Risk factors for severe hypoglycemia in black and white adults with diabetes: the Atherosclerosis Risk in Communities (ARIC) study
Open accessAbstract
OBJECTIVE: Severe hypoglycemia is a rare but important complication of type 2 diabetes. Few studies have examined the epidemiology of hypoglycemia in a community-based population. RESEARCH DESIGN AND METHODS: We included 1,206 Atherosclerosis Risk in Communities (ARIC) Study participants with diagnosed diabetes (baseline: 1996–1998). Severe hypoglycemic events were identified through 2013 by ICD-9 codes from claims for hospitalizations, emergency department visits, and ambulance use. We used Cox regression to evaluate risk factors for severe hypoglycemia. RESULTS: The mean age of participants was 64 years, 32% were black, and 54% were female. During a median follow-up period of 15.2 years, there were 185 severe hypoglycemic events. Important risk factors after multivariable adjustment were as follows: age (per 5 years: hazard ratio [HR] 1.24; 95% CI 1.07–1.43), black race (HR 1.39; 95% CI 1.02–1.88), diabetes medications (any insulin use vs. no medications: HR 3.00; 95% CI 1.71–5.28; oral medications only vs. no medications: HR 2.20; 95% CI 1.28–3.76), glycemic control (moderate vs. good: HR 1.78; 95% CI 1.11–2.83; poor vs. good: HR 2.62; 95% CI 1.67–4.10), macroalbuminuria (HR 1.95; 95% CI 1.23–3.07), and poor cognitive function (Digit Symbol Substitution Test z score: HR 1.57; 95% CI 1.33–1.84). In an analysis of nontraditional risk factors, low 1,5-anhydroglucitol, difficulty with activities of daily living, Medicaid insurance, and antidepressant use were positively associated with severe hypoglycemia after multivariate adjustment. CONCLUSIONS: Poor glycemic control, glycemic variability as captured by 1,5-anhydroglucitol, kidney damage, and measures of cognitive and functional impairments were strongly associated with increased risk of severe hypoglycemia. These factors should be considered in hypoglycemia risk assessments when individualizing diabetes care for older adults.
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Epidemiologic studies of hypoglycemia predominantly rely on claims data to assess hypoglycemia-related hospitalizations and emergency department visits.
“Epidemiologic studies of hypoglycemia predominantly rely on claims data to assess hypoglycemia-related hospitalizations and emergency department visits (87)(88)(89)(90).”
From 6. Glycemic Goals, Hypoglycemia, and Hyperglycemic Crises: Standards of Care in Diabetes-2026. (2026) · cites this paper as [88]
The Severe Hypoglycemia section (page not provided) says this study used CMS claims to identify hypoglycemia-related hospitalizations and emergency department visits. The Conclusions likewise describe the value of that linkage. These passages support claims-data use in this study, but do not establish that epidemiologic studies predominantly rely on claims data. (LLM, conf=0.82)
Experimental — accuracy not yet measuredOlder adults are at higher risk of hypoglycemia for many reasons, including erratic meal intake, insulin deficiency necessitating insulin therapy, and progressive renal insufficiency.
“Older adults are at higher risk of hypoglycemia for many reasons, including erratic meal intake, insulin deficiency necessitating insulin therapy, and progressive renal insufficiency (29).”
From 13. Older Adults: <i>Standards of Care in Diabetes—2024</i> (2024) · cites this paper as [29]
The Abstract (page not provided) reports that older age and insulin use were associated with severe hypoglycemia. The Conclusions (page not provided) identify kidney disease as a risk factor. The paper does not identify erratic meal intake as a cause or say that age-related insulin deficiency necessitates insulin therapy; it studies severe hypoglycemia in adults with type 2 diabetes, rather than hypoglycemia generally. (LLM, conf=0.88)
Experimental — accuracy not yet measuredOlder adults may be at higher risk of hypoglycemia for many reasons, including irregular meal intake, insulin deficiency necessitating insulin therapy, and worsening kidney function.
“Older adults may be at higher risk of hypoglycemia for many reasons, including irregular meal intake, insulin deficiency necessitating insulin therapy, and worsening kidney function (32).”
From 13. Older Adults: Standards of Care in Diabetes—2025 (2025) · cites this paper as [32]
The paper says severe hypoglycemia is more common after age 60 and, in the Conclusions (page unavailable), identifies kidney disease as a risk factor. It also links difficulty with eating or preparing meals to hypoglycemia risk, but does not establish irregular meal intake specifically. Although it discusses insulin use in older adults, our copy does not say that insulin deficiency necessitating insulin therapy explains their higher risk. (LLM, conf=0.88)
Experimental — accuracy not yet measuredOlder adults may be at higher risk of hypoglycemia for many reasons, including irregular meal intake, particularly in the setting of requiring insulin therapy, and worsening kidney function.
“Older adults may be at higher risk of hypoglycemia for many reasons, including irregular meal intake, particularly in the setting of requiring insulin therapy, and worsening kidney function (36).”
From 13. Older Adults: Standards of Care in Diabetes—2026 (2026) · cites this paper as [36]
The Abstract reports higher severe-hypoglycemia risk with older age and insulin use, and the Conclusions describe kidney disease as a risk factor. The Conclusions also link difficulty eating or preparing meals to hypoglycemia risk, but do not establish irregular meal intake—particularly while using insulin—as the claimed risk factor. The association with reduced kidney function was no longer statistically significant after adjustment. (LLM, conf=0.86)
Experimental — accuracy not yet measuredNevertheless, epidemiologic studies reveal a substantial burden of hypoglycemia-related hospital utilization in the community.
“Nevertheless, they reveal a substantial burden of hypoglycemia-related hospital utilization in the community (87)(88)(89)(90).”
From 6. Glycemic Goals, Hypoglycemia, and Hyperglycemic Crises: Standards of Care in Diabetes-2026. (2026) · cites this paper as [88]
In a community-based epidemiologic cohort of older adults with type 2 diabetes, important risk factors for level 3 hypoglycemia include insulin use, poor or moderate versus good glycemic control, albuminuria, and poor cognitive function.
“In addition to age and race, other important risk factors found in a community-based epidemiologic cohort of older adults with type 2 diabetes include insulin use, poor or moderate versus good glycemic control, albuminuria, and poor cognitive function (88).”
From 6. Glycemic Targets: <i>Standards of Care in Diabetes—2023</i> (2023) · cites this paper as [88]
African American individuals are at substantially increased risk of level 3 hypoglycemia.
“African American individuals are at substantially increased risk of level 3 hypoglycemia (88,89).”
From 6. Glycemic Targets: <i>Standards of Care in Diabetes—2023</i> (2023) · cites this paper as [88]
Studies relying on claims data reveal a high burden of hypoglycemia in adults over 60 years of age in the community.
“Studies of rates of level 3 hypoglycemia that rely on claims data for hospitalization, emergency department visits, and ambulance use substantially underestimate rates of level 3 hypoglycemia (87) yet reveal a high burden of hypoglycemia in adults over 60 years of age in the community (88).”
From 6. Glycemic Targets: <i>Standards of Care in Diabetes—2023</i> (2023) · cites this paper as [88]
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- Authors
- Lee, A. K., Lee, C. J., Huang, E. S., Sharrett, A. R., Coresh, J., & Selvin, E.
- Affiliations
- Johns Hopkins University (US)
- University of Chicago (US)
- Corresponding author
- Selvin, Elizabeth
- Venue
- Diabetes Care
- Publisher
- American Diabetes Association
- Published
- 2017-09-19
- Volume
- 40
- Issue
- 12
- Pages
- 1661-1667
- ISSN
- 0149-5992 (ISSN-L)
- 1935-5548
- PMC
- PMC5711330
- OpenAlex
- W2754097489
- Cited by
- 119
- References
- 44
- Citations by year
- 2026: 5 · 2025: 12 · 2024: 17 · 2023: 9 · 2022: 16 · 2021: 18 · 2020: 17 · 2019: 13 · 2018: 10 · 2017: 2
- FWCI
- 9.09
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Diabetes Care (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Heart, Lung, and Blood Institute (HHSN268201100005C, HHSN268201100006C, HHSN268201100007C, HHSN268201100008C, HHSN268201100009C, HHSN268201100010C, HHSN268201100011C, HHSN268201100012C)
- National Institute of Diabetes and Digestive and Kidney Diseases (K24-DK-106414, R01-DK-089174)
- NHLBI (T32HL007024)
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
- Keywords
- severe hypoglycemia, type 2 diabetes, risk factors, glycemic control, glycemic variability, 1,5-anhydroglucitol, insulin use, oral antidiabetic drugs, macroalbuminuria, cognitive function, racial disparities, Black people, activities of daily living, antidepressant use, Medicaid, Atherosclerosis Risk in Communities Study, hospitalization
- MeSH terms
- Activities of Daily Living, Aged, Antidepressive Agents, Blood Glucose, Cognition, Diabetes Mellitus, Type 2, Ethnicity, Female, Follow-Up Studies, Humans, Hypoglycemia, Hypoglycemic Agents, Insulin, Male, Middle Aged, Prospective Studies, Risk Factors, Incidence, Prevalence, Risk Assessment, Atherosclerosis
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