INTRODUCTION

Diabetes mellitus is a chronic (lifelong) disease marked by high levels of glucose in the
blood1. As per national statistics, in 2008, an estimated 347 million people in the world had
diabetes and the prevalence is growing, particularly in low- and middle-income countries.
India had 69.2 million people living with diabetes (8.7%) as per the 2015 data. Of these, it
remained undiagnosed in more than 36 million people. The number of diabetes patient in
India in 2016 was estimated as 422 million and was considered to be 700 million by the year
2030.The prevalence of diabetes is higher in men than women, but there are more women
with diabetes than men2. Nearly 1 million Indians die due to diabetes every year. Kerala
reported a prevalence of diabetes at 35% and prediabetes at 11%. The WHO estimates that
diabetes resulted in 1.5 million deaths in 2012, making it the 8th leading cause of death.
However another 2.2 million deaths worldwide were attributable to low blood glucose level.
Hypoglycemia is the clinical syndrome that results from low blood sugar. The symptoms of
hypoglycemia can vary from person to person as do the severity. Hypoglycemia is diagnosed
by a low blood sugar with symptoms that resolve when the sugar level returns to the normal
range3.

Prevention of hypoglycemia is to monitor blood glucose level frequently and be prepared to

treat promptly. Patient at risk for hypoglycemia should always carry glucose tablets, hardly
candy or other source of fast acting carbohydrates. Blood glucose awareness training can
improve a person’s ability to recognize low blood glucose earlier, which may help to prevent
episodes of hypoglycaemia3.Managing diabetes, while minimizing hypoglycemia, is a key
treatment goal in the Pharmacological control of diabetes.

Hypoglycemia is the condition, when one’s blood glucose is lower than normal, usually less
than 70mg/dl. It occurs because of a mismatch between insulin dose, food intake and energy
expenditure. The individual fails to become aware of hypoglycaemia and can result in
prolonged hypoglycemia with consequent brain injury, seizure and loss of consciousness4.

An awareness programme about hypoglycemia unawareness in Chennai, India stated that

hypoglycemia is the most frequent and serious complication of insulin therapy and is three
times more common in those who are intensively treated. Low blood glucose awareness
training programme can help to identify and prevent hypoglycemia unawareness5.

Hypoglycemia may have serious consequence in terms of morbidity and mortality, occurring
in the elderly diabetic patients, but this severe prognosis is less frequently observed. The rate
of severe hypoglycaemia remains low, but increases rapidly in the very elderly and also with
insulin therapy, as well as with unawareness of symptoms6.

1. Philip E C, Brain MF, International textbook of diabetes mellitus. 3rd ed. USA: John Wiley
& Sons, ltd; 2004:1082.

2. David KM. Management of Hypoglycemia during treatment of diabetes mellitus: 2008

May

3. The Juvenile Diabetes Research Foundation International, The American Diabetes

Association (ADA), the NIDDK , The NINDS the NICHD and NASA. A workshop on
Hypoglycemia and brain 2000 Sep:7-8

4. Altman JJ. Glycemic emergencies Rev Part 2007 Sep15:57(13):1446-54.

5. Meldanie MC, Evelyn MV, Theoretical basis for nursing 2nd ed.
Philadelphia:J.B.lippincott company:2000

6. Anthony M. Treatment of Hypoglycemia in hospitalized adults Diabetes Educator

2007:33(4):709-15.

I. Introduction

“No fasting: No feasting”

Diabetes mellitus is a multisystem disease related to abnormal insulin production, impaired

insulin utilization or both. Diabetes mellitus is a serious health problem through out the
world.1 Diabetes mellitus is not modern disease. In 1500 B.C. Papyreus of ancient Egyptians
recorded a number of remedies for passing urine. In 1000 B.C. itself Indian physician
sushurutha diagnosed diabetes. In 1798, J.Jhon, the Greek physician found diabetes is
associated with excess of glucose in blood. Discovery of insulin by Banting and Best in 1921
is a land mark in diabetes history.2

The term diabetes, refers to diabetes mellitus, which roughly translates to excessive sweet
urine (known as "glycosuria"). Several rare conditions are also named diabetes. The most
common of these is diabetes insipidus in which large amounts of urine are produced
(polyuria), which is not sweet (insipidus meaning "without taste" in Latin).The term "type 1
diabetes" has replaced several former terms, including childhoodonset diabetes, juvenile
diabetes, and insulin-dependent diabetes mellitus (IDDM). Likewise, the term "type 2
diabetes" has replaced several former terms, including adult-onset diabetes, obesity-related
diabetes, and noninsulin-dependent diabetes mellitus (NIDDM). Beyond these two types,
there is no agreed-upon standard nomenclature. Various sources have defined "type 3
diabetes" as: gestational diabetes. 3

World diabetes day is the major global awareness campaign for patient with diabetes mellitus
through out the world. World diabetes day was introduced in 1991, celebrated on 14
November each year, to co-inside with the birthday of Fredrick Banting who, along with
Charles best first conceived the idea that lead to the discovery of insulin.7

Diabetes is an ―Iceberg‖ disease. All through increase in both the prevalence and incidence
of type 2 diabetes have occurred globally, they have been especially dramatic in societies in
economic transition, in newly industrialized countries and developing countries. Currently the
number of diabetes Worldwide is estimated to be around 150 million. This number is
predicted to double by 2025, with the greatest number of cases being expected in China and
India. The racing prevalence of diabetes in developing countries is closely associated with
industrialization and socio economic development. It is estimated that 20% of the current
global diabetic population resides in the south East Asian region. The number of a diabetic
person in the countries of the Region is likely to triple by the year 2025, increasing from the
present estimates of about 30 million to 80 million.9 Currently in the United States 7.8% of
the population or around 23.6 million people have diabetes with 5.7 million being
undiagnosed. Most of those diagnosed have Type-2 diabetes and are usually 45 years of age
or older. But this snapshot is changing as more children and adolescents are increasingly
being diagnosed with this type of diabetes. Studies show that the most common complication
of Type-2 diabetes is cardiovascular and it is also the most costly complication at a cost of
approximately $7 billion of the $44 billion annual direct medical costs for diabetes. This
figure is from 1997 and many estimate that these figures could have doubled by now.10

As of 2000 it was estimated that 171 million people globally suffered from diabetes or 2.8%
of the population. Type-2 diabetes is the most common type worldwide. Figures for the year
2007 show that the 5 countries with the largest amount of people diagnosed with diabetes
were India (40.9 million), China (38.9 million), US (19.2 million), Russia (9.6 million), and
Germany (7.4 million).Currently, India is the diabetes capital of the world. It is estimated that
over 40 million of those with diabetes are currently in India and that by 2025 that number
will grow to 70 million. In other words, 1 in every 5 diabetics in the world will live in India.
Diabetes is the number one cause of kidney failure, is responsible for 5% of blindness in
adults and 1 million limb amputations.10 Because of the chronic nature of diabetes, the
relentlessness of its complications and the means required to control both diabetes and its
complications; this disease is very costly, not only for affected individuals and families but
also for the healthcare systems. Studies done in India estimate that for a low income family
with an adult having diabetes, as much as 25% of the family's income may need to be
devoted to diabetes care.

References

[1]. Lewis and Coller. Medical surgical nursing . 5th edition. New York (USA); Mosby
Publication, 2003: 1444-1476.

[2]. The challenge of Diabetes. The Hindu 2003 Aug 19; 4-6.

[3]. "Other "types" of diabetes". American Diabetes Association. August 25, 2005.
http://www.diabetes.org/other-types.jsp.

[4]. "Diseases: Johns Hopkins Autoimmune Disease Research Center".

http://autoimmune.pathology.jhmi.edu/diseases.cfm?systemID=3&DiseaseID=23. Retrieved
2007-09-23.

[5]. Rother KI (April 2007). "Diabetes treatment—bridging the divide". The New England
Journal of Medicine 356 (15): 1499–501. doi:10.1056/NEJMp078030. PMID 17429082.

[6]. "Type 2 Diabetes Overview". Web MD. http://diabetes.webmd.com/guide/type-2-

diabetes.

[7]. Dr Krishnaswami. Who is afraid of diabetes. The Hindu (Magazine) 2004 Nov 14; 1- 4.

[8]. J.E. Park and K. Park. Text book of preventive and social medicine. 17 th Edition.
Jabalpur; Bansari Bai Bhanot publishers, 2003: 294-297.

[9]. diabetesinformationhub.com. Diabetes Information - Symptoms, Causes and Prevention

of Diabetes

[10]. diabetes.co.in. Diabetes Mellitus Information, Diabetes Symptoms and Treatment

[11]. Brunner and Siddharth. Text book of Medical- surgical nursing. 10th edition,
philadelpia; Lippincott Williams and Wilkins, 2004: 1150-1200.

[12]. World diabetes day. The Indian express 2001 Nov 14 ; 8-9 .
[13]. Neders, Nadagh P. Individualized education can improve foot care for patients with
diabetes. Home health care nurse, 2003 Dec; 21(12):837-840 .

[14]. Burden M. Diabetes treatment and complications-the nurse’s role. Nursing times, 2003
Jan: 99(2): 30-32 .

[15]. Beebe C, O Donnel M. Educating patients with type-2 diabetes. Nursing clinics of
North America, 2001; 36(2) : 361-4 .

Introduction

Hypoglycemia is an acute medical situation that occurs when blood sugar falls below the
recommended level. Individuals taking diabetic medications are at increased risk of
experiencing low blood sugar [1,2].

An estimated 2-4% of people with type 1 diabetes mellitus die from hypoglycemia each year.
It might explain the “dead in bed syndrome” unexplained death of a person with type 1
diabetes occurring during night time [3]. The symptoms of low blood sugar vary from person
to person, and can change over time. During the early stages a person with low blood sugar
level may have sweating, trembling, feeling hungry and feeling anxious. The symptoms can
become more severe, and can include difficulty of walking, weakness, visual disturbance;
bizarre behavior, personality changes, confusion and unconsciousness or seizure may be
observed [4] .

Knowledge about these symptoms is an important step to self care practice, because informed
people are more likely to have better self care practice [5]. It is important for patients with
diabetes especially, those receiving insulin to learn about hypoglycemia, and to carry some
form of simple sugar with them at all times. Self care practice in diabetes management also
includes dietary regulation, medication, physical activity and self monitoring of blood
glucose (SMBG) [6]. Additionally, these patients should always wear an identification
bracelet or tag [7,8].

Several retrospective studies indicate that risk factors for hypoglycemia in 1,418 type2
diabetes mellitus are of drug- induced and fasting as the major risk factors for sever
hypoglycemia and require hospitalization [9]. Majority of hospitalized diabetic patients and
their relatives had inadequate understanding of diabetes and its consequences or
complications, and they had lack of confidence in own ability to manage diabetes effectively
[10]. Patients knowledge about various aspect of the disease together with the understanding
of the aims and objectives of various treatment outcomes have tremendous impact on patients
self care practice, skills necessary to control of self blood glucose (SMBG) [11,12].

Despite the abundance of studies on self-care practice and knowledge about hypoglycemia,
there are no available studies done on knowledge and practice regarding hypoglycemia
prevention among diabetic patients. But this study tried to identify determinants of
knowledge and practice regarding hypoglycemia among diabetic patients.

1. U.S. Hypoglycemia (2008) National Institute of Health Puplication. (09- 3926): 1-10.
2. Philip E, Irene E, Michael M, et al. (2010) Hypoglycemia in type 1 Diabetes mellitus,
Pathophysiology, Prevalence and Prevention. Endocrinol Metabol clin North Am 39:
2-3. [Crossref]
3. Cryer PE, Axelrod L, Grossman AB, Heller SR, Montori VM, et al. (2009) Evaluation
and management of adult hypoglycemic disorders: an Endocrine Society Clinical
Practice Guideline. J Clin Endocrinol Metab 94: 709-728. [Crossref]
4. David M (2012) Diabetic hypoglycemia. Meds cape’s 1: 10-11.
5. Peyrot M, Rubin RR (1994) Modeling the effect of diabetes education on glycemic
control. Diabetes Educ 20: 143-148. [Crossref]
6. Suzanne C, Brenda G (1995) Medical surgical nursing. Philadelphia: Lippincott, (10th
Edn.), pp: 1178-1180.
7. Siguroardottir A (2004) Model of factors affecting self care in diabetes. Journal of
Clinical Nursing 1: 3011-3014.
8. Anne S, Rémi R, Irene S, et al. (2008) Barriers to Physical Activity among Patients
with Type 1 Diabetes, knowledge and practice of nutrition related hypoglycemia and
related factors in diabetic patient. Diabetic care 31: 2108-2109. [Crossref]
9. Seltzer HS (1989) Drug-induced hypoglycemia. A review of 1418 cases. Endocrinol
Metab Clin North Am 18: 163-183. [Crossref]
10. Zeinab H (2011) Health and Knowledge Progress among Diabetic Patients after
Implementation of a Nursing Care Program. Diabetic metabolism, Nursing College,
Hellwan University, 2-10.
 11. Shaheen C, Zia U, Tofail A, Sharifa N (2005) Knowledge assessment of diabetes
patients. Bangladesh Journal of Medical Science 5: 8-16.
12. Rafique G, Azam S, White F (2006) Diabetes knowledge, beliefs and Practices among
people with diabetes attending a university hospital in Karachi, Pakistan. Eastern
Mediterranean health journal 12: 591-593. [Crossref]

The term diabetes was probably coined by Apollonius of Memphis around 250 BC. Diabetes
was first recorded in English, in the form diabetes, in a medical text written around 1425. In
1675, Thomas Willis added the word mellitus, from the Latin meaning “honey,” a reference
to the sweet taste of urine in patients with diabetes. This sweet taste had been noticed in the
urine of diabetic patients by the ancient Greeks, Chinese, Egyptians, Indians, and Persians. In
1776, Mathew Dobson confirmed that the sweet taste was due to an excess of a kind of sugar
in the urine and blood of people with diabetes. The ancient Indians tested a person for
diabetes by observing whether ants were attracted to a person’s urine and called the ailment
“sweet urine disease.”[1]

A Study to Assess the Impact of Structured Teaching Programme on Knowledge and Skill
Regarding Self-monitoring of Blood Glucose Level for Prevention of Hypoglycemia among
Type 2 Diabetes Mellitus Patients in Endocrinology Ward of Skims Soura Foziya Manzoor

Department of Medical-Surgical Nursing (Nursing Education), Mader-e-Meharban Institute

of Nursing Sciences and Research, Sher-i-Kashmir Institute of Medical

Sciences, Srinagar, Jammu and Kashmir, India

Foziya Manzoor, Noorpora Tehsil - Awantipora, Pulwama, Srinagar, Jammu and Kashmir,
India. Phone: +91-9596021020. E-mail: bhattshifa24@gmail.com

Access this article online

Website: http://innovationalpublishers.com/Journal/ijnmi

ISSN No: 2656-4656

DOI: 10.31690/ijnmi/45

This is an open-access journal, and articles are distributed under the terms of the Creative
Commons Attribution Noncommercial Share Alike 4.0 License,
which allows others to remix, tweak, and build upon the work non-commercially, as long as
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under the identical terms

Manzoor

16 International Journal of Nursing and Medical Investigation ¦ Volume 4 ¦ Issue 2 ¦ April-

June 2019

According to the World Health Organization (WHO), approximately 180 million people
worldwide suffer from diabetes. Its incidence is increasing rapidly, and it is estimated that by
the year 2030, this number will almost double.[2]

Hypoglycemia is an acute complication of diabetes mellitus. It occurs when the blood glucose
falls to <70 mg/dl. It can be caused by too much insulin intake or oral hypoglycemic agents,
too little food or excessive physical activity. Hypoglycemia is also a term in popular culture
and alternative medicine used for a common, often self-diagnosed, condition characterized by
sweating, tremor, tachycardia, palpitation, nervousness, hunger, confusion, slurred speech,
emotional changes, double vision, drowsiness, and sleeplessness. The individual fails to
become aware of hypoglycemia and can result in prolonged hypoglycemia with consequent
brain injury, seizure, and loss of consciousness. It is treated by changing eating patterns.[3]

Hypoglycemia is an abnormally low plasma glucose concentration that may expose the
individuals to potential harm. It is associated with the treatment of Type 1 and Type 2
diabetes mellitus. Recognizing hypoglycemia and its risk factors and identifying the high-risk
patients can assist with prevention and management. Education of patients and health-care
practitioners is also a key factor in hypoglycemia prevention.[4]

Self-monitoring of blood glucose (SMBG) is a part of the regular management plan for
patients with diabetes mellitus. SMBG provides information regarding an individual’s
dynamic blood glucose profile. Lack of regular SMBG predicts hospitalization for diabetes-
related complications. SMBG is an essential tool for people with diabetes who are taking
insulin or for those who experience fluctuations in their blood glucose levels, especially
hypoglycemia.[5]

Need for the study

Diabetes mellitus is one of the most common diseases with which humankind throughout the
world is affected today. It is primarily due to the luxurious lifestyle and unhealthy food
habits. Hence, as many people are suffering from diabetes mellitus and are taking intensive
treatment. The major adverse effect of intensive therapy is an increased incidence of
hypoglycemia.

The WHO predicted as of 2015; an estimated 415 million people had diabetes worldwide,[6]
with type 2 diabetes mellitus making up about 90% of the cases.[7,8] This represents 8.3% of
adult population,[8] with equal rates in both men and women.[9]

As of 2014, trends suggested that rate would continue to rise.[6] Diabetes at least doubles a
person’s risk of early death. From 2012 to 2015, approximately 1.5–5 million deaths each
year resulted from diabetes.[6] The WHO predicted net loss in national income from diabetes
mellitus and cardiovascular disease of 5572 billion US dollars in China, 3032 billion US
dollars in Russian Federation and 2366 billion US dollars in India.[10]

The researcher had a personal experience with some of the relatives who were diagnosed with
type 2 diabetes mellitus and who had frequent hypoglycemia due to fear of disease. Also it is
evident from the above studies that the number of diabetes mellitus patients is increasing and
the disease is now prevalent in all age groups. It is seen that patients with diabetes mellitus
lack knowledge about the disease condition, its complications (mostly hypoglycemia) and
management. Hence, the researcher felt that it is necessary to design a structured teaching
program on knowledge on prevention of hypoglycemia among Type 2 diabetes mellitus
patients.

1. Ananya M. Diabetes Mellitus. Available from: http://www.newsmedical.net/health/history-

of-Diabetes. [Last accessed on 2017Aug 03].

2. Katz MJ. Diabetes, Type 2. Wild Iris Medical Education. Available from:
http://www.nursingceu.com/courses/208/index_nceu.html.

3. Smeltzer SC, Bare B. Brunner and Suddarth’s.Text book of MedicalSurgical Nursing. 10th
ed. Philadelphia: Lippincott Williams and Wilkins; 2004. p. 1150-80.

4. Shaefer C, Hinnen D, Sadler C. Hypoglycemia and diabetes: Increased need for awareness.
Curr Med Res Opin 2016;32:1479-86.
5. Kirk JK, Stegner J. Self-monitoring of blood glucose: Practical aspects. J Diabetes Sci
Technol 2010;4:435-9.

6. Polonsky KS. The past 200 years in diabetes. N Engl J Med 2012;367:1332-40.

7. Hardin R. Willaims Textbook of Endocrinology. 12th ed. Philadelphia: Elsevier/Saunders;

2014. p. 1371-435.

8. Shi Y, Hu FB. The global implications of diabetes and cancer. Lancet 2014;383:1947-8.

9. Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, et al. Years lived with
disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: A systematic
analysis for the global burden of disease study 2010. Lancet 2012;380:2163-96.

10. Allen NJ, Meyer JP. Affective, continuance and normative commitment to the
organization: An examination of construct validity. J Vocat Behav 2006;49:252-76.

11. Pai SA, George P. IOSR Journal of Dental and Medical Sciences. IOSR J Int Organ Sci
Res 2015;14:11-3.

12. Bhutani G, Karla S, Lamba S, Verma PK, Saini R, Grewal M. Effect of diabetic education
on the knowledge, attitude and practices of diabetic patients towards prevention of
hypoglycemia. Ind J Endocrino Metab 2015;19:383-6.

13. Kaur H. Effective of STP regarding self care management in relation to prevention of
complications among diabetics. Asian J Nurs Educ Res 2014;4:279-83.

14. Mamta, Kalyan V. A pre experimental study to assess the effectiveness of structured
teaching programme on level of knowledge regarding prevention of complications among
Diabetes Mellitus patients. Int J Recent Sci Res 2016;7:14618-21.

15. Krishnan V, Thirunavukkarasu J. Assessment of knowledge of self blood glucose

monitoring and extent of self titration of anti-diabetic drugs among diabetes mellitus patients
a cross sectional, community based study. J Clin Diagn Res 2016;10:FC09-11.

16. Nandeesha KS. Experimental Study to Assess the Effectiveness of Structured Teaching
Programme on Knowledge and Practice of Self Monitoring of Blood Glucose Level Among
50 Type 2 Diabetes Mellitus Patients. Nursing Sciences [Thesis]. Tumkur: Rajiv Gandhi
University Karnataka; 2012.
17. Mastura I, Mimi O, Piterman L, Teng CL, Wijesinha S. Self-monitoring of blood glucose
among diabetes patients attending government health clinics. Med J Malaysia 2007;62:147-
51.

Introduction

Diabetes Mellitus (DM) is a major health problem in the world. It is one of the most prevalent
metabolic diseases which can lead to enormous medical as well as socio economic
consequences. Diabetes mellitus describes a metabolic disorder of multiple etiologies
characterized by chronic hypoglycemia with disturbance of carbohydrate, fat and protein
metabolism resulting from defects in insulin secretion, insulin action or both. The effects of
diabetes mellitus include long-term damage, dysfunction or failure of various organs.

Diabetes mellitus may present with characteristics such as thirst, polyuria, blurring of vision,
and weight loss. In its most severe forms, ketoacidosis or non ketotic hyperosmolar state may
develop and lead to stupor and coma. The long term effect of diabetes include progressive
development of the specific complication of retinopathy with potential blindness,
nephropathy that may lead to renal failure and nephropathy with risk of foot ulcer,
amputation, charcot joints, and features of autonomic dysfunction, including sexual
dysfunction. Two aspect of diabetes mellitus are hypoglycemia and hyperglycemia.
Hyperglycemia is increase in blood glucose level and hypoglycemia is lower than normal
level of blood glucose level.

Diabetes mellitus is currently the fastest growing debilitating disease in the world. It
estimated that one out of five people aged 20 to 79 lives with this disease, while a similar
percentage of the population is at risk of developing it. Recent studies od geographical and
ethical influences shown that people of Indian origin are highly prone to diabetes. The
number of adult suffering from diabetes mellitus in India is expected to increase three fold
from 19.4 million in 2005to 57.2 million 2025. Diabetes is rapidly gaining the status o
potential epidemic in India around 65 million people are expected to cross the 100 million
mark and it is increasing to nearly 2 million in a year (Public health foundation of India,
2016).
International Journal of Midwifery and Nursing Practice http://www.nursingpractice.net ~ 26
~

Hypoglycemia is a true medical emergency, which requires prompt recognition and treatment
to prevent organ and brain damage. The spectrum of symptom depended on duration and
severity of hypoglycemia and varied from autonomic activation to behavioral change to
altered cognitive function to seizures or coma. The short and long term complication include
neurologic damage, trauma, cardiovascular events and death. Severe untreated hypoglycemia
can cause a significant economic and personal burden.

Diabetic ketoacidosis (DKA) is a life threatening condition with characteristics insulin

deficiency and increased hormones of cortisol, glucagon, catecholamine, and growth
hormones. The insulin deficiency and increased hormones lead to dehydration, electrolyte
imbalance, hyperglycemia and ketosis. Those with severe DKA have a much higher mortality
rate and risk of complication. This paper will summarize and evaluate two articles that
discuss diabetic ketoacidosis (DKA) treatment protocol and the management of DKA.

According to the World Health Organization (WHO, Jan 2016) [2] report, India today heads
the world with over 32 million diabetic patients and this number is projected to increase to
79.4 million by the year 2030. Recent surveys indicate that diabetes now affects a staggering
10-16% of urban population and (5-8%) of rural population in India.

There is very little data on the level of awareness and prevalence about diabetes in
developing countries like India. Such data is important to plan the public health program.

Ahmed Maashi Alanazi (2018) [3] conducted a study on Awareness of risk factors of DKA
among diabetic adults in KSA. This is a exploratory cross- sectional study conducted among
100 diabetic patient aged from 16 to above 35 year in Riyadh city, kingdom of Saudi Arabia.
Both quantitative and qualitative method were used in this study. The questionnaire was
divided into 2 section, the first section was concerned with information of the participant,
while the second section was evaluating the personal knowledge about DKA. Data analysis
was carried out using Microsoft Excel 2016 and the statistical package for social science
version 23.A total of 100 Saudi Arabia diabetic adult were enrolled in the current study, 81%
of which were female while 19% were male. Age group ranged from 16 more than 35 years
old. Educational stage was also diverse from high school student to graduates. 56% of
participants had Type 1 DM while 44% had DM type 2.Our results revealed a compelling
need to bridge the disparity in awareness of DKA among Saudi adults with both type.
Pramela (2016) conducted a study on a study to assess the awareness on management of
hypoglycemia among diabetic clients in PSG hospitals, Coimbatore in view of preparing an
information booklet. Descriptive survey design was adopted by selecting 60 samples using
purposive sampling technique. Out of 60 samples, majority of the samples 32(53.4%) were
male and only 28(46.6%) of the sample were female. Most of the sample 23(38.33%) belongs
age group between 31-40 years. More than half of the samples 40(66.66%) were using
hypoglycemic agents. 33(55%) were taking medication once a day. 18((30%) samples were
having the history of hypoglycemic symptoms. Whereas, 7(11.66%) of them were not sure
about the hypoglycemic symptoms. Only 24(40%) of them were aware about the self–
management of hypoglycemia. The study highlights that the diabetes mellitus clients
13(21.6%) were having adequate knowledge, 39(65%) were having moderately adequate
knowledge and 8(13.3%) had inadequate knowledge on management of hypoglycemia. The
study findings reveled that, diabetic patients had moderately adequate knowledge regarding
awareness on hypoglycemia. So the diabetic patients should be aware on management of
hypoglycemia by using information booklet which enhance the patients knowledge to
manage the hypoglycemia and prevent.

Mary Minolin T; (2020) A study to assess the effectiveness of structured teaching programme
on management and prevention of diabetic emergency among diabetic patients attending
medicine OPD at SMCH, Thandalam. International Journal of Midwifery and Nursing
Practice 2020; 3(2): 25-30 E-ISSN: 2663-0435 P-ISSN: 2663-0427 www.nursingpractice.net
IJMNP 2020; 3(2): 25-30

Diabetes mellitus is a major cause of morbidity and mortality worldwide, as a result of its
impact on cardiovascular system, eyes, kidneys, and nerves [1]. Optimizing blood glucose
control is demanding, since it requires balancing the need for glycemic control with the risk
of hypoglycemia [2,3,4]. In fact, the risk of hypoglycemia is a barrier to optimal treatment of
type 1 diabetes (T1DM) and type 2 diabetes (T2DM), especially within the context of insulin
therapy [5].

Hypoglycemic episodes may manifest in different ranges from asymptomatic to severe

neurological symptoms, like dizziness, confusion, weakness and loss of consciousness
[6,7,8]. Recurrent asymptomatic episodes characterizes hypoglycemia unawareness, which
has been shown to increase the risk of severe hypoglycemic episodes [6, 9]. Moreover,
patient fear of hypoglycemia is frequent and may also affect treatment adherence and, thus,
glycemic control [6, 10].

Some observational studies have reported that individuals with T1DM experience about
42.0–136.8 non-severe hypoglycemic events per patient-year [11, 12]. Regarding T2DM,
non-severe hypoglycemia seems to occur less frequently (0.2 to 48.0 events per patient-year)
but, like in T1DM, may increase with longer duration of insulin therapy [11, 12].
Nonetheless, most studies had a retrospective/cross-sectional design, and are almost limited
to North American and European health contexts [12].

The Hypoglycemia Assessment Tool (HAT) study was a multinational non-interventional

study that included 27,585 adult T1DM or T2DM patients, from 24 countries in six world
regions. The study results have shown that, during a 4-week prospective period, 83.0%
T1DM patients and 46.5% T2DM patients had at least one hypoglycemic episode [12].
However, the study initially did not include Brazil, one of the top 10 countries in number of
people living with diabetes: it was estimated that 11.9 million Brazilian adults were living
with diabetes in 2013, which correspond to a prevalence of 11.9% [13].

Recognizing the scarce data about hypoglycaemia and how this affects diabetes control and
management, the HAT study was implemented in Brazil to determine the proportion of
patients experiencing hypoglycemic events, to characterize patient awareness, fear and
attitudes towards hypoglycemia, and to estimate health resource use and costs of managing
hypoglycemic events among patients with T1DM or insulin-treated T2DM.

1. American Diabetes Association. Diagnosis and classification of diabetes mellitus.

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the development and progression of long-term complications in insulin-dependent
diabetes mellitus. N Engl J Med. 1993;329:977–86.
3. Turner R. Intensive blood-glucose control with sulphonylureas or insulin compared
with conventional treatment and risk of complications in patients with type 2 diabetes
(UKPDS 33). Lancet. 1998;352:837–53.
4. ACCORD Study Group, Gerstein HC, Miller ME, Genuth S, Ismail-Beigi F, Buse JB,
et al. Long-term effects of intensive glucose lowering on cardiovascular outcomes. N
Engl J Med. 2011;364:818–28.
5. Kunt T, Snoek FJ. Barriers to insulin initiation and intensification and how to
overcome them. Int J Clin Pract. 2009;63:6–10.
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2003;26:1902–12.
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Hypoglycemia and diabetes: a report of a workgroup of the American Diabetes
Association and the Endocrine Society. Diabetes Care. 2013;36:1384–95.
8. International Hypoglycaemia Study Group. Minimizing hypoglycemia in diabetes.
Diabetes Care. 2015;38:1583–91.
9. Martín-Timón I, del Cañizo-Gómez FJ. Mechanisms of hypoglycemia unawareness
and implications in diabetic patients. World J Diabetes. 2015;6:912–26.
10. Wild D, von Maltzahn R, Brohan E, Christensen T, Clauson P, Gonder-Frederick L. A
critical review of the literature on fear of hypoglycemia in diabetes: Implications for
diabetes management and patient education. Patient Educ Couns. 2007;68:10–5.
11. Elliott L, Fidler C, Ditchfield A, Stissing T. Hypoglycemia event rates: a comparison
between real-world data and randomized controlled trial populations in insulin-treated
diabetes. Diabetes Ther. 2016;7:45–60.
12. Khunti K, Alsifri S, Aronson R, Cigrovski Berković M, Enters-Weijnen C, Forsén T,
et al. Rates and predictors of hypoglycaemia in 27,585 people from 24 countries with
insulin-treated type 1 and type 2 diabetes: the global HAT study. Diabetes Obes
Metab. 2016;18:907–15.
13. Guariguata L, Whiting DR, Hambleton I, Beagley J, Linnenkamp U, Shaw JE. Global
estimates of diabetes prevalence for 2013 and projections for 2035. Diabetes Res Clin
Pract. 2014;103:137–49.
14. Workgroup on Hypoglycemia, American Diabetes Association. Defining and
reporting hypoglycemia in diabetes: a report from the American Diabetes Association
Workgroup on Hypoglycemia. Diabetes Care. 2005;28:1245–9.
15. Bahia L, Kupfer R, Momesso D, Cabral DAP, Tschiedel B, Puñales M, et al. Health-
related quality of life and utility values associated to hypoglycemia in patients with
type 1 diabetes mellitus treated in the Brazilian Public Health System: a multicenter
study. Diabetol Metab Syndr. 2017;9:9.
 16. Cryer PE. Mechanisms of hypoglycemia-associated autonomic failure in diabetes. N
Engl J Med. 2013;369:362–72.
17. Unger J. Uncovering undetected hypoglycemic events. Diabetes Metab Syndr Obes.
2012;5:57–74.

Introduction

Diabetes mellitus is one of the most common noncommunicable chronic diseases and is a
major public health problem worldwide.[[1]] Based on the recent statistics by the
International Diabetes Federation, the estimated number of people with diabetes worldwide in
2015 was 415 million adults aged 20–79 years old, and by 2040, this will reach 642 million.
[[2]] The number of adults who died from diabetes were 5 million in 2015.[[2]] In Saudi
Arabia which is among the top 10 countries of the world with the highest prevalence of
diabetes, the estimated number of patients with diabetes in 2015 was 3.4 million, with an
associated mortality of 23,420 among adults aged 20 years old or older.[[2]]

One of the true medical emergencies associated with Type 1 diabetes (T1D) and Type 2
diabetes (T2D) is hypoglycemia. According to the American Diabetes Association,
hypoglycemia is defined as blood glucose level fall below 3.9 mmol/L (70 mg/dL) and
classified into symptomatic and asymptomatic hypoglycemia.[[3]] Hypoglycemia occurs
about two to three times more frequently in T1D than in T2D. However, because T2D is more
prevalent than T1D, most episodes of hypoglycemia, including severe hypoglycemia, occur
in people with T2D.[[4]]

According to a systemic review that was published in 2015, episodes of hypoglycemia often
occur because of patient inability to recognize symptoms of hypoglycemia and poor
knowledge about how to respond appropriately.[[5]] Hypoglycemia has a significant impact
on an individual's quality of life and has many risks, including taking place in dangerous
situations such as driving or operating machinery in work.[[6]]

Hypoglycemia can also lead to major complications in the vital organs such as brain and
kidneys which can lead to permanent neurological and renal damage.[[7]] Some principles of
prevention of hypoglycemia had been published. These principles include education about
diabetes self-management, self-monitoring of blood glucose levels, flexible and proper
insulin and/or other drug regimens, personalized glycemic goals, and consideration of known
risk factors of hypoglycemia.[[8]],[[9]]

Recognition of factors associated with the knowledge of hypoglycemic self-management and

selection of appropriate educational programs for health-care professionals and patients with
diabetes are the major issues to improve hypoglycemic attacks self-management and to
minimize the long-term complications.[[10]],[[11]]

References

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https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases. [Last accessed
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Diabetes mellitus is a common noncommunicable disease in India, as well as the rest of the
world. It has emerged as a major public health problem, with low- and middle-income
countries facing the greatest burden.[1] As of 2013, India ranks second in the list of diabetes
among people aged 20–79 years next only to China. India had 65.1 million diabetic people
aged 20–79 years, while China had 98.4 million people.[2] Probably because of a staggering
rise in obesity, diabetes has manifested as a global epidemic. The change in life expectancy
and lack of improvement in healthcare are in part responsible for the astounding rise in the
incidence of this disease. Even in the rural Indian, population is undergoing lifestyle
transition due to socioeconomic growth which can also be cited as a reason for increasing
incidence of diabetes in rural areas.[3]

Diabetes is a chronic disease, requiring a multipronged approach for its management, wherein
the patient has an important role to play.[4] They are required to follow certain self-care
practices to achieve an optimal glycemic control and prevent complications. These practices
include regular physical activity, appropriate dietary practices, daily foot care practice,
compliance with treatment regimen, and tackling complications such as hypoglycemic
episodes.[5] Thus, the objective of this study was to assess the baseline knowledge and self-
care behavioral practices regarding diabetes among the rural population so that it will serve as
a benchmark for future comparisons to assess the effectiveness of any educational training
program for the diabetic patients.

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[2,3] Hence, the American Diabetes Association (ADA) guidelines emphasize on
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diabetes and comorbidities.[4]

The symptoms of hypoglycemia are varied. The symptoms may be nonspecific with intensity
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effectively and take steps to prevent the recurrence.

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in India, that blood sugar levels can drop below normal while on drugs was known to around
40% of the diabetic subjects only.[6]
In this background, the knowledge and awareness about the varied presentations of
hypoglycemia and the possible preventive strategies for the same would go a long way in
type 2 diabetes management. There is a need for shared responsibility in the prevention of
hypoglycemia. We proposed to study the knowledge about hypoglycemia among type 2
diabetes patients attending a Large Diabetes Clinic in a Teaching Hospital from Chennai.

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Int. J. Pharm. Sci. Rev. Res., 41(1), November - December 2016; Article No. 44, Pages: 237-
241 ISSN 0976 – 044X International Journal of Pharmaceutical
Sciences Review and Research International Journal of Pharmaceutical Sciences Review and
Research Available online at www.globalresearchonline.net © Copyright protected.
Unauthorised republication, reproduction, distribution, dissemination and copying of this
document in whole or in part is strictly prohibited. Available online at
www.globalresearchonline.net 237
Dr. Sahbanathul Missiriya* Professor, Saveetha College of Nursing, Saveetha University,
Thandalam-602105, Tamilnadu, India. *Corresponding author’s E-mail:
shabanajalal1999@yahoo.com Accepted on: 10-08-2016; Finalized on: 31-10-2016.

INTRODUCTION iabetes is a complex metabolic disease that may lead to many

circulatory and neurological disorders. Diabetes is a disease of the endocrine system
where the body is not able to maintain the blood sugar at the required level for good health
and well being. Diabetes has become a big problem of great magnitude recently.1 It is
estimated that 10-12% of the urban residing Clients and 4-6% of rural Clients of
India are having diabetes mellitus. There is also a corresponding increasing in the
diabetic related complication for example diabetic neuropathy, diabetic retinopathy, and
diabetic nephropathy.2 Diabetes Mellitus occurs due to defect in the beta cells of islets of
langerhans, in pancreas. This leads to deficient production of insulin that is responsible for
maintenance of blood glucose. There are two types of diabetes. They are insulin dependent
and non insulin dependent diabetes mellitus. The development of disease may be
caused by various factors including, hereditary, viruses, and immunological factors.3
Diabetes mellitus has emerged as a major health care problem in India. According to
diabetes atlas published by international diabetic federation (IDF) there were estimated 40
million Clients with diabetes in 2007 and this number predicted to rise to almost 70
million Clients by 20254. The countries with largest number of diabetes will be in India,
China and USA by 2030. It is estimated that every 5th person with diabetes will be an
Indian2. Diabetes is considered as mother for all diseases. Increased glucose in the blood
for a long time can create many problems. That can damage many parts of the body,
such as heart, blood vessels, eyes and kidneys. Heart and blood vessels diseases can lead
to heart attacks and strokes, which are main killer of mankind. If Clients control diabetes
properly with time to time medicines and regular checkups and follow up, that may result
in to good glycemic control and thus reduce diabetic complications3. Ultimately,
diabetes prevention needs societal and community support and behavioral change on the
part of individual and their families. Now it is the time for India to wake up to the imminent
problem of diabetes mellitus and act before arising of damage to the body parts. Need for the
study A study was conducted to estimate the prevalence of diabetes and the number of
all age which diabetes for year 2000 and 2030.The prevalence of diabetes for all age group
worldwide was estimated to be 2.8% in 2000 and 4.4% in 2030 the total number of
Clients with diabetes project to rise from 171 million in 2000 to 366 million in 20305.
The Even minor trauma can lead to infection of foot ulcers and amputation is major
course of morbidity, disability and cost for Clients with diabetes mellitus6. Diabetic
nephropathy is the leading cause of end stage of renal disease worldwide and develops in
20-40% of patient with type I or type II diabetes mellitus. Diabetic retinopathy is
common complication of diabetes mellitus and is one of the leading causes of visual loss in
working Knowledge and Practice of Self Care Management on Diabetes Mellitus among
Urban People

Int. J. Pharm. Sci. Rev. Res., 41(1), November - December 2016; Article No. 44, Pages: 237-
241 ISSN 0976 – 044X International Journal of Pharmaceutical
Sciences Review and Research International Journal of Pharmaceutical Sciences Review and
Research Available online at www.globalresearchonline.net © Copyright protected.
Unauthorised republication, reproduction, distribution, dissemination and copying of this
document in whole or in part is strictly prohibited. Available online at
www.globalresearchonline.net 238 age population in developed and developing
countries. The known risk of retinopathy is directly related to the degree and duration of
hyperglycemic7. According to World Health Organization, in the year 2012, Diabetes is the
single most important metabolic disorder which can nearly affect every organ and system
in the body. In India it is estimated that presently 19.4 million individuals are affected by
this deadly disorder, which is likely to go up 57.2 million by the year 20258. In the current
health care environment there will be no administrative movement toward improving
quality of diabetes care unless there is a related profit incentive (or) a care deficit related
penalty. Evidence based improved method and tolls for achieving optional glycemic
control are now available. It is ironic that barriers exist simultaneously to prevent the
delivery of state-of-the-art diabetes assessment, care and self management education to
this population of clients in the most cost-effective care delivery setting the home9. Recent
researches suggested that Indians were genetically predisposed to diabetes. For a given
body mass index, Indians have higher amount of fat around the middle as compared to
other races.4 According to Chennai based Diabetes Research center there were 1.02 lakh
diabetes related death in India in 1999-2000.10 In Bangalore 3lakh Clients are known
diabetics. It is estimated that 30 million Clients in India are affected by diabetes and India
is the country with highest rate of diabetes.2 A study was conducted to assess the
effectiveness on demonstration regarding urine testing in practice among client with
diabetes mellitus. The aim of the study was to investigate the awareness of diabetes and
related factors in diabetes. The study reported that the participants were having adequate
knowledge regarding the risk factors and lack of awareness of diabetes controlled
programme. Diabetes cannot be cured, but can be controlled. Clients with Diabetes must
incorporate a complicated regimen of self management in to their lives that is, taking
medication, adherence of diet, exercise and also recognition of symptoms associated
with glycosuria and hypoglycemia.11 Diabetes self management is the corner stone for
controlling Diabetes and preventing Diabetes complication.12 If inadequately treated
develop multiple chronic complications leading to irreversible disability and death. Diabetes
can be effectively controlled and complications can be prevented by self care like diet,
exercise, medication, self monitoring of blood glucose level, foot and skin care.13 The
client who is knowledgeable about his or her condition and treatment can practice the
instruction given to prevent further complications. In order to carry out these functions
client must be thoroughly instructed in self care management and their knowledge and
practice should be checked periodically. The investigator observed from experience that
Clients do not have adequate knowledge about the consequences of diabetes due to their
ignorance. That is reason make the Clients for irregular checkup and medications. Instead of
making to avail regular checkup, the better convenient way for the Clients to have
diabetes in their control is self care management. So the investigator had an idea to
demonstrate the Clients for self monitoring of blood glugose level and self administration
of insulin injection. Hence the investigator felt need to assess the effect of self care
management demonstration to practice routinely among Clients with diabetes mellitus. Aim
of the Study  To assess the knowledge and practice on demonstration of regarding blood
sugar testing and insulin injection administration among client with diabetes mellitus in
pre and post test.  To determine the effectiveness of demonstration regarding self care
management in knowledge and practice among client with diabetes.  To find out the
association between knowledge and practice score of client with selected demographic
variables
. Todd Cade, Diabetes-Related Micro vascular and Macro vascular Diseases in the
Physical Therapy Setting, Journal of American Physical Therapy. 2008 Nov; 88(11):
1322–1335. 2. Seema Abhijeet Kaveeshwar and Jon Cornwall, The current state of diabetes
mellitus in India, Australian Medical Journal. 2004; 7(1): 45-48. 3. American Diabetes
Association, Diagnosis and Classification of Diabetes Mellitus, Diabetes Care Journal.
2009 Jan; 32(Suppl 1): S62–S67. 4. Mohan.V, Sandeep.S, Deepa.R, Shah.B & Varghese.C,
Epidemiology of type 2 diabetes: Indian scenario, Indian Journal Medical Research. 2007
March; 125: 217-230. 5. Wild. S, Roglic. G, Green. A, Sicree. R,& King. H, Global
prevalence of diabetes: estimates for the year 2000 and projections for 2030, Diabetes
Care. 2004 May; 27(5):1047-53. 6. Stephanie. C Wu, Vickie. R Driver, James. S Wrobel,
& David. G Armstrong, Foot ulcers in the diabetic patient, prevention and treatment,
Journal of Vascular Health Risk Management. 2007 Feb; 3(1): 65–76. 7. Andy K.H. Lim,
Diabetic nephropathy – complications and treatment, International Journal of Nephrology
and Renal Vascular Diseases. 2014; 7: 361–381. 8. Pradana Soewondo, Alessandra Ferrario
and Dicky Levenus Tahapary, Challenges in diabetes management in Indonesia: a literature
review, Journal of Globalalization Health. 2013 Dec; 9: 63. 9. Patricia Landi Linekin,
Home Health Care and Diabetes Assessment, Care, and Education, Journal of Diabetes
Spectrum 2003 Oct; 16(4): 217-222. 10. Anjali D. Deshpande, Marcie Harris-Hayes &
Mario Schootman, Epidemiology of Diabetes and Diabetes-Related Complications,
American Journal Physical Therapy. 2008 Nov; 88(11): 1254–1264. 11. Surendranath. A,
Nagaraju. B, Padmavathi. G.V, Anand S.V, Patan Fayaz & Balachandra. G, A study to
assess the knowledge and practice of insulin self-administration among patients with
diabetes mellitus, Asian Journal of Pharmaceutical and Clinical Research 2012 Oct;
5(1): 63-66. 12. Xu. Y, Toobert. D, Savage. C, Pan. W & Whitmer. K, Factors influencing
diabetes self-management in Chinese people with type 2 diabetes, Journal of Research
Nursing Health. 2008 Dec; 31(6): 613-25. 13. Clark, Physical activity efficacy and
effectiveness among men and women diabetes care, 7th edition New Delhi: Lipponcott;
2004: 237-352. 14. Muninarayana. C, Balachadra. G, Hiremath. S.G, Krishna Iyengar,
and N. S. Anil, N.S, Prevalence and awareness regarding diabetes mellitus in rural
Tamaka, Kolar, International Journal Diabetes Developing Countries. 2010 Jan-Mar;
30(1): 18–21. 15. Idongesit L. Jackson, Maxwell O. Adibe, Matthew J. Okonta, and
Chinwe V. Ukwe, Knowledge of self-care among type 2 diabetes patients in two states
of Nigeria, Pharmacy Practice (Granada). 2014 Jul-Sep; 12(3): 404. 16. Chamil Vidusha
Madushan, A study to determine the knowledge and practice of foot care in patients
with chronic diabetic ulcers, International Journal of Collaborative Research on Internal
Medicine & Public Health, internalmedicine.imedpub.com

Vol 11, Issue 1, 2018Online - 2455-3891 Print - 0974-2441KNOWLEDGE ON

HYPOGLYCEMIA AMONG PATIENTS WITH DIABETES MELLITUSTHENMOZHI
P1*, VIJAYALAKSHMI M21Department of Nursing, Saveetha College of Nursing, Saveetha
University, Chennai, Tamil Nadu, India. 2Department of Nursing, Saveetha College of
Nursing, Saveetha University, Chennai, Tamil Nadu, India. Email:
thenmozhi.sethu@gmail.comReceived: 02 September 2017, Revised and Accepted: 12
October 2017ABSTRACTObjective:

INTRODUCTION

Hypoglycemia is an acute complication of diabetes mellitus, and it is the medical term for a
state produced by a lower than normal level of blood glucose [1]. Diabetes mellitus is a
metabolic disorder characterized by elevated blood glucose levels and disturbances in
carbohydrates, fats, and protein metabolism and associated with metabolic complications that
can subsequently lead to premature death [2]. The term hypoglycemia literally means “under-
sweet blood.” It occurs when the blood glucose falls to <40–50 mg/dl which may endanger
patient’s life as well as other person’s lives. It can be caused by too much insulin intake or
oral hypoglycemic agents, too little food, or excessive physical activity [3]. Diabetes
medications including insulin and sulfonylureas are among the most common causes of
hypoglycemia in diabetic subjects [4]. The longer-acting sulfonylureas such as glibenclamide
and chlorpropamide are associated with more severe hypoglycemia than the shorter-acting
drugs [5]. Metformin was the most frequent used oral hypoglycemic agents (66.4 %)
followed by sulfonylurea and the most prevalent combination therapy was
metformin/glibenclamide regimen (28.5%). The majority of patients treated with metformin
at the time when they were diagnosed with diabetes (45.3 %). Hypoglycemic episodes were
most commonly reported adverse events with insulin and gastric upset with oral
hypoglycemic agents. 60.3% of the patients didn’t follow regular blood glucose checkup [6].
Several reports reveal that various pharmacological agents like metformin, rosiglitazone etc.,
which have wide ranging side effects, including weight gain, hypoglycemia and risk of
coronary heart disease [7]. Occasional episodes of hypoglycemia with metformin, as the most
commonly used antidiabetic drug, are reported when an imbalance between food intake and
dose of metformin is presented [8]. Hypoglycemia is a condition characterized by sweating,
tremor, tachycardia, palpitation, nervousness, hunger, confusion, slurred speech, emotional
changes, double vision, drowsiness, sleeplessness, and often self-diagnosed [1,3]. In type 2
diabetes, one longitudinal cohort study in elderly patients revealed that severe hypoglycemia
episodes are associated with an increased risk of dementia in this population, although the
impact of mild episodes on dementia risk remains unknown [9]. A recent study found that
severe hypoglycemia causes brain damage in cortex and the hippocampus regions and the
extent of damage was closely correlated to the presence of seizure-like activity. The results
were indicative of elevation of the sensitivity of the cortex to the damaging effects following
an episode of severe hypoglycemia [10]. Hypoglycemia is a common problem in old people
with diabetes. Aging modifies the cognitive, symptomatic, and counter-regulatory hormonal
responses to hypoglycemia [11]. The effect of aging on the increased risk of unawareness or
severe episodes of hypoglycemia has also been recognized [12]. Diabetes mellitus is treating
with synthetic drugs, namely, sulfonylureas, thiazolidinediones, glinide, and metformin, but
they retain many side effects [13].Most of the patients who lack of knowledge to recognize
all these symptoms may lead to delayed treatment which causes even death. The individual
fails to become aware of hypoglycemia due to lack of knowledge to recognize these
symptoms and can result in prolonged hypoglycemia with consequent brain injury, seizure,
and loss of consciousness because the brain is dependent on the blood glucose for energy
necessary for its activity and cannot survive more 6 min without glucose. Severe
hypoglycemia is usually associated with increased mortality and impaired cognitive function
and affects patient’s quality of life.The American Diabetes Association defines the
hypoglycemia as “any abnormally low plasma glucose concentration that exposes the subject
to potential harm,” and proposes a threshold of <70 mg% [14]. The spectrum of symptoms
depends on duration and severity of hypoglycemia and varies from autonomic activation to
behavioral changes to altered cognitive function to seizures or coma © 2018 The Authors.
Published by Innovare Academic Sciences Pvt Ltd. This is an open access article under the
CC BY license (http://creativecommons. org/licenses/by/4. 0/) DOI:
http://dx.doi.org/10.22159/ajpcr.2018.v11i1.22336Research Article
237Asian J Pharm Clin Res, Vol 11, Issue 1, 2018, 236-239 Thenmozhi and Vijayalakshmi
[15].

The short- and long-term complications include neurologic damage, trauma, cardiovascular
events, and death. There can be a six-fold higher incidence of death, increased costs of
medical care, and loss of productivity due to hypoglycemia [16]. Apart from patient-related
factors such as lifestyle and comorbid conditions of the patients, various other factors such as
choice, dose, timing, and combination of antidiabetic drugs together with simultaneous use of
other interacting drugs can increase the risk of hypoglycemia in diabetics.The immediate
treatment of hypoglycemia should be known by all the diabetic patients so that treatment of
hypoglycemia may not be delayed and need for hospitalization could be avoided. Illiterate
patients and elderly patients with dementia must be more educated about hypoglycemia.
Thus, improving patient skills self-management, self-monitoring of sugar, and adjustments of
dose based on requirements can reduce the risk of hypoglycemia. Awareness on
hypoglycemia symptoms and its early management was average among diabetics. Initiation
of home care followed by hospitalized care is the most ideal way to prevent severe spells of
hypoglycemia. The health-care professional has an important role in educating diabetics on
hypoglycemia so that hypoglycemic episodes and morbidity could be reduced or
prevented.The investigator felt that the number of diabetes patients is increasing and the
disease is now prevalent in all age groups in India. Diabetes mellitus is one of the important
public health issues and challenging the world in the 21st century. The prevalence of diabetes
has reached epidemic proportions in most populations. According to the UN World Health
Organization (WHO), more than 220 million people worldwide have diabetes, from which
more than 70% live in low- and middle-income countries. It is expected that the number of
diabetic subjects grows to 366 million by 2030, a figure that is more than twice the number in
2000. Epidemiologic evidence suggest that unless effective preventive measures are
implemented the global prevalence will continue to rise [17]. It is seen that patients with
diabetes mellitus have lack of knowledge about the disease condition, especially diabetes
mellitus and its management moreover about hypoglycemia. With this background, the
investigators felt it necessary to conduct a study to assess the level of knowledge on
hypoglycemia in diabetes patients.

REFERENCES1. Chintamani, Mani M. Lewi’s Medical Surgical Nursing. 1st ed. India:
Reed Elsevier India private Ltd., Publication; 2011. p. 766-86.2. Jain R, Jain P, Jain P. A
review on treatment and prevention of diabetes mellitus. Int J Curr Pharm Res 2016;8:16-8.3.
Hinkle JL. Brunner and Siddarth’s Textbook of Medical-Surgical Nursing. 13th ed.
Philadelphia, PA: Wolters Kluwer Health Publication; 2014. p. 862-5.4. Malouf R, Brust JC.
Hypoglycemia: Causes, neurological manifestations, and outcome. Ann Neurol 1985;17:421-
30.5. Stahl M, Berger W. Higher incidence of severe hypoglycaemia leading to hospital
admission in Type 2 diabetic patients treated with long-acting versus short-acting
sulphonylureas. Diabet Med 1999;16:586-90.6. Moradi M, Mousavi S. Drug use evaluation
of diabetes mellitus in non-hospitalized patients. Int J Pharm pharm Sci 2016;8:337-41.7.
Kalsi A, Singh S, Taneja N, Kukal S, Mani S. Current treatments for Type 2 diabetes, their
side effects and possible complementary treatments. Int J Pharm Pharm Sci 2015;7:13-8.8.
Holstein A, Egberts EH. Risk of hypoglycaemia with oral antidiabetic agents in patients with
Type 2 diabetes. Exp Clin Endocrinol Diabetes 2003;111:405-14.9. Whitmer RA, Karter AJ,
Yaffe K, Quesenberry CP Jr, Selby JV. Hypoglycemic episodes and risk of dementia in older
patients with Type 2 diabetes mellitus. JAMA 2009;301:1565-72.10. Bree AJ, Puente EC,
Daphna-Iken D, Fisher SJ. Diabetes increases brain damage caused by severe hypoglycemia.
Am J Physiol Endocrinol Metab 2009;297:E194-201.11. Alagiakrishnan K, Mereu L.
Approach to managing hypoglycemia in elderly patients with diabetes. Postgrad Med
2010;122:129-37.12. Avila-Fematt FM, Montaña-Alvarez M. Hypoglycemia in the elderly
with diabetes mellitus. Rev Invest Clin 2010;62:366-74.13. Rupeshkumar M, Kavitha K,
Haldar PK. Role of herbal plants in the diabetes mellitus therapy: An overview. Int J Appl
Pharm 2014;6:1-3.14. Workgroup on Hypoglycemia, American Diabetes Association.
Defining and reporting hypoglycemia in diabetes. A report from the American Diabetes
Association Workgroup on Hypoglycemia. Diabetes Care 2005;28:1245-9.15. Shafiee G,
Mohajeri-Tehrani M, Pajouhi M, Larijani B. The importance of hypoglycemia in diabetic
patients. J Diabetes Metab Disord 2012;11:17.16. Dejager S, Schweizer A. Minimizing the
risk of hypoglycemia with vildagliptin: Clinical experience, mechanistic basis, and
importance in Type 2 diabetes management. Diabetes Ther 2011;2:51-66.17. Alberti KG,
Zimmet P, Shaw J. International Diabetes Federation: A consensus on Type 2 diabetes
prevention. Diabet Med 2007;24:451-63.18. Shriraam V, Mahadevan S, Anitharani M,
Jagadeesh NS, Kurup SB, Vidya TA, et al. Knowledge of hypoglycemia and its associated
factors among Type 2 diabetes mellitus patients in a Tertiary Care Hospital in South India.
Indian J Endocrinol Metab 2015;19:378-82.19. Pai SA, George P. Study on awareness of
symptoms of hypoglycaemia and early management among patients with diabetes. IOSR J
Dent Med Sci 2015;14:11-3.20. Gezie GN, Alemie GA, Ayele TA. Knowledge and practice
on prevention of hypoglycemia among diabetic patients in South Gondar, Northwest
Ethiopia: Institution based cross-sectional study. Integr Obes Diabetes 2015;1:56-60.21.
Reifegerste D, Hartleib S. Hypoglycemia-related information seeking among informal
caregivers of Type 2 diabetes patients: Implications for health education. J Clin Transl
Endocrinol 2016;4:7-12.22. Tawfeeq W, Baker TY, Hatem SA, Jasem MK. Knowledge of
Diabetic Patients about Hypoglycemia. Available from: http://www.iasj.net/iasj?
func=fulltext&aId=35225. [Last Retrieved on 27 Aug 2017].23. Gul N. Knowledge, attitudes
and practices of Type 2 diabetic patients. J Ayub Med Coll Abbottabad 2010;22:128-31.

1. Introduction

Diabetes mellitus (DM) is becoming a global public health problem, characterized by its high
prevalence and mortality. Globally, there were more than 460 million people diagnosed with
DM in 2019, which is estimated to rise to 700 million by 2045. The prevalence of DM is
higher in low- and middle-income countries with the dominance of type 2 diabetes mellitus
(T2DM) [1, 2]. Diabetes mellitus is among the leading causes of deaths worldwide,
accounting for 1.6 million deaths each year. It also leads to several severe complications to
the heart, kidneys, eyes, nerves, blood vessels, and teeth during the course of the disease [3].

In Vietnam, DM is recognized as a major public health burden with approximately 5.76

million people suffering from this condition. The age-adjusted prevalence doubled from 2.7%
to 6% between 2002 and 2017 [4, 5]. Diabetes mellitus is the top cause of mortality and
disability combined and represents 3.96% disability-adjusted life years [6, 7]. Coupled with
the aging population in Vietnam, the prevalence of negative impacts of DM on individuals
and society presents an urgent demand for proper intervention and management strategies.

Besides lifestyle modification and oral antidiabetic medications, glycemic control is the
cornerstone of diabetes management strategy [8]. Insulin therapy, which is essential for
treating of both type 1 diabetes mellitus and T2DM, plays a vital role in the maintenance of
blood glucose level and reduces diabetes complications. Of the variety of insulin being
introduced, the insulin pen appears to be easier to use, portable, accurate, and safe compared
to traditional vial and syringe [9, 10]. Effective insulin management using an insulin pen
helps patients improve adherence, facilitate self-management of people with DM, prevent the
risk of hypoglycemia, and improve the quality of life [11, 12].

However, a large body of literature indicates that patients with DM have insufficient
knowledge about hypoglycemia [13, 14] and insulin use [15, 16]. The lack of such
knowledge will likely result in the increased risk of hypoglycemia and severe complications.
Therefore, strategies for enhancing knowledge about hypoglycemia and insulin use in
patients with T2DM need to be developed. Among intervention approaches, health education
is a key strategy in diabetes management to improve knowledge and practice related to self-
management of hypoglycemia and insulin use [17, 18]. However, to date, little is known
about the effectiveness of health education in enhancing the knowledge of hypoglycemia and
insulin pen use in outpatients with T2DM who manage their condition at home, particularly
in settings like Vietnam.

Therefore, this study is aimed to evaluate the effectiveness of health education on knowledge
about hypoglycemia and insulin pen use among outpatients with T2DM at a primary care
hospital in Vietnam and to examine the potential factors influencing this effectiveness.
Findings from this study can serve as scientific evidence for further development of well-
designed healthcare programs to optimize the treatment and to improve the quality of care
and quality of life in patients with DM.

International Diabetes Federation, “Diabetes facts & figures,” 2020,

https://www.idf.org/aboutdiabetes/what-is-diabetes/facts-figures.html/.

World Health Organization, “Diabetes,” 2020,

https://www.who.int/news-room/fact-sheets/detail/diabetes/.

International Diabetes Federation, “Diabetes complications,” 2020,

https://www.idf.org/aboutdiabetes/complications.html/.

International Diabetes Federation, IDF Diabetes Atlas - Ninth edition 2019, International
Diabetes Federation, 2019.
K. T. Nguyen, B. T. T. Diep, V. D. K. Nguyen, H. van Lam, K. Q. Tran, and N. Q. Tran, “A
cross-sectional study to evaluate diabetes management, control and complications in 1631
patients with type 2 diabetes mellitus in Vietnam (DiabCare Asia),” International Journal of
Diabetes in Developing Countries, vol. 40, no. 1, pp. 70–79, 2020.

Institute for Health Metrics and Evaluation, “Viet Nam,” 2017,

http://www.healthdata.org/vietnam/.

Institute for Health Metrics and Evaluation, “GBD Compare - Viz Hub,” 2019,
https://vizhub.healthdata.org/gbd-compare/.

P. E. Cryer, “The barrier of hypoglycemia in diabetes,” Diabetes, vol. 57, no. 12, pp. 3169–
3176, 2008.

T. S. Bailey and S. V. Edelman, “Insulin pen use for type 2 Diabetes—A clinical perspective,”
Diabetes Technology & Therapeutics, vol. 12, no. S1, pp. S-86–S-90, 2010.

W. Ramadan, N. Khreis, and W. Kabbara, “Simplicity, safety, and acceptability of insulin pen
use versus the conventional vial/syringe device in&nbsp;patients with type 1 and type 2
diabetes mellitus in Lebanon,” Patient Preference and Adherence, vol. 9, pp. 517–528, 2015.

R. M. Cuddihy and S. K. Borgman, “Considerations for Diabetes,” American Journal of

Therapeutics, vol. 20, no. 6, pp. 694–702, 2013.

P. Lasalvia, J. E. Barahona-Correa, D. M. Romero-Alvernia et al., “Pen devices for insulin

self-administration compared with needle and Vial,” Journal of Diabetes Science and
Technology, vol. 10, no. 4, pp. 959–966, 2016.

A. Ejegi, A. J. Ross, and K. Naidoo, “Knowledge of symptoms and self-management of

hypoglycaemia amongst patients attending a diabetic clinic at a regional hospital in
KwaZulu-Natal,” African Journal of Primary Health Care & Family Medicine, vol. 8, no. 1,
pp. 1–6, 2016.

T. P and V. M, “knowledge on hypoglycemia among patients with diabetes mellitus,” Asian

Journal of Pharmaceutical and Clinical Research, vol. 11, no. 1, pp. 236–239, 2018.
S. Priscilla, S. Malarvizhi, A. K. Das, and V. Natarajan, “The level of knowledge and attitude
on insulin therapy in patients with diabetes mellitus in a teaching hospital of Southern India,”
Journal of Family Medicine and Primary Care, vol. 8, no. 10, pp. 3287–3291, 2019.

B. Tosun, F. I. Cinar, Z. Topcu et al., “Do patients with diabetes use the insulin pen
properly?” African Health Sciences, vol. 19, no. 1, pp. 1628–1637, 2019.

G. Bhutani, S. Kalra, S. Lamba, P. K. Verma, R. Saini, and M. Grewal, “Effect of diabetic

education on the knowledge, attitude and practices of diabetic patients towards prevention of
hypoglycemia,” Indian Journal of Endocrinology and Metabolism, vol. 19, no. 3, pp. 383–
386, 2015.

Introduction

Hypoglycemia is an acute medical situation that occurs when blood sugar falls below the
recommended level. Individuals taking diabetic medications are at increased risk of
experiencing low blood sugar [1,2]. An estimated 2-4% of people with type 1 diabetes
mellitus die from hypoglycemia each year. It might explain the “dead in bed syndrome”
unexplained death of a person with type 1 diabetes occurring during night time [3]. The
symptoms of low blood sugar vary from person to person, and can change over time. During
the early stages a person with low blood sugar level may have sweating, trembling, feeling
hungry and feeling anxious. The symptoms can become more severe, and can include
difficulty of walking, weakness, visual disturbance; bizarre behavior, personality changes,
confusion and unconsciousness or seizure may be observed [4] .

Knowledge about these symptoms is an important step to self care practice, because informed
people are more likely to have better self care practice [5]. It is important for patients with
diabetes especially, those receiving insulin to learn about hypoglycemia, and to carry some
form of simple sugar with them at all times. Self care practice in diabetes management also
includes dietary regulation, medication, physical activity and self monitoring of blood
glucose (SMBG) [6]. Additionally, these patients should always wear an identification
bracelet or tag [7,8].

Several retrospective studies indicate that risk factors for hypoglycemia in 1,418 type2
diabetes mellitus are of drug- induced and fasting as the major risk factors for sever
hypoglycemia and require hospitalization [9]. Majority of hospitalized diabetic patients and
their relatives had inadequate understanding of diabetes and its consequences or
complications, and they had lack of confidence in own ability to manage diabetes effectively
[10]. Patients knowledge about various aspect of the disease together with the understanding
of the aims and objectives of various treatment outcomes have tremendous impact on patients
self care practice, skills necessary to control of self blood glucose (SMBG) [11,12].

Despite the abundance of studies on self-care practice and knowledge about hypoglycemia,
there are no available studies done on knowledge and practice regarding hypoglycemia
prevention among diabetic patients. But this study tried to identify determinants of
knowledge and practice regarding hypoglycemia among diabetic patients.

References

U.S. Hypoglycemia (2008) National Institute of Health Puplication. (09- 3926): 1-10.

Philip E, Irene E, Michael M, et al. (2010) Hypoglycemia in type 1 Diabetes mellitus,

Pathophysiology, Prevalence and Prevention. Endocrinol Metabol clin North Am 39: 2-3.
[Crossref]

Cryer PE, Axelrod L, Grossman AB, Heller SR, Montori VM, et al. (2009) Evaluation and
management of adult hypoglycemic disorders: an Endocrine Society Clinical Practice
Guideline. J Clin Endocrinol Metab 94: 709-728. [Crossref]

David M (2012) Diabetic hypoglycemia. Meds cape’s 1: 10-11.

Peyrot M, Rubin RR (1994) Modeling the effect of diabetes education on glycemic control.
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Siguroardottir A (2004) Model of factors affecting self care in diabetes. Journal of Clinical
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Anne S, Rémi R, Irene S, et al. (2008) Barriers to Physical Activity among Patients with Type
1 Diabetes, knowledge and practice of nutrition related hypoglycemia and related factors in
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Implementation of a Nursing Care Program. Diabetic metabolism, Nursing College, Hellwan
University, 2-10.

Shaheen C, Zia U, Tofail A, Sharifa N (2005) Knowledge assessment of diabetes patients.

Bangladesh Journal of Medical Science 5: 8-16.

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Physicians of the utmost fame, were called at once, but when they came, They answered, as
they took their fees, there is no cure for this disease Hilary belloc1

Diabetes mellitus is a group of metabolic disorder arising either due to relative or absolute
deficiency of a digestive hormone called insulin or inability or resistance of body cells to use
the available insulin. Diabetes mellitus is a silent disease and is now recognized as one of the
fastest growing threats to public health in almost all countries of the world. Every 5th person
who suffer from diabetes in the world today is an Indian2

Diabetes mellitus is a group of metabolic disorder characterized by elevated levels of glucose

in the blood (hyperglycaemia), resulting from defects in insulin secretion, insulin action or
both. American nurses association expert committee and classification of diabetes
mellitus(2003).3

The main underlying causes of the disease are genetic and environmental factors, such as
urbanization and industrialization, as well as increased longevity and changes in lifestyle
from a traditional healthy and active life to a modern, sedentary, stressful life and over-
consumption of energy-dense foods. The prevalence of diabetes mellitus varies among
populations due to differences in genetic susceptibility and social risk factors such as change
in diet, obesity, physical inactivity and, possibly, factors relating to intrauterine development.
Migrants are especially affected.

Diabetes mellitus needs to be treated by a holistic approach through dietary adjustment,

exercise, medication (if needed), education and self-care measures. Type 2 diabetes mellitus
is a preventable disease. These need to focus on health promoting activities to raise awareness
among healthy people of the risk factors for diabetes mellitus4.

Diabetes is one of the most frequently occurring chronic diseases in the world affecting
nearly 2-4% of the population (world health organization, 1998) research studies have shown
that the progress of diabetes is also associated with a high risk of developing vascular, renal,
retinal and neuropathy complication leading to premature disability and death.

The world health organization health report (1998) quotes that in India diabetes directly
causes approximately 38, 000 deaths per year and may contribute to as many as 300, 000
deaths annually, including many from heart disease and kidney failure. The number of cases
is increasing approximately 6% a year, making diabetes as important and formidable health
problem of India. The prevalence of diabetes has been found to be approximately 2% in the
rural and 3% in urban areas with local peaks as high as 8% with urbanization, changing
lifestyle and dietary habits. Thus, diabetes can have a deleterious effects on the overall health
and quality of life of an individual5.

Diabetes is a chronic health problem, and it is now growing as an epidemic in both developed
and developing countries. India leads the world today with the largest number of diabetes in
any given country followed by china and USA6.

Diabetes is becoming more common in the world. every day, every 21st seconds someone is
diagnosed with diabetes. Around 40- 70% of population is affected by foot ulcer. Many
serious complications such as kidney failure or blindness, can affect individuals with
diabetes7.

The pre-disposition to diabetes mellitus was thought to be hereditary. More recent theories
Suggest that glucagon plays a major part in the patho physiology of diabetes mellitus and this
theories regarding hereditary predisposition are being questioned8.

Obesity precedes in 85% of adult with diabetes mellitus. According to Roy’s adaptation
theory obesity presents an increased demand for insulin, because the beta cells within the
pancreas that secrets insulin become exhausted as a result individual develops diabetes
mellitus. Diabetes mellitus is more common in women than in men, and it is thought that this
may be because of the higher incident of obesity among women. It is also more common of
obesity in women who have borne children or to hormonal influence related to pregnancy9.
The mother with gestational diabetes mellitus is a high risk of hypertension, preeclampsia,
hydramnios, urinary tract infections, caesarian section and future diabetes mellitus, and some
of the foetal complications are macrosomia, hypoglycemia, prematurity and congenital
anomalies. The aim of management of gestational diabetes mellitus is to control blood
glucose levels to avoid maternal and foetal complications. Components of management
include diet therapy, exercise, insulin therapy and diabetic education10.

Patients with diabetes mellitus cannot be cured, but they can control it with regular exercise,
diet, and drug. Regular and proper administration of drug can provide desired outcome,
control diabetes, and prevent its complication. Undiagnosed or inadequately treated diabetes
mellitus patients develop multiple complications leading to hospital admission. Diabetes
mellitus in children adolescents and old people can be controlled by, effective teaching and
awareness programme about foot care, exercise, diet, its complications early detection and
prevention11.

NEED OF THE STUDY:

Knowledge is the key to healthier life, and education is powerful medicine” (K.Park)12

Diabetes is an ‘ice berg’ disease. Although it increases in both the prevalence and incidence
of non insulin dependent diabetes occurred globally, they have been especially dramatic in
societies, in newly industrialized countries and in developing countries. Currently the number
of cases a diabetes worldwide is estimated to around 150 million. The number is predicted to
be doubled by the year 2025. A prevalence rate of about 5.4% with the greatest number of
cases being expected in china and India. By 2030 as much as 9% of the population would be
diabetic.13

The world health organization estimates that more than 180 million people worldwide have
diabetes. These numbers are likely to more than double by 2030. In 2005, as estimated 1.1
million people died from diabetes. Almost 80% of diabetes deaths occur in low and middle
income countries. Almost half of diabetes deaths occur in people under the age of 70 years.
55% of diabetes deaths are in women only. Most notably, diabetes deaths are projected to
increase by over 80% in upper- middle income countries between 2006 and 2015. The overall
risk of dying among people with diabetes is at least double the risk of their peers without
diabetes. Diabetes and its complications impose significant economic consequences on
individual, families, health systems and countries14.
A study was conducted at total of 342 diabetics; 53% were men and 161 43% were women.
The majority, 63% was Hindu, 26% were Christian and 11% were muslin by faith. The
majority 37% of the respondents were in the age group of 61-70 year, followed by 24%, 20%
and 19% in the age group of 41-50 years, 51-60 years and >70 years respectively. 37% were
high school pass followed by 24% higher primary, 17% primary, 15% graduate and 7% were
illiterate. 73% had a per capita monthly income of rupee 3000 or more. 56% of the
respondents had adequate knowledge about the symptoms of hypoglycaemia. Men were
found to be more aware than women and this difference was statistically significant. Only
15% of the respondents knew about the chronic complication of diabetes. Here also men had
better knowledge than women but the difference was statistically non-significant.
Respondents with per capita income of rupee two thousand or more and having ten or more
years of schooling were more aware regarding the disease and its chronic complications. No
difference in the awareness was observed across various religious groups15.

All the respondents were aware regarding diet control but only 43% followed the
recommended diet schedules. It was observed that more women 52% than men 32% followed
the recommended diet schedules. Eighty two percent of the respondents were aware that
regular physical exercise is helpful but only nine percent of the men and four percent of the
women followed this advice. 41% and 36% of the total respondents had the knowledge that
alcohol and cigarette smoking are harmful for diabetics but only 19% of the alcohol drinkers
and 14% of the smokers stopped using these products on the advice of their doctor after being
diagnosed as diabetics16.

There is a deep need for an increase in the awareness of diabetes management and its
complications in the primary healthcare sector. Continuing education on diabetes mellitus and
its complications for primary healthcare providers is crucial and this should be accompanied
by a regular assessment of their diabetic knowledge. Screening for diabetes is important, but
equally crucial is patient education and counseling. It is evident from this study that patients
are not sufficiently equipped with the knowledge to comprehensively manage their disease.
Knowledge of diabetes is therefore essential for primary healthcare and other diabetic
patients in order to prevent co-morbidities, which may compromise their lifestyles as well as
increase the burden on public health care17.

An important area of focus in future studies should be the physical observation of nurses
counseling diabetic patients. The inclusion of this parameter in a study will highlight the
possible barriers to patient counseling and will also be an important tool in measuring the
efficacy of counseling in terms of the use of appropriate language and techniques with the
different patient groups, more aggressive counseling for elderly patients, more focus on
counseling rural dwellers beyond the urban hub, and the efficacy of post-plasma glucose test
counseling. The evaluation of the actual and perceived level of nursing knowledge regarding
diabetes mellitus and its co-morbidities is also an area of importance and it would be
interesting if a correlation is done between this and patient knowledge, and the prevalence of
diabetes-related co-morbidities at the particular clinic. A study of youth awareness of diabetes
mellitus in rural settings is also a viable study area, as education will be the key to prevention
and disease management in later years. The key to unraveling the knots in rural diabetic
patient management thus lies in empowering the patient and the healthcare provider with the
essential18.

REFERENCES:

1. Hilary belloc, text book of medical surgical nursing, 6th edition page no. 1276

2. Gala DR, Gala S. Diabetes, high blood pressure without any fear. Mumbai: Navneet
Publications (India) Ltd. 2004.

3. Siddhartha’s and Brunner, text book of medical surgical nursing, 12th edition ‘page
no.1197.

4. World health organization fact sheet. Diabetes. Available from

URL:http://www.who.int.

5. Melba Sheila Desouza, K. Subrahmanya Nairy. Health promoting behaviour and

quality of life among adults with Diabetes mellitus (Improved after nurse directed
interventions). Nightingale Nursing times. 2008 March; 3(12):17.

6. Makol N. Diabetes an emerging health problem in India. Health Action 2008 Sep 4

7. Black JM. Lukman and Sorenson’s medical surgical nursing. A psychological

approach. 4th ed. Philadelphia: W. B. Saunders Company; 1993.

8. Polit DF, Hungler BP. Nursing research: principles and methods. Philadelphia: J. B.
Lippincott co; 1999.

9. Kar K, Singh MM, Kumar W. Knowledge and self care practice of diabetes in
resettlement colony of Chandigarh. Indian J Med Sci 1998 Aug; 52(8):341-7
10. Dhanwal Dinesh, Mukkhopadhay surabhi; gestational diabetes mellitus and pregnancy,
Obs. and Gynae. today; January 1999; 4(1); 22-24.

11. Sheeba J, Snehalatha C.Self administration of insulin in diabetes.Nightingales Nursing

Times 2011 Mar; 6(12):33-5, 37-8, 53.

12. K.park, community health nursing, 5th edition pp 298

13. Sheeba J, Snehalatha C. Self administration of insulin in diabetes.Nightingales Nursing

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14. World health organization fact sheet. Diabetes. Available from

URL:http://www.who.int.

15. Ms. Lakhwinder kaur, Ms. Amanjit Kaur, Ms. Amanjot Kaur, Ms. Amardeep Kaur, Ms.
Gagandeep Kaur. Prevalence of obesity among adolescents. Nightingale Nursing times. 2008
February; 3(11):33 and 58.

16. Madden SG, Loeb SJ, Smith CA. An integrative literature review of lifestyle
interventions for the prevention of type II diabetes mellitus. Journal of Clinical Nursing. 2008
September; 17(17):2243-256.

17. Lakerveld J, Bot SD, Chinapaw MJ, van Tulder MW, van Oppen P, Dekker JM.
Primary prevention of diabetes mellitus type 2 and cardiovascular diseases using a cognitive
behavior program aimed at lifestyle changes in people at risk: Design of a randomized
controlled trial. BMC Endocrine Disorders. 2008 June 24; 8:6

18. Bhardwaj S, Misra A, Khurana L, Gulati S, Shah P, Vikram NK. Childhood obesity In
Asian Indians: a burgeoning cause of insulin resistance, diabetes and sub-clinical
inflammation. Asia Pacific journal of Clinical Nutrition. 2008; 17(1):172

19. Vang A, Singh PN, Lee JW, Haddad EH, Brinegar CH. Meats, processed meats,
obesity, weight gain and occurrence of diabetes among adults: findings from Adventist Health
Studies. Annals Nutrition and Metabolism. 2008; 52(2):96-04.

1. Introduction

Hypoglycemia is a true medical emergency [1] and has a critical effect on mortality,
morbidity, and quality of life [2] . Hypoglycemia is a major barrier for attaining treatment
goals and reduction of long-term complications in diabetes management and therefore it is an
important reason for increased costs of medical care [3] .

The American Diabetes Association defines the hypoglycemia as “any abnormally low
plasma glucose concentration that exposes the subject to potential harm”, and proposes a
threshold of <70 mg/dl [4] . The spectrum of symptoms depends on the duration and severity
of hypoglycemia and varies from autonomic activation to behavioral changes to altered
cognitive function to seizures or coma and even death [5] .

Two types of hypoglycemia symptoms are documented. The first one is neuroglycopenia
which causes symptoms such as blurred vision, fatigue, concentrating disturbance, confusion
and behavioral changes, and may lead to loss of consciousness, seizures, brain damage, and
death [6] [7] . The second one is neurogenic symptoms and this occurs by the hormones and
neurotransmitters delivered as a result of low brain glucose levels, causing symptoms such as
tremor, palpitation, anxiety, sweating, hunger, dizziness and drowsiness [7] [8] .

Patient’s awareness and knowledge of every hypoglycemia symptoms are very important to
be early recognized and to take measures for treatment and avoid risks that may even cause
death [7] .

Many studies [9] [10] report that younger diabetes patients have high knowledge about
diabetes in general and this is because older have a low cognitive function which hinders
diabetes education programs, whilst younger ages have higher motivation [11] and
adaptability towards disease.

Higher educated patients usually have higher knowledge about diabetes and this is attributed
to the fact that educated patients can easily respond to education programs and have the
ability to communicate with other sources of knowledge that provides medical programs such
as television, radio, and internet [11] .

Diabetes management is a complex and cost-effective process and requires an integrated

multi-disciplinary team consisting of physicians, nurses, dietitians, exercise specialists,
pharmacists, dentists, podiatrists, and mental health professionals, however, unless the
presence of educated patients who are able to care about themselves. The efforts of this team
will not provide effective care. Participation of diabetic patients in diabetes self-management
education (DSME) is an essential element of diabetes care [12] . Education helps people with
diabetes to initiate effective self-management and cope with diabetes when they are first
diagnosed. DSME helps patients to optimize metabolic control, prevent and manage
complications, and maximize the quality of life in a cost-effective manner [13] .

In the past few decades, a great shift has occurred regarding tradition clinical pharmacists
role, as medications dispenser, to direct patients’ pharmaceutical care such as diabetes
management [14] [15] including diabetes patients’ education [16] .

Knowledge and awareness of symptoms of hypoglycemia in diabetes prevent patients from

many risks of diabetes; however, the presence of studies that check patient’s knowledge about
this important part of diabetes self-management is scarce and fragmented in Sudan.

References

[1] Shafiee, G., et al. (2012) The Importance of Hypoglycemia in Diabetic Patients.
Journal of Diabetes & Metabolic Disorders, 11, 17. https://doi.org/10.1186/2251-6581-11-17

[2] Bruce, D., et al. (2009) Severe Hypoglycaemia and Cognitive Impairment in Older
Patients with Diabetes: The Fremantle Diabetes Study. Diabetologia, 52, 1808.
https://doi.org/10.1007/s00125-009-1437-1

[3] Bhutani, G., et al. (2015) Effect of Diabetic Education on the Knowledge, Attitude
and Practices of Diabetic Patients towards Prevention of Hypoglycemia. Indian Journal of
Endocrinology and Metabolism, 19, 383. https://doi.org/10.4103/2230-8210.152781

[4] Association, A.D. (2018) 6. Glycemic Targets: Standards of Medical Care in Diabetes
—2018. Diabetes Care, 41, S55-S64. https://doi.org/10.2337/dc18-S006

[5] Ejegi, A., Ross, A.J. and Naidoo, K. (2016) Knowledge of Symptoms and Self-
Management of Hypoglycaemia amongst Patients Attending a Diabetic Clinic at a Regional
Hospital in KwaZulu-Natal. African Journal of Primary Health Care & Family Medicine, 8,
1-6. https://doi.org/10.4102/phcfm.v8i1.906

[6] Towler, D.A., et al. (1993) Mechanism of Awareness of Hypoglycemia: Perception of

Neurogenic (Predominantly Cholinergic) Rather than Neuroglycopenic Symptoms. Diabetes,
42, 1791-1798. https://doi.org/10.2337/diab.42.12.1791
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among Type 2 Diabetes Mellitus Patients in a Tertiary Care Hospital in South India. Indian
Journal of Endocrinology and Metabolism, 19, 378. https://doi.org/10.4103/2230-
8210.152779

[8] Cefalu, C.A. and Cefalu, W.T. (2005) Controlling Hypoglycemia in Type 2 Diabetes:
Which Agent for Which Patient? At Each New Stage of Treatment, Choices Can Be Made to
Reduce Risk. Journal of Family Practice, 54, 855-863.

[9] Thomson, F., et al. (1991) Lack of Knowledge of Symptoms of Hypoglycaemia by

Elderly Diabetic Patients. Age and Ageing, 20, 404-406.
https://doi.org/10.1093/ageing/20.6.404

[10] Mutch, W. and Dingwall-Fordycet, I. (1985) Is It a Hypo? Knowledge of the

Symptoms of Hypoglycaemia in Elderly Diabetic Patients. Diabetic Medicine, 2, 54-56.
https://doi.org/10.1111/j.1464-5491.1985.tb00593.x

[11] Shrestha, N., et al. (2015) Diabetes Knowledge and Associated Factors among
Diabetes Patients in Central Nepal. International Journal of Collaborative Research on
Internal Medicine & Public Health, 7, 82.

[12] Mulcahy, K., et al. (2003) Diabetes Self-Management Education Core Outcomes
Measures. The Diabetes Educator, 29, 768-803.
https://doi.org/10.1177/014572170302900509

[13] Nicholas, D., et al. (2001) Digital Health Information Provision and Health Outcomes.
Journal of Information Science, 27, 265-276. https://doi.org/10.1177/016555150102700409

[14] Chisholm-Burns, M.A., et al. (2010) US Pharmacists’ Effect as Team Members on

Patient Care: Systematic Review and Meta-Analyses. Medical Care, 923-933.
https://doi.org/10.1097/MLR.0b013e3181e57962

[15] Simpson, S.H., et al. (2011) Effect of Adding Pharmacists to Primary Care Teams on
Blood Pressure Control in Patients with Type 2 Diabetes: A Randomized Controlled Trial.
Diabetes Care, 34, 20-26. https://doi.org/10.2337/dc10-1294

[16] Farsaei, S., et al. (2011) Effect of Pharmacist-Led Patient Education on Glycemic
Control of Type 2 Diabetics: A Randomized Controlled Trial. Journal of Research in Medical
Sciences: The Official Journal of Isfahan University of Medical Sciences, 16, 43.
The researcher has observed the complications of diabetic patients during her working
experience. The individuals who carry most of their weight and longer period uncontrolled
diabetes tend to have a higher risk of diabetes foot. So these factors instigated the researcher
to perform a study to assess the knowledge and attitude regarding diabetic foot care among
diabetic patients19.

INTRODUCTION

Diabetes is a significant long-term disease that people experience when the amount of
glucose in their blood is elevated over a prolonged period of time. It is categorized into Type
1 diabetes (T1D), an autoimmune disorder enabling the body to produce insulin, and Type 2
diabetes (T2D), with insufficient production of insulin, or production of non-functional
insulin.[1] Despite many advances in diabetes management, hypoglycemia, defined as a
blood glucose concentration of <70 mg/dL, is the most common acute adverse event of
insulin treatment.[2]

It has a negative impact on perceived quality of life and constitutes the main barrier for
achieving and maintaining optimal glycemic control in diabetes. It interferes with everyday
activities, which requires help from another person to restore blood glucose levels, thus
creating a risk of physical damage (such as when driving).[3] Patients with T1D have a much
increased rate of severe hypoglycemia (20–25%[4]), albeit less cardiovascular comorbidity
compared with people with T2D.[5,6]

Impaired awareness of hypoglycemia (IAH) is an acquired syndrome in people with insulin-

treated diabetes, predominantly T1D, and can be defined as a condition in which patients
experience an attenuation of hypoglycemic symptoms, leading to a diminished or absent
ability to perceive the onset of hypoglycemia.[7,8] Patients with IAH experience
neuroglycopenic symptoms as the first sign of hypoglycemia and rely on the assistance of
others to manage their episodes of hypoglycemia. The risk of severe hypoglycemia is 6-fold
more common in those with IAH, which, in turn, has been linked to increase in overall
mortality.[9,10]

In the absence of identification and immediate treatment for a hypoglycemic episode, the
blood glucose can proceed to drop and causing severe hypoglycemia and other complexities,
such as seizures, coma, emergency room admissions, and possibly death.[1,11-13] For cases
with IAH and recurrent severe hypoglycemia, pancreas or islet transplantation can be taken
into account as possible therapy options, however, it is currently limited by graft availability,
expense, and the necessity for dedicated lifelong immunosuppressant use.[14] Therefore,
real-time continuous glucose monitoring (CGM) has become a valuable tool in the
management of diabetic patients by presenting immediate information regarding blood
glucose levels, glycemic trends, and alerts to hypoglycemic events.[15] Recent evidence
suggests that it may lower the incidence of hypoglycemic events yet, it did not reverse IAH in
some subjects.[16,17] At present, no previous study was performed in Saudi Arabia region to
ascertain the IAH prevalence. Therefore, the aim of the current study was to investigate the
self-reported prevalence of moderate, severe hypoglycemia and IAH among patient visiting
KFMC Obesity Metabolic Endocrine Centre (OEMC) Type1 and Type 2 diabetics. In
addition, we assessed the possible determinants of IAH.

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