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Fear of hypoglycemia ‘psychological stressor’ associated with greater glycemic variability

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January 26, 2017

In young adults with type 1 diabetes, self-reported fear of hypoglycemia was associated with greater glycemic variability, increased calorie intake and reduced physical activity, study findings show.

“Despite state-of-the-science diabetes treatment regimens with insulin pump therapy, all of the participants reported having some degree of [fear of hypoglycemia],” Pamela Martyn-Nemeth, PhD, RN, assistant professor at the University of Illinois at Chicago College of Nursing, and colleagues wrote, “We acknowledge that some degree of worry about hypoglycemia is appropriately adaptive and serves as a protective mechanism to prevent life-threatening hypoglycemia. High [fear of hypoglycemia] levels, however, may lead to increased anxiety and result in a delay to action or inappropriate action.”

Martyn-Nemeth and colleagues analyzed data from 35 adults with type 1 diabetes using insulin pump therapy (mean age, 26 years; 63% women; mean diabetes duration, 13 years; 88% white). Participants completed the Fear of Hypoglycemia Scale II at baseline and recorded their daily fear of hypoglycemia using a 5-point scale with a daily diary. Episodes of hypoglycemia — including time spent in hypoglycemia — were measured by continuous glucose monitoring (CGM) and daily diary. Participants completed food frequency questionnaires at baseline and wore actigraphy monitors to record continuous physiologic activity. Researchers analyzed within- and between-person associations of daily fear of hypoglycemia, glucose variability and self-management behaviors (carbohydrate intake, daily insulin dose and daily physical activity), controlling for sex, age, diabetes duration, hypoglycemic episodes and HbA1c, and used a linear mixed-effects model to identify overall predictors of glycemic variability.

Within the cohort, diary-recorded hypoglycemic events occurred at a median of one time per day; CGM-derived data were consistent with diary-recorded events, occurring a median of 1 hour per day. Diary-recorded hypoglycemic events were associated with evening fear of hypoglycemia (P = .018), according to the researchers.

They observed that overall glycemic variability was predicted by morning fear of hypoglycemia and daily carbohydrate intake. Morning fear of hypoglycemia was associated with same-day variability (P = .011) and previous-evening fear levels were associated with next-day glycemic variability (P = .007).

Fear of hypoglycemia was also associated with greater calorie intake (r = 0.492; P = .003), carbohydrate intake (r = 0.424; P = .012) and less physical activity (r = –0.341; P = .045).

HbA1c was not associated with any fear measures. The findings, the researchers noted, suggest that daily fear of hypoglycemia serves as a “psychological stressor” that influences short-term glucose variability.

“Our findings should be interpreted with caution due to the small sample and exploratory nature of the study,” the researchers wrote. “However, we raise important questions regarding the association of [fear of hypoglycemia] with [glucose variability] and the need to examine these factors further to develop interventions to reduce or manage [fear of hypoglycemia] to promote healthy diabetes outcomes.” by Regina Schaffer

Disclosure: The researchers report no relevant financial disclosures.

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Simon Heller
Simon Heller
Martyn-Nemeth and colleagues have examined the relationship between fear of hypoglycemia and glucose variability in a short, prospective study involving 35 young adults with type 1 diabetes. They found an association with the fear of hypoglycemia scale and glucose variability, as measured by continuous glucose monitoring (CGM). They also found associations between aspects of dietary self-management and sedentary behavior. They speculate that the fear of hypoglycemia is relevant to hypoglycemic episodes, which are likely to be more frequent in those with greater glucose variability, and that this is reflected in self-management behaviors which may lead to worse outcomes. They conclude that reducing fear of hypoglycemia (presumably by developing interventions which reduce glucose variability) will improve patient outcomes.
The  findings seem logical, although, as the researchers point out, the research is limited by relatively small numbers and the short duration of the study. These limitations also prevented a detailed exploration of glucose variability and the risk for hypoglycemia. This particularly applies to severe episodes, which are more likely to increase fear of hypoglycemia, although this relationship has been identified in previous studies.
Finally, while I would agree that interventions which reduce fear of hypoglycemia are likely to improve longer-term outcomes, this should extend beyond merely addressing glucose variability. The risk for hypoglycemia can be reduced in a variety of different ways, and a wide approach is arguably more likely to reduce fear of hypoglycemia and lead to more successful self-management.

Simon Heller, DM, FRCP
Professor of clinical diabetes, University of Sheffield, UK
Disclosure: Heller reports no relevant financial disclosures.