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Type 1 diabetes hypoglycemia burden persists despite technology use

Author
Lynda Williams

medwireNews: A survey of people with type 1 diabetes shows that severe hypoglycemic events (SHEs) and poor awareness of hypoglycemia persist despite engagement with continuous glucose monitors (CGMs) and automated insulin delivery systems (AIDs).

A group of US adults with type 1 diabetes were recruited from the T1D Exchange Registry and online community and asked to complete online surveys in spring 2021 and 2023. Responses on the number of SHEs in the prior 12 months, as well as information on glycemic metrics and technology use were collected from 2044 participants in the first survey and 1056 in the second survey.

Participants in the first and second surveys were aged an average of 43–46 years, 71–72% were women, and most were White (95–97%) and had private health insurance (76–78%). The average duration from diagnosis was 26–29 years, and 38–39% had a normal BMI (18.5–24.9 kg/m2), while 32% had an overweight BMI (25–29.9 kg/m2), and 27–28% had an obese BMI (≥30.0 kg/m2).

The majority of participants in the first (88.0%) and second (93.5%) survey had not experienced an episode of diabetes-related ketoacidosis in the past 12 months but 4.8% and 3.2% reported one episode, respectively, and 5.1% and 2.6% more than one episode.

At the first and second surveys, there was a high use of both CGMs (92 vs 94%) and insulin pumps (78 vs 80%), and among pump users there was increasing use of hybrid closed-loop features (47 vs 65%), and decreasing use of manual mode (25 vs 5%).

However, there was little change in the proportion of participants between the first and second survey who had impaired awareness of hypoglycemia (31 vs 29%), defined as a modified Gold score of 4 or above out of a possible 7, where a score of 1–2 indicates normal awareness.

Of concern, 16.8% of participants had one or more SHEs in the 12 months before the first survey and 19.0% in the second survey. The corresponding rates for two or more SHEs were 9.6% and 10.0%.

A closer look at the 201 second survey respondents who experienced at least one SHE in the past 12 months showed that the average number was 2.4, and 10% reported having five or more SHEs, report Jeremy Pettus (University of California San Diego, La Jolla, USA) and co-authors in Diabetes Care.

These SHEs were most often related to overestimates of insulin dose or carbohydrate count (58%), physical activity (36%), delayed or small meals (21%), and other not specified reasons (19%), with SHEs linked to alcohol use (10%) and missed meals (8%) also frequent.

Although 99% of respondents to both surveys reported having had a glycated hemoglobin (HbA1c) measurement in the past 12 months, the average decrease was just 0.2% from a mean of 6.6% (49 mmol/mol) in their first survey result. And at the follow-up survey, just 47.4% and 67.4% reported HbA1c levels below 6.5% (48 mmol/mol) or 7.0% (53 mol/mol), respectively.

“This study highlights a critical challenge that remains with current type 1 diabetes management; even in a highly engaged cohort with a high uptake of diabetes technology, a notable proportion of participants continue to experience SHEs and maintain glycemic averages higher than the recommended target range,” Pettus et al emphasize.

“Despite the increased uptake of advanced technologies, a substantial unmet need remains, underscoring the necessity of innovative strategies and therapies to improve care for individuals with type 1 diabetes.”

medwireNews is an independent medical news service provided by Springer Healthcare Ltd. © 2026 Springer Healthcare Ltd, part of Springer Nature

Diabetes Care 2026; doi:10.2337/dc25-2345

Raising the standard: ensuring patient safety through minimum requirements for CGM performance

Prof. Chantal Mathieu highlights how the absence of rigorous performance standards for continuous glucose monitors in Europe contributes to wide variability in device accuracy, raising important concerns about patient safety.

Supported by:
  • Abbott Diabetes Care
Prof. Chantal Mathieu
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Image Credits
Woman completing online survey/© Scandistock / E+ / Getty Images (symbolic image with model), Woman monitoring glucose level with sensor and an app on her phone while training at swimming pool/© (M) Goffkein, stock.adobe.com (symbolic image with model)