|Year : 2017 | Volume
| Issue : 1 | Page : 29-37
Hypoglycemia in a resource-poor Nigerian environment: A cross-sectional study of knowledge of symptoms, causes, and self-management practices among ambulatory type 2 diabetic patients in South-East Nigeria
Gabriel Uche Pascal Iloh1, Peace Ifeoma Collins2
1 Department of Family Medicine, Federal Medical Centre, Umuahia, Abia State, Nigeria
2 Department of Nutrition and Dietetics, Federal Medical Centre, Umuahia, Abia State, Nigeria
|Date of Submission||19-Feb-2017|
|Date of Acceptance||26-Apr-2017|
|Date of Web Publication||1-Jun-2017|
Gabriel Uche Pascal Iloh
Department of Family Medicine, Federal Medical Centre, Umuahia, Abia State
Source of Support: None, Conflict of Interest: None
Background: Hypoglycemic emergencies are potentially life-threatening complication of diabetes management that predisposes the patients to higher risk of disability and premature death. As the impetus for the prevention of diabetes-related hypoglycemic endpoints grows, emphasis should also be focused on patients' knowledge of symptoms, causes, and self-management practices for hypoglycemia.
Aim: The study was aimed at describing the knowledge of symptoms, causes, and self-management practices for hypoglycemia among ambulatory type 2 diabetic patients in Eastern Nigeria.
Materials and Methods: A cross-sectional descriptive study was carried out on 145 type 2 diabetic Nigerians at a primary care clinic in Eastern Nigeria. Data on knowledge of symptoms, causes, and self-management practices for hypoglycemia were collected using pretested, structured, and researcher-administered questionnaire.
Results: The age of the type 2 diabetic patients ranged from 32 to 78 years with mean age of 44 ± 10.2 years. There were 59 (40.7%) male and 86 (59.3%) female. Thirty-six (24.8%), 22.8%, and 29.0% had adequate knowledge of symptoms, causes, and self-management practices for hypoglycemia with the most common symptom, cause, and self-management practice being dizziness (69.7%), overdose of antidiabetic medications (91.0%), and taking drink containing glucose (67.6%), respectively. Educational level was significantly associated with adequate knowledge of symptoms (P = 0.039), causes (P = 0.02), and self-management practices (P = 0.016) for hypoglycemia.
Conclusion: Knowledge of causes, symptoms, and self-management practices for hypoglycemia was inadequate. The most common symptom, cause, and self-management practice for hypoglycemia were dizziness, overdose of medications, and taking of drink containing glucose, respectively. Adequate knowledge of causes, symptoms, and self-management practices for hypoglycemia was associated with educational level. There is a need for hypoglycemic-oriented diabetes education, especially in resource-poor environment.
Keywords: Hypoglycemia, knowledge, Nigeria, primary care, type 2 diabetes
|How to cite this article:|
Iloh GU, Collins PI. Hypoglycemia in a resource-poor Nigerian environment: A cross-sectional study of knowledge of symptoms, causes, and self-management practices among ambulatory type 2 diabetic patients in South-East Nigeria. BLDE Univ J Health Sci 2017;2:29-37
|How to cite this URL:|
Iloh GU, Collins PI. Hypoglycemia in a resource-poor Nigerian environment: A cross-sectional study of knowledge of symptoms, causes, and self-management practices among ambulatory type 2 diabetic patients in South-East Nigeria. BLDE Univ J Health Sci [serial online] 2017 [cited 2019 Sep 22];2:29-37. Available from: http://www.bldeujournalhs.in/text.asp?2017/2/1/29/207426
Diabetes mellitus is a clinicopathologic medical condition in which there is disturbance of energy homeostasis., It is multidimensional disease entity that requires complex therapeutic interventions and lifestyle changes which need to be maintained for life., As a lifelong metabolic disorder requiring long-term management, standard care of diabetes mellitus involves significant participation of the patients and their families in the process of care.,, It involves the diabetic patients adhering to their prescribed medications, recommended diet, and other lifestyle measures.
Hypoglycemia is a medical emergency , and occurs when blood glucose drops to a level that is too low to sustain normal functioning in most people and is defined by the American Diabetes Association as blood glucose <70 mg/dL. It arises from abnormalities in the mechanism involved in glucose homeostasis and is characterized by reduction in plasma glucose concentration to a level that induces manifestations of neurogenic (adrenergic) and neuroglycopenic symptoms and signs with altered mental status and sympathetic nervous system stimulation.
Globally, research studies have documented that intensive glycemic control does not minimize all-cause mortality  rather it is rarely achieved safely without hypoglycemia. The occurrence of hypoglycemia in diabetic patients has been reported in Nigeria  and other parts of the world such as South Africa,, India, France, Turkey, in the United Kingdom Prospective Diabetes Study, and among pilgrims on Haji, in Saudi Arabia. The goal of diabetic therapy is to prevent acute illness and to reduce the risk of long-term complications.,, The reasonable objective of treatment is therefore to approach normal glycemic excursions without provoking severe or recurrent hypoglycemia., In as much as the risk of hypoglycemic adverse events outweighs the changes in the surrogate diabetic clinical endpoints, prevention of hypoglycemia should be one of the health-care concerns in addition to controlling the effects of hyperglycemia. Mild hypoglycemia can be distressing to the diabetic patients; moderate hypoglycemia can be frightening while severe hypoglycemia is a medical emergency that could result in disability and unnecessary death. However, iatrogenic hypoglycemia resulting from overzealous effort to achieve tight glycemic control has been reported in biomedical literature in different parts of the world,,,,,, and this could be potentially harmful with fatal , and nonfatal outcomes such as cardiac arrhythmias and ischemia, hypoglycemia-associated autonomic failure, cognitive decline, decrease work productivity, and reduced health-related quality of life ,, and can influence diabetic treatment satisfaction., Although good glycemic control remains a desired goal for both diabetic patients and their physicians, unintended symptomatic hypoglycemia is alarming to the patient and family members and could lead to fear of antidiabetic medication use.,
The role of patient-related factors in the management of diabetes mellitus such as knowledge of hypoglycemia has been reportedly variable worldwide depending on the clinicoepidemiological characteristics of the study population. In a study in the United States of America, 55% of adult living with diabetes experienced at least one episode of hypoglycemia while 22% and 17% reported dizziness and shakiness as the common symptoms of hypoglycemia; in Makkah, Saudi Arabia, 50% of diabetic patients lack knowledge of hypoglycemia; among the Indians, good knowledge of hypoglycemia of 66.1% was reported in a Medical College in Chennai, South India, 40% was reported in Erode district of Tamil Nadu in India, and 51.5% was reported in a Christian Medical College, Ludhiana. In a review of hypoglycemia in South African family practice setting, 42% of the diabetic patients experienced symptoms of hypoglycemia while 39% had no education on hypoglycemia; among the patients attending diabetic clinic in KwaZulu-Natal, 66% of diabetic patients had at least good knowledge of hypoglycemia with 24% unaware of what to do during hypoglycemic event. In Nigerian Africa, 34.2% of diabetic patients in Kaduna, Northern Nigeria, were aware of hypoglycemia while 50% knew the action to take during hypoglycemic episode.
With rising incidence and prevalence of diabetes mellitus in Nigeria , and other parts of the world , and inadequate knowledge of its management across global type 2 diabetic patients,, 4, ,,,, diabetic patients often present to the emergency department of hospitals with variable symptoms of hypoglycemia which constitute a limiting factor in diabetic management. Of great concern in Nigeria is that a large gap in knowledge exists between hypoglycemic and hyperglycemic emergencies among diabetic Nigerians., Effective reduction of hypoglycemic crisis syndrome in diabetic Nigerians depends largely on the adequate knowledge of symptoms, causes, and appropriate lifesaving self-management interventions. It is against this background that the authors were motivated to study the knowledge of symptoms, causes, and self-management practices for hypoglycemia among ambulatory type 2 diabetic Nigerians in a tertiary hospital in South-East Nigeria with the opportunity to identify high-risk diabetic patients in the hospital.
| Materials and Methods|| |
This was a clinic-based cross-sectional descriptive study that was carried out on 145 type 2 diabetic patients from July 2016 to October 2016 at the Department of Family Medicine of a tertiary hospital in South-East Nigeria.
The Department of Family Medicine serves as a primary care clinic within the tertiary hospital setting of the medical center. All adult patients excluding those who need emergency health-care services, pediatric patients, and antenatal women are first seen at the Department of Family Medicine where diagnoses are made. Patients who need primary care are managed and followed up in the clinic while those who need other specialists' care are referred to the respective core specialist clinics for further management. The clinic is run by consultant family physicians and postgraduate resident doctors in family medicine.
The inclusion criteria were adult diabetic patients aged ≥18 years who had been on treatment for diabetes mellitus for at least 1 month. The exclusion criteria were critically ill diabetic patients, treatment-naïve diabetic patients, and patients with gestational diabetes.
Sample size estimation was determined using the formula for estimating minimum sample size for descriptive studies  using the formula n = Z2pq/d2 and nf = n/1 + n/N where n = desired sample size when population is more than 10,000; nf = desired sample size when population is <10,000; Z = standard normal deviate set at 1.96 which corresponds to 95% confidence limit; P = authors assumed that 50% (0.50) of the type 2 diabetic patients would have adequate knowledge of causes, symptoms, and self-management practices for hypoglycemia at 95% confidence limit and 5% margin of error; and d = desired level of precision set at 0.05. When studying population <10,000 using an estimated population size in a given year, the estimated total number of adult diabetic patients that attended family medicine clinic in 2015 was 220. These 220 adult diabetic patients excluded diabetic patients referred to and being followed up in the diabetic clinic and other outpatient clinics of the medical center, diabetic patients on emergency, and inpatient admissions. This gave a sample estimate of 142 patients. However, selected sample of 145 adult diabetic patients was used to improve the precision of the study.
The eligible adult diabetic patients were consecutively recruited for the study based on the inclusion criteria until the sample size of 145 was achieved.
The instrument for data collection was developed by the researchers around the objectives of the study and to suit Nigerian environment through robust review of literature on previous studies on hypoglycemia.,,,,,,,,,,, The questionnaire consisted of sections on sociodemographic variables, knowledge of symptoms, causes, and self-management practices for hypoglycemia. It consisted of dichotomous questions, which were structured in such a way that could elicit immediate answers from the respondents in a yes or no format. The 20-item questionnaire was interviewer administered to avoid incomplete information on the study tool. Twelve, five, and three questions were asked on the symptoms, causes, and self-management practices for hypoglycemia, respectively. Every correct answer was awarded one point and incorrect or unsure answer no point. Knowledge was categorized into adequate and inadequate. Adequate knowledge refereed to highest score of 12, 5, and 3 points in the domain of knowledge of symptoms, causes, and self-management practices while inadequate knowledge meant scores less the 12, 5, and 3 in specific domains, respectively.
The questionnaire tool was pretested using five type 2 diabetic patients. The pretesting was done to find how the questions would interact with the respondents and ensure there were no ambiguities. However, no change was necessary after the pretesting as the questions were interpreted with the same meaning as intended.
Operationally, knowledge of hypoglycemia referred to possession of information and correct response to knowledge-based questions on symptoms, causes, and self-management practices for hypoglycemia. Every correct answer was awarded one point and incorrect or unsure answer no point. Household family in Nigerian demographic expression referred to a number of persons eating from the same pot.
Commonly used antidiabetic medications in the ambulatory care and outpatient department of the hospital are categorized based on their site and mechanism of action into the following: exogenous insulin (humulin 70/30 is most commonly used); insulin secretagogues (a combination of sulfonylurea-glibenclamide is most commonly available and used, a combination of glinides-repaglinide is most commonly used); insulin sensitizers (a combination of biguanides-metformin is most commonly available and used, a combination of thiazolidinediones [glitazones]-pioglitazone is rarely used); gliptins (DPP-4 inhibitors) (sitagliptin and vildagliptin are uncommonly used due to costs); and various fixed dose formulations of oral hypoglycemic agents. Incretin mimetics (GLP-1 analogs) and sodium-glucose cotransporter 2 inhibitors (gliflozins) are not used.
Ethical certification was obtained from Health Research and Ethics Committee of the hospital. Informed consent was also obtained from the respondents included in the study.
The data generated were analyzed using software International Business Machines Corporation, Statistical Package for Social Sciences (IBM SPSS) version 21, New York, USA. Categorical variables were described by frequencies and percentages. Bivariate analysis involving Chi-square test was used to test for significance of association between categorical variables. The level of significance was set at P < 0.05.
| Results|| |
The age of the type 2 diabetic patients ranged from 32 to 78 years with mean age of 44 ± 10.2 years. There were 59 (40.7%) male and 86 (59.3%) female with male-to-female ratio of 1:1.5 [Table 1].
[Table 2] shows the clinical characteristics of the type 2 diabetic patients. Forty-three (29.7%) had their duration of diabetes 1 year and less while 102 (70.3%) had their duration of diabetes more than 1 year; 55 (37.9%) of the patients possessed glucometer at home while 90 (62.1%) had no glucometer; 46 (31.7%) had previous education on hypoglycemia while 96 (68.3%) had no previous education on hypoglycemia. On antidiabetic medications, 67 (46.2%) of the type 2 diabetic patients were on insulin secretagogues and other antidiabetic medications are shown in [Table 2].
On the distribution of the type 2 diabetic patients by frequency of knowledge of symptoms of hypoglycemia, the most common symptom was dizziness (69.7%) and other symptoms are shown in [Table 3]; 36 (24.8%) of the type 2 diabetic patients had adequate knowledge of symptoms of hypoglycemia while 109 (75.2%) had inadequate knowledge of symptoms of hypoglycemia.
|Table 3: Distribution of type 2 diabetic patients by frequency of knowledge of symptoms of hypoglycemia and knowledge status|
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On the distribution of the type 2 diabetic patients by frequency of knowledge of causes of hypoglycemia, the most common cause of hypoglycemia was overdose of antidiabetic medications (91.0%) and other causes are shown in [Table 4]; 33 (22.8%) of the type 2 diabetic patients had adequate knowledge of causes of hypoglycemia while 112 (77.3%) had inadequate knowledge of causes of hypoglycemia.
|Table 4: Distribution of type 2 diabetic patients by frequency of knowledge of causes of hypoglycemia and knowledge status|
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On the distribution of the type 2 diabetic patients by frequency of knowledge of self-management practice for hypoglycemia, the most common self-management practice was taking drink or fluid containing glucose immediately (67.6%) and other self-management practices are shown in [Table 5]; 42 (29.0%) of the type 2 diabetic patients had adequate knowledge of self-management practice for hypoglycemia while 103 (71.0%) had inadequate knowledge of self-management practice for hypoglycemia.
|Table 5: Distribution of type 2 diabetic patients by frequency of knowledge of self-management practices for hypoglycemia and knowledge status|
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Bivariate analyses of the demographic variables as related to knowledge of symptoms, causes, and self-management practices for hypoglycemic educational status (secondary education and more) were statistically significant for knowledge of symptoms (χ2 = 6.503; P = 0.039), causes (χ2 = 9.632; P = 0.02), and self-management practices (χ2 = 13.101; P = 0.016) while other demographic variables were not statistically significant for to knowledge of symptoms, causes, and self-management practices for hypoglycemia [Table 6],[Table 7],[Table 8].
|Table 6: Association between sociodemographic variables and knowledge of symptoms of hypoglycemia|
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|Table 7: Association between sociodemographic variables and knowledge of causes of hypoglycemia|
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|Table 8: Association between sociodemographic variables and knowledge of self-management practices for hypoglycemia|
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| Discussion|| |
This study has shown that 24.8% of the type 2 diabetic patients had adequate knowledge of the symptoms of hypoglycemia with the most common symptom being dizziness (69.7%). This is similar but varies in proportion to the most common symptom of hypoglycemia known by respondents in India (81.4%) and in the United States of America  with most common symptom of hypoglycemia reported by the respondents being dizziness which occurred among 22.0% of the study participants. Although neurogenic and neuroglycopenic symptoms that characterize the pathophysiology of hypoglycemia vary from person to person and from time to time , and patients often confuse with symptoms of hypoglycemia with that of hyperglycemia, symptoms of hypoglycemia occur very quickly within minutes while hyperglycemia occur slowly over several days. However, if the symptoms make the patient uncomfortable and blood glucose has not been checked, medication has been taken; the patient should eat first and check the blood glucose later. For as much as individual reaction to hypoglycemia is different ,, and dizziness may not be the first symptom to appear in every treated type 2 diabetic patient, it is important for diabetic patients to be aware of every symptom of hypoglycemia generally and his or her own symptoms specifically to institute immediate and appropriate measures during hypoglycemic crisis. Early recognition of the warning symptoms of hypoglycemia remains quintessential in its treatment and will avert delay in self-management, delay in diagnosis or missed diagnosis at various levels of health facility, and delay in definitive treatment. The finding of this study is a clarion call for patient-centered  evaluation for hypoglycemic event, especially at the critical period of the episode of red flag symptoms of hypoglycemia.
Thirty-three (22.8%) of the type 2 diabetic patients had adequate knowledge of the causes of hypoglycemia with the most common cause known by the respondents being overdose of antidiabetic medications (91.0%). This finding is in contrast with the reports from India where missing or delayed food consumption was the most common cause of hypoglycemia  and in the United States of America where 27.0% of the respondents did not know that skipping meal can cause hypoglycemia. The overdose of antidiabetic medications among the type 2 diabetic patients can be attributed to patient- and physician-related factors in addition to sociocontextual issues as regards antidiabetic medication use and diet among type 2 diabetic Nigerians.,,, Of great concern in Nigeria is poor medication education for diabetic patients and low societal health literacy on dietary management of diabetes, especially the societal belief that people living with diabetes mellitus should not consume dietary carbohydrates. This erroneous disposition results in hypoglycemic crisis particularly when such patient adhered consistently with prescribed antidiabetic medications. More so, hypoglycemic events could also be due to self-medication involving concurrent use of two or more insulin secretagogues, intercurrent use of insulin and insulin secretagogues, and other medications that reduce blood glucose usually purchased from patent medicine dealers and vendors. Among the physician-related factors are the magnitude of overzealous prescription of antidiabetic medications which is better imagined than witnessed in Nigerian health-care environment. The implication is that physicians may attribute inadequate glycemic control to treatment as therapeutic failure rather than problem with adherence to medication resulting in the decision of increasing the dose of antidiabetic medications, changing medication, or adding another antidiabetic medication without adequate patient education. There is therefore the need for rational use of antidiabetic medications  in addition to patient and family education  on antidiabetic medications and dietary management of diabetes. This is because optimal care of diabetic patients requires partnership among the patient, the family, significant others, and the health team., Furthermore, the diabetes management practices that link clinical guidelines with appropriate patient preferences should be strengthened. This is necessary because decision on medication administration is made on a daily basis by patients and the members of their families. The clinicians attending to diabetic patients should explore for the types of antidiabetic medications, adherence to medications, and lifestyle modifications at every clinical encounter with diabetic patients.
Forty-two (29.0%) of the type 2 diabetic patients had adequate knowledge of self-management practices for hypoglycemia with the most common practice known by respondents being consumption of fluid or drink containing glucose immediately (67.6%). This finding is in contradiction to report from India where the most common self-management practice was eating of sweets or chocolates or biscuits. Although symptoms of hypoglycemia are nonspecific and can differ from person to person and from time to time, it is important for every diabetic patient to recognize his or her own symptoms. However, symptoms begin at blood glucose of 70 mg/dL, and impairment of brain function starts at blood glucose of 50 mg/dL. In hypoglycemic unawareness, the individuals have blood glucose <70 mg/dL and feel no symptoms, and these persons may require a higher glucose goal range. The finding of this study calls for patient-centered assessment  and patient empowerment  for hypoglycemia, especially self-management practices for hypoglycemia. This invariably will help to differentiate hypoglycemia from hyperglycemia as well as detection of hypoglycemia-unaware patients who are at higher risk of mortality from hypoglycemic events. Glycemic control should therefore be individualized based on diabetic patient characteristics with some degree of patient safety. Recognition of hypoglycemia risk factors, selection of appropriate regimens, and educational interventions for clinicians and diabetic patients are the critical issues in maintaining glycemic control to the recommended goal and minimize the risk of hypoglycemia.
Knowledge of symptoms, causes, and self-management practices for hypoglycemia was significantly associated with educational attainment with the patient who had at least secondary education having adequate knowledge for symptoms, causes, and self-management practice for hypoglycemia when compared with their counterparts with less than secondary education. The finding of relatively higher knowledge of symptoms, causes, and self-management practice for hypoglycemia among the more literate type 2 diabetic patients is similar to the reports from South Africa, India, and Saudi Arabia. This is probably due to the fact that education influences the receptivity of health-related message on hypoglycemia and affords a wider scope for interactions and information exchange on hypoglycemia, its symptoms, causes, and appropriate self-management practice. The result of this study has demonstrated that diabetic patient-oriented participation in diabetic management should include education on hypoglycemia. This requires a well-informed and activated patient in learning how to identify the tell-tale symptoms of hypoglycemia and appropriate self-management practice. Since the rise in blood glucose in diabetic patients correlates better with glucose content of the food and drinks, the treatment of hypoglycemia should therefore entail consumption of easily digestible source of carbohydrate or more appropriately glucose-containing drink or food. Although pure glucose is the preferred mode of treatment, any form of carbohydrate that contains glucose will increase the blood glucose appropriately. The “rule of 15” by the American Diabetes Association which entails consuming 15 g of easily digestible carbohydrate followed by 15 min wait, rechecking the blood glucose in 15 min, and repeat 15 g of carbohydrate if blood glucose remains low because overconsumption of carbohydrate does not speed recovery process and will produce hyperglycemia afterward. There is a need to educate diabetic patients on glycemic control, especially insulin dose or oral hypoglycemic agent dose adjustment to the actual need, varying dietary consumption to daily need, self-monitoring of blood glucose, and other risk reduction behaviors that predispose to adverse hypoglycemic event. This appears to be one of the ways; type 2 diabetic Nigerians will benefit from satisfaction with quality of care, improved quality of life, and longevity with antidiabetic medications reported among their counterparts in advanced countries of the world.
Implications of the study
Hypoglycemic crisis syndrome is one of the leading causes of morbidity and mortality from diabetes-related acute complications in Nigeria. Although the awareness of diabetes mellitus is increasing in Nigeria, knowledge of the causes, symptoms of diabetes-related hypoglycemia, and appropriate response to hypoglycemic episode is observably inadequate. Since primary care is one of the mainstay services in the chronic care of diabetic patients, primary care clinicians and other physicians attending to diabetic patients should strive to make diabetes-related hypoglycemic adverse event more visible in the interest of implementing diabetes self-management education for hypoglycemia with significant patient- and family-oriented goals. There is a need to consider the risk of hypoglycemia during prescription of antidiabetic medications, and this should be incorporated during clinical encounter with diabetic patients.
Limitations of the study
The limitations of the study are those inherent in questionnaire-based study and relied on the accuracy of the recognition of symptoms of hypoglycemia by the type 2 diabetic patients. There was no opportunity to confirm the responses. However, there is possibility that the respondents could have overreported or underreported hypoglycemic events.
| Conclusion|| |
Knowledge of causes, symptoms, and self-management practices for hypoglycemia was inadequate. The most common symptom, cause, and self-management practice for hypoglycemia were dizziness, overdose of antidiabetic medications, and taking of fluid or drink containing glucose, respectively. Adequate knowledge of causes, symptoms, and self-management practices for hypoglycemia was associated with at least secondary educational level.
This study signals the need more than ever before for hypoglycemic-oriented diabetes education with emphasis on causes, symptoms and self-management practices for hypoglycemia. The educational interventions should also focus on improving the knowledge of hypoglycemia in relation to the risk factors of hypoglycemia. The diabetic patients should balance antidiabetic medications with appropriate carbohydrate intake and lifestyle measures, especially exercise and alcohol consumption.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]