Hypoglycemia associated with food insecurity in older adults with diabetes

A survey of older adults with type 2 diabetes taking insulin or sulfonylureas found that both economic and physical food insecurity were related to increased risk for severe hypoglycemic events.

Hypoglycemia prevention efforts among older patients with diabetes using hypoglycemia-prone medications should address food insecurity, according to a recent study.

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.

To study associations between food insecurity and severe hypoglycemia, researchers designed a survey-based cross-sectional study of 1,164 people ages 65 years and older (mean age, 74.5 years) who had type 2 diabetes and were treated with insulin or sulfonylureas in 2019. The main outcome measures were risk ratios (RRs) for economic and physical food insecurity associated with self-reported severe hypoglycemia (defined as low blood glucose requiring assistance), adjusted for age, financial strain, HbA1c level, Charlson comorbidity score, and frailty. Results were published May 20 in the Journal of General Internal Medicine.

Overall, 12.3% of respondents reported food insecurity. Of these, 38.4% reported only economic food insecurity, 21.1% reported only physical food insecurity, and 40.5% reported both. Both types of food insecurity were most common in respondents who also reported financial strain (50.0% and 30.1%, respectively), but financially secure respondents also reported economic and physical food insecurity (1.2% and 2.8%, respectively). Sixty-two respondents (5.4%) reported a severe hypoglycemic event in the last 12 months.

A strong association was seen between economic food insecurity (RR, 4.3; P=0.02) and physical food insecurity (RR, 4.4; P=0.002) and severe hypoglycemia. The most common reason given for hypoglycemia (77.5%) was missed meals ("skipped meals, not eating enough or waiting too long to eat"). Food insecurity overall was strongly associated with severe hypoglycemia (RR, 4.1 [95% CI, 1.7 to 9.9]; P=0.002) after adjustment for age, frailty, HbA1c level, Charlson comorbidity score, and financial strain. The association with severe hypoglycemia was stronger when both economic and physical food insecurity were present versus food security or one type of food insecurity (RR, 5.4 [95% CI, 1.5 to 19.2]; P=0.009).

"The physical and economic causes of food insecurity may require distinct solutions; failure to consider both causes can lead to underestimating the burden of food insecurity, overlook a segment of the population who need food assistance or interventions to prevent the clinical consequences of food insecurity or lead to inappropriate responses to different underlying problems," the authors wrote. "In research and practice, standard food insecurity questions are often limited to querying only about economic food insecurity which will fail to identify patients (1 in 5 older patients with diabetes in our study) who have physical food insecurity only."