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Food Insecurity and Hypoglycemia among Older Patients with Type 2 Diabetes Treated with Insulin or Sulfonylureas: The Diabetes & Aging Study

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Abstract

Background

Severe hypoglycemia is a serious adverse drug event associated with hypoglycemia-prone medications; older patients with diabetes are particularly at high risk. Economic food insecurity (food insecurity due to financial limitations) is a known risk factor for hypoglycemia; however, less is known about physical food insecurity (due to difficulty cooking or shopping for food), which may increase with age, and its association with hypoglycemia.

Objective

Study associations between food insecurity and severe hypoglycemia.

Design

Survey based cross-sectional study.

Participants

Survey responses were collected in 2019 from 1,164 older (≥ 65 years) patients with type 2 diabetes treated with insulin or sulfonylureas.

Main Measures

Risk ratios (RR) for economic and physical food insecurity associated with self-reported severe hypoglycemia (low blood glucose requiring assistance) adjusted for age, financial strain, HbA1c, Charlson comorbidity score and frailty. Self-reported reasons for hypoglycemia endorsed by respondents.

Key Results

Food insecurity was reported by 12.3% of the respondents; of whom 38.4% reported economic food insecurity only, 21.1% physical food insecurity only and 40.5% both. Economic food insecurity and physical food insecurity were strongly associated with severe hypoglycemia (RR = 4.3; p = 0.02 and RR = 4.4; p = 0.002, respectively). Missed meals (“skipped meals, not eating enough or waiting too long to eat”) was the dominant reason (77.5%) given for hypoglycemia.

Conclusions

Hypoglycemia prevention efforts among older patients with diabetes using hypoglycemia-prone medications should address food insecurity. Standard food insecurity questions, which are used to identify economic food insecurity, will fail to identify patients who have physical food insecurity only.

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Abbreviations

EHR:

Electronic health record

KPNC:

Kaiser Permanente Northern California

ED:

Emergency department

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Funding

This research was supported by funding from grants from National Institute of Aging (R01-AG051683: Preferences, Management, and Outcomes in the Oldest Patients with Diabetes and R01-AG063391: Optimizing Medical Decision Making for Older Patients with Type 2 Diabetes) and National Institute of Diabetes and Digestive and Kidney Diseases (Centers for Diabetes Translational Research: P30 DK092924 (Karter and Seligman) and P30 DK092949 (Huang and Laiteerapong)). Funding from Centers for Medicare & Medicaid Services to develop and evaluate publicly reported quality measures and royalties from UpToDate (Lipska).

Author information

Authors and Affiliations

  1. Kaiser Permanente Northern California Division of Research, Pleasanton, CA, USA

    Andrew J. Karter PhD, Melissa M. Parker MS, Howard H. Moffet MPH, Jennifer Y. Liu MPH & Richard W. Grant MD, MPH

  2. Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, IL, USA

    Elbert S. Huang MD, MPH & Neda Laiteerapong MD, MS, FACP

  3. Division of General Internal Medicine at San Francisco General Hospital, University of California San Francisco Center for Vulnerable Populations, San Francisco, CA, USA

    Hilary K. Seligman MD, MAS

  4. Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA

    James D. Ralston MD, MPH

  5. Kaiser Northern California Diabetes Program, Endocrinology and Internal Medicine, Kaiser Permanente, South San Francisco Medical Center, South San Francisco, CA, USA

    Lisa K. Gilliam MD, PhD

  6. Section of Endocrinology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA

    Kasia J. Lipska MD, MHS

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  1. Andrew J. Karter PhD
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  2. Melissa M. Parker MS
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Contributions

AJK, ESH, HHM, JYL, KJL, MMP, NL, RWG designed the survey. AJK and MMP researched the data. AJK, KJL, MMP, HHM wrote the first draft of the manuscript. All authors reviewed and edited the manuscript. All authors approved the final version of the manuscript.

AJK is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Corresponding author

Correspondence to Andrew J. Karter PhD.

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IRB Approval

Kaiser Permanente Northern California Institutional Review Board approved the study.

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The authors declare that they do not have a conflict of interest.

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Karter, A.J., Parker, M.M., Huang, E.S. et al. Food Insecurity and Hypoglycemia among Older Patients with Type 2 Diabetes Treated with Insulin or Sulfonylureas: The Diabetes & Aging Study. J GEN INTERN MED (2024). https://doi.org/10.1007/s11606-024-08801-y

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