P&T Around the World

Knowledge, Attitude, and Practice Outcomes:

Evaluating the Impact of Counseling in Hospitalized
Diabetic Patients in India
Subish Palaian, MPharm, Leelavathy D. Acharya, MPharm, Padma Guru Madhva Rao, MPharm, PhD,
P. Ravi Shankar, MD, Nidin Mohan Nair, MPharm, and Nibu P. Nair, MPharm

ABSTRACT
Background. Patient involvement forms the cornerstone of
the management of chronic diseases such as diabetes mellitus.
Objective. We evaluated the results of counseling selected
hospitalized diabetic patients about their medications, disease,
and lifestyle modifications in terms of knowledge, attitude, and
practice outcomes.
Methods. Diabetic patients were counseled via regular bedside meetings, via the distribution of leaflets throughout their
hospital stay, and during regular follow-up visits for two months
after discharge from the hospital.
Results. Forty-six patients (19 in the test group and 27 controls) completed the study. In the test group, 12 patients (63.1%)
were counseled in Kannada, the local language of the study
site. A total of 30 to 60 minutes was spent in counseling 63.1% of
the patients. Insulin was explained to 13 patients (68.4%); among
the oral antidiabetic agents, metformin was discussed with 10
(52.6%) of the 19 patients. Although knowledge scores in the test
group of patients improved, compared with those of the control
group, as determined by the MannWhitney test (P < .05), we
did not observe significant improvement in attitude or practice
outcomes.
Conclusion. Patient counseling by a clinical pharmacist
improved knowledge scores, but this improved knowledge did
not lead to appropriate attitudes or practices.
KEY WORDS diabetes; knowledge, attitude, and practice outcomes; patient counseling

INTRODUCTION
The role of pharmacists has changed dramatically over the
past 30 years. Traditionally, pharmacists have been viewed as
individuals who dispense medications to the public. The concept
of pharmacy practice has gradually changed from a productoriented activity to a patient-oriented one. Pharmacists are now
At the time of this writing, Mr. Palaian was a student in the Department
of Pharmacy Practice at Manipal College of Pharmaceutical Sciences in
Manipal, India. He is currently a Lecturer at Manipal Teaching Hospital/Manipal College of Medical Sciences in Pokhara, Nepal. Mrs. Acharya
is a Senior Lecturer and Dr. Rao is a Professor, both at Manipal College
of Pharmaceutical Sciences in Manipal. Dr. Shankar is an Assistant
Professor at Manipal Teaching Hospital/Manipal College of Medical
Sciences in Pokhara. Mr. Nidin Nair and Mr. Nibu Nair are Lecturers in
the Department of Pharmacy Practice at the Manipal College of Pharmaceutical Sciences in Manipal.

becoming indispensable in monitoring drug therapy in institutional settings.1

It is well documented that safe and effective drug therapy
occurs most frequently when patients are well informed about
medications and their use.2 It is the responsibility of pharmacists
to counsel patients before dispensing medications.3 Counseling
is the sympathetic interaction between pharmacist and patient;
it may go beyond the conveying of straightforward information
about the drug and how and when to use it.4 The ultimate goal
of this counseling is to provide information directed at encouraging the safe and appropriate use of drugs, thereby enhancing
therapeutic outcomes.5 Several guidelines specify patient categories and the steps involved in patient counseling.57
Diabetes is a syndrome caused by an absolute or relative
lack of insulin. It is probably no surprise to most health care professionals in the U.S. that 20.8 million children and adults, or 7%
of the American population, have diabetes.8 What is less well
known is the fact that 25 to 30 million patients in India also have
diabetes.9
If left untreated, diabetes leads to various complications such
as neuropathy, nephropathy, retinopathy, hyperlipidemia, foot
ulcers, and infections.10 These complications adversely affect
the quality of life for all diabetic patients.11 Diabetes management
depends not only on drug therapy but also on physical exercise,
diet, and other lifestyle changes.12
Several studies have confirmed that the complications of
diabetes can be reduced by proper control of blood glucose13,14
and that patients understanding of the disease improves when
pharmacists provide them with useful, practical information.15
In India, the concept of patient counseling by a pharmacist is still
in its infancy; pharmacists still consider the dispensing of medications to be their major role.
The concept of clinical pharmacy has recently been introduced in India. This has enabled the clinical pharmacists in
Kasturba Hospital in Manipal, India, to become more patientoriented. Within the hospitals Department of Pharmacy Practice, a counseling center provides advice for patients who obtain
their drugs from the outpatient pharmacy.
A study conducted in a community pharmacy in South India
concluded that pharmacist-provided patient counseling resulted
in better glycemic control and improved quality of life for the test
patients, compared with the control group of diabetic patients.16
The results of this study cannot be extrapolated to hospitalized patients; further data on the impact of patient counseling
on knowledge, attitude, and practice (KAP) of diabetic patients
are lacking in India.

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Counseling Diabetic Patients

OBJECTIVE
Our study was conducted with the following goals:
1. to counsel selected hospitalized diabetic patients about
their disease, medications, and lifestyle modifications
2. to evaluate the impact of counseling in terms of KAP
outcomes

MATERIALS AND METHODS

Duration
Our study, which ran from November 1, 2002, to April 30,
2003, was conducted in two units in the Department of Medicine
at Kasturba Hospital. This is a 1,500-bed, tertiary-care teaching
hospital with various specialty departments. The average bed
occupancy in these units is 20 to 30 patients each.

Tools
The Knowledge, Attitude, and Practice (KAP) Questionnaire,
developed by the hospital, was prepared in three languages:
Kannada, Malayalam, and English. It consisted of 25 questions:
seven attitude/practice questions (numbers 8, 11, 13, 16, 17, 23,
and 24) and 18 knowledge-related questions (Appendix A).
For the knowledge questions, each question was scored as
one (1) for a correct answer and as zero (0) for an incorrect
answer.
For the practice questions, adhering to the guidelines for
disease management or instructions from the patients health
care provider merited a score of 1; nonadherence was given a
score of 0. Although we did not carry out a pilot study to test the
questionnaires validity and reliability, we performed a reliability analysis and calculation of the Cronbach alpha value (0.72)
after obtaining data from the respondents. The Cronbach alpha
is used to assess the reliability of scales.

sessions for both the test and the control patients and then documented the details in a patient profile form developed for the
study.
To improve patient compliance, we supplied the test group of
patients with aids such as envelopes containing their medication
and a medication calendar. We observed the patients for at least
two months from the day of discharge, with an interval of one
month or more between each follow-up visit. During the followup periods, we evaluated KAP outcomes using the same questionnaire on two occasions, with at least one month between
each follow-up evaluation.
We carried out the Wilcoxon Signed-Rank test to analyze the
changes in KAP following patient counseling in the test group
(P < .05). We then compared KAP scores from the day of admission, the day of discharge, and the first and second follow-up
appointments among the control and the test groups using the
Mann-Whitney test (P < .05).

RESULTS
A total of 59 patients were enrolled in the study from November 1, 2002, to April 30, 2003. Although both type-1 and type-2
diabetic patients met the inclusion criteria, no patients with
type-1 diabetes were enrolled. Patients who completed all followup visits until April 30, 2003, were included in the analysis.
Of the 59 patients enrolled, 46 completed the study (27 controls and 19 test patients); of the remaining subjects, two patients
died during their follow-up period and 11 patients withdrew
from the study for unknown reasons. Because the KAP scores
did not follow a normal distribution, we used the nonparametric Mann-Whitney test and the Wilcoxon Signed-Rank test
instead of the Student t-test. Selection or attrition bias might have
been introduced, because we did not analyze information from
the patients who dropped out of the study.

DEMOGRAPHICS
Criteria for Enrollment
Men and women with type-1 and type-2 diabetes mellitus as
the chief reason for hospital admission, with or without other
diseases, and who were receiving drug therapy for diabetes
were eligible for inclusion in the study. Children, pregnant
women, and mentally incompetent patients were excluded from
the study.

Age and Sex

The age distribution was as follows:

five patients (10.86%), 30 to 40 years of age

14 patients (30.43%), between 41 and 50 years of age
15 patients (32.6%), 51 to 60 years of age
eight patients (17.39%), 61 to 70 years of age
four patients (8.69%), older than 70 years of age

Modality of Operation and Data Analysis

Patients were enrolled according to the inclusion and exclusion criteria of the study after obtaining written informed consent in their local language. We used the KAP Questionnaire to
evaluate baseline scores for all enrolled patients on the day of
admission (see Appendix A). Throughout their hospital stay,
patients in the test group were counseled regarding their disease, medications, and lifestyle modifications (e.g., nutrition,
physical activity, self-monitoring of blood glucose, possibly using
dipsticks and Benedicts test for urinalysis, taking medications).
Patients received drug counseling in accordance with the recommendations of the Omnibus Budget Reconciliation Act-1990
(OBRA-1990).
To provide better counseling, we gave the test group a patient
information leaflet on diabetes, prepared in the participants
respective local languages. The pharmacist provided follow-up

The sex distribution of patients was almost equal, consisting

of 22 women (48%) and 24 men (52%).

Patient History
Among the participants in the study population, 16 patients
(34.78%) had a history of diabetes of less than five years duration. Of the remaining patients, 10 (21.73 %) had a history ranging from five to 10 years; 11 patients (23.91%), from 11 to 15
years; six patients (13.04%), from 16 to 20 years; and three
patients (6.52%), more than 20 years.
No patient had a history of diabetes of less than five years duration.

Language
Kannada was the language most frequently used (for 12
continued on page 389

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continued from page 384

Insulin

Metformin

Glibenclamide

Other sulfonylureas

Pioglitazone

Acarbose

1 1
5
13
5

10

Figure 1 Number of patients counseled about specific drugs.

patients, or 63.1%); this was followed by Malayalam for six

patients (31.5%) and by English for one patient (5.2%).

Time Required for Counseling

Most patients (12 [63.1%]) were counseled for a period of
30 to 60 minutes during the initial visit with the pharmacist. Of
the remaining patients, four (26%) were counseled for more
than an hour. Patients were also counseled on the subsequent
days of their hospital stay based on their requirements. In general, the most time was devoted to elderly patients, patients
using insulin therapy, and patients receiving multiple drugs.

Medications
Figure 1 shows the drugs for which the test group had
received detailed counseling. Most of the test patients (13
patients, 68.4%) were using insulin, followed by:
metformin (e.g., Glucophage, Bristol-Myers Squibb)
(10 patients, 52.6%).
glibenclamide (five patients, 26.3%).
other sulfonylureas (five patients, 26.3%).
pioglitazone (Actos, Eli Lilly/Takeda) (one patient, 5.2%).
acarbose (Precose, Bayer) (one patient, 5.2%).
No patients were taking meglitinides.

EVALUATION OF THE QUESTIONNAIRE AND THE

EFFECT OF COUNSELING ON SCORES
The scores corresponding to the number of questions answered correctly by the control patients and the test patients are
listed in Tables 1 and 2, respectively.
The median attitude/practice score of the test group on the
first follow-up visit was 5; this score was significantly higher than
on the day of admission (P = .013). Similarly, the median attitude/practice score on the second follow-up evaluation was
5, and it was significantly higher than on the day of admission
(P = .022), according to the Wilcoxon Signed-Rank test. However, no such improvement was observed in the control group.

Details are presented in Table 3.

The median knowledge score of the test group on the day of
discharge was 14; this was significantly higher than the knowledge score on the day of admission (P = .003). Similarly, the median knowledge scores during the first and second follow-up
evaluations were significantly higher (P < .001) than on the day
of admission (P < .001). Details are provided in Table 4.
Knowledge scores for the test group were significantly higher
at the first follow-up visit (P = .004) and at the second follow-up
visit (P = .000), compared with the corresponding values for the
control group. However, no such differences were observed in
the attitude/practice scores.
There was no significant correlation between the proportion
of subjects who answered the knowledge questions correctly
and those who answered the behavioral questions appropriately, as determined by Pearsons correlation coefficient (.325).
Patients may have been counseled by the treating physician,
nurses, relatives, and other patients and might have obtained
diabetes-related information from other sources. This could be
a confounding factor, and we did not account for it during the
study.

DISCUSSION
Our study evaluated the impact of pharmacist-provided counseling in terms of diabetic patients understanding of their disease, drug therapy, and lifestyle changes. We found that counseling by pharmacists was effective in improving patients
knowledge but not in improving their attitudes and practices.
Because there was no correlation between attitude and practice,
we cannot assume that improved patient knowledge would
result in appropriate behavior.
Management of chronic disease is strongly linked to lifestyle
modifications. For effective disease prevention and treatment,
behavioral changes are required.
For patients with chronic diseases, home is usually the
central site of managing the illness. This is true for diabetic
patients who also need knowledge about their illness in order
to manage it effectively.17 The role of the pharmacist is especially

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Counseling Diabetic Patients

important in helping patients control chronic diseases like diabetes. The pharmacist can monitor and track patients blood glucose levels. During contact with the pharmacist, patients can ask
questions that they might have been reluctant to ask their physicians. In general, it is the pharmacists role to help diabetic patients to cope with their disease.18
Every patient enrolled in our study was taking at least one
drug as a part of a diabetes-management regimen, and the clinical pharmacist provided counseling according to OBRA recommendations.6 The questions patients most commonly asked
about their medications had to do with the following:
technique of insulin administration
when to take oral hypoglycemic drugs (before or after
meals)
management of hypoglycemia
Hypoglycemia is a common problem associated with diabetes management. Pharmacists should emphasize the methods used to detect and prevent hypoglycemia. In the study population, insulin was the drug used in the majority of patients.

A major objective of counseling is to improve patient compliance. Several strategies may be taken to encourage the patient
to adhere to therapy.19 Our study used patient information
leaflets to promote counseling. The leaflet was written in local
languages, which enhanced understanding among the patients.
A study by Hawkins and colleagues assessed the effectiveness
of interventions by clinical pharmacists in managing hypertensive and diabetic patients.20 The controls received conventional
care by one physician; the test group of patients received care
directly from a pharmacist and were closely monitored by a
physician. The investigators noted an increase in patient satisfaction and patient compliance with the treatment regimen for
the test group. In our study, the pharmacist monitored the
patient chart for correct doses, drug interactions, and any
needed dosage adjustments.
Patient involvement is of paramount importance for the successful management of diabetes. Lifestyle changes are usually
necessary; these include dietary adjustments, exercise, monitoring of blood glucose levels at home, sometimes monitoring
urine changes, and following an appropriate drug regimen).21
Shilling conducted a program that utilized a pharmacist for

Table 1 Knowledge, Attitude, and Practice (KAP) Scores of the Control Group of Patients (C1C27)
Patient
No.

C1
C2
C3
C4
C5
C6
C7
C8
C9
C10
C11
C12
C13
C14
C15
C16
C17
C18
C19
C20
C21
C22
C23
C24
C25
C26
C27

KAP Score
Day of Admission

Day of Discharge

1st Follow-up

2nd Follow-up

Knowledge

Attitude/
Practice

Knowledge

Attitude/
Practice

Knowledge

Attitude/
Practice

Knowledge

Attitude/
Practice

11
14
6
9
8
12
7
15
13
6
11
13
12
16
13
9
10
13
9
12
14
13
11
13
11
13
0

4
6
5
5
4
4
4
5
6
5
3
5
3
6
5
5
5
3
6
5
7
6
3
5
7
6
0

14
14
8
12
6
11
6
14
15
7
13
12
11
15
13
10
10
12
12
11
15
8
12
12
12
13
14

2
6
4
3
6
5
3
5
5
4
4
5
3
6
6
5
5
3
5
6
6
4
3
4
6
7
6

12
12
10
11
8
12
7
14
15
4
14
12
13
14
12
11
10
12
12
13
14
9
12
11
0
0
14

4
7
4
5
5
5
4
6
5
6
3
5
2
6
6
5
5
3
7
7
6
3
3
5
7
0
6

13
12
8
11
9
11
6
15
14
6
13
13
11
14
13
11
10
12
12
11
13
10
12
12
10
13
14

4
6
5
5
4
6
4
6
6
4
4
5
2
7
6
5
5
4
4
6
6
3
2
5
6
7
7

Note: The numbers in each column represent KAP scores of the patients on different days following hospital admission.

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Table 2 Knowledge, Attitude, and Practice (KAP) Scores of the Test Group of Patients (T1T9)
Patient
No.

T1
T2
T3
T4
T5
T6
T7
T8
T9
T10
T11
T12
T13
T14
T15
T16
T17
T18
T19

KAP Score
Day of Admission

Day of Discharge

1st Follow-up

2nd Follow-up

Knowledge

Attitude/
Practice

Knowledge

Attitude/
Practice

Knowledge

Attitude/
Practice

Knowledge

Attitude/
Practice

16
10
10
12
11
7
8
4
10
10
8
7
7
3
9
13
9
10
13

6
2
4
3
5
4
2
3
4
7
7
1
4
3
5
6
6
6
4

17
14
14
16
10
7
14
17
15
13
13
13
11
3
11
15
17
11
14

7
2
3
3
4
2
4
3
4
7
7
3
5
3
5
5
6
6
6

17
16
16
15
11
12
14
17
16
13
11
14
11
10
13
15
17
10
15

7
4
4
4
4
5
4
4
4
7
7
4
5
6
5
6
6
5
6

18
17
16
17
13
15
15
16
16
14
14
14
13
8
14
15
18
12
14

7
6
5
7
5
6
5
5
4
7
5
4
7
4
4
6
6
6
7

Note: The numbers in each column represent KAP scores of patients on different days following hospital admission.

monitoring and treating diabetic patients in a 58-bed hospital.22

The study enrolled 193 diabetic patients; 50% of the patients
were monitored for 19 months. The increased involvement of
the pharmacist resulted in better use of their abilities and more
time for physicians to spend with patients who had complications.
In our study, we could not evaluate the amount of physicians
time saved as a result of the increased pharmacist involvement;
however, it is clear that a period of physicians time was saved
as a result of the pharmacists clearly explaining instructions on
drug use to the test group of patients.
Sczupak and Conrad assessed the effect of patient-oriented
pharmaceutical services on the treatment outcomes of ambulatory patients with diabetes mellitus.23 The test group was monitored for drug therapy via a patient profile form, and the

Table 3 Effect of Patient Counseling in Terms of

Attitude and Practice Outcomes
Median Interquartile Range
Group

Day of
Day of
1st
2nd
Admission Discharge Follow-up Follow-up

Test (n = 19)
43
Control (n = 27) 5 2

43
52

5 2*
52

5 2
52

*P = .013 compared with attitude/practice scores on the day of

admission.
P = .022 compared to attitude/practice scores on the day of
admission.

participants received information and training to improve compliance. These study findings indicated that the test group
experienced fewer medication errors, fewer hospital admissions, and fewer changes in therapeutic regimens compared
with the control group.23
Self-monitoring of blood glucose is considered a key element
in diabetes care, and it is widely recommended. This activity
helps patients adjust their insulin dosage, diet, and exercise
regimens, and it aids in detecting and preventing hypoglycemia.24
A study conducted in South India on diabetic patients knowledge and beliefs about the disease and their practices in terms
of diet, medications, and self-monitoring of blood glucose levels
revealed a large gap between knowledge and action. The findings illustrate the need for increased efforts in the area of
patient education.25 In our study, patients were taught the
importance of self-monitoring.
It is essential to dedicate an appropriate amount of time to
achieve improved patient counseling. The amount of time spent
generally depends on factors such as a patients interest, the
number of medications needed, the seriousness of the patients
condition, and the pharmacists work schedule. Lack of time is
one of the barriers to providing counseling.26 It is also necessary
to spend more time counseling certain patient groups, such as
those who need multiple drugs, those who have complicated
drug regimens, and the elderly. However, our study did not
consider these factors to be barriers to providing counseling.
The need for teaching diabetic patients about their illness is
obvious, because the success of the diabetes treatment depends
on lifestyle modifications in addition to the drug therapy. Patient

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Table 4 Effect of Patient Counseling in Terms of
Knowledge Outcomes
Median Interquartile Range
Day of
Day of
1st
2nd
Admission Discharge Follow-up Follow-up

Group

Test (n = 19)
10 4
Control (n = 27) 12 4

14 4*
12 4

14 5
12 3

15 2
12 3

*P = .003 compared with knowledge scores on the day of admission.

P < .001 compared with knowledge scores on the day of admission.
P < .001 compared with knowledge scores on the day of admission.

compliance is another paramount factor in treatment that warrants increased education and counseling.

STUDY LIMITATIONS
Our study did not evaluate the impact of patient counseling
on compliance with treatment. More reliable methods such as
determining glycosylated hemoglobin might be a better parameter to evaluate the extent of patient compliance.
Our sample size was very small. Confounding factors, such
as counseling obtained from other sources, were not taken into
account.

CONCLUSION
Our study identified diabetic patients, and counseling was
provided to them in their local language. The results demonstrate the importance of consultations with a pharmacist in a
hospital setting.The improved knowledge scores clearly indicate
the benefits of pharmacist-provided counseling, although they
did not translate into improved attitudes or practice outcomes.
In summary, we have seen that in developing countries such
as India, pharmacists have an immense responsibility for educating hospitalized patients with chronic diseases like diabetes.
Strategies should be implemented so that improved patient
knowledge about diabetes treatment can lead to better attitudes
and outcomes.

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The Knowlege, Attitude, and Practice Questionnaire

begins on page 395.

Counseling Diabetic Patients

Appendix A: Knowledge, Attitude, and Practice (KAP) Questionnaire
1.

Diabetes is a condition in which the body contains:

o a higher level of sugar in the blood than normal.
o a lower level of sugar in the blood than normal.
o either a higher or a lower level of sugar in the blood
than normal.
o I dont know

2.

The major cause of diabetes is:

o an increased availability of insulin in the body.
o a decreased availability of insulin in the body.
o I dont know

3.

4.

The symptom(s) of diabetes is/are:

o increased frequency of urination.
o increased thirst and hunger.
o increased tiredness.
o slow healing of wounds.
o all the above
o I dont know
Diabetes, if not treated:
o can lead to eye problems.
o can lead to kidney problems.
o can lead to foot ulcers.
o can lead to heart problems.
o all the above
o I dont know

5.

The most accurate method of monitoring diabetes is:

o checking blood glucose levels.
o checking urine sugar.
o I dont know

6.

In a diabetic patient, high blood pressure can increase or

worsen:
o the risk of heart attack.
o the risk of stroke.
o the risk of eye problems.
o the risk of kidney problems.
o all the above
o I dont know

7.

8.

A diabetic patient should measure his or her blood pressure:

o once a year.
o once every six months.
o once every two months.
o once every month.
o need not check at all
o I dont know
When was your blood pressure checked last?
o one week ago
o one month ago
o two months ago
o six months ago
o one year ago

9.

The lifestyle modification(s) required for diabetic patients

is/are:
o weight reduction.
o stopping smoking.
o stopping alcohol intake.
o all the above
o I dont know

10. A diabetic patient should have his or her eyes checked:

o once a year.
o once every six months.
o need not check at all
11. When did you have your last eye examination?
o one month ago
o six months ago
o one year ago
o two years ago
o not done at all
12. Regular urine tests will help in knowing:
o the status of liver function.
o the status of kidney function.
o the control of diabetes.
o I dont know
13. When was your last urine exam?
o one month ago
o six months ago
o one year ago
o not done at all
14. The important factors that help in controlling blood sugar
are:
o a controlled and planned diet
o regular exercise
o medication
o all the above
o none
15. A regular exercise regimen will help in:
o increasing blood circulation.
o enhancing insulin action.
o I dont know
16. Do you exercise regularly?
o Yes
o No
If yes, how often?
o Every day o Once weekly

o Once monthly

17. Are you following a controlled and planned diet?

o Yes
o No
If yes, how often?
o Always
o Sometimes

Rarely

continued on page 400

Vol. 31 No. 7 July 2006

P&T 395

Counseling Diabetic Patients

18. The well-balanced diet includes:
o green leafy vegetables.
o fiber-rich food.
o low sugar, oil, and fat.
o I dont know
19. For proper foot care, a diabetic patient:
o should inspect and wash the feet daily.
o should select the best possible footwear.
o should walk barefoot inside and outside the house.
o should not walk barefoot inside and outside the house.
20. Treatment of diabetes comprises:
o antibiotic therapy.
o blood transfusions.
o substituting insulin.
o taking more bitter vegetables.
o I dont know
21. Diabetes cannot be treated with:
o insulin.
o glibenclamide.
o metformin.
o antibiotics.
o I dont know
22

Upon control of diabetes, the medicines:

o can be stopped immediately.
o can be stopped after one month.
o should be continued for life.
o I dont know

23. Do you miss taking the doses of your diabetic medication?

o Yes
o No
If yes, how often?
o occasionally
o once a week
o once a month
24. Are you aware of blood sugar levels falling below normal
when you are taking drugs?
o Yes
o No
If yes, did you at any time experience any of the following
symptoms?
o weakness
o confusion
o visual disturbances
o I dont know
25. How do you manage hypoglycemic symptoms?
o by taking sugar
o by taking medicines
o by taking insulin
o I dont know