Skip Navigation
Skip to contents

Diabetes Metab J : Diabetes & Metabolism Journal



Page Path
HOME > Diabetes Metab J > Volume 42(2); 2018 > Article
Letter: Patient Understanding of Hypoglycemia in Tertiary Referral Centers (Diabetes Metab J 2018;42:43-52)
Jae-Han Jeonorcid
Diabetes & Metabolism Journal 2018;42(2):173-174.
Published online: April 19, 2018
  • 28 Download

Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea.

Corresponding author: Jae-Han Jeon. Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, 680 Gukchaebosang-ro, Jung-gu, Daegu 41944, Korea.

Copyright © 2018 Korean Diabetes Association

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

As intensive diabetes care based on insulin or multiple oral agents have recently been emphasized [1], the management of hypoglycemia in both physicians' and patients' perspectives have been highlighted.
The concern of hypoglycemia is a major barrier to appropriate insulin injections in patients. The adherence rate to insulin was approximately 70% in patients with type 2 diabetes mellitus [2]. In one study conducted in the United Kingdom (UK), 29% and 46% of patients with basal insulin and basal-bolus insulin, respectively, experienced hypoglycemia during the 30 days of survey period [3]. The frequent hypoglycemic episodes in these patients were causally related with missing (16%) or reducing (19%) insulin doses [3]. Nevertheless, it turned out that the majority of patients are not correctly aware of hypoglycemic symptoms. In another study conducted in the UK [4], only one-thirds or -fourths of patients with diabetes correctly understand classical hypoglycemic symptoms such as trembling, sweating, or feeling hungry. In this regard, the importance of education on hypoglycemia cannot be overemphasized. Indeed, several studies suggest the critical role of patient education in minimizing hypoglycemic risk [5].
In this issue, Cho et al. [6] reported the extent of patient understanding of hypoglycemia in tertiary referral centers. Among 758 participants, 62.1% self-reported hypoglycemia. Given that this study was conducted in tertiary referral centers, it is not surprising that 47.1% were insulin-users. However, although their mean duration of diabetes was approximately 12 years, the majority (68.1%) were not previously provided with any education about hypoglycemia. It seems that health care professionals are still devoid of opportunities to provide information about hypoglycemia to their patients.
One of the most striking finding of this study was that the average score of choosing the correct hypoglycemic score was only 3.3 out of 12. Twelve examples were presented as questions about what is right as a symptom of hypoglycemia, and 12 examples were all correct. However, the person who viewed the questionnaire would have been hard to think that all 12 questions were correct. Therefore, it is highly likely that the score is underestimated by some degree in indicating the actual knowledge of the patients.
This study also provides important information that many patients are still inaccurately aware of foods that are helpful for overcoming hypoglycemia, suggesting that the diabetes education program for patients needs to be revised to a more practical form. It is noteworthy that the educated group have previously experienced significantly higher rate of hypoglycemia compared with uneducated group. This finding suggests that those who experience hypoglycemia less either tend to not recognize the necessity of understanding hypoglycemia or are not be provided with enough opportunity to be educated about hypoglycemia due to endocrinologists' indifference. However, it turns out that patients' low perception of hypoglycemia is not confined to this study. In a recent study conducted in Germany, 32% of patients failed to answer any correct method to deal with hypoglycemia [6].
This study by Cho et al. [6] provides an important, real-world perception on hypoglycemia in patients with diabetes. Although patients were being treated for diabetes for a long duration and rather frequently confront hypoglycemic episodes, their practical knowledge seems insufficient to cope with hypoglycemic situations. Therefore, improvement of educational system should not rely on each physician's devotion, but rather needs to be systematically established on a nation-wide level.

CONFLICTS OF INTEREST: No potential conflict of interest relevant to this article was reported.

  • 1. American Diabetes Association. 6. Glycemic targets: standards of medical care in diabetes-2018. Diabetes Care 2018;41(Suppl 1):S55-S64. ArticlePubMedPDF
  • 2. Karter AJ, Subramanian U, Saha C, Crosson JC, Parker MM, Swain BE, Moffet HH, Marrero DG. Barriers to insulin initiation: the translating research into action for diabetes insulin starts project. Diabetes Care 2010;33:733-735. PubMedPMC
  • 3. Munro N, Barnett AH. Incidence, worry and discussion about dosing irregularities and self-treated hypoglycaemia amongst HCPs and patients with type 2 diabetes: results from the UK cohort of the Global Attitudes of Patient and Physicians (GAPP2) survey. Int J Clin Pract 2014;68:692-699. ArticlePubMed
  • 4. Barnett AH, Brice R, Hanif W, James J, Langerman H. Increasing awareness of hypoglycaemia in patients with type 2 diabetes treated with oral agents. Curr Med Res Opin 2013;29:1503-1513. ArticlePubMed
  • 5. Iqbal A, Heller SR. The role of structured education in the management of hypoglycaemia. Diabetologia 2018;61:751-760. ArticlePubMedPDF
  • 6. Cho NH, Kim NK, Han E, Hong JH, Jeon EJ, Moon JS, Seo MH, Lee JE, Seo HA, Kim MK, Kim HS. Patient understanding of hypoglycemia in tertiary referral centers. Diabetes Metab J 2018;42:43-52. ArticlePubMedPMCPDF

Figure & Data



    Citations to this article as recorded by  

      • PubReader PubReader
      • Cite this Article
        Cite this Article
        export Copy Download
        Download Citation
        Download a citation file in RIS format that can be imported by all major citation management software, including EndNote, ProCite, RefWorks, and Reference Manager.

        • RIS — For EndNote, ProCite, RefWorks, and most other reference management software
        • BibTeX — For JabRef, BibDesk, and other BibTeX-specific software
        • Citation for the content below
        Letter: Patient Understanding of Hypoglycemia in Tertiary Referral Centers (Diabetes Metab J 2018;42:43-52)
        Diabetes Metab J. 2018;42(2):173-174.   Published online April 19, 2018
      • XML DownloadXML Download
      Jeon JH. Letter: Patient Understanding of Hypoglycemia in Tertiary Referral Centers (Diabetes Metab J 2018;42:43-52). Diabetes Metab J. 2018;42(2):173-174.

      Diabetes Metab J : Diabetes & Metabolism Journal
      Close layer