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Omitting Follow-up Food After Initial Hypoglycaemic Treatment Does not Increase the Likelihood of Repeat Hypoglycaemia

Introduction Guidelines for self-treatment of hypoglycaemia specify initial treatment with quick-acting carbohydrate until blood glucose levels normalize and then follow-up with longer-acting carbohydrate. The few studies investigating follow-up show 29–57% omission or undertreatment with follow-up carbohydrate but do not investigate the association of this with repeat hypoglycaemia. This study aimed to develop, validate and administer a questionnaire to delineate this association. The timeframe targeted was 2 h post primary hypoglycaemic event (PPHE), the time influenced by long-acting carbohydrate. Methods A questionnaire was generated, test–retest reliability assessed, and it was piloted on convenience samples from the target population. The final version was administered to all insulin-treated individuals attending an outpatient diabetes clinic over 4 weeks (169). Results Questionnaire development: readability (69.6—standard/easy), test–retest reliability (Cohen’s kappa 0.57–0.91) and return rate (72.2%) were all acceptable. Questionnaire data: questionnaires were returned by 122 participants (63 males/59 females). Method of insulin administration was subcutaneous insulin injections (91%) and continuous subcutaneous insulin infusion (CSII) (9%). Repeat hypoglycaemia within 2 h PPHE was reported by 8.2% of respondents. There was no significant difference for age, gender and diabetes duration between those reporting repeat hypoglycaemia and those without. Consumption of follow-up longer-acting carbohydrate was reported by 58.2% of responders with 48% of these using long-acting and 52% medium-acting carbohydrate foods. Method of insulin administration and consumption of follow-up food were significantly associated with repeat hypoglycaemia (P = 0.015, 0.039) but presence or absence of symptoms and duration of action of carbohydrate were not significantly associated (P = 0.103, 0.629). Hierarchical logistic regression analysis showed omission of follow-up food PPHE was not a significant predictor of increased likelihood of repeat hypoglycaemia within 2 h PPHE, irrespective of method of insulin administration (P = 0.085). Conclusion This study supports guidelines that recommend judicious, rather than routine use of follow-up longer-acting carbohydrate PPHE.


INTRODUCTION
Hypoglycaemia is a common complication of insulin treatment resulting from relative insulin excess and suboptimal glucose counterregulation [1]. Mean rates of hypoglycaemia in insulin-treated diabetes are reported as 42.89 (type 1) and 16.37 (type 2) events per person per year (population-based study) [2] and 29.0 (type 1 [15 years duration) and 10.2 (type 2 [5 years duration) events per person-year (secondary health based study) [3].
Hypoglycaemia is cited as the main impediment to euglycemia [4] and the most feared complication of insulin-treated diabetes [5].
It has been reported that 90.8% of adults with type 1 and 84.5% with type 2 diabetes self-treat their hypoglycaemia [6]. Recommendations for self-treatment advise ingestion of quick-acting carbohydrate, reassessment of blood glucose and repeat treatment until blood glucose levels normalise.
There are few reports in the literature on the extent of adherence to recommendations for follow-up treatment with longer-acting carbohydrate [17][18][19]. Sommerfield

Development of the Questionnaire
The one-page questionnaire was couched in simple language with explanation of technical terms and aimed at completion within 10 min.
It commenced with a brief preamble assuring

Questionnaire Development
Test-retest reliability of the questionnaire was evaluated by percent agreement and also using the kappa statistic (j), which measures the amount by which agreement exceeds that expected by chance. Kappa was calculated for the self administered-interview data with 95% confidence intervals based on 1,000 bootstraps.

Data from Questionnaire
Descriptive statistics were used for participant characteristics and hypoglycaemic frequency.

Development of Questionnaire
Readability of the questionnaire was assessed as 69.6 on Flesch Reading Ease Formula (standard-easy level) and 6.2 on Flesch-Kincaid Grade Level Formula consistent with a grade 6 level, thus theoretically understandable by 85-90% of the population [27]. Test-retest reliability and response rate for individual items are shown in Table 1. Response rates and percent agreement were uniformly high. Values for j exceeded 0.61, indicating substantial agreement for six of the seven questions, with moderate agreement for the other [30].

Data from Questionnaire
Questionnaires were returned by 122 out of 169 participants (63 males, 59 females) giving a return rate of 72.2%, well above the estimated acceptable rate of 65% for self-completed postal questionnaires [31]. Participant characteristics are shown in Table 2 and self-reported frequency, symptoms and treatment of hypoglycaemia in Table 3. Repeat hypoglycaemia was reported by 8.2% (n = 10) of participants and correlated well with a separate question on self-reported frequency of repeat hypoglycaemia (P\0.001).
There was no significant difference in the distribution of age, gender and duration of diabetes between those reporting repeat hypoglycaemia and those without (P = 0.343, 1.00, 0.458 respectively). All participants reported consuming initial treatment food.
Follow-up food ingestion was reported by 58.2% of item responders with 48% of these using long-acting and 52% medium-acting carbohydrate. Ninety percent of those using medium-acting carbohydrate chose food sources in the lower half of this category, i.e. GI \62 (Fig. 1).
Both method of insulin administration and

DISCUSSION
Insulin-treated individuals in the target population are routinely taught to ingest follow-up food post-hypoglycaemia; therefore, it might be presumed they may be reluctant to admit they do not carry this out. In view of this, the data collection method considered optimal for this study was an anonymous selfadministered questionnaire. This mode has been shown to decrease biased responses and result in more accurate and less 'socially desirable' responses to sensitive health-related questions than information obtained by interview [32]. A negative aspect of selfadministered questionnaires is a possible decrease in reliability for open and more complex questions [33], but this was not demonstrated in this study. Advanced notification ahead of self-administration of a questionnaire has been shown to raise response rates and credibility without affecting questionnaire response type [33], and the initial contact by diabetes educators with Potentially many factors influence repeat hypoglycaemia [23]. We have investigated one of these (follow-up food) and sought to control for the other factor (method of insulin administration) that showed a significant association within the specified timeframe. Perhaps surprisingly, lack of symptoms of hypoglycaemia was not a modifier, possibly a function of the inclusion of individuals with insulin-treated type 2 diabetes and the associated lower rate of compromised counterregulation [34].
A limitation of this study was the inability to differentiate between type 1 and insulin-treated type 2 diabetes. It was considered that selfreported data on this may be inaccurate. Similarly, we collected no data on alcohol consumption, a modifier of hypoglycaemia, as this requires strategies to obtain accurate information outside the scope of this study [35].
Hierarchical  [17,19]. The use of medium-acting foods for follow-up is consistent with some recommendations [9,13,14], but notably, in this study, the majority of respondents selecting medium-acting follow-up foods tended towards those that were sloweracting in this category and this may account for the lack of association of duration of action of carbohydrate with incidence of repeat hypoglycaemia.
The relative percentages of reported repeat hypoglycaemia and omission of follow-up longer-acting carbohydrate PPHE suggest many individuals do omit follow-up food with impunity. The situation is rather complex, with some guidelines recommending routine consumption of follow-up food [7,9,12] and others stating follow-up food may be required [10,13,14]. CSII treatment is cited as one instance where follow-up food may be unnecessary as short-term insulin status is more controllable [14]; however, in this study omission of follow-up food PPHE did not significantly increase the likelihood of repeat hypoglycaemia irrespective of method of insulin administration.

CONCLUSION
The results of this study support guidelines recommending judicious, rather than routine use of follow-up longer-acting carbohydrate PPHE.
the study. Sally Vindedzis is the guarantor for this article, and takes responsibility for the integrity of the work as a whole. No funding or sponsorship was received for this study or publication of this article.