Epidemiology and risk factors of hypoglycemia in type 1 diabetes in Brazil

Daniela Barros, post graduate student of the Surgical Clinic Program at Ribeirão Preto Medical School, University of São Paulo (FMRP-USP). Ribeirão Preto, SP, Brasil.

The aim of the trial Epidemiology and risk factors of hypoglycemia in subjects with type 1 diabetes in Brazil: a cross-sectional, multicenter study was to investigate the factors associated with hypoglycemia and severe hypoglycemia (SH), the most common adverse event associated with insulin therapy, in individuals with type 1 diabetes mellitus (T1D) in Brazil (SOUZA, A.B.C, et al). SH, defined as an event requiring third-party assistance, occurs in approximately 30% of the individuals with T1D and is an important cause of morbidity (McCOY, R.G., et al).

Another Brazilian study evaluating the association between hypoglycemia severity and some chronic complications of diabetes in individuals with T1D has shown heart rate variability, chronic kidney disease, and macrovascular complications to be independent predictors of moderate hypoglycemia and SH (KATON, W.J., et al). Still, data on this topic are still lacking in our population (GOMES, M.B., et al).

Based on these considerations, the Brazilian Type 1 Diabetes Study Group (BRAZDiab1SG), led by SOUZA, et al, from University of São Paulo Medical School and Rio de Janeiro State University, performed a nationwide survey to evaluate the relationship between diabetes features and demographic and socioeconomic characteristics with the prevalence of nonsevere hypoglycemia and SH (SOUZA, A.B.C, et al).

This multicenter, cross-sectional study was conducted between August 2011 and August 2014 across 10 Brazilian cities. The data were obtained from 1,760 individuals withT1D. Sociodemographic and clinical characteristics related to hypoglycemic events in the previous 4 weeks were evaluated (SOUZA, A.B.C, et al).

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Of 1,760 individuals evaluated, 1,319 (74.9%) reported at least one episode of hypoglycemia in the previous 4 weeks. The main factors associated with hypoglycemia were lower hemoglobin A1c (HbA1c) level, better adherence to self-monitoring of blood glucose (SMBG), and higher education level. Episodes of SH were reported by 251 (19%) individuals who, compared with subjects with nonsevere hypoglycemia, received lower doses of prandial insulin and higher doses of basal insulin, in addition to reporting less frequent use of long-acting basal insulin analogs (SOUZA, A.B.C, et al). Similar results have been reported in the HYPOS-1 study, which found a prevalence of 78.6% of hypoglycemic events (GIORDA, C.B., et al).

The percentage of SH episodes was evenly distributed across all ranges of HbA1c levels, and there were no correlations between the mean number of nonsevere or severe hypoglycemic events and HbA1c values. Although some clinical trials have shown that intensive glucose control strategies increase the risk of hypoglycemia (JHONSON-RABBETT, B., et al), the results of most recent studies have reported conflicting results in terms of an inverse correlation between HbA1c values and hypoglycemia.

Higher alcohol consumption and more frequent hospitalizations were independently associated with SH (SOUZA, A.B.C, et al).

Noteworthy, the present study has several limitations. Because of its cross-sectional design, conclusions about causality cannot be drawn; thus, the author’s understanding of the observed associations is limited. In addition, the sample does not represent the Brazilian population since all included individuals lived in large cities, received medical care from public health care centers and were treated by specialists (SOUZA, A.B.C, et al).

The main messages of the present study are the importance of avoiding high doses of basal insulin and educating individuals about alcohol consumption and its consequence on glycemic control, a simple measure that can contribute to reducing SH events (SOUZA, A.B.C, et al).

References

GIORDA, C.B., et al. Incidence and risk factors for severe and symptomatic hypoglycemia in type 1 diabetes. Results of the HYPOS-1 study. Acta Diabetol [online]. 2015, vol. 52, no. 5, pp. 845-853 [viewed 23 January 2023]. https://doi.org/10.1007/s00592-015-0713-4. Available from: https://pubmed.ncbi.nlm.nih.gov/25670242/

GOMES, M.B., et al. Cause-specific mortality in a cohort of Brazilian patients with type 1 diabetes. Acta Diabetol [online]. 2017, vol. 54, no. 6, pp. 535-542 [viewed 23 January 2023]. https://doi.org/10.1007/s00592-017-0975-0. Available from: https://pubmed.ncbi.nlm.nih.gov/28251285/

JHONSON-RABBETT, B., et al. Hypoglycemia in diabetes: The dark side of diabetes treatment. A patient-centered review. J Diabetes [online]. 2019, vol. 11, no. 9, pp. 711-718 [viewed 23 January 2023]. https://doi.org/10.1111/1753-0407.12933.Available from: https://pubmed.ncbi.nlm.nih.gov/30983138/

KATON, W.J., et al. Association of depression with increased risk of severe hypoglycemic episodes in patients with diabetes. Ann Fam Med [online]. 2013, vol. 11, no. 3, pp. 245-250 [viewed 23 January 2023]. https://doi.org/10.1370/afm.1501. Available from: https://pubmed.ncbi.nlm.nih.gov/23690324/

McCOY, R.G., et al. Self-report of hypoglycemia and health-related quality of life in patients with type 1 and type 2 diabetes. Endocr Pract [online]. 2013, vol. 19, no. 5, pp. 792-799 [viewed 23 January 2023]. https://doi.org/10.4158/ep12382.or. Available from: https://pubmed.ncbi.nlm.nih.gov/23757608/

To read the article, access

SOUZA, A.B.C, et al. Epidemiology and risk factors of hypoglycemia in subjects with type 1 diabetes in Brazil: a cross-sectional, multicenter study. Arch Endocrinol Metab [online]. 2022, vol. 66, no. 6, pp. 784-791 [viewed 23 January 2023]. https://doi.org/10.20945/2359-3997000000523. Available from: https://www.scielo.br/j/aem/a/xvr6YvDN4CWjHQQTG6jvYBP/

External links

Archives of Endocrinology and Metabolism – AEM: https://www.scielo.br/aem

Alexandre Barbosa Câmara de Souza: https://orcid.org/0000-0002-4029-3667