Resea ch: Complica ions
Sel - epo ed non-se e e hypoglycaemic e en s in Eu ope
C. G. O
¨s enson
1
, P. Geelhoed-Duij es ijn
2
, J. Lah ela
3
, R. Wei gasse
4,5
, M. Ma ke Jensen
6
and U. Pede sen-Bje gaa d
7
1
Depa men o Molecula Medicine and Su ge y, Ka olinska Ins i u e , S ockholm, Sweden,
2
Depa men o In e nal Medicine, Medical Cen e Haaglanden,
The Hague, Ne he lands,
3
Depa men o Medicine, Uni e si y o Tampe e, Tampe e, Finland,
4
Depa men o In e nal Medicine, Diakonissen Hospi al Salzbu g,
Salzbu g, Aus ia,
5
Depa men o In e nal Medicine, Salzbu g Gene al Hospi al, Pa acelsus Medical Uni e si y Salzbu g, Salzbu g, Aus ia,
6
No o No disk
Scandina ia AB, Copenhagen, Denma k and
7
Depa men o Ca diology, Neph ology and Endoc inology, Hille ød Uni e si y Hospi al, Denma k
Accep ed 18 June 2013
Abs ac
Aims Hypoglycaemia p esen s a ba ie o op imum diabe es managemen bu da a a e limi ed on he equency o
hypoglycaemia inciden s ou side o clinical ials. The p esen s udy in es iga ed he a es o sel - epo ed non-se e e
hypoglycaemic e en s, hypoglycaemia awa eness and physician discussion o e en s in people wi h Type 1 diabe es
melli us o insulin- ea ed Type 2 diabe es melli us.
Me hods People in se en Eu opean coun ies aged >15 yea s wi h Type 1 diabe es o insulin– ea ed Type 2 diabe es
(basal-only, basal-bolus and o he insulin egimens) we e ec ui ed ia consume panels, nu ses, elephone ec ui men
and amily e e als. Responden s comple ed ou online ques ionnai es. The i s ques ionnai e collec ed backg ound
in o ma ion on demog aphics and hypoglycaemia- ela ed beha iou , whils all ou ques ionnai es collec ed da a on
non-se e e hypoglycaemic e en s in he p eceding 7 days.
Resul s Analysis was based on 11 440 esponden -weeks om 3827 esponden s. All pa icipan s comple ed he i s
ques ionnai e and 57% comple ed all ou . The mean numbe o e en s/ esponden –week was 1.8 (Type 1 diabe es) and
0.4–0.7 (Type 2 diabe es, wi h di e en insulin ea men s) co esponding o annual e en a es o 94 and 21–36,
espec i ely. A o al o 63% o esponden s wi h Type 1 diabe es and 49–64% o esponden s wi h Type 2 diabe es,
ea ed wi h di e en insulin egimens, who expe ienced hypoglycaemic e en s, epo ed impai ed hypoglycaemia
awa eness o unawa eness. A high p opo ion o esponden s a ely o ne e in o med hei gene al p ac i ione /
specialis abou hypoglycaemia: 65% (Type 1 diabe es) and 50–59% (Type 2 diabe es). O e all, 16% o esponden s
wi h Type 1 diabe es and 26% o esponden s wi h Type 2 diabe es epo ed no being asked abou hypoglycaemia
du ing ou ine appoin men s.
Conclusion Non-se e e hypoglycaemic e en s a e common amongs people wi h Type 1 diabe es and insulin– ea ed
Type 2 diabe es in eal-wo ld se ings. Many a ely o ne e in o m hei gene al p ac i ione /specialis abou hei
hypoglycaemia and he eal bu den o hypoglycaemia may be unde es ima ed.
Diabe . Med. 31, 92–101 (2014)
In oduc ion
The goal o diabe es managemen o people wi h Type 1 o
Type 2 diabe es melli us is o main ain no moglycaemia so
as o educe diabe ic complica ions and he isk o
mo ali y; howe e , he in ensi ica ion o he apy o achie e
his goal may inc ease he incidence o hypoglycaemic
episodes.
Hypoglycaemia emains a common and unp edic able side
e ec o insulin he apy, and has a nega i e physical and
emo ional impac on people wi h diabe es [1]. Hypoglycae-
mic episodes a e cha ac e ized as ei he se e e o non-se e e
acco ding o whe he assis ance is equi ed om ano he
indi idual, o whe he he pe son wi h diabe es can manage
he e en alone, espec i ely [2,3]. Non-se e e hypoglycae-
mic e en s accoun o 88–98% o all hypoglycaemic e en s
Co espondence o: M. Ma ke Jensen. E-mail: mm j@no ono disk.com
This pape was p e iously p esen ed as ollows: O
¨s enson CG,
Geelhoed-Duij es ijn PH, Jensen MM, Pede sen-Bje gaa d U. Pa ien - epo ed
hypoglycaemia in eal-wo ld se ings in se en Eu opean coun ies. ISPOR 15 h
Annual Eu opean Cong ess 2012 A277 DB4.
This is an open access a icle unde he e ms o he C ea i e Commons
A ibu ion-NonComme cial License, which pe mi s use, dis ibu ion and
ep oduc ion in any medium, p o ided he o iginal wo k is p ope ly ci ed and
is no used o comme cial pu poses.
92
ª2013 The Au ho s.
Diabe ic Medicine published by John Wiley & Sons L d on behal o Diabe es UK.
DIABETICMedicine
DOI: 10.1111/dme.12261
[4–6] and ha e been shown o a ec unc ioning [7],
heal h- ela ed quali y o li e [4,8], heal hca e esou ce use
[4] and wo k p oduc i i y [7]. Fu he mo e, hypoglycaemia
p esen s a signi ican ba ie o op imum diabe es manage-
men , as ea o hypoglycaemic e en s may cause exagge a ed
a oidance beha iou and consequen ly subop imum insulin
he apy and poo glycaemic con ol [9,10]. Whils he
impo ance o educa ion abou he ecogni ion and ea men
o hypoglycaemia is acknowledged in he cu en Eu opean
Associa ion o he S udy o Diabe es and Ame ican Diabe es
Associa ion consensus s a emen [11], he eal-wo ld le els o
communica ion be ween heal hca e p o essionals and people
wi h diabe es ega ding hypoglycaemia a e no ully unde -
s ood.
Da a on he equency o hypoglycaemia, speci ically
non-se e e hypoglycaemic e en s, ou side o clinical ial
se ings a e limi ed and a ied [1,5,6,8]. The a iabili y o
da a is p obably a ibu able o di e ing s udy popula ions
(deg ee o selec ion, Type 1 diabe es and/o insulin- ea ed
Type 2 diabe es), a ge s o glycaemic con ol, du a ion o
ea men , me hods o da a collec ion and coun y co e age
wi hin hese s udies.
Ou aim was o in es iga e he eal-wo ld equency o
sel - epo ed non-se e e hypoglycaemic e en s, le els o
impai ed hypoglycaemia awa eness and discussion o hypo-
glycaemic e en s wi hin physician consul a ions. We used a
mul i-coun y ques ionnai e-based su ey in a la ge non-
in e en ional coho o people wi h Type 1 diabe es o
insulin- ea ed Type 2 diabe es. The ques ionnai e also
explo ed he heal h- ela ed impac and economic bu den o
hypoglycaemia, he esul s o which a e o be p o ided in a
ollow-on publica ion.
Subjec s and me hods
The ques ionnai e-based su ey was conduc ed be ween
No embe 2011 and May 2012 and ec ui ed esponden s
om Aus ia, Denma k, Finland, No way, Sweden, Swi ze -
land and he Ne he lands. Responden s we e p ima ily
ec ui ed ia exis ing la ge consume panels ha we e
es ablished o e lec a ep esen a i e sample o he gene al
diabe es popula ion, based on age, gende and o he demo-
g aphic cha ac e is ics. Whe e su icien numbe s o espon-
den s could no be iden i ied ia consume panels, o he
me hods o ec ui men we e ini ia ed, including he use o
ad e isemen s on diabe es- ela ed websi es and pa ien
associa ion websi es (wi h a link o he sc eene o inclusion
in he su ey), ace- o- ace ec ui men , elephone ec ui -
men and subsequen e e als om iends/ amily. In addi-
ion, some esponden s we e di ec ly ec ui ed a gene al
p ac i ione clinics by nu ses who we e asked o iden i y
pa icipan s and seek consen o pa icipa ion, be o e
p o iding con ac de ails o hose eligible o ake pa in
he su ey. All esponden s comple ed a sc eening s age o
de e mine eligibili y o s udy inclusion. Be o e s udy en y,
esponden s we e unawa e ha he su ey ela ed o hypo-
glycaemia. A a ge o 600 esponden s pe coun y was se
wi h an expec a ion ha he p obabili y o a hypoglycaemic
e en would ha e a 95% CI o 4%.
The inclusion c i e ia we e a diagnosis o ei he Type 1
diabe es o Type 2 diabe es om a heal hca e p o essional,
cu en insulin ea men and age >15 yea s. In addi ion,
esponden s we e equi ed o ead and speak he na i e
language o he coun y in which hey esided and ha e an
email add ess in o de o comple e he ques ionnai e online.
Responden s we e o e ed a small incen i e o comple ion o
he en i e su ey (€5–25), in line wi h cu en ma ke
esea ch guidelines and o ensu e he e was no undue
incen i e o pa icipa e. All esponden s we e anonymous
acco ding o he egula ions and p ac ice o he ma ke
esea ch go e ning bodies, he Eu opean Socie y o Opinion
and Ma ke ing Resea ch [12] and he Eu opean Pha maceu-
ical Ma ke Resea ch Associa ion [13].
Eligible esponden s we e in i ed by email o comple e an
online ques ionnai e, in ou wa es. They ecei ed in i a-
ions o he second, hi d and ou h ques ionnai es 7 days
a e hey had comple ed he p e ious ques ionnai e.
Ques ionnai es we e adap ed om hose used in a p e ious
s udy [7], which had been designed using insigh s collec ed
du ing ocus g oups on he impac o hypoglycaemia
epo ed by people wi h diabe es [14]. Da a collec ed in
he i s ques ionnai e included esponden demog aphics,
p e ious expe ience wi h and awa eness o hypoglycaemia,
he impac o hypoglycaemia and he numbe o non-se e e
hypoglycaemic e en s and se e e hypoglycaemic e en s.
Wha ’s new?
•Limi ed da a exis on he equency o non-se e e
hypoglycaemic e en s in people wi h Type 1 o Type 2
diabe es in eal-wo ld p ac ice, as non-se e e hypogly-
caemic e en s, by de ini ion, do no equi e heal hca e
p o essional in e ac ions (a e no ou inely egis e ed).
•The equency o non-se e e hypoglycaemic e en s in
eal-wo ld p ac ice may di e om ha obse ed in
clinical ials because o he cha ac e is ics o clinical
ial designs.
•To ou knowledge, his is he i s s udy epo ing he
equency o non-se e e hypoglycaemic e en s in eal--
wo ld p ac ice in he se en coun ies in ol ed in ou
s udy.
•Non-se e e hypoglycaemic e en s a e common amongs
people wi h Type 1 o insulin- ea ed Type 2 diabe es.
•Many people wi h diabe es a ely o ne e in o m hei
gene al p ac i ione /specialis abou hei hypoglyca-
emia and he eal bu den may be unde es ima ed.
ª2013 The Au ho s.
Diabe ic Medicine published by John Wiley & Sons L d on behal o Diabe es UK. 93
Resea ch a icle DIABETICMedicine
Responden s we e also asked abou hypoglycaemia- ela ed
discussions du ing gene al p ac i ione /specialis consul a-
ions. Responden s who had expe ienced a non-se e e
hypoglycaemic e en we e asked whe he hey no mally
in o med hei gene al p ac i ione /specialis a e hey had
had a hypoglycaemic e en . A non-se e e hypoglycaemic
e en was de ined as symp oms o hypoglycaemia (e.g.
swea ing, shaking, headache) wi h o wi hou a blood
glucose measu emen , o a low blood glucose measu emen
(≤3.1 mmol/L) wi hou symp oms, ha he indi idual
managed wi hou assis ance om ano he pe son. A se e e
hypoglycaemic e en was de ined as an e en o low blood
glucose le el needing help om a hi d pa y o manage (e.g.
help om a amily membe o a heal hca e p o essional,
including eme gency oom isi s and hospi aliza ion). Ques-
ions also e e ed o non-se e e hypoglycaemic e en s
occu ing du ing he day ime o he nigh - ime (while he
esponden was in bed/asleep). The subsequen ques ion-
nai es ocused only on he numbe o non-se e e hypogly-
caemic e en s and he impac o hese e en s. Comple ion o
he su ey in ou wa es p o ided da a o he numbe o
non-se e e hypoglycaemic e en s occu ing o e he pas
4 weeks, whils minimizing he ecall pe iod (i.e. ou 7-day
pe iods we e epo ed). The es ima ed o al amoun o ime
o comple e all ou ques ionnai es was 35 min. Ques ion-
nai es we e comple ed anonymously bu esponses could be
acked ac oss he ou wa es by an iden i ica ion numbe
assigned a s udy ini ia ion.
Limi s o uppe and lowe en y alues we e included
wi hin he ques ionnai e o minimize e oneous alues. In
addi ion, da a we e cleaned using a logical consis ency check
ha allowed he emo al o indi idual answe s o which
inco ec calcula ions had been made by a esponden (e.g.
whe e longe ea men du a ion han diabe es du a ion was
epo ed), o he emo al o he esponden om he en i e
analysis in ins ances whe e ype o diabe es was no known o
whe e e oneous epo ing o simple demog aphic a iables
occu ed (e.g. diabe es du a ion longe han cu en age).
The a e o non-se e e hypoglycaemic e en s was calcula ed
using da a om all esponden s who comple ed a leas one
wa e o he su ey. The i s ques ionnai e collec ed da a o
non-se e e hypoglycaemic e en s in he las 4 weeks and he
las 7 days. All subsequen wa es epo ed only he numbe o
non-se e e hypoglycaemic e en s in he las 7 days, so he
es ima ed weekly a es om he 4-week a e p o ided in wa e
one could be ma ched wi h he weekly a es epo ed by he
ou imes 7-day a es ac oss wa es one, wo, h ee and ou .
Annual e en a es we e calcula ed using he subsequen wa e
mean e en a e pe esponden -week mul iplied by 52.
The ela ionships be ween demog aphic ac o s and he
annual a e o non-se e e hypoglycaemic e en s we e
analysed in eg ession models. The con inuous dependen
a iable o he annual e en a e was es ima ed by combining
wo a iables: he 4-weekly non-se e e hypoglycaemia e en
a e and, o esponden s who did no expe ience a
hypoglycaemic e en in he p e ious 4 weeks, answe s o
he ques ion, ‘How o en do you no mally ha e non-se e e
hypoglycaemic e en s?’ This analysis used da a collec ed
du ing he i s wa e o he su ey. Analysis on Type 1 and
Type 2 diabe es was ca ied ou sepa a ely. Reg ession
analyses we e conduc ed o he whole s udy popula ion, as
he s udy was no designed o c oss-coun y compa isons.
The classi ica ion sys em o awa eness o hypoglycaemia
was based on a p ospec i ely alida ed s udy by Pede sen-
Bje gaa d e al. 2003 [15]. Any esponden who answe ed
‘some imes’ o ‘ne e ’ o he ques ion, ‘Can you eel when
you blood suga is low?’ was classi ied as being unawa e o
hypoglycaemia, hose who answe ed ‘usually’ we e classi ied
as ha ing impai ed awa eness and hose who answe ed
‘always’ we e classi ied as awa e.
S anda d desc ip i e me hods (means/pe cen age and s an-
da d de ia ions) we e used o epo esul s o esponden s
in he ollowing ou g oups: people wi h Type 1 diabe es,
people wi h Type 2 diabe es ecei ing basal-only/long-ac ing
insulin-only he apy, people wi h Type 2 diabe es ecei ing
basal-bolus/bo h sho - and long-ac ing insulin he apy, o
people wi h Type 2 diabe es ecei ing ano he o m o insulin
he apy. Compa isons we e pe o med using - es s and a
P alue <0.05 was conside ed o indica e s a is ical
signi icance.
Resul s
A o al o 3959 esponden s ac oss se en coun ies we e
ec ui ed o he s udy and 132 (3.3%) we e excluded as a
esul o inadequa e ques ionnai e comple ion. The emaining
3827 esponden s comple ed he ini ial su ey, wi h 76, 66
and 57% comple ing wa es wo, h ee and ou , espec i ely,
esul ing in a o al o 11 440 esponden -week eco ds.
The demog aphics o esponden s wi h Type 1 diabe es
and hose wi h Type 2 diabe es a e shown in Table 1 and
we e simila ac oss coun ies (da a no shown). Di e ences
be ween esponden s wi h Type 1 diabe es and esponden s
wi h Type 2 diabe es we e consis en wi h hose expec ed
(age, diabe es du a ion e c.). Age and BMI we e nega i ely
co ela ed wi h he annual a e o non–se e e hypoglycaemic
e en s (P<0.05). Female gende and du a ion o insulin
ea men we e posi i ely co ela ed wi h he annual e en
a e (P<0.05).
The mean sel - epo ed non-se e e hypoglycaemic e en
a e was 1.8 pe esponden -week o esponden s wi h Type
1 diabe es and 0.5 o esponden s wi h Type 2 diabe es
(Table 2). Indi idual coun y da a a e also epo ed in
Table 2. Ra es o esponden s wi h Type 2 diabe es we e 0.4
( esponden s ecei ing basal-only/long-ac ing insulin-only
he apy), 0.7 ( esponden s ecei ing basal-bolus/bo h sho -
and long-ac ing insulin he apy) and 0.5 ( esponden s
ecei ing ano he o m o insulin he apy; Table 2). The
calcula ed mean annual e en a es we e he e o e 91.0,
20.3, 35.4 and 27.0 in he ou g oups (Table 2). The
94
ª2013 The Au ho s.
Diabe ic Medicine published by John Wiley & Sons L d on behal o Diabe es UK.
DIABETICMedicine Sel - epo ed non-se e e hypoglycaemic e en s in Eu ope C. G.
€
Os enson e al.
p opo ion o noc u nal non-se e e hypoglycaemic e en s
we e sligh ly g ea e in esponden s wi h Type 2 diabe es
han in esponden s wi h Type 1 diabe es: 22% (Type 1
diabe es), 32% ( esponden s wi h Type 2 diabe es ecei ing
basal-only/long-ac ing insulin-only he apy), 22% ( espon-
den s wi h Type 2 diabe es ecei ing basal-bolus/bo h sho -
and long-ac ing insulin he apy) and 27% ( esponden s wi h
Type 2 diabe es ecei ing ano he o m o insulin he apy;
Table 2). Fou -week non-se e e hypoglycaemic e en a es
ecalled by esponden s in ques ionnai e one we e simila o,
al hough sligh ly lowe han, hose collec ed o e he ou
wa es o he s udy (Table 2).
The mean numbe o sel - epo ed se e e hypoglycaemic
e en s expe ienced in he las yea was 0.7 o esponden s
wi h Type 1 diabe es, 0.1 o esponden s wi h Type 2
diabe es ecei ing basal-only/long-ac ing insulin-only he -
apy, 0.2 o esponden s wi h Type 2 diabe es ecei ing
basal-bolus /bo h sho - and long-ac ing insulin he apy and
0.2 o esponden s wi h Type 2 diabe es ecei ing ano he
o m o insulin he apy (Table 2).
O e all, 76% o s udy esponden s (87% o esponden s
wi h Type 1 and 59–78% o esponden s wi h Type 2
diabe es) had p e iously expe ienced a hypoglycaemic e en
a any poin (i.e. no jus in he s udy ecall pe iod). In
esponden s who had p e ious expe ience o hypoglycaemic
e en s, impai ed awa eness was epo ed by 53% o espon-
den s wi h Type 1 diabe es, 45% o esponden s wi h Type 2
diabe es ecei ing basal-only/long-ac ing insulin he apy
only, 43% o esponden s wi h Type 2 diabe es ecei ing
basal-bolus/bo h sho - and long-ac ing insulin he apy and
43% o esponden s wi h Type 2 diabe es ecei ing ano he
o m o insulin he apy (Table 3). A u he 10, 19, 6 and
8% we e classi ied as unawa e o each esponden ype,
espec i ely. Responden s wi h Type 1 diabe es who we e
unawa e had signi ican ly highe a es o non-se e e hypo-
glycaemic e en s han hose who we e always awa e
(P<0.05; Table 3). Among esponden s wi h Type 2
diabe es ecei ing basal-only/long-ac ing insulin-only he -
apy and esponden s wi h Type 2 diabe es ecei ing
basal-bolus/bo h sho - and long-ac ing insulin he apy,
esponden s wi h impai ed awa eness had signi ican ly
highe non-se e e hypoglycaemic e en a es han hose
who we e awa e (P<0.05). In esponden s wi h Type 2
diabe es ecei ing ano he o m o insulin he apy, signi -
ican ly lowe non-se e e hypoglycaemic e en a es we e
obse ed in unawa e esponden s han in esponden s who
we e always awa e (P<0.05; Table 3). Signi ican ly highe
a es o se e e hypoglycaemic e en s we e epo ed by
esponden s wi h Type 1 diabe es classi ied ei he as unawa e
o as ha ing impai ed awa eness, compa ed wi h awa e
esponden s (P<0.05).
A high p opo ion o esponden s who had expe ienced a
non-se e e hypoglycaemic e en s a ed ha hey ‘ a ely’
o ‘ne e ’ in o med hei gene al p ac i ione /specialis
abou hei hypoglycaemia: 65% ( esponden s wi h Type 1
Table 1 Responden - ela ed cha ac e is ics
Type 1
diabe es
Type 2
diabe es
Numbe o esponden s,
n(%)
1631 (43) 2196 (57)
Mean (SD) age*44.3 (14.1) 60.3 (10.7)
Gende , emale, n(%)
†
722 (44) 735 (33)
Educa ion, n(%)
‡
P ima y school 244 (15) 393 (18)
High school 808 (49) 1147 (52)
Uni e si y (plus PhD.
o highe )
517 (32) 558 (25)
O he 62 (4) 98 (5)
Mean (SD) BMI*25.87 (4.88) 31.54 (6.39)
Smoking, n(%)
§
Smoke 458 (28) 450 (20)
Ex-smoke 418 (26) 1008 (46)
Non-smoke 755 (46) 738 (34)
Diabe es du a ion, n(%)
<2 yea s 20 (1) 41 (2)
2–5 yea s 220 (14) 317 (15)
5–9 yea s 145 (10) 394 (19)
10–14 yea s 197 (13) 546 (26)
15 +yea s 957 (62) 806 (38)
Insulin ea men ype,
n(%)
¶
Long-ac ing insulin only 134 (8) 812 (37)
Bo h sho - and
long-ac ing insulin
1058 (65) 942 (43)
O he insulin ypes 439 (27) 442 (20)
Du a ion o insulin
ea men , n(%)**
<2 yea s 113 (7) 311 (14)
2–5 yea s 189 (12) 741 (35)
5–9 yea s 136 (9) 394 (18)
10 +yea s 1101 (72) 659 (32)
HbA
1c§
Mean mmol/mol (SD); 61 (16.1) 60 (16.9)
Na ional Glycohaemoglobin
S anda disa ion
P og amme%, (SD)
7.7 (1.5) 7.6 (1.5)
Medical complica ions,
none epo ed, n(%)
††
1036 (64) 1148 (52)
*Signi ican nega i e co ela ion wi h yea ly numbe o
non-se e e hypoglycaemic e en s ( o bo h Type 1 diabe es
and Type 2 diabe es, acco ding o eg ession analysis;
P<0.05).
†Signi ican posi i e co ela ion wi h yea ly numbe o non-
se e e hypoglycaemic e en s ( o bo h Type 1 diabe es and
Type 2 diabe es, acco ding o eg ession analysis; P<0.05).
‡Signi ican (P<0.05) nega i e co ela ion wi h yea ly numbe
o non-se e e hypoglycaemic e en s (Type 2 diabe es only).
§No signi ican co ela ion wi h yea ly numbe o non-se e e
hypoglycaemic e en s.
¶Va iable no included in he eg ession analysis.
**Du a ion o insulin ea men was co ela ed wi h diabe es
du a ion, and hus du a ion o ea men was included in he
eg ession analysis. A signi ican posi i e co ela ion was ound
be ween du a ion o ea men and yea ly numbe o non-se e e
hypoglycaemic e en s ( o bo h Type 1 diabe es and Type 2
diabe es; P<0.05).
††Medical complica ions we e co ela ed wi h age. Medical
complica ions we e no signi ican ly associa ed wi h yea ly
numbe o non-se e e hypoglycaemic e en s, independen o
hei associa ion wi h age. Ques ionnai e op ions o medical
complica ions included: None, Eye p oblems, Neu opa hy,
Ca dio ascula disease, Renal disease, Ampu a ions, O he
(please speci y).
ª2013 The Au ho s.
Diabe ic Medicine published by John Wiley & Sons L d on behal o Diabe es UK. 95
Resea ch a icle DIABETICMedicine
Table 2 Sel - epo ed, ecalled a es o hypoglycaemic e en s
Ra es based on 11440 w epo s om 3827 esponden s
To al:
N=3827; 11440 w
Aus ia:
n=553;
1773 w
Swi ze land:
n=395;
1116 w
Denma k:
n=601;
1894 w
Finland:
n=628;
1364 w
Ne he lands:
n=692;
2456 w
No way
n=379;
918 w
Sweden
n=579;
1919 w
Mean (SD) sel - epo ed NSHE
a e pe esponden pe week*
Type 1 diabe es 1.8 (2.3) 1.6 (2.3) 1.4 (1.8) 1.9 (2.4) 1.3 (2.1) 2.0 (2.5) 1.8 (2.2) 2.0 (2.5)
Type 2 diabe es: BOT 0.4 (1.1) 0.3 (0.8) 0.4 (0.9) 0.5 (1.5) 0.2 (0.6) 0.5 (1.2) 0.4 (1.0) 0.4 (1.1)
Type 2 diabe es: BB 0.7 (1.3) 0.5 (1.1) 0.6 (1.0) 0.7 (1.6) 0.5 (1.1) 0.7 (1.2) 1.0 (1.7) 0.9 (1.7)
Type 2 diabe es: O he 0.5 (1.2) 0.4 (0.8) 0.7 (1.2) 0.4 (1.0) 0.2 (0.6) 0.9 (1.7) 0.6 (1.2) 0.4 (0.7)
Mean annual calcula ed NSHE
a es (52 weeks)*
Type 1 diabe es 91.0 84.8 73.3 98.8 67.1 105.0 93.1 106.1
Type 2 diabe es: BOT 20.3 15.1 18.7 23.4 10.4 24.4 20.3 22.4
Type 2 diabe es: BB 35.4 27.6 32.2 38.5 25.0 34.3 50.4 45.8
Type 2 diabe es: O he 27.0 18.7 36.9 21.8 12.5 44.7 29.6 18.7
P opo ion o NSHE ha occu
whils sleeping, %*
Type 1 diabe es 22 19 20 22 31 13 19 20
Type 2 diabe es: BOT 32 22 49 27 22 33 18 39
Type 2 diabe es: BB 22 22 28 24 33 16 26 20
Type 2 diabe es: O he 27 15 42 38 39 25 11 19
Based on all esponden s comple ing wa e 1, n=3825
Mean (SD) sel - epo ed
NSHE 4 week a e
†
Type 1 diabe es 6.3 (8.2) 5.5 (6.9) 6.0 (7.8) 7.7 (9.3) 4.2 (7.6) 7.9 (9.1) 6.3 (8.0) 7.4 (7.6)
Type 2 diabe es: BOT 1.2 (3.2) 0.7 (1.7) 0.8 (1.6) 1.6 (4.3) 0.5 (1.4) 1.5 (4.2) 1.2 (2.1) 1.5 (3.5)
Type 2 diabe es: BB 2.6 (5.1) 1.6 (2.4) 2.1 (3.9) 3.1 (6.2) 1.6 (2.9) 3.1 (5.0) 2.5 (3.3) 3.5 (7.9)
Type 2 diabe es: O he 1.7 (3.9) 1.3 (2.5) 0.6 (1.3) 1.4 (3.0) 0.8 (1.1) 3.4 (5.7) 2.9 (7.1) 1.5 (2.6)
Based on all esponden s comple ing wa e 1, n=3820
Mean (SD) numbe o
SHEs in he las yea
‡
Type 1 diabe es 0.7 (2.4) 0.7 (2.1) 0.6 (2.0) 0.6 (2.3) 0.6 (2.0) 0.9 (2.3) 1.0 (3.2) 0.9 (2.8)
Type 2 diabe es: BOT 0.1 (0.8) 0.1 (0.5) 0.2 (0.6) 0.1 (0.2) 0.1 (0.3) 0.1 (0.3) 0.2 (0.6) 0.3 (1.6)
Type 2 diabe es: BB 0.2 (0.8) 0.2 (0.6) 0.5 (1.4) 0.1 (0.6) 0.1 (0.3) 0.2 (0.9) 0.4 (1.4) 0.1 (0.4)
Type 2 diabe es: O he 0.2 (0.8) 0.2 (0.5) 0.3 (1.1) 0.3 (1.3) 0.1 (0.4) 0.2 (0.5) 0.1 (0.3) 0.1 (0.3)
w, esponden week; NSHE, non-se e e hypoglycaemic e en ; BOT, basal-only/long-ac ing insulin-only he apy; BB, basal bolus/sho - and long-ac ing insulin he apy; SHE, se e e hypoglycaemic
e en ; O he , e.g. mixed insulin.
*All esponden -weeks epo ed; includes all esponden s ega dless o whe he comple ing all ou ques ionnai es.
†All esponden s comple ing wa e 1 ( wo esponses we e emo ed because o e oneous answe s o his ques ion).
‡All esponden s comple ing wa e 1 (se en esponses we e emo ed because o e oneous answe s o his ques ion).
96
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DIABETICMedicine Sel - epo ed non-se e e hypoglycaemic e en s in Eu ope C. G.
€
Os enson e al.

diabe es), 50% ( esponden s wi h Type 2 diabe es ecei ing
basal-only/long-ac ing insulin-only he apy), 59% ( espon-
den s wi h Type 2 diabe es ecei ing basal-bolus/bo h sho -
and long-ac ing insulin he apy) and 53% ( esponden s wi h
Type 2 diabe es ecei ing ano he o m o insulin he apy;
Table 4). The lowes le el o communica ion was epo ed in
he Ne he lands (da a no shown). The p opo ion o
esponden s in he Ne he lands who a ely o ne e in o med
hei gene al p ac i ione /specialis abou hei hypoglycae-
mic e en s was 86% ( esponden s wi h Type 1 diabe es),
64% ( esponden s wi h Type 2 diabe es ecei ing basal-only
he apy/long-ac ing insulin-only he apy), 77% ( esponden s
wi h Type 2 diabe es ecei ing basal-bolus/bo h sho - and
long-ac ing insulin he apy) and 79% ( esponden s wi h
Type 2 diabe es ecei ing ano he o m o insulin he apy).
E en a es o non-se e e hypoglycaemic e en s we e
signi ican ly highe o esponden s wi h Type 1 diabe es o
Type 2 diabe es who a ely o ne e in o med a physician
abou hei non-se e e hypoglycaemic e en s (P<0.05).
When esponden s we e asked abou opics discussed du ing
gene al p ac i ione /specialis consul a ions, 17% (Type 1
diabe es), 28% (Type 2 diabe es ecei ing basal-only/
long-ac ing insulin-only he apy), 26% (Type 2 diabe es
ecei ing basal-bolus/bo h sho - and long-ac ing insulin
he apy) and 21% (Type 2 diabe es ecei ing ano he o m o
insulin he apy) o esponden s s a ed ha hei gene al
Table 3 Sel - epo ed esponden awa eness o hypoglycaemia and co esponding e en a es in esponden s who had p e iously expe ienced a
hypoglycaemic e en
Responden s, N=2925*
Type 1
diabe es,
n=1420
Type 2 diabe es
BOT, n=479 BB, n=736 O he , n=290
Can you eel when you blood suga is low? Always awa e,% 36 36 51 49
Impai ed awa eness,% 53 45 43 43
Unawa e,% 10 19 6 8
Mean (SD) NSHE a es o hose esponden s
who a e awa e, ha e impai ed
awa eness o a e unawa e
Always awa e 1.7 (2.3) 0.5 (1.0) 0.8 (1.5) 0.7 (1.4)
Impai ed awa eness 1.9 (2.2) 0.6 (1.2)
†
0.9 (1.5)
†
0.7 (1.2)
Unawa e 2.6 (3.0)
†
0.4 (1.0) 0.7 (1.1) 0.3 (0.7)
†
Mean (SD) SHE a es o hose esponden s who
a e awa e, ha e impai ed awa eness o a e
unawa e
Always awa e 0.4 (1.8) 0.2 (0.6) 0.2 (0.9) 0.2 (0.5)
Impai ed awa eness 0.8 (1.9)
†
0.2 (1.1) 0.2 (0.7) 0.2 (1.2)
Unawa e 2.7 (5.2)
†
0.1 (0.5) 0.4 (1.0) 0.2 (0.5)
BOT, basal-only/long-ac ing insulin-only he apy; BB, basal-bolus/sho - and long-ac ing insulin he apy; O he , e.g. mixed insulin; NSHE,
non-se e e hypoglycaemic e en ; SHE,se e e hypoglycaemic e en .
*All esponden s who had p e iously expe ienced a NSHE a any poin (i.e. no jus in he s udy ecall pe iod; n=2925).
†P<0.05 signi icance agains always awa e.
Table 4 Communica ion be ween esponden s and gene al p ac i ione s/specialis s
All esponden s, N=3827*
Type 1 diabe es,
n=1631
Type 2 diabe es
BOT, n=812 BB, n=942 O he , n=442
Gene al p ac i ione /specialis did no ask
abou hypoglycaemia du ing ou ine
appoin men s,%*
17 28 26 21
All esponden s who ha e e e
expe ienced a NSHE, N=2925
†
Type 1 diabe es,
n=1420
Type 2 diabe es
BOT, n=479 BB, n=736 O he , n=290
P opo ion o esponden s a ely o ne e
in o ming hei gene al p ac i ione /specialis
o a hypoglycaemic e en , %
†
65 50 59 53
Mean (SD) NSHE a es o hose esponden s
communica ing e sus hose who do no ell
hei gene al p ac i ione /specialis
†
Always/Mos ly 1.5 (1.9) 0.4 (0.9) 0.6 (1.0) 0.6 (0.9)
Ra ely/Ne e 2.2 (2.3)
‡
0.6 (1.0)
‡
1.0 (1.5)
‡
0.8 (1.2)
BOT, basal-only/long-ac ing insulin-only he apy; BB, basal-bolus/sho - and long-ac ing insulin he apy; O he , e.g. mixed insulin; NSHE,
non-se e e hypoglycaemic e en .
*All esponden s comple ing ques ionnai e one (n=3827).
†All esponden s who ha e e e expe ienced a NSHE (n=2925).
‡P<0.05 signi icance.
ª2013 The Au ho s.
Diabe ic Medicine published by John Wiley & Sons L d on behal o Diabe es UK. 97
Resea ch a icle DIABETICMedicine
p ac i ione /specialis ‘did no ask abou hypoglycaemia
du ing ou ine appoin men s’ (Table 4).
Discussion and conclusions
This s udy cap u es he sel - epo ed, ecalled a es o
non-se e e hypoglycaemic e en s and se e e hypoglycaemic
e en s in bo h people wi h Type 1 diabe es and hose wi h
insulin- ea ed Type 2 diabe es, and shows ha hypoglycae-
mic e en s emain a common ad e se e en o insulin he apy
in bo h g oups. The majo i y o he published li e a u e on
hypoglycaemic e en a es includes only people wi h Type 1
diabe es, o is ocused on epo ing se e e hypoglycaemic
e en s only, and may no adequa ely e lec he equency o
hypoglycaemic e en s (especially non-se e e hypoglycaemic
e en s) ac oss he insulin- ea ed diabe es popula ion. In
con as , he p esen s udy explo ed he equency o
non-se e e hypoglycaemic e en s and se e e hypoglycaemic
e en s in people wi h Type 1 diabe es and people wi h
insulin- ea ed Type 2 diabe es ac oss se en Eu opean
coun ies.
The ecalled a es o non-se e e hypoglycaemic e en s o
esponden s wi h Type 1 diabe es (1.8 pe esponden , pe
week) in his s udy a e compa able wi h esul s om h ee
p e iously conduc ed s udies in No he n Eu ope, which
epo ed non-se e e hypoglycaemic e en a es o 1.8, 2.0 and
2.2 pe esponden , pe week [6,16,17]. Ra es o non-se e e
hypoglycaemic e en s o esponden s wi h Type 2 diabe es in
he cu en s udy a e highe han hose epo ed in a
p ospec i e single-cen e s udy in Sco land, UK (0.4–0.7 s
0.3 pe esponden , pe week) bu his a ia ion may be
a ibu able o di e ences in he geog aphical egion, Type 2
diabe es ea men egimen, and s udy sample size, o he way
in which hypoglycaemic e en s had been de ined [5]. Hypo-
glycaemic e en s occu ed less equen ly in esponden s wi h
insulin- ea ed Type 2 diabe es compa ed wi h esponden s
wi h Type 1 diabe es, and p e ious s udies sugges he
equency o se e e hypoglycaemic e en s in Type 2 diabe es
o be app oxima ely one- hi d o ha expe ienced by people
wi h Type 1 diabe es [5,18]. The esul s epo ed in he
p esen s udy o se e e hypoglycaemic e en s a e consis en
wi h his end (Type 1 diabe es 0.7; Type 2 0.1–0.2) and
sugges a simila a io o non-se e e hypoglycaemic e en s
(Type 1 diabe es 1.8; Type 2 0.4–0.7). I should be no ed ha
he equency o hypoglycaemic e en s in esponden s wi h
Type 2 diabe es a ies acco ding o he ea men egimen
(basal-only/long-ac ing insulin-only he apy, basal-bolus/
bo h sho - and long-ac ing insulin he apy, o ano he o m
o insulin he apy); howe e , his was o be expec ed gi en he
di e en insulin co e age hey p o ide [11].
O e all, noc u nal e en s ep esen ed be ween one qua e
and one hi d o all non-se e e hypoglycaemic e en s. In
he p esen s udy, he p opo ion o o e all non-se e e
hypoglycaemic e en s occu ing a nigh was 22% ( espon-
den s wi h Type 1 diabe es), 32% ( esponden s wi h Type 2
diabe es ecei ing basal-only/long–ac ing insulin-only he -
apy), 22% ( esponden s wi h Type 2 diabe es ecei ing
basal-bolus/bo h sho - and long-ac ing insulin he apy), and
27% ( esponden s wi h Type 2 diabe es ecei ing ano he
o m o insulin he apy). Few o he s udies ha e epo ed a es
o noc u nal e en s, al hough he p opo ion o noc u nal
e en s would be expec ed o a y be ween insulin egimens.
In he p esen s udy, we in es iga ed le els o hypoglyca-
emia awa eness and epo ed 10% (Type 1 diabe es) and
6–19% (Type 2 diabe es) o esponden s o be classi ied as
unawa e and 53% (Type 1 diabe es) and 43–45% (Type 2
diabe es) o ha e impai ed awa eness o hypoglycaemia
(based on esponden s wi h expe ience o hypoglycaemic
e en s). A compa able p opo ion o esponden s wi h Type
1 diabe es we e ound o ha e impai ed awa eness (47%) o
be classi ied as unawa e (13%) in a 1-yea p ospec i e s udy
ha used he alida ed ques ion, ‘Do you ecognise symp-
oms when you ha e a hypo?’ [15]. Fu he mo e, a c oss-
sec ional s udy in a coho o 401 people wi h Type 2
diabe es, also using his ques ion, epo ed a simila p opo -
ion o esponden s wi h impai ed awa eness (46%) o ha
in he cu en s udy (43–45%) [18]. The e is no consensus on
how o classi y awa eness, bu ou me hod bene i s om he
use o h ee ca ego ies (ins ead o wo, ‘awa e’ o ‘unawa e’,
as in he Cla ke e al. [19] and Gold e al. [20] me hods),
which enables iden i ica ion o he g adual loss o awa eness.
In addi ion, i is he only me hod p o en o pe o m simila ly
ac oss language ba ie s [21].
Some conside a ion should be gi en o he di e en
esponden demog aphics wi hin he cu en s udy. Fo
example, symp oms o hypoglycaemia ha e been shown o
decline wi h inc easing age and he p e alence o impai ed
awa eness o hypoglycaemia is epo ed o inc ease wi h
du a ion o Type 1 diabe es [6]; esul s may be con ounded
by hese ac o s. In addi ion, he s udy by Ak am e al. [18]
epo ed impai ed awa eness o hypoglycaemia o be he
mos impo an isk ac o o se e e hypoglycaemia. Resul s
o he cu en s udy show ha esponden s wi h Type 1
diabe es classi ied as unawa e o as ha ing impai ed awa e-
ness o hypoglycaemia epo ed signi ican ly highe a es
(P<0.05) o se e e hypoglycaemic e en s han esponden s
who we e always awa e. Unawa e esponden s wi h Type 1
diabe es also epo ed signi ican ly highe a es o non-se e e
hypoglycaemic e en s compa ed wi h awa e esponden s
(P<0.05). This could be explained by unawa e esponden s
ailing o ake ac ion o p e en he onse o an e en because
o an inabili y o ecognize he symp oms o low blood suga .
Addi ionally, his inabili y may cause esponden s o o e -
compensa e by es ing hei blood glucose mo e equen ly,
esul ing in he iden i ica ion o mo e e en s; howe e , his is
an a ea ha equi es u he in es iga ion, especially as hese
ends we e no obse ed in esponden s wi h Type 2
diabe es.
An impo an inding o he cu en s udy was he high
p opo ion o esponden s wi h Type 1 diabe es (65%) and
98
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Diabe ic Medicine published by John Wiley & Sons L d on behal o Diabe es UK.
DIABETICMedicine Sel - epo ed non-se e e hypoglycaemic e en s in Eu ope C. G.
€
Os enson e al.
Type 2 diabe es (50–59%) who a ely o ne e in o med
hei gene al p ac i ione /specialis abou hei hypoglycae-
mic e en s. Despi e hese esul s, only 17% o esponden s
wi h Type 1 diabe es and 21–28% o esponden s wi h Type
2 diabe es said ha hei gene al p ac i ione /specialis did
no ask hem abou hypoglycaemia du ing ou ine appoin -
men s, sugges ing some le el o communica ion ega ding
hypoglycaemic e en s is aking place. The eluc ance o
people wi h diabe es o discuss hei hypoglycaemia may be
caused by wide ac o s such as conce ns ega ding d i ing
p i ileges [9], implica ions o employmen , o ea ha hey
may be pe cei ed by hei gene al p ac i ione /specialis o
ha e poo con ol o hei diabe es. Fu he esea ch is
needed o unde s and he easoning behind why people may
no ac i ely be epo ing hei hypoglycaemic e en s. Along
wi h discussions on he equency o non-se e e hypoglycae-
mic e en s and se e e hypoglycaemic e en s, o he impo an
aspec s such as impai ed hypoglycaemia awa eness [18] and
ea o hypoglycaemia [9,10] should be add essed, gi en ha
hese a e associa ed wi h an inc eased isk o se e e
hypoglycaemic e en s [18] and a isk o subop imum
glycaemic con ol [9,10], espec i ely. An oppo uni y exis s
o mo e s anda dized measu es o hese sel - epo ed ou -
comes, which may also help o imp o e unde s anding o
people wi h diabe es, and imp o e communica ion le els.
Wi h he endo semen by bo h he Ame ican Diabe es
Associa ion and he Eu opean Associa ion o he S udy o
Diabe es o educa ion ega ding ecogni ion and ea men o
hypoglycaemia [11], i is hoped ha communica ion be ween
people wi h diabe es and hei physicians will inc ease
u he . Whils g ea e educa ion could be expec ed o
imp o e blood glucose managemen , he e will s ill be an
unde lying inc ease in hypoglycaemic complica ions as insu-
lin ea men egimens a e in ensi ied o e ime [1]. This is
suppo ed by ou cu en eg ession analysis, whe e he
numbe o non-se e e e en s inc eased wi h du a ion o
insulin ea men .
The equency o hypoglycaemic e en s epo ed du ing
andomized ials, such as he Diabe es Con ol and Com-
plica ions T ial [22], and he Uni ed Kingdom P ospec i e
Diabe es S udy [23], may no be e lec i e o he incidence in
eal-wo ld p ac ice because o ial inclusion and exclusion
c i e ia and because obse a ional s udies ha e epo ed a
highe incidence o hypoglycaemic e en s in unselec ed
popula ions [1]. In addi ion, he e a e key bene i s o
ob aining da a di ec ly om people wi h diabe es, pa icu-
la ly since a high numbe o hem a e no epo ing
non-se e e hypoglycaemic e en s o hei doc o .
I is impo an ha he limi a ions o his s udy a e
conside ed. Responden demog aphics show ha 8% o
esponden s wi h Type 1 diabe es ecei e long-ac ing
insulin-only he apy. I is likely ha his igu e may be
he esul o inco ec epo ing o diabe es ype by
esponden s wi h Type 2 diabe es. As a esul , gi en ha
esponden s wi h Type 2 diabe es ha e ewe hypoglycae-
mic e en s, ou s udy may unde es ima e he equency o
e en s o esponden s wi h Type 1 diabe es. The su ey is
based upon he ecall o bo h se e e hypoglycaemic e en s
and non-se e e hypoglycaemic e en s and he in e p e a ion
o symp oms is open o bias. A p e ious s udy showed ha
a esponden ’s abili y o emembe non-se e e hypoglycae-
mic e en s du ing he p e ious week was no signi ican ly
di e en om he p ospec i e eco ding o e en s o e
1 week [6]. The cu en s udy was he e o e designed o
maximize he op imum ecall pe iod, by asking esponden s
o eco d e en s occu ing in he p e ious week o each o
he ou ques ionnai es o e 4 consecu i e weeks. Also, a
p e ious s udy has shown ha people wi h Type 1 diabe es
and people wi h Type 2 diabe es a e able o accu a ely
ecall se e e hypoglycaemic e en s wi hin a 1-yea pe iod
(co esponding o he ecall pe iod in he cu en s udy)
[15]. The e is also he po en ial ha he du a ion o he
s udy may o e - o unde es ima e he annual equency o
hypoglycaemia, gi en ha seasonal a ia ion was no
conside ed ( he s udy was conduc ed Decembe –May).
The ec ui men o esponden s, mos ly ia online panels
and he equi emen o an email add ess in o de o
pa icipa e in he s udy could ha e in oduced selec ion
bias; howe e , he in e ne pene a ion a es o all o he
coun ies s udied a e high (80–97%) [24]. The anonymous
na u e o he online panel may allow a be e means o
ob aining sel - epo ed da a on a eas such as communica-
ion le els wi h physicians. Rec ui men was ia b oad
panels e lec i e o he gene al popula ion and esponden s
we e in i ed ia email o pa icipa e in he su ey by
ollowing a link, and we e no in o med ha he su ey was
abou hypoglycaemia be o e hey clicked on he link o
en e he su ey. The e a e he e o e no easons o sugges
any selec ion bias owa ds people s uggling wi h hypo-
glycaemia in he i s wa e o he s udy; howe e , since he
esponse a es o subsequen wa es diminished (76, 66 and
57% o esponden s comple ed wa es wo, h ee and ou ,
espec i ely) we canno exclude he possibili y ha la e
wa es we e comple ed by esponden s who had mo e
expe ience o hypoglycaemic e en s. Ne e heless, a sub-
sequen analysis compa ing e en a es o he di e en
wa es did no sugges any ends owa ds highe equency
in la e wa es. The a ge ec ui men a e o 600 espon-
den s pe coun y was no eached in Aus ia, No way and
Swi ze land because o di icul ies in accessing people wi h
diabe es; howe e , esul s we e ema kably consis en
ac oss he coun ies. Some esponden s did no comple e
all ou wa es, bu only small changes in he non-se e e
hypoglycaemic e en a es (1.09 in wa e 1 o 0.93 in
wa e 4) we e seen when compa ing da a ac oss wa es.
This was a desc ip i e s udy, he e o e, ew compa isons
we e explo ed and no adjus men s we e made o
mul iple c oss-coun y compa isons; howe e , a ia ions in
non-se e e hypoglycaemic e en a es ac oss coun ies we e
1.3–2.0 pe esponden , pe week in Type 1 diabe es, and
ª2013 The Au ho s.
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Resea ch a icle DIABETICMedicine
0.2–1.0 pe esponden , pe week in Type 2 diabe es
(0.2–0.5 in Type 2 diabe es esponden s ecei ing basa-
l-only/long-ac ing insulin-only he apy, 0.5–1.0 in Type 2
diabe es esponden s ecei ing basal-bolus/bo h sho - and
long-ac ing insulin he apy and 0.2–0.9 in Type 2 diabe es
esponden s ecei ing ano he o m o insulin he apy). This
migh e lec o he demog aphic di e ences which we e no
cap u ed, such as local di e ences in ea men egimens,
di e en pa ien educa ion le els o a ge s o glycaemic
con ol. Addi ionally, he ec ui men me hod does no
di e en ia e be ween p ima y and seconda y ca e pa ien s,
which may also ha e an impac .
Despi e hese limi a ions, he p esen s udy epo s he
eal-wo ld a es o hypoglycaemic e en s in a la ge numbe
o people wi h Type 1 diabe es and people wi h Type 2
diabe es ac oss se en Eu opean coun ies and p o ides
e idence o a need o minimize he equency o hypo-
glycaemia. I is acknowledged ha bo h se e e and
non-se e e hypoglycaemic e en s a e mo e equen in
people wi h Type 1 diabe es, bu he associa ed social and
economic bu den o e en s in people wi h Type 2 diabe es
is likely o be subs an ial gi en he global epidemic o Type
2 diabe es [25]. Hypoglycaemia p esen s a ba ie o
op imum glycaemic con ol, inc easing he isk o diabe ic
complica ions and mo ali y; he e o e, discussion du ing
physician consul a ions and educa ion on he ecogni ion
and ea men o hypoglycaemic e en s o people wi h
diabe es a e impe a i e o encou age g ea e communica-
ion wi h physicians.
Funding sou ces
This s udy was unded by No oNo disk.
Compe ing in e es s
R. Wei gasse has ecei ed hono a ia o lec u es and as a
membe o he Ad iso y Boa d o No o No disk, Eli Lilly,
Sano i, No a is, Med onic, MSD, Takeda, As a Zeneca/
BMS, Boeh inge -Ingelheim and Roche Diagnos ics.
J. Lah ela has ecei ed hono a ia as a symposium speake
o No a is, Sano i, No o No disk, MSD symposia. C. G.
€
Os enson has ecei ed hono a ia as a symposium speake o
No o No disk Scandina ia. P. Geelhoed-Duij es ijn has
ecei ed hono a ia o lec u es om No o No disk and as
a membe o he Ad iso y Boa ds o Med onic, Sano i
A en is and Elli Lilly. U. Pede sen-Bje gaa d has ecei ed
hono a ia o lec u es and consul ancy om No o No disk,
Sano i A en is, and BMS and has se ed as a membe o
Ad iso y Boa d o No o No disk. M. Ma ke Jensen is
employed by No o No disk Scandina ia AB.
Acknowledgemen s
Edi o ial suppo was p o ided by Adelphi Values.
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DIABETICMedicine Sel - epo ed non-se e e hypoglycaemic e en s in Eu ope C. G.
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Os enson e al.