Self-reported hypoglycemia in adult diabetic patients in East Gojjam, Northwest Ethiopia: institution based cross-sectional study

The study was conducted from November 15, 2017 to January 15, 2018, for 8 consecutive weeks at Debre Markos referral hospital; which is located in Debre Markos town, East Gojjam zone, Amhara Regional State, Ethiopia. Debre Markos referral hospital is the only referral hospital in East Gojjam zone. There is a separate follow up clinic for medical patients and two days per week is dedicated to diabetic patients. There are four internists and 10 general practitioners working in the follow-up clinics. Currently, there are about 1100 diabetic patients who are registered and have regular follow up at the clinics [19] .

Institution-based cross-sectional study design was used to assess hypoglycemia among diabetic patients. Samples were selected from diabetic patients who have follow-up at Debre Markos referral hospital. Patients with gestational diabetes were excluded from the study.

Sample size calculation for this study was determined using single population proportion formula. The sample size was calculated with the assumption of 61% of patients might have hypoglycemic episode since diagnosis, which was taken from a previous study [17]. After 10% non-response rate consideration, the total sample size for the study was 403.

Most of the diabetic patients are appointed at interval of four to eight weeks. However, for some patients the frequency of their visits can vary depending on their blood glucose level. The total number of diabetic patients who had follow-up from September 15, 2017 to November 15, 2017 was taken to estimate the patient flow. The sampling fraction was calculated by dividing N/n (850/403=2.1), where N = estimated number of patients that will be seen during the study period and n = calculated sample size using single population proportion formula. Then systematic sampling technique was employed to approach the study participants. The first patient was selected by lottery method from the first two patients. Then study participant was selected every two patients until the required sample size is achieved. From the selected diabetic patients, 394 of them gave consent and participated in the study.

The dependent variable of the study was hypoglycemia. The independent variables were socio-demographic variables, membership to the diabetic association, blood glucose level, type of diabetes mellitus (DM), duration of diabetes, type of treatment, the presence of chronic complications of DM, and presence of other comorbid chronic diseases. Hypoglycemia was defined as an event during which there are typical symptoms of hypoglycemia which are improved after administering carbohydrates, glucagon, or other corrective actions or there is a measured plasma glucose concentration of ≤70 mg/dL (≤3.9 mmol/L) [4]. Severe hypoglycemia was defined as a hypoglycemic event requiring assistance of another person to actively administer carbohydrates, glucagon, or take other corrective actions [4].

Data were collected with structured questionnaire, which was developed through reviewing different literature [4, 17, 20]. The questionnaire had three parts; the first part assessed socio-demographic characteristics of respondents. The second & third part of the questionnaire aimed to assess diabetes-related variables and other diabetes-related complications. The content validity of the questionnaire was examined by seven experts who had more than five-year research and work experience of which two of them from medicine department, three of them from public health department, one from nursing department of Debre Markos university and one of them from internal medicine department of Addis Ababa University. The questionnaire was translated to Amharic and then back to English by language experts, in order to check for consistency and comparability of the finding. A two days training was given to the data collectors and the supervisor, by the principal investigator. Four Bachelor of Science (BSc) professionals from nursing department participated in data collection. For data collection, the pre-tested interviewer-administered structured questionnaire was used to interview the respondents in the follow up clinic. Whenever necessary, the patients’ document was reviewed to ascertain some information like diabetes related complications, blood glucose level, and comorbidities. Diabetes related complications and comorbidities are usually evaluated by the physicians, nurses and optometrists working in the hospital and are documented on the patients chart after bi-annual or annual blood pressure measurement, foot examination, serum creatinine determination and eye examination.

A total of 394 diabetes mellitus patients participated in the study. Ninety-one (23.1%) of respondents belonged to age group 45–54 years of age, with median age of 43 (IQR = 29–55) years. Two hundred twenty-eight (57.9%) of the respondents were males and 252(64.0%) were married. Ninety-one (23.1%) of the respondents were farmers. From the total participants, only 26(6.6%) were found to be members of the Ethiopian diabetic association (Table 1).

Two hundred eleven (53.6%) of the respondents had type 1 diabetes mellitus, and the mean duration of diabetes was 5.5 years (SD ± 5.2 years). Two hundred fifty-three (64.2%) of the participants were taking insulin only and 108(27.4%) were taking oral hypoglycemic agents (OHA) only; 33(8.4%) were taking both OHA and insulin. From type 2 diabetic patients 108(59.02%) were treated with OHA, 54(29.51%) were treated with insulin only and 21(11.46%) were treated with both insulin and OHA. Twenty-two (5.6%) of the respondents had a fasting blood glucose level of less than 70 mg/dl at the day of their visit during data collection. (Table 2).

Hypertension was documented in 96(24.4%) of participants. Retinopathy was found in 65 (16.5%) of the study participants while other complications and comorbidities including neuropathy, cardiac disease, nephropathy, foot ulcer and sexual dysfunction were documented in 58(14.7%), 10(2.5%), 11(2.8%), 7(1.8%) and 6(1.5%) of the patients’ card, respectively. We used chi-square test or fisher’s exact test to assess statistical significance (Table 3).

Out of the total participants, 279(70.8, 95% CI: 66.8–75.6%) of them had history of hypoglycemia since they were diagnosed with diabetes mellitus. Out of the 211 type 1 diabetic patients, 183(86.7%) of them had history of hypoglycemia; 96(52.5%) of the 183 type 2 diabetic patients had history of hypoglycemia since they were told to have diabetes. The frequency of hypoglycemic episodes were described as never, one to two per year, 4 to 12 per year, 1 or more per month and one or more per week and there was statistically significant difference between type 1 and type 2 diabetes at p value of less than 0.001.From the total participants, 7.1% of respondents with type 1 diabetes and 22.1% of respondents with type 2 diabetes have never experienced a hypoglycemic episode (Fig. 1).

Among the total participants, 105(26.6%) had history of severe hypoglycemia out of which 89 (22.6% of the total participants) reported that they had one or more episode of severe hypoglycemia in the preceding year. Only 24 individuals (6.1%) reported that they measure their blood glucose level before exercise or heavy work. Three hundred sixty-nine (93.7%) of the participants have mentioned appropriate corrective actions for hypoglycemia (take sugar, take food or go to a nearby health facility). We used chi-square test or fisher’s exact test to assess statistical significance (Table 4).

Consequently, the multivariable logistic regression analysis was used by taking all the 14 factors into account simultaneously and only four of the most contributing factors remained to be significantly and independently associated with hypoglycemia and have an overall significant effect on the outcome variable at 5% level of significance. Occupation, type of diabetes, duration of diabetes and type of medication were found to have significant association with hypoglycemia.

Diabetic patients who are government employees’ were 71% less likely to have hypoglycemia as compared with farmer diabetic patients with (AOR = 0.29, 95%CI: 0.11, 0.78). And diabetic patients who are merchants were 71% less likely to have hypoglycemia as compared with farmer diabetic patients with (AOR = 0.29, 95%CI: 0.09, 0.96).

Concerning with the type of diabetes, patients with type 2 diabetes were 66% less likely to have hypoglycemia as compared with those patients with type 1 diabetes with (AOR = 0.34, 95% CI: 0.14, 0.82).

Diabetic patients with duration of diabetes since diagnosis of 2–4 years (AOR = 3.22, 95% CI:1.58,6.58), 5–9 years (AOR = 3.88,95% CI:1.75,8.61), and 10–14 years (AOR = 6.34,95% CI:2.12,18.96) were more likely to have hypoglycemic episode when compared to those with < 2 years duration of diabetes.

Furthermore, type of medication has shown statistically significant association with the outcome variable. Patients who were taking insulin were 4.93 times more likely to have history of hypoglycemia as compared with those who were taking OHA only with (AOR = 4.93, 95% CI: 2.05, 11.86) (Table 5).

There are limitations to this study. First, there may be recall bias of hypoglycemic episodes since it is a self-reported data. On the other hand, some of the patients didn’t confirm all of the episodes of hypoglycemia with capillary glucometer; so they could also be reporting symptoms without having a blood glucose level of below 70 mg/dl. It is also worth mentioning the limitation of accuracy and availability of the diagnostic methods routinely employed to make the diagnosis of chronic complications of diabetes. Therefore, the findings of this study would be best if it is interpreted in the context of such inevitable limitations of the study.