Self-reported hypoglycemia and impact on quality of life and depression among adults with type 2 diabetes mellitus

doi:10.1016/j.diabres.2012.01.002

Diabetes Research and Clinical Practice

Volume 96, Issue 3, June 2012, Pages 313-318

https://doi.org/10.1016/j.diabres.2012.01.002 Get rights and content

Abstract

Aims

This study evaluated the rate of self-reported hypoglycemia and examined the association of hypoglycemia with quality of life and depression among adults with type 2 diabetes mellitus (T2DM).

Methods

Respondents to the 2008 US Study to Help Improve Early evaluation and management of risk factors Leading to Diabetes (SHIELD) survey were asked the number of times they experienced hypoglycemia in the past 4 weeks and past 12 months. Respondents also completed the short form-12 (SF-12) questionnaire and the patient health questionnaire (PHQ-9). T2DM respondents reporting at least 1 hypoglycemic episode were compared with T2DM respondents who did not report hypoglycemia in the previous 12 months.

Results

Of 2718 T2DM respondents, 23% reported experiencing hypoglycemia in the past 12 months. Respondents reporting hypoglycemia (n = 627) had significantly lower (p < 0.001) SF-12 scores for both physical health (mean ± SD: 37.4 ± 12.7 versus 40.9 ± 12.7) and mental health (50.1 ± 11.7 versus 52.4 ± 10.1) compared with those without hypoglycemia (n = 2091). Mean PHQ-9 scores were significantly higher (p < 0.001) among respondents reporting hypoglycemia (5.2 ± 5.8), compared with respondents who did not report hypoglycemia (3.9 ± 5.0), indicating greater depression burden.

Conclusion

Self-reported hypoglycemia was prevalent among individuals with T2DM and associated with lower health-related quality of life, and greater burden of depression.

Introduction

Hypoglycemia is a leading limiting factor in the glycemic management of adults with type 2 diabetes mellitus (T2DM) [1]. Glycemic control prevents or delays microvascular complications (retinopathy, nephropathy, and neuropathy) in T2DM [2]. However, diabetes management is complex, and hypoglycemia is a barrier to the achievement of glycemic control. Hypoglycemia is itself an emergency that is uncomfortable, disruptive to an individual's routine, and occasionally dangerous if it is severe and results in neuroglycopenia, and so must be avoided. As a result, metabolic control may be compromised, which increases the risk of microvascular complications of diabetes [3].

Hypoglycemia often causes physical and psychosocial morbidity and sometimes causes death [3]. A recent study in the United States found a significant association between hypoglycemia and lower health-related quality of life (HRQOL) [4], [5]. Frequency of severe hypoglycemia (i.e. that requiring assistance of another individual) during aggressive insulin therapy in T2DM ranged from 3 to 73 episodes per 100 patient-years [3]. Over 6 years of follow-up of patients with T2DM in the United Kingdom Prospective Diabetes Study (UKPDS) clinical trial, 2.4% of those using metformin, 3.3% of those using a sulfonylurea, and 11.2% of those using insulin reported major hypoglycemic events that required medical attention or admission to the hospital [2]. However, data from patients with T2DM treated in general clinical practice are limited. This investigation was designed to provide current, real-world rates of self-reported hypoglycemia and to determine the impact of hypoglycemia on HRQOL and association with depression among adults with T2DM.

Section snippets

Methods

The present investigation is a cross-sectional analysis of data from the Study to Help Improve Early evaluation and management of risk factors Leading to Diabetes (SHIELD) assessing the association between hypoglycemia and HRQOL and depression. SHIELD is a 5-year, survey-based study conducted to better understand patterns of health status, health behavior, and knowledge and attitudes of people living with diabetes and those with varying levels of cardiometabolic risk.

Prevalence of hypoglycemia

A total of 3000 respondents with T2DM were included in the 2008 SHIELD survey, and 23% (n = 690) reported at least 1 episode of hypoglycemia in the past 12 months. Additionally, 20.5% of T2DM respondents reported having hypoglycemia during the 4 weeks prior to completing the survey. Over the 4-week period, T2DM respondents reported an average of 6.4 (SD = 11.7) episodes of hypoglycemia.

A significantly (p < 0.001) larger proportion of T2DM respondents reporting hypoglycemic episodes consisted of

Discussion

Self-reported hypoglycemia was prevalent and frequent among adults with T2DM, with approximately one-fourth of respondents reporting hypoglycemia within a 12-month period. Physical and mental quality of life was significantly lower among T2DM respondents reporting hypoglycemia than among those who did not report hypoglycemia. Those with more hypoglycemic episodes in a 4-week period had significantly lower physical health quality of life than respondents with 1 episode. Respondents reporting

Conflict of interest

The authors have a competing interest to declare. This research was supported by funds from AstraZeneca LP.

Acknowledgments

Members of the SHIELD Study Group are: Harold Bays, MD, Louisville Metabolic and Atherosclerosis Research Center, Louisville, KY; Debbra D. Bazata, RD, CDE, St. Luke's Primary Care South, Overland Park, KS; James R. Gavin III, MD, PhD, Emory University School of Medicine, Atlanta, GA; Andrew J. Green, MD, Midwestern Endocrinology, Overland Park, KS; Sandra J. Lewis, MD, Northwest Cardiovascular Institute, Portland, OR; Michael L. Reed, PhD, Vedanta Research, Chapel Hill, NC; and Helena W.

References (19)

M.F. Pollack et al.
Patient-reported tolerability issues with oral antidiabetic agents: associations with adherence; treatment satisfaction and health-related quality of life
Diabetes Res Clin Pract
(2010)
S.A. Williams et al.
Effects of hypoglycemia on health-related quality of life, treatment satisfaction and healthcare resource utilization in patients with type 2 diabetes mellitus
Diabetes Res Clin Pract
(2011)
P.E. Cryer
Hypoglycaemia: the limiting factor in the glycaemic management of type I and type II diabetes
Diabetologia
(2002)
Intensive blood-glucose control with sulfonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes
Lancet
(1998)
P.E. Cryer et al.
Hypoglycemia in diabetes
Diabetes Care
(2003)
H.E. Bays et al.
The relationship of body mass index to diabetes mellitus, hypertension and dyslipidaemia: comparison of data from two national surveys
Int J Clin Pract
(2007)
H.E. Bays et al.
Prevalence of self-reported diagnosis of diabetes mellitus and associated risk factors in a national survey in the US population: SHIELD (study to help improve early evaluation and management of risk factors leading to diabetes)
BMC Public Health
(2007)
US Census Bureau
Annual supplement to the current population survey: Census Bureau resident population estimates of the United States
(2003)
J.E. Ware et al.
How to score version of the SF-36 health survey
(2000)

There are more references available in the full text version of this article.

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Hypoglycemia: A closer look at a community pharmacist's impact in optimizing diabetes care
2022, Journal of the American Pharmacists Association
Hypoglycemia is a complication of diabetes and can have considerable clinical impact on mortality, morbidity, and quality of life. Certain patient populations with diabetes are at an increased risk of experiencing hypoglycemia, posing as a safety concern and may have possible negative affect(s) on diabetes if not appropriately managed. With community pharmacies often being an accessible means of health care, there is potential for widespread diabetes education in this setting.
Assess impact of pharmacist-initiated education on proper recognition/management of hypoglycemia in patients with type 1 and 2 diabetes. Secondary objectives aim to optimize diabetes care: (1) assessment of patient need for a glucagon kit prescription, (2) evaluation of adherence to highly recommended vaccinations for individuals with diabetes and acceptance of pharmacist vaccination recommendations, and (3) assessment of patient satisfaction with the study intervention.
A community pharmacy in the Suffolk County of Massachusetts serving middle- to lower-class and medically underserved patients. Most of the population includes an elderly, Hispanic, and Asian demographic.
Outcomes evaluated through change in hypoglycemia questionnaire scores from preintervention to postintervention, the percentage of patients who received a prescription for glucagon kit post pharmacist intervention, the percentage of patients that received a vaccination because of pharmacist intervention, and Likert scale–based survey for the assessment of patient satisfaction.
Participant knowledge of hypoglycemia awareness/treatment improved significantly post pharmacist intervention (P < 0.001). Average gain in questionnaire scores from pre-edcation to posteducation was 6.4 points (maximum score = 9, P < 0.001). Glucagon prescriptions were facilitated/dispensed for 28.5% of eligible participants. Fifty-eight vaccinations were recommended, and 25.8% were administered. Patients’ overall satisfaction score averaged 4.7 out of a maximum of 5 (higher scores more favorable).
An educational service in a community pharmacy setting can provide effective education to recognize signs, symptoms, and proper treatment of hypoglycemia in patients on diabetes therapy that carries a high risk.
Contributing factors of fatigue in patients with type 2 diabetes: A systematic review
2021, Psychoneuroendocrinology
Citation Excerpt :
Hypoglycemia symptoms can be exacerbated through patients’ ineffective disease management, side effects of disease, and consequences of complications. Thus, effective self-management is significant for preventing the occurrence of hypoglycemia symptoms (Green et al., 2012). The relationship between blood glucose variables especially HbA1c is controversial (Menting et al., 2016; Karakoç and Yurtsever, 2010).
Remarkable evidence supports the link between type 2 diabetes (T2DM) and fatigue. However, a unifying recommendation to identify and prevent fatigue or to prevent its clinical consequences in T2DM is not available at present. Therefore, this study aimed to conduct a systematic review to summarize the definition, measurement tools, and contributing factors of fatigue in T2DM. Nine articles were included for analysis, and results showed that T2DM fatigue was associated with five major factors, including sociodemographic factors, clinical disease factors, inflammatory factors, psychological factors, and behavior and lifestyle. The contributing factors of T2DM fatigue are reviewed, and clinical benefits provide a theoretical basis for further clinical intervention to prevent the occurrence of fatigue and improve the patient’s treatment compliance and self-management ability and may be beneficial to their quality of life.
Incidence and prevalence of hypoglycaemia in type 1 and type 2 diabetes individuals: A systematic review and meta-analysis
2020, Diabetes Research and Clinical Practice
Previous meta-analysis investigating the incidence and prevalence of hypoglycaemia in both types of diabetes is limited. The purpose of this review is to conduct a systematic review and meta-analysis of the existing literature which investigates the incidence and prevalence of hypoglycaemia in individuals with diabetes.
PubMed, Embase and Cochrane library databases were searched up to October 2018. Observational studies including individuals with diabetes of all ages and reporting incidence and/or prevalence of hypoglycaemia were included. Two reviewers independently screened articles, extracted data and assessed the quality of included studies. Meta-analysis was performed using a random effects model with 95% confidence interval (CI) to estimate the pooled incidence and prevalence of hypoglycaemia in individuals with diabetes.
Our search strategy generated 35,007 articles, of which 72 studies matched the inclusion criteria and were included in the meta-analysis. The prevalence of hypoglycaemia ranged from 0.074% to 73.0%, comprising a total of 2,462,810 individuals with diabetes. The incidence rate of hypoglycaemia ranged from 0.072 to 42,890 episodes per 1,000 person-years: stratified by type of diabetes, it ranged from 14.5 to 42,890 episodes per 1,000 person-years and from 0.072 to 16,360 episodes per 1,000-person years in type 1 and type 2 diabetes, respectively.
Hypoglycaemia is very common among individuals with diabetes. Further studies are needed to investigate hypoglycaemia-associated risk factors.
Prediction of hypoglycemia by quality of life measures: A retrospective analysis of electronically patient-reported data
2020, Endocrine Practice
Citation Excerpt :
Patients with type 1 diabetes, who are almost always treated with insulin and experience frequent hypoglycemia, had better Physical and Mental PROMIS T-Scores than patients with type 2 diabetes. This highlights the potential physical and psychologic toll that type 2 diabetes patients experience with more diabetes-related complications and comorbidities leading to decrements in QoL (20,21). In our study, the incidence of hypoglycemia was significantly higher in association with depression and psychiatric disorders.
Objective: We aimed to examine the utility of electronically patient-reported data (e-PRD) in exploring the risk of diabetes-related hypoglycemia and to evaluate hypoglycemia prediction by the quality of life (QoL) measures.
Methods: A retrospective analysis of e-PRD for patients with diabetes mellitus who completed the American Diabetes Association’s Low Blood Sugar Questionnaire (Hypo-Q) and the Patient-Reported Outcomes Measurement Information System (PROMIS) for QoL assessment. Associations between Hypo-Q answers and PROMIS scores were described using Spearman correlations and 95% confidence intervals, or medians and quartiles.
Results: Records of 538 subjects were reviewed; 55% were female, 95% were non-Hispanic, with a mean age (± SD) of 53 ± 15 years. Patients with type 1 diabetes had a longer disease duration and more hypoglycemic episodes (P<.001) with higher PROMIS Physical and Mental T-scores (P<.001, both), when compared to patients with type 2 diabetes. The latter had a higher number of co-existing conditions. Having >5 episodes of either moderate or severe hypoglycemia in a year were reported by 18% and 5% of all patients, respectively. Mean PROMIS Physical and Mental health T-scores were 46 ± 10 and 47 ± 10, respectively. Patients with fewer moderate and severe hypoglycemic episodes had better Physical (P = .047 and P<.001) and Mental (P = .015 and P<.001) PROMIS T-scores with incremental decreases in the odds of hypoglycemia with each point increase in PROMIS T-scores.
Conclusion: e-PRD of QoL measures and Hypo-Q were effective in exposing the risks for hypoglycemia and reproducing published findings with significant associations between QoL measures and hypoglycemia risks while providing new insights.
Impacts of gestational diabetes on quality of life in Chinese pregnant women in urban Tianjin, China
2020, Primary Care Diabetes
This study aimed to examine impacts of gestational diabetes mellitus (GDM) on quality of life (QoL) domains in Chinese pregnant women.
We recruited 13,358 pregnant women in Tianjin, China. GDM was diagnosed using the criteria of International Association of Diabetes and Pregnancy Study Group. QoL was measured using the 36-Item Short-Form Health Survey. General linear model was used to obtain β-coefficient and 95% confidence intervals (CI) of GDM for QoL domain and summary scores.
7.25% of the pregnant women developed GDM. Among the QoL domain and summary scores, only general health (GH) score was lower in the GDM group than in the non-GDM group. GDM and advanced maternal age (i.e., ≥ versus <30 years) were negatively associated with GH in multivariable analyses (β-coefficient: −1.17, 95%CI: −2.17 to −0.17 & −0.79, −1.40 to −0.18, respectively). In subgroup analyses, the β-coefficient of GDM for GH among women with maternal age ≥30 years was enhanced to −2.17 (−3.94 to −0.40) in multivariable analysis while the β-coefficient of GDM for GH among women aged <30 years was attenuated to non-significance.
GDM and advanced maternal age were associated with reducing GH, and presence of advanced maternal age markedly increased the effect of GDM on GH.
Risk of hyperglycemic crisis episode in diabetic patients with depression: A nationwide population-based cohort study
2020, Journal of Diabetes and its Complications
This study aims to investigate the risk of hyperglycemic crisis episode (HCE) in diabetic patients with depression and to examine the relationship between the duration of antidepressants use and the risk of HCE.
In all, 26,746 diabetic patients with depression and 106,853 controls (without depression) matched by gender, age, index year, and Charlson Comorbidity Index (CCI) score were included between 1999 and 2010, then followed until the end of 2013. During the follow-up period, participants who developed HCE were identified. Cox regression analysis was used to calculate the hazard ratio (HR) with 95% confidence interval (CI) of the HCE incidence rate between the two groups studied.
Diabetic patients with depression had a significantly increased risk of HCE compared to unaffected controls after adjusted for gender, age, CCI score, and duration of antidepressants use (2.87 versus 2.50 per 1000 person-years, HR: 1.78, 95% CI: 1.56–2.03). Also, long-term use of antidepressants in diabetic patients with depression showed a significantly reduced risk of HCE compared to non-users after adjusting for the above-mentioned variables (HR: 0.44, 95% CI: 0.35–0.55).
This study shows diabetic patients with depression have an increased risk of HCE, and the use of antidepressants may reduce its risk.

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Self-reported hypoglycemia and impact on quality of life and depression among adults with type 2 diabetes mellitus

Abstract

Aims

Methods

Results

Conclusion

Introduction

Section snippets

Methods

Prevalence of hypoglycemia

Discussion

Conflict of interest

Acknowledgments

Diabetes Res Clin Pract

Diabetes Res Clin Pract

Hypoglycaemia: the limiting factor in the glycaemic management of type I and type II diabetes

Diabetologia

Intensive blood-glucose control with sulfonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes

Lancet

Hypoglycemia in diabetes

Diabetes Care

The relationship of body mass index to diabetes mellitus, hypertension and dyslipidaemia: comparison of data from two national surveys

Int J Clin Pract

Prevalence of self-reported diagnosis of diabetes mellitus and associated risk factors in a national survey in the US population: SHIELD (study to help improve early evaluation and management of risk factors leading to diabetes)

BMC Public Health

Annual supplement to the current population survey: Census Bureau resident population estimates of the United States

How to score version of the SF-36 health survey