anxiety over blood sugar levels. Users may feel more in control of their body and less concerned about a sudden drop in their blood glucose levels. The journal Diabetes Care also found that depression levels were reduced when people with diabetes learned BGAT.

How Does BGAT Work?
BGAT participants use “blood glucose awareness diaries” and plot their glucose estimates against their actual numbers on an “error grid.” According to an article in Diabetes Spectrum, “The blood glucose awareness diary involves users’ observing and recording any blood glucose–relevant cues, estimating their blood glucose level based on these cues, and comparing their estimate to the current self-monitoring of blood glucose reading… This process is repeated throughout BGAT, with emphases on different cues as patients progress through different units, progressively refining their blood glucose estimation accuracy.”

After starting people with their records, the program teaches better understanding of external cues (foods, insulin, and physical activity), to help make sense of why blood glucose is where it is and what changes are likely to occur in the future. “The emphasis is on improving patients’ ability to identify mismatches in these three critical aspects of self-management that lead to blood glucose extremes,” the authors say.

Then the program teaches symptoms or internal cues, so the participants can better recognize and interpret symptoms of extreme blood glucose. People who seem highly unaware of hypoglycemia symptoms can often learn to become more aware with training.

As you probably know, early symptoms of low blood sugar include perspiration, shaking or trembling, tingling of the mouth or fingers, hunger, and/or rapid heartbeat. As sugar continues to drop, people might feel weak, sleepy, dizzy, or confused. They may have trouble speaking, thinking, walking, or operating machinery.

The problem is that, with time and repeated episodes of hypoglycemia, some of the early symptoms stop happening. You have to be more aware of what you’re feeling and look for subtler cues, because the symptoms may become less strong.

To me, this is the important part. Can we become more aware? That would involve paying more attention to our bodies, and less to all the tasks we have to do, the stresses we’re under, and to the constant distractions from the environment. In theory, people could learn to estimate their sugars as well as any meter. But they would have to pay a lot more attention to how they feel.

Another way is to monitor task performance levels as an indicator of glucose level. According to this article, a secretary might monitor his or her typing ability and notice if typing is slower, for instance. Or a carpenter might learn that dropping nails is a good indicator of hypoglycemia.

An article in Diabetes Care reports that after BGAT, people made better decisions. They were less likely to operate a car or heavy machinery when they were going low. A follow-up study found that people who had gone through BGAT almost five years earlier still had better blood glucose estimation accuracy, fewer motor vehicle collisions, and fewer episodes of severe hypoglycemia compared to control subjects. They also had significantly improved A1C levels relative to baseline measures.

So BGAT can prevent hypos, but how can it help prevent people running high? I wonder about your experience with this. Do you know when your sugars are up or down? How well can you estimate them? What symptoms do you notice?

If you want to take a BGAT program, you probably have to ask your doctor or local diabetes educator. You can also check online. BGAT will soon be available on the Internet at this University of Virginia Web site. (Not this week, though — apparently UoV is having technical issues. But you can register now and take the program when it’s ready.)

On my blog Reasons to Live, I’ve posted two inspiring stories of recovery, one through flowers and the other through manicures. Check them out.


  1. David,

    You might be interested in reading this - http://blog.sstrumello.com/2008/08/trials-show-bgat-delivered-online.html#.Tkxh5F1Taso

    The site was ready to go then, but lack of funding has prevented it for about three years.

    Good blog and I am glad to see it, even though I was finding my way to this on my own. Now I am going to need to follow up on the sources you provided. Thanks

    Posted by Bob Fenton |
  2. The main problem is that the medical profession is placing the burden of glucose awareness on patients who may no longer sense hypos instead of on the drug industry that produces products (insulin and insulin receptor ligands, e.g. “analogues”) who continue to make products with substantial efficacy failure (e.g. insulin that can cause hypoglycemia because it must always be dosed in a non-physiological manner even with costly insulin pumps, which although more accurate than syringes, still rely on the patient and his/her medical team to make regular dosage adjustments to basal rates and insulin-to-carbohydrate ratios which does not have to happen in completely healthy individuals). Presently, only one company - SmartCells, Inc. which was acquired last year by Merck is developing such an insulin, while the big 3 (Lilly, Novo Nordisk and Sanofi) are doing little if anything in this arena because selling existing products is such a huge revenue stream they have no incentive to fix the problems with their current product lineups.

    Posted by Scott S |
  3. I certainly don’t feel either highs or lows as much as I used to. But I still do feel them, and test if there’s any doubt. Sometimes I feel low, and turn out to be high. So for me, the awareness is there, it’s just not very accurate. My meter is my friend!

    Posted by Natalie Sera |
  4. Medicare guidelines for testing on Type II is once a day. They will allow more than once per doctor’s orders but then required to keep a log and send in every 6 months. In order for me to check more than once a day for comparison I would skip a couple of days. With doctors orders I can now check twice a day but don’t know how long Medicare will allow it. It’s sad that doctors aren’t allowed to do what is necessary for treatment because Medicare have their rules. I think it will get worse.

    Posted by Ferne |
  5. I am living well as a type 2 diabetic since 1979. In a Taking Care of Your Diabetes Conference, I learned that insulin-dependent diabetics on the insulin pump use a meter worn on their belt or person that provides their blood sugar measurements throughout the day. What about diabetics NOT on the insulin pump? Is there a way for them to have access to the same or similar meter to give them ready information? Insurance companies don’t reimburse for this unless the person is on the pump. My question is why not? If it is available, why not make it available to other diabetics to afford them another important tool to manage their disease? I hope someone will answer me or comment. Thank you. Cissy

    Posted by Cissy Butler |
  6. there is mention of early symptoms for those having low blood sugar. But what are the early symptoms of persons having high blood sugar which they should aware of are not mentioned in the article. I feel that would educate people like me to aware of high blood sugar without meter testing.

    Posted by G V Rao |
  7. Hi , I’m sending this email from the Gold Coast in Queensland Australia. I have been a Type 2 Diabetic for 20 years and was interested in reading your article. For the last 4 years I have been Insulin dependent. I walk a minimum of 6 Kilometers most days extending to 10 or 12 at least twice a week depending upon the weather. I have a healthy breakfast before walking but always take a Health Bar, Banana and plenty of water with me I don’t have problems with Hypos on short walks but on long walks I sometimes experience mild sweating or tingling in my lips. I know then it is time to eat my Banana or Health Bar which will tide me over until my next meal. I test my Bsl’s at least 3 times a day sometimes more if I have reason to suspect my sugar is getting low? My latest HbA1c was 6.6 and has been under 7.0 for the last 2 years. Even though I don’t think I need your program I feel it could be of great benefit for Type 2 sufferers here in Australia?
    I would appreciate more information. Thank you for the work you are doing…..

    Posted by Barry J Ransom |

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