Key Takeaways
- Many patients experience asymptomatic hypoglycemia. Because these episodes are often undetected without CGM, patients may have an impaired awareness of their risk, which can lead to severe emergency situations.
- Beyond the physical risks, the fear of hypoglycemia creates a heavy emotional burden, prompting patients to adopt defensive self-management behaviors that can compromise glycemic targets.
- Nocturnal hypoglycaemia is particularly concerning because episodes last nearly twice as long as daytime events and are harder to manage during sleep. These prolonged drops not only decrease sleep quality but also place a heavy emotional and physical burden on family members who often wake up to monitor the patient.
- High consumption of refined carbohydrates like white rice and noodles leads to significant post-meal glucose spikes in many Asian patients. Continuous Glucose Monitoring (CGM) is a vital tool here, as it provides the real-time data necessary for patients to adjust their insulin or make better dietary choices.
- CGM technology allows healthcare professionals to shift focus from the three-month HbA1c average toward time-in-range and real-time glycemic trajectory. While onboarding requires a multi-disciplinary team and patience - especially with older populations - such a data-driven approach enables more precise insulin prescriptions and empowers patients to make better dietary choices and self-titrate insulin.
This is a verbatim transcript of an interview conducted with Dr Daphne Gardner in Dec 2025. The transcript has been lightly edited for clarity.
Introduction
Hello, my name is Dr Daphne Gardner. I’m a Senior Consultant Endocrinologist at Singapore General Hospital in Singapore. Through the years, our focus in SGH has been on young adults with diabetes. These individuals often require multidisciplinary input, have multiple needs, and it has really prompted our interest in trying to plug the needs gaps for those, particularly requiring intensive insulin regimens as the burden with regards to self-care and insulin dosing decisions are high.
Hypoglycaemia is a common complication in people with diabetes on insulin and is often an important limiting factor in optimising glycaemic management. From your clinical perspective, how does hypoglycaemia impact the daily self-management of your patients?
The impact of hypoglycaemia on daily self-management is profound, affecting patient safety, psychological well-being, and overall adherence to treatment plans. First, the issue of awareness is critical. We know that hypoglycaemic episodes detected by the continuous glucose monitoring (CGM) systems can be frequent and unrecognized by the patient. In one study of patients with type 2 diabetes, 75% experienced at least one asymptomatic hypoglycaemic episode.
Impaired awareness of hypoglycaemia increases the risk of severe episodes requiring emergency help. This risk is heightened in older patients with type 2 diabetes who may already fail to perceive symptoms effectively due to advancing age. Hypoglycaemia introduces a significant psychological burden, often leading to defensive self-management practices. Hypoglycaemia or the fear of it can lead to defensive eating practices and reduced medication adherence, which ultimately undermine treatment plans. Patients deliberately keep their glucose levels higher to prevent lows, which then contributes directly to poorer overall glycaemic control.
Hypoglycaemia can be frequent throughout the 24-hour cycle. In one CGM study of patients with type 2 diabetes, there was no significant difference in the frequency of daytime hypoglycaemia compared to nocturnal hypoglycaemia. However, nocturnal hypoglycaemia is more difficult to manage and prevent due to the diminished autonomic and symptomatic response to hypoglycaemia during sleep.
Since nocturnal hypoglycaemia (NH) is often prolonged and unpredictable, what are the clinical concerns you have regarding the overall physical and psychological burden of NH on your patients and their families?
This can be quite a concern particularly because nocturnal hypoglycaemia events are often prolonged. They are significantly longer than daytime events, lasting a median of 60 minutes for levels below 70mg/dL, compared to 35 minutes during the day. In one of our studies with people with type 1 diabetes, nocturnal hypoglycaemia during the late sleep period, that is, from 3:00 am to 6:00 am, significantly reduced the odds of participants reporting better sleep quality. However, nocturnal hypoglycaemia occurring during the early sleep period, that is, from 12:00 am to 3:00 am did not show a significant effect.
Disturbed sleep may lead to daytime sleepiness, lack of concentration, poor mental performance, and risk of accidents. For family members, the burden is also high, with 63.4% reporting concern over nocturnal hypoglycaemia. Our data showed that 87.5% of patients with type 1 diabetes and 66.7% of parents with children of type 1 diabetes woke at least 1 to 2 times per week to manage nocturnal glycaemia.
Beyond hypoglycaemia, postprandial glucose excursion significantly drives glycaemic variability in people with type 2 diabetes. In your clinical practice, how concerned are you about glycaemic variability itself, and how does it influence your management strategies?
Food remains an integral part of our Asian cultures. Dietary diversity and complexity within the Asian community present a challenge in terms of post-meal glycaemic excursions and appropriate meal-time insulin coverage. The most recent national nutrition survey conducted in 2022 showed that Singaporeans consume close to 300g of carbohydrates daily, mostly in the form of refined grains like white rice and noodles. This would obviously have enormous implications on post-prandial excursions. Continuous glucose monitoring offers real-time data that enables reflection and better dietary choices, empowering the individual living with diabetes in decision making.
Can you detail your experience of using CGM systems in managing insulin-treated type 2 diabetes patients? What remains the challenge still?
In our setting, we work in a multi-disciplinary team with diabetes nurses, pharmacists, and dietitians to effectively onboard people with diabetes on CGM and deliver structured education that teaches them how to use their glucose data effectively towards self-titration of insulin or better dietary choices. It is important that people with diabetes recognise that measures of glycaemia go beyond HbA1c towards achieving time-in-ranges since this gives them greater understanding of their glucose targets and provides an approach towards achieving these targets.
On the healthcare professional front, CGM enables precise prescription according to the glycaemic trajectory rather than targeting mean glycaemia in HbA1c. And as we use CGM more, it is incumbent upon HCPs to help our patients understand their data and use it effectively in self-management. This may take more time during consults but bears fruit for self-management and better glycaemia in the longer run. The older population may fear onboarding new devices and our experience has been that patience, encouragement, and reiteration with simple messaging has been helpful in onboarding technology in these individuals, and they could benefit enormously in terms of safety and efficacy.
The views and opinions expressed by Dr Daphne Gardner are her own views and opinions. Roche disclaims all liability in relation to these views and opinions.
References
- Kultzer B., et al. Nocturnal Hypoglycemia in the Era of Continuous Glucose Monitoring. J Diabetes Sci Technol. 2024 Sep;18(5):1052-1060.
- Gehlaut, Richa R., et al. Hypoglycemia in Type 2 Diabetes – More Common Than You Think. J Diabetes Sci Technol. 2015 Apr 27;9(5):999–1005.
- Eichenlaub M., et al. “Characteristics of Nocturnal Hypoglycaemic Events and Their Impact on Glycaemia” J Diabetes Sci Technol. 2024 Sep;18(5):1035-1043.
- Chandran SR., et al. “Type 1 Diabetes in Singapore: Self-Care Challenges, Diabetes Technology Awareness, Current Use, and Satisfaction, an Online Survey”. Indian J Endocrinol Metab. 2024 Mar-Apr;28(2):167-176.