Letter: Patient Understanding of Hypoglycemia in Tertiary Referral Centers (Diabetes Metab J 2018;42:43-52).

As intensive diabetes care based on insulin or multiple oral agents have recently been emphasized [1], the management of hypoglycemia in both physicians' and patients' perspectives have been highlighted.

The concern of hypoglycemia is a major barrier to appropriate insulin injections in patients. The adherence rate to insulin was approximately 70% in patients with type 2 diabetes mellitus [2]. In one study conducted in the United Kingdom (UK), 29% and 46% of patients with basal insulin and basal-bolus insulin, respectively, experienced hypoglycemia during the 30 days of survey period [3]. The frequent hypoglycemic episodes in these patients were causally related with missing (16%) or reducing (19%) insulin doses [3]. Nevertheless, it turned out that the majority of patients are not correctly aware of hypoglycemic symptoms. In another study conducted in the UK [4], only one-thirds or -fourths of patients with diabetes correctly understand classical hypoglycemic symptoms such as trembling, sweating, or feeling hungry. In this regard, the importance of education on hypoglycemia cannot be overemphasized. Indeed, several studies suggest the critical role of patient education in minimizing hypoglycemic risk [5].

In this issue, Cho et al. [6] reported the extent of patient understanding of hypoglycemia in tertiary referral centers. Among 758 participants, 62.1% self-reported hypoglycemia. Given that this study was conducted in tertiary referral centers, it is not surprising that 47.1% were insulin-users. However, although their mean duration of diabetes was approximately 12 years, the majority (68.1%) were not previously provided with any education about hypoglycemia. It seems that health care professionals are still devoid of opportunities to provide information about hypoglycemia to their patients.

One of the most striking finding of this study was that the average score of choosing the correct hypoglycemic score was only 3.3 out of 12. Twelve examples were presented as questions about what is right as a symptom of hypoglycemia, and 12 examples were all correct. However, the person who viewed the questionnaire would have been hard to think that all 12 questions were correct. Therefore, it is highly likely that the score is underestimated by some degree in indicating the actual knowledge of the patients.

This study also provides important information that many patients are still inaccurately aware of foods that are helpful for overcoming hypoglycemia, suggesting that the diabetes education program for patients needs to be revised to a more practical form. It is noteworthy that the educated group have previously experienced significantly higher rate of hypoglycemia compared with uneducated group. This finding suggests that those who experience hypoglycemia less either tend to not recognize the necessity of understanding hypoglycemia or are not be provided with enough opportunity to be educated about hypoglycemia due to endocrinologists' indifference. However, it turns out that patients' low perception of hypoglycemia is not confined to this study. In a recent study conducted in Germany, 32% of patients failed to answer any correct method to deal with hypoglycemia [6].

This study by Cho et al. [6] provides an important, real-world perception on hypoglycemia in patients with diabetes. Although patients were being treated for diabetes for a long duration and rather frequently confront hypoglycemic episodes, their practical knowledge seems insufficient to cope with hypoglycemic situations. Therefore, improvement of educational system should not rely on each physician's devotion, but rather needs to be systematically established on a nation-wide level.