Awareness about hypoglycemia among patients on insulin therapy in a tertiary care hospital: A cross-sectional study.
Diabetes, one of the priority non-communicable diseases (NCDs) which the global leaders are fighting, is an important public health problem. It is a serious, chronic disease that occurs either when the pancreas does not produce enough insulin, or when the body cannot effectively use the insulin it produces. Both the number of cases and the prevalence of diabetes have been steadily increasing over the past few decades.  The number of people with diabetes has risen from 108 million in 1980 to 422 million in 2014. In 2016, an estimated 1.6 million deaths were directly caused by diabetes.  There were over 7 2,946,400 cases of diabetes in India in 2017 with a prevalence of 8.8%.  India, currently, faces an uncertain future in relation to the potential burden that diabetes may impose on the country. Diabetes requires continuous medical care and patient self-management education to prevent acute complications and reduce the risk of long-term complications.
The overall objective of diabetes's management is to achieve and maintain blood glucose control. Diabetes and its complications place a very heavy burden on health care systems, and for diabetic patients, hypoglycemia is one of the life-threatening complications. Both the American Diabetes Association and the European Medicines Agency have defined hypoglycemia as "any abnormally low plasma glucose concentration that exposes the subject to potential harm" with a proposed threshold plasma glucose value <70 mg/dL. Approximately 90% of all patients who receive insulin would experience hypoglycemic episodes. Patients with type1 diabetes have an average of two episodes of symptomatic hypoglycemia per week and one episode of severe hypoglycemia once a year. An estimated 2-4% of deaths in diabetics have been attributed to hypoglycemia.  Inadequate awareness is one of the causes for hypoglycemia. Sudden nocturnal deaths also known as "dead in bed" syndrome has been attributed to nocturnal hypoglycemia, which accounts for 5-6% of all deaths among young people with type 1 diabetes. Hypoglycemia can lead to coma and even death, depending on its severity or duration. 
Irrespective of the burden that it imposes on the individual, family and the nation, diabetes is one such condition which has medications of proven efficacy and would never be a life-threatening condition until and unless the blood sugar levels are not maintained. Many studies have been published regarding the poor knowledge on diabetes in the general population and poor self-care practices among diabetics. Hypoglycemia is a preventable and treatable complication of diabetes. There are several studies on the awareness of hypoglycemia but very few on how different components such as knowledge of symptoms, precipitating factors, prevention, and immediate action to be taken during an attack are interlinked with each other. Thus, the study was undertaken to analyze the knowledge of diabetic patients on different components of hypoglycemia and the influence of sociodemographic characteristics on the same.
The objectives are as follows:
1. To study the sociodemographic profile of participants
2. To study the awareness of hypoglycemia among patients on insulin therapy.
MATERIALS AND METHODS
The study was done on diabetic patients admitted to a tertiary care hospital in Mysore, who were on insulin. It was a cross-sectional study done from June 2017 to November 2017. A pretested semi-structured pro forma was used to interview the patients. Considering the absolute error of 10% at the level of significance 5% and taking 54% as prevalence the calculated sample size is 100.  Diabetic inpatients who were on insulin therapy for at least 1 year were considered in the study.
Percentages and t-test for two proportions were done to compute the results.
Ethical clearance has been obtained from the Institution Ethical Committee.
The mean age of the participants was 55.8 years. Out of the 100 participants, 69 were females and 31 males. The study population had an almost equal proportion of literates and illiterates. Around 80% of the participants were from rural background, Hindu by religion, and belonged to lower class. Overall, 65% of the participants had knowledge of at least three symptoms of hypoglycemia. Most common symptoms were dizziness, sweating, and tremors. Around 68% of the participants had knowledge about precipitating factors, 72% about immediate action to be taken during an attack, and 57% on the measures to prevent hypoglycemia.
The proportion of participants who had awareness did not vary significantly among males and females. However, there is a statistically significant difference among illiterates and literates on the awareness of symptoms, immediate action during attack and measures to prevent further episodes of hypoglycemia. The participants who hail from urban background had better knowledge on symptoms and precipitating factors than those who belonged to rural, whereas those who received health education had more knowledge on immediate action to be taken and measures to prevent further attacks. History of the previous hypoglycemic attack had indeed a strong impact on knowledge about symptoms, precipitating factors, immediate action to be taken, and how to prevent further attacks [Tables 1-4].
Among the 68%, around 39% of the participants mentioned improper dietary habits such as avoiding timely meals, skipping meals before medication, and food inadequate in quantity and quality, whereas 18% mentioned irregular medication, noncompliance to physicians advise and another 11% both improper diet and irregular medication as the precipitating factors for hypoglycemia. Nearly half of them (48%) mentioned that they would consume sugar water immediately during the hypoglycemic attack, 17% wanted to restore sugar levels by eating whatever is available to them at that time, and 3% stressed on calling up treating physician and following their instructions. As far as the prevention of further hypoglycemic attacks was concerned, 38% suggested following the instructions given by the treating physician strictly and other 19% having an adequate and timely diet.
In the current study, the knowledge regarding hypoglycemia was found to be average. Many participants thought they were aware of the immediate action to be taken during the attack, expressed difficulty in recognizing the symptoms of hypoglycemia. Literacy, history of the previous attack, health education given by doctor or nurse and urban background were the factors significantly influencing the knowledge. Gender had no influence on the knowledge.
Around two-third of the participants in our study were females which is similar to another study done in South India where 76.5% of the subjects were females.  A study done in Mangalore had an equal proportion of males and females.  Almost all the participants belonged to lower class which might be due to the tertiary care hospital where the current study was done since it is a government set up and most of them were hailing from the rural area. In the current study, around two-third of the participants were aware of at least three symptoms of hyperglycemia. Similarly, in other studies, the awareness regarding symptoms varied from 52% to 66%. [6-8] In the current study, awareness did not vary based on gender but educational status, urban background, previous health education sessions by physician or nurse and a hypoglycemic attack in the past had significant influence on the knowledge of the study participants regarding symptoms, precipitating factors, immediate measures to be taken during an attack and to prevent further episodes. Similarly, in a study done in Mangalore, it was found that more the patient was literate more was the awareness regarding symptoms.  A study done in South India also revealed that gender was not associated with knowledge on hypoglycemia, however, illiteracy and lower socioeconomic class were associated with poor knowledge.  In contrast, a study done in Coimbatore found that there was no significant association between gender, religion, educational status, occupation, duration of diagnosis, treatment for diabetes mellitus, and information on hypoglycemia.  In the current study, two-third of the patients had a hypoglycemic attack in the past. All the participants were on insulin therapy and the incidence of hypoglycemia is reported to be more common among them  and also the incidence is more among type 1 than type 2 diabetes mellitus.  In the current study, the knowledge was more among those who had a previous hypoglycemic attack. A study done on rural population revealed that awareness of various aspects of diabetes was found to be better among the diabetics in comparison with the general population.  A study revealed patients on insulin therapy have more knowledge as compared to others.  In our study, participants who received health education from either physician or nurse had more knowledge as compared those who did not. An intervention study done on diabetic patients revealed those who received health education had gained more knowledge after the implementation of the program; particularly, in the areas of the nature and signs and symptoms of the disease, signs and symptoms of hypo and hyperglycemia, causes and warning signs of foot problems, foot care, and importance of exercises and hence concluded that health education of diabetic patients is crucial for control of diabetes.  Improper dietary practices and irregular medication were mentioned as the causes for hypoglycemic attack. In a community based study on misconceptions regarding diabetes more than 50% of the respondents felt that drugs can be stopped once diabetes is controlled. About 28.25% felt that diabetes can be treated with all bitter substances. Dietary practice was one of the important factors influencing the achievement of good blood sugars in the participants.  Consuming sugar water during acute attack and following proper diet and medication were the measures mentioned by the participants to prevent complications and manage their blood glucose levels. In a study done in Mangalore, 49% of patients preferred taking glucose powder or sugar with water as an immediate measure. Majority of patients felt going to the casualty or emergency department was the right option for hypoglycemia.  In a hospital-based study on practices of diabetic patients most patients resorted to timely meals (85%) to avert future attacks.  In Coimbatore study participants mentioned regular exercise can prevent the risk of hypoglycemia. 
This study provides a comprehensive knowledge of all the components related to hypoglycemia and how poor knowledge in one component (e.g., Symptoms) effects though they have adequate knowledge in other components (e.g., Immediate action). This stands out as the main strength of the article. However, community-based study with a larger sample size would have given an accurate snapshot of the situation since patients who have poor knowledge are tend to be hospitalized more.
The main goal of diabetes management is to maintain optimum blood glucose levels. Hypoglycemia being one of the life-threatening complications can be prevented by adopting appropriate self-care practices, providing counseling at every session, being compliant with medication and following appropriate dietary practices. Awareness regarding hypoglycemia was average among the study participants which was further hampered by illiteracy, lack of counseling sessions from treating physicians. Literacy plays a significant role in creating awareness. Counseling sessions at the start of insulin therapy help to act aptly during emergencies. The previous history of similar experiences plays a significant role in enhancing awareness.
* Counseling sessions to the patients on insulin therapy at each visit in the outpatient department regarding the untoward effects and also diabetics to check blood glucose levels at home for better care.
* Workshops on the same can be conducted for NCD patients in hospitals.
* A separate helpline number for NCD patients to get immediate assistance in case of emergencies.
Awareness of hypoglycemia was found to be average among participants. Diabetics on insulin therapy are more prone for hypoglycemia. Therefore knowing the awareness levels and perceptions is important. It may help to plan the necessary objectives of health education sessions among target population.
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Department of Community Medicine, Mysore Medical College and Research Institute, Mysore, Karnataka, India
Correspondence to: Manjunatha S N, E-mail: firstname.lastname@example.org
Received: December 16, 2018; Accepted: January 09, 2019
Table 1: Awareness on symptoms of hypoglycemia Variables Distribution P value Frequency Total Gender Male 19 31 0.603 Female 46 69 Education 0.000 Illiterate 22 48 Literate 45 52 Residence 0.005 Rural 46 79 Urban 19 21 Health education Received 41 60 0.389 Not received 24 40 History of hypoglycemic attack 0.000 Yes 58 67 No 7 33 Table 2: Awareness on precipitating factors of hypoglycemia Variables Distribution P value Frequency Total Gender 0.337 Male 19 31 Female 49 69 Education Illiterate 28 48 0.794 Literate 29 52 Residence 0.012 Rural 40 79 Urban 17 21 Health education 0.741 Received 35 60 Not received 22 40 History of hypoglycemic attack Yes 44 67 0.012 No 13 33 Table 3: Awareness on immediate action during hypoglycemic attack Variables Distribution P value Frequency Total Gender 0.667 Male 22 31 Female 46 69 Education 0.004 Illiterate 26 48 Literate 42 52 Residence 0.880 Rural 54 79 Urban 14 21 Health education 0.006 Received 47 60 Not received 21 40 History of hypoglycemic attack 0.000 Yes 57 67 No 11 33 Table 4: Awareness on measures to prevent hypoglycemic attacks Variables Distribution P value Frequency Total Gender 0.307 Male 20 31 Female 37 69 Education 0.000 Illiterate 16 48 Literate 41 52 Residence 0.631 Rural 46 79 Urban 11 21 Health education 0.000 Received 44 60 Not received 13 40 History of hypoglycemic attack 0.012 Yes 44 67 No 13 33
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|Title Annotation:||Research Article|
|Author:||Jayashree, Sajja; Manjunatha S.N.|
|Publication:||International Journal of Medical Science and Public Health|
|Date:||Mar 1, 2019|
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