Lifestyle changes for Hypoglycemia prevention
Overview of the Study
This study seeks to understand the link between a combination of lifestyle changes and the risk of severe hypoglycemia (SH) in patients with type 2 diabetes mellitus (T2DM).
Health screening of all ages and genders of the T2DM patient population could be used to identify healthy lifestyle habits could benefit their disease state.
Severe Hypoglycemia (SH)
According to the revised classification by the International Hypoglycemia Study Group, severe hypoglycemia (SH) is defined as severe events characterized by altered mental and/or physical status requiring assistance for recovery. It is a severe type of hypoglycemia that can cause seizures, dementia, cardiovascular disease, and death.
Accumulating observational evidence indicates that several CV events occur during SH either as a result of hypoglycemia itself or via activation of the sympathoadrenal response. Several underlying pathophysiological processes have been proposed including (1) hemodynamic changes that increase cardiac workload and attenuate myocardial perfusion; (2) arrhythmogenic electrophysiological changes; (3) the induction of a prothrombotic state; and (4) the release of inflammatory cytokines. Ultimately, it is likely that multiple factors contribute to CV events, which can be triggered by SH in high-risk patients
Hypoglycemia is a major barrier to achieving optimal glycemic control in patients with T2DM. Treatment-induced hypoglycemia is associated with an increased risk of cardiovascular (CV) events and all-cause mortality in patients with type 1 diabetes mellitus (T1DM) and T2DM [5]. Moreover, hypoglycemia has a negative impact on emotional well-being, cognitive function, and quality of life, particularly in patients with severe hypoglycemia (SH), which negates the benefits of strict glycemic control. Hypoglycemic events incur substantial economic and psychosocial costs for patients, their family members, and society.
Prevention is recognized as the most effective strategy for the management of hypoglycemia in patients with T2DM. Therefore, an understanding of adverse CV outcomes related to SH and screening for patients with T2DM at high risk for SH are of particular importance.
Patient Education in Prevention of SH
Patient education plays an important role in diabetes care. Intensive patient education delivered by certified professional healthcare providers has been shown to be cost-effective and to improve glycemic control, self-care behavior, well-being, and reduce CV risk factors.
Materials and Methods
Subjects with adult T2D who underwent consecutive two-year interval health screening programs from 2009 to 2012 from the Korean National Health Insurance Service database were included and followed up until 2018. Information on the history of smoking status, alcohol consumption, and physical activity, as well as changes to these factors, were obtained. The researchers screened a total of 2,745,637 subjects with T2D who were aged≥20 years and underwent health examination from January 1, 2009, to December 31, 2012.
The Korean National Health Insurance Service (NHIS) program established a computerized database (DB) containing all claims data, including patient demographics, drug prescriptions, diagnostic codes based on the disease coding system, the International Classification of Diseases, insurers’ payment coverage, patients’ deductibles, and claimed treatment details. Therefore, because the Korean NHIS DB is representative of the Korean population, the data are useful for a population-based nationwide study of patients with T2DM. Six diabetes-related CV complications, including ischemic heart disease, acute myocardial infarction, ischemic stroke, hemorrhagic stroke, percutaneous coronary intervention, and coronary artery bypass graft were identified in the NHIS claims DB.
To understand the association of any lifestyle changes with SH development, the researchers included participants who received an additional consecutive health examination within 2years from baseline(n=1,947,440) and followed them up until December 31, 2018. Exclusion of those with missing information on lifestyle factors, cancer, liver cirrhosis, end-stage renal disease(ESRD), and alcoholic liver disease, resulted in a total of1,490,233 participants for the main analysis.
The researchers investigated the associations between SH episodes and CVD (newly developed myocardial infarction, stroke, heart failure) and all-cause mortality in patients with T2DM. The incidence of adverse outcomes tended to be higher in the group who experienced SH.
Experiencing three or more SH episodes was associated with an approximately 2-fold higher risk of each type of CV event and a 3.28-fold higher risk of all-cause mortality. After adjusting for confounding factors, the HR of myocardial infarction significantly and sequentially increased: 0 vs. 1 episode (HR, 1.56; 95% CI, 1.46 to 1.64); 0 vs. 2 episodes (HR, 1.86; 95% CI, 1.61 to 2.15); and 0 vs. 3 or more episodes (HR, 1.86; 95% CI, 1.48 to 2.35; p for trend < 0.001).
Similarly, the number of SH episodes was associated with sequential increases in the risk of stroke, heart failure, and all-cause mortality. Moreover, we found a dose-response relationship between the number of SH events and all main outcomes (p for trend < 0.001). The risks for all CV outcomes and mortality were highest within 1 year of the index date and showed decreasing trends on follow-up. Significant results from the dose-response, temporal, and sensitivity analyses suggest direct causality between SH and CV outcomes and mortality.
Results
Of the 1,490,233 T2D subjects, 30,539 (2.1%) subjects developed SH. Current smokers and heavy drinkers had an increased risk of SH, compared to nonsmokers and nondrinkers, respectively(hazard ratio (HR) 1.28 [1.23-1.34]; HR 1.22 [1.15-1.30]).
In this study, the researchers found that unhealthy lifestyle factors, defined as current smoking, heavy alcohol consumption, and lack of regular exercise, were significantly associated with an increased risk of SH in individuals with T2D. A combination of unhealthy lifestyle factors was significantly associated with higher SH risk in people withT2D in a dose-dependent manner. Notably, compared to those who were adherent to unhealthy lifestyles, individuals with any improvements in these unhealthy lifestyle factors had a lower risk of subsequent SH events.
Conclusion
Treatment of patients with T2DM in the clinical setting should take note detrimental effects of hypoglycemia on prognosis, major CV events, and mortality. The accurate assessment of SH risk proves that quick intervention should be considered for patients deemed high risk, including setting a less stringent glycated hemoglobin target, modifying antidiabetic management, increasing self-monitoring of plasma glucose levels, adopting lifestyle modification practices, and regular mealtimes, and SH education. The researchers believe that SH education is the most effective way to prevent SH. It is then important to provide attention and medical resources to education for patients with T2DM at high risk of SH.
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