Fear of hypoglycaemia

How does Fear of Hypoglycaemia develop?

Despite the progress in diabetes management over the past 20 years, hypoglycaemia remains a major barrier to achieving optimal diabetes control in people with insulin-requiring diabetes mellitus [1]. Hypoglycaemia is defined as blood glucose levels below 4.0 mmol/l. Hypo’s are generally experienced as unpleasant, due to negative physical, neurological and psychological symptoms and, in severe cases, by coma, insults or death [2]. Hypoglycaemia symptoms can vary between patients, however common adrenergic and neurglycopenic symptoms include weakness, trembling/shaking, sweating, irritability, hunger, light headedness, headache, dizziness, lack of concentration, behaviour change, tearful/crying, and numbness around the lips and fingers. On average, people with type 1 diabetes experience two symptomatic episodes of mild or moderate hypoglycaemia per week, and one or more episodes of severe hypoglycaemia (where the person with diabetes needs external assistance to recover from the hypoglycaemic episode) per year [3]. With progressive insulin deficiency, incidence rates of severe hypoglycaemia in people with type 2 diabetes are similar to those of type 1 diabetes patients [4]. Frequent hypoglycaemia can lead to a blunted counterregulatroy response with subsequent impaired awareness of hypoglycaemia symptoms, presenting reduced opportunities to avoid severe hypoglycaemia.

Hypoglycaemia can be very disruptive and impinges on every aspect of daily life like work-performance, personal relationships and recreational activities [5]. Fearfulness of hypoglycaemia often equals the level of fear associated with the threat of long-term diabetes complications, like retinopathy and nephropathy. A major cause for Fear of Hypoglycaemia is a history of (severe) hypoglycaemia [6], especially when the event has been traumatizing due to loss of consciousness and stupors.

Why is Fear of Hypoglycaemia Important?

Following evidence from the DCCT [7] that indicated improved control by intensive insulin treatment reduced complication rates, there has been a drive towards more intensive insulin regimens. One consequence of this is a marked increased in the frequency of hypoglycaemia [8]. In very young children (age range 0-4 years), there is concern that severe hypoglycaemia can disrupt normal brain development and could cause some cognitive impairment [9].

Diabetes patients and their families ‘learn quickly that hypoglycaemic episodes are physically aversive, potentially dangerous and a source of possible social embarrassment’ [10]. As such, they ‘acknowledge significant anxiety about the occurrence of hypoglycaemic episodes, maintain marginally elevated blood glucose levels and engage in premature treatment of apparent hypoglycaemia’ [11].

The associated risks of long-term complications may be overshadowed by short-term goals to avoid hypoglycaemia. This “hypoglycaemia avoidance behaviour” may lead to poorer glycaemic control increasing the risk of long-term complications.

Who Experiences Fear of Hypoglycaemia?

Fear of hypoglycaemia is experienced at different levels by many people with diabetes, their family members, carers and spouses. It is estimated that fear of hypoglycaemia (FoH) presents in 20-30% of insulin-treated patients reporting elevated distress levels [12]. Patients with pre-existing high trait anxiety or phobia are at increased risk of developing extreme fear of hypoglycaemia and associated avoiding behaviours. Increased maternal depression and anxiety have found to be associated with greater fear of hypoglycaemia [13].

Parental fear of hypoglycaemia is common especially amongst mothers. Monaghan et al [14] found that approximately one third of parents reported regularly monitoring their child's blood glucose level after their child was asleep. Parental fear of hypoglycaemia appears to be determined particularly by the severity of hypoglycaemia, especially if the episode is associated with hypoglycaemic convulsions. Nocturnal hypoglycaemia in particular poses significant stress.

What Can Healthcare Professionals do to Assess and Alleviate Fear of Hypoglycaemia?

The risk of severe hypoglycaemia can be minimized by appropriate self-monitoring of blood glucose, regular review of insulin regimen, review of the quantity and timing of carbohydrate intake, and the use of CSII [15]. Better understanding of the disease might overcome any tendency to allow poor glycaemic control because of fear of hypoglycaemia.

New technologies, like Continuous Glucose Monitoring and Closed Loop insulin delivery systems could aid in reducing time spend in hypoglycaemia, but evidence is mainly anecdotal. There is good evidence that Blood Glucose Awareness Training (BGAT) and psycho-educational programs derived from or similar to this intervention are effective in improving early recognition of hypoglycaemia symptoms and thereby reducing levels of fear of hypoglycaemia [6].

To assist patients and carers in coping with their anxieties around hypoglycaemia, it is important that healthcare professionals recognize and acknowledge the extent of fear of hypoglycaemia and provide opportunities in routine out-patient clinic appointments to discuss this fear and strategies to overcome it.

A helpful tool to assess fear of hypoglycaemia is the Hypoglycemia Fear Survey (HFS-II). It is composed of two subscales, the Behavior (HFS-B) and Worry (HFS-W) subscale. HFS-B items describe behaviors in which patients may engage to avoid hypoglycaemic episodes and/or their negative consequences (e.g., keeping blood glucose levels above 150 mg/dL (8,3 mmol/L), making sure other people are around, and limiting exercise or physical activity). HFS-W items describe specific concerns that patients may have about their hypoglycaemic episodes (e.g., being alone, episodes occurring during sleep, or having an accident) [16]. Based on a comprehensive psycho-medical assessment patients can be offered technological and/or psychological support to help restore their self-confidence in avoiding severe hypoglycaemia without compromising glycaemic control.


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  15. ^ Hirsch IB, Farkas-Hirsch R, Skyler JS: Intensive Insulin Therapy for Treatmtne of Type 1 Diabetes .Diabetes Care1990, 13:1265-83.

  16. ^ Gonder-Frederick LA, Schmidt KM, Vajda KA, Greear ML, Singh H, Shepard JA, Cox DJ. Psychometric Properties of the Hypoglycemia Fear Survey-II for Adults With Type 1 Diabetes. Diabetes Care2011; 34(4): 801–806.


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