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Food insecurity linked to severe low blood sugar in older patients with diabetes

Kaiser Permanente study highlights need to ask patients about both economic and physical food insecurity

New research from Kaiser Permanente shows that food insecurity is common among older adults with type 2 diabetes and puts them at heightened risk of low blood sugar (hypoglycemia). The study also found that many older adults with food insecurity will be overlooked if health care providers ask only about economic food insecurity — not being able to afford food — and don’t ask about physical food insecurity — not being able to shop for food or prepare meals.

Andrew Karter wearing a black sweater over a blue and white striped button down shirt.
Andrew J. Karter, PhD

Food insecurity occurs when people don’t have enough to eat and don’t know where their next meal will come from. “Standard questions used by the U.S. Department of Agriculture and health care systems typically ask only about economic food insecurity,” said lead author Andrew J. Karter, PhD, a senior research scientist with the Kaiser Permanente Division of Research. “Our research shows that not asking about physical food insecurity misses 1 in 5 patients at risk of severe hypoglycemia whose food insecurity is not due to financial limitations.”

The new study, published in the Journal of General Internal Medicine, analyzed survey responses from 1,164 women and men ages 65 and older who are enrolled in the Kaiser Permanente Northern California Diabetes and Aging Study. The survey asked people questions about whether they ran out of food before having enough money to buy more as well as whether they had difficulty shopping for food or preparing meals.

All the adults included in the new study were taking insulin or a sulfonylureas to treat their type 2 diabetes. These medications are used to keep blood sugar levels stable, but if a person taking them eats less or exercises more than they typically would, the medications can lower their blood sugar to dangerous levels.

Our research shows that not asking about physical food insecurity misses 1 in 5 patients at risk of severe hypoglycemia.

— Andrew J. Karter, PhD

The study found that 12.3% of the survey respondents said they had experienced food insecurity. Of these, 38.4% said they experienced only economic food insecurity; 21.1% said they experienced only physical food insecurity; and 40.5% said they experienced both.

Kasia Lipska in black jacket over brown shirt
Kasia Lipska, MD, MHS

Hypoglycemia is considered severe when it necessitates assistance from another person to actively administer glucose, provide emergency treatment, or call 911. The patients who experienced both economic and physical food insecurity were 4 times more likely to have a severe hypoglycemic episode than those who did not face food insecurity. The study also found that 78% of the respondents said the primary reason for experiencing a severe hypoglycemic episode was skipping a meal, not eating enough, or waiting too long to eat.

More than 44 million people in the U.S. face food insecurity. The number of older adults experiencing food insecurity has doubled over the past 20 years. Economic food insecurity is a known risk factor for hypoglycemia, or low blood sugar. Less is currently known about the relationship between physical food insecurity and overall health.

“Hypoglycemia prevention efforts among older patients with diabetes using medications that put them at risk of hypoglycemia should identify and address both physical and economic causes of food insecurity as they may require distinct solutions,” said senior author Kasia Lipska, MD, MHS, an endocrinologist at Yale University School of Medicine

Hliary Seligman wearing glasses.
Hilary Seligman, MD, MAS

The researchers said they also hope their findings will highlight changes that are needed to improve how patients are screened for food insecurity.

“Our study suggests health care providers need to consider asking many patients about physical food insecurity and not just economic food insecurity,” said study co-author Hilary Seligman, MD, MAS, a professor at the University of California, San Francisco. “This is particularly important for patients who are at high risk of poor diabetes outcomes.”

The study was funded by the National Institute of Aging and National Institute of Diabetes and Digestive and Kidney Diseases.

Co-authors include Melissa M. Parker, MS, Howard H. Moffet, MPH, Jennifer Y. Liu, MPH, and  Richard W. Grant, MD, MPH, of the Division of Research; Elbert S. Huang, MD, MPH, and Neda Laiteerapong, MD, MS, of the University of Chicago; James D. Ralston, MD, MPH, Kaiser Permanente Washington Health Research Institute; and Lisa K. Gilliam, MD, PhD, of The Permanente Medical Group.

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About the Kaiser Permanente Division of Research

The Kaiser Permanente Division of Research conducts, publishes and disseminates epidemiologic and health services research to improve the health and medical care of Kaiser Permanente members and society at large. It seeks to understand the determinants of illness and well-being, and to improve the quality and cost-effectiveness of health care. Currently, DOR’s 600-plus staff is working on more than 450 epidemiological and health services research projects. For more information, visit or follow us @KPDOR.


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