Associations between hypoglycemia awareness status and symptoms of hypoglycemia among adults with type 1 or insulin-treated type 2 diabetes using the Hypo-METRICS smartphone application

Introduction This study examined associations between hypoglycemia awareness status and hypoglycemia symptoms reported in real-time using the novel Hypo-METRICS smartphone application (app) among adults with insulin-treated type 1 (T1D) or type 2 diabetes (T2D). Methods Adults who experienced at least one hypoglycemic episode in the previous three months were recruited to the Hypo-METRICS study. They prospectively reported hypoglycemia episodes using the app for 10 weeks. Any of eight hypoglycemia symptoms were considered present if intensity was rated between 'A little bit' to 'Very much' and absent if rated 'Not at all'. Associations between hypoglycemia awareness (as defined by Gold score) and hypoglycemia symptoms were modelled using mixed-effects binary logistic regression, adjusting for glucose monitoring method and diabetes duration. Results Of 531 participants (48% T1D, 52% T2D), 45% were women, 91% white and 59% used Flash or continuous glucose monitoring. Impaired awareness of hypoglycemia (IAH) was associated with lower odds of reporting autonomic symptoms than normal awareness of hypoglycemia (NAH) (T1D OR 0.43 [95%CI 0.25-0.73], p=0.002); T2D OR 0.51 [0.26-0.99], p=0.048), with no differences in neuroglycopenic symptoms. In T1D, relative to NAH, IAH was associated with higher odds of reporting autonomic symptoms at a glucose concentration < 54 mg/dL than > 70 mg/dL (OR 2.18 [1.21-3.94], p=0.010). Conclusion The Hypo-METRICS app is sensitive to differences in hypoglycemia symptoms according to hypoglycemia awareness in both diabetes types. Given its high ecological validity and low recall bias, the app may be a useful tool in research and clinical settings.