Predictors of hypoglycemia in insulin-treated patients with type 2 diabetes mellitus in Basrah

Table 1 Incidence, types, timing, and causes of hypoglycemia in 336 patients

Variable	n (%)
Hypoglycemia in the last 3 mo	253 (75.3)
Type of hypoglycemia
Severe treated in hospital	34 (10.2)
Sever confirmed hypoglycemia treated at home by family ( ≤ 70 mg/dL)	49 (14.6)
Severe unconfirmed hypoglycemia treated at home by family or blood glucose > 70 mg/dL	100 (29.7)
Mild confirmed hypoglycemia ( ≤ 70 mg/dL)	72 (21.4)
Mild unconfirmed hypoglycemia or blood glucose > 70 mg/dL	168 (50.0)
Total severe hypoglycemia treated at home by family	149 (44.3)
Total mild hypoglycemia	240 (71.4)
Timing of hypoglycemia in the last 3 mo
Nocturnal	22 (8.7)
Day time	83 (32.8)
Nocturnal and day time	148 (58.5)
Precipitating factors hypoglycemia
Missed meal, delayed meal, eating a less amount of food	214 (84.6)
Performing an exercise	42 (16.6)
Doctor change the dose of insulin recently	12 (4.7)
Insulin dose adjusted by the patient, errors in the dose of insulin	7 (2.8)
No obvious cause	22 (8.7)
Awareness of hypoglycemia in the last 3 mo
No	19 (7.5)

Table 2 Relation of hypoglycemia in the last 3 mo with age, gender, education, marital status and residence among 336 patients

	Hypoglycemia in the last 3 mo		Total (n)	P value
	Yes	No
Age (yr)	n (%)	n (%)	27	0.944
29-39	22 (81.5)	5 (18.5)
40-49	48 (73.8)	17 (26.2)	65
50-59	97 (75.8)	31 (24.2)	128
60-69	70 (74.5)	24 (25.5)	94
≥ 70	16 (72.7)	6 (27.3)	22
Gender
Male	93 (72.7)	35 (27.3)	128	0.776
Female	160 (76.9)	48 (23.1)	208
Education
Illiterate	61 (76.2)	19 (23.8)	80	0.016
Just literate	37 (75.5)	12 (24.5)	49
Primary school	83 (83.0)	17 (17.0)	100
Intermediate school	44 (77.2)	13 (22.8)	57
Secondary school	8 (50.0)	8 (50.0)	16
College and more	20 (58.8)	14 (41.2)	34
Marital status
Single	5 (83.3)	1 (16.7)	6	0.604
Married	200 (74.3)	69 (25.7)	269
Divorced	3 (60.0)	2 (40.0)	5
Widowed	45 (80.4)	11 (19.6)	56
Residence
Basrah city	164 (72.6)	62 (27.4)	226	0.215
Northern Basrah	40 (72.4)	13 (27.65	53
Southern Basrah	5 (83.3)	1 (16.7)	6
Eastern Basrah	12 (100.0)	0 (0.0)	12
Western Basrah	32 (82.1)	7 (17.9)	39

Table 3 Relation of hypoglycemia in the last 3 mo with diabetes mellitus family history, duration of diabetes mellitus, duration of insulin treatment, type of insulin, frequency and total dose

	Hypoglycemia in the last 3 mo		Total (n)	P value
	Yes n (%)	No n (%)
Family history of DM
None	85 (78.7)	23 (21.3)	108	0.601
One	68 (73.1)	25 (26.9)	93
More than one	100 (74.1)	35 (25.9)	135
Duration of DM (yr)
1-10	140 (75.7)	45 (24.3)	185	0.877
11-20	92 (76.0)	29 (24.0)	121
21-30	18 (69.2)	8 (30.8)	26
≥ 31	3 (75.0)	1 (25.0)	4
Duration of insulin treatment (yr)
1-10	238 (74.8)	80 (25.2)	318	0.578
> 10	15 (83.3)	3 (16.7)	18
Type of insulin
Premix	75 (72.1)	29 (27.9)	104	0.239
Regular	6 (75.0)	2 (25.0)	8
NPH	24 (64.9)	13 (35.1)	37
Combination of 2 or 3 insulin types	148 (79.1)	39 (20.9)	187
Frequency of insulin administration/d
Once	3 (30.0)	7 (70.0)	10	0.001
Twice	107 (74.3)	37 (25.7)	144
Thrice	126 (84.0)	24 (16.0)	150
≥ Four times	17 (53.1)	15 (46.9)	32
Total dose of insulin (unit/d)
< 20	3 (37.5)	5 (62.5)	8	0.007
21-40	46 (75.4)	15 (24.6)	61
41-60	121 (79.1)	32 (20.9)	153
61-80	59 (81.9)	13 (18.1)	72
81-100	17 (56.7)	13 (43.3)	30
> 100	7 (58.3)	5 (41.7)	12

DM: Diabetes mellitus; NPH: Neutral protamine hagedorn.

Table 4 Relation of hypoglycemia during the last 3 mo with dose of insulin, family/social support, mobility, source of medications and knowledge of hypoglycemia symptoms

	Hypoglycemia in the last 3 mo		Total (n)	P value
	Yes n (%)	No n (%)
Regular dose (unit)
1-10	7 (100.0)	0 (0.0)	7	0.347
11-20	84 (80.2)	21 (19.8)	105
21-30	57 (77.0)	17 (23.0)	74
> 30	5 (62.5)	3 (37.5)	8
Total	153 (79.0)	41 (21.0)	194
Premix dose (unit)
1-10	2 (100.0)	0 (0.0)	2	0.45
11-20	78 (78.8)	21 (21.2)	99
21-30	86 (77.3)	25 (22.7)	111
> 30	10 (62.5)	6 (37.5)	16
Total	176 (77.1)	52 (22.9)	228
NPH dose (unit)
1-10	4 (100.0)	0 (0.0)	4	0.528
11-20	37 (73.1)	14 (26.9)	51
21-30	27 (66.7)	14 (33.3)	41
> 30	6 (85.7)	1 (14.3)	7
Total	74 (72.4)	29 (27.6)	103
Family/social support
Self	190 (74.8)	64 (25.2)	254	0.914
Others	51 (76.1)	16 (23.9)	67
Self and others	12 (80.0)	3 (20.0)	15
Vision
Good	203 (74.6)	69 (25.4)	272	0.560
Poor	50 (78.1)	14 (21.9)	64
Mobility
Mobile alone	223 (75.6)	72 (24.4)	295	0.698
Mobile with assistance or use wheel chair	9 (81.8)	2 (18.2)	11
Walk on stick	21 (70.0)	9 (30.0)	30
Source of medications
FDEMC1	63 (75.0)	21 (25.0)	84	0.507
Public clinic	7 (58.3)	5 (41.7)	12
Private sector	13 (72.2)	5 (27.8)	18
More than one source	170 (76.6)	52 (23.4)	222
Knowledge of hypoglycemia symptoms
Yes	246 (76.9)	74 (23.1)	320	0.003

¹Al-Faiha Specialized Diabetes, Endocrine and Metabolism Center. NPH: Neutral protamine hagedorn.

Table 5 Relation of hypoglycemia during the last 3 mo with availability, frequency of self-monitoring of blood glucose, common co-morbidities, and concomitant medication use (other than OHD)

	Hypoglycemia in the last 3 mo		Total (n)	P value
	Yes n (% )	No n (% )
Availability of SMBG
Available and used	124 (75.2)	41 (24.8)	165	0.996
Not available	102 (75.6)	33 (24.4)	135
Available and not used	27 (75.0)	9 (25.0)	36
Frequency of SMBG use
Once/mo	19 (79.2)	5 (20.8)	24	0.164
1-2 times/wk	48 (67.6)	23 (32.4)	71
Once daily	23 (74.2)	8 (25.8)	31
Twice daily	8 (88.9)	1 (11.1)	9
Thrice daily	2 (50.0)	2 (50.0)	4
According to patients condition	25 (89.3)	3 (10.7)	28
Common co-morbidities
HTN	106 (72.1)	41 (27.9)	147	0.232
IHD	50 (86.2)	8 (13.8)	58	0.034
CVA	15 (75.0)	5 (25.0)	20	0.975
Amputation	7 (70.0)	3 (30.0)	10	0.693
Diabetic foot	72 (79.1)	19 (20.9)	91	0.322
CKD	66 (73.3)	24 (26.7)	90	0.614
PNP	235 (77.6)	68 (22.4)	303	0.004
Insulin use by other family members
At home	21 (80.8)	5 (19.2)	26	0.764
Outside home	42 (76.4)	13 (23.6)	55
Non	190 (74.5)	65 (25.5)	255
Concomitant medication use (other than OHD)
Yes	215 (74.1)	75 (25.9)	290	0.216

SMBG: Self-monitoring of blood glucose; HTN: Hypertension; IHD: Ischemic heart diseases; CVA: Cerebrovascular accidents; CKD: Chronic kidney disease; PNP: Peripheral neuropathy.

Table 6 Relation of hypoglycemia during the last 3 mo with body mass index, systolic blood pressure; diastolic blood pressure; hemoglobin A1c; serum creatinine; urine for albumin

Variables	Hypoglycemia in the last 3 mo		Total (n)	P value
	Yes n (%)	No n (%)
BMI (kg/m2)
Thin or normal (< 25.00)	46 (83.6)	9 (16.4)	55	0.123
Overweight (25.0-29.9)	95 (77.2)	28 (22.8)	123
Obese (30.00-39.99)	93 (68.9)	42 (31.1)	135
Morbid obesity (≥ 40)	18 (81.8)	4 (18.2)	22
Total	252 (75.2)	83 (24.8 )	3351
Systolic blood pressure (mmHg)
Normal (< 130)	91 (79.8)	23 (20.2)	114	0.157
Prehypertension (130-139)	62 (79.5)	16 (20.5)	78
Stage 1 hypertension (140-159)	76 (71.0)	31 (29.0)	107
Stage 2 hypertension (≥ 160)	24 (64.9)	13 (35.1)	37
Total	25 (375.3)	83 (24.7)	336
Diastolic blood pressure (mmHg)
Normal (< 80)	63 (78.8)	17 (21.2)	80	0.792
Pre-hypertension (80-89)	148 (74.4)	51 (25.6)	199
Stage 1 hypertension (90-99)	38 (74.5)	13 (25.5)	51
Stage 2 hypertension (≥ 100)	4 (66.7)	2 (33.3)	6
Total	253 (75.3)	83 (24.7)	336
HbA1c (%)
< 7.0	10 (83.3)	2 (16.7)	12	0.117
7.0-10.0	136 (79.1)	36 (20.9)	172
10.1-13.0	85 (73.3)	31 (26.7)	116
> 13.0	22 (61.1)	14 (38.9)	36
Total	253 (75.3)	83 (24.7)	336
Serum creatinine (mg/dL)
< 0.7	66 (72.5)	25 (27.5)	91	0.632
0.7-1.4	167 (75.9)	53 (24.1)	220
> 1.4	3 (100.0)	0 (0.0)	3
Total	236 (75.2)	78 (24.8)	3142
Urine for albumin (positive)	65 (75.6)	21 (24.4)	86	0.947
Total	235 (75.3)	77 (24.7)	3123

¹BMI had not been measured for one patient due to bilateral lower limb amputation; ^2,3Unequal numbers because some of the patients did not complete their investigations. BMI: Body mass index; HbA1c: Hemoglobin A1c.

Table 7 Results of logistic regression showing significant predictors of hypoglycemia in the last 3 mo

	B	Sig.	Exp (B)
Significant predictors
Residence	-0.247	0.030	0.782
Knowledge of hypoglycemia symptoms	1.133	0.044	3.104
Availability of SMBG	-0.599	0.030	0.550
Frequency of SMBG	-0.228	0.031	0.796
PNP	-1.391	0.002	0.249
Diastolic blood pressure	-0.046	0.013	0.955
Systolic blood pressure	0.020	0.053	1.020
HbA1c	0.153	0.021	1.165
Non-significant predictors
Age	0.002	0.960	1.002
Gender	-0.425	0.200	0.654
Education	0.067	0.505	1.069
Duration of DM	-0.019	0.42	0.981
Frequency of insulin administration/d	-0.381	0.259	0.683
Dose of regular insulin	-0.021	0.215	0.979
Dose of premix insulin	-0.027	0.305	0.974
Dose of NPH	-0.022	0.429	0.979
A total dose of insulin	0.018	0.148	1.018
Mobility	0.117	0.440	1.124
HTN	0.594	0.117	1.811
IHD	-0.758	0.081	0.469
CKD	0.307	0.614	1.359
BMI	0.033	0.208	1.033

SMBG: Self-monitoring of blood glucose; HbA1c: Hemoglobin A1c; HTN: Hypertension; IHD: Ischemic heart diseases; CKD: Chronic kidney disease; PNP: Peripheral neuropathy; BMI: Body mass index; DM: Diabetes mellitus; NPH: Neutral protamine hagedorn.