Fear of hypoglycemia

Few people with diabetes have lasting ill effects of hypoglycemia on cognitive function, and hypoglycemic encephalopathy appears to occur quite infrequently, but there is no doubt that hypoglycemia is a common, and costly, complication of treatment of type 1 diabetes (T1D). Hypoglycemia is uncomfortable and tracks with anxiety, in both experimental models and clinical settings. Thus, despite strong evidence that tight glycemic control reduces long-term complications of diabetes, such control may have a “dark side”, with a substantial number of people with T1D developing an understandable, but ultimately counterproductive, cycle of fear of hypoglycemia (FoH) leading to anxiety, with a consequent reduction in quality of life as well as worsening control and complication rates. Not all studies have shown a correlation of greater degrees of FoH with higher HbA1c, but this association has been noted by a number of authors. In a survey of 485 French T1D patients, only 28.3% reached their target HbA1c value, with 40.3% not reaching their target because of FoH. In that survey, both patients and their diabetologists felt that hypoglycemia impaired their quality of life, with hypoglycemia “. the most disturbing trouble for a diabetic patient” in 68.8% of those over 50 years of age and in 43.5% of those below 18 years of age. Hypoglycemia fears among patients included loss of glycemic control, particularly at older age (60%), embarrassing relatives (59%), avoiding driving (27%), avoiding physical exercise (39%), and refusing some professional tasks (25%). Because of FoH, 23.0% of patients reduced their insulin dose, 20.1% consumed more sugar than required for the degree of hypoglycemia, and 12.1% regularly ate more (8% doing so at bedtime); greater FoH was correlated with all these “counteractive behaviors”. Fear of hypoglycemia has been reported to occur more commonly among women than men with T1D, despite women’s lower likelihood in another survey of having severe hypoglycemia and of requiring emergency services. In a survey of 764 Swedes with T1D, both symptoms of being worried and fear in situations of being alone were associated with frequency of severe hypoglycemia and with the number of symptoms during mild hypoglycemia. Again, FoH was greater among women than men. A similar survey of 229 people with T1D showed FoH again occurred to a greater extent among women than men, particularly with hypoglycemia unawareness, with greater FoH among those performing more frequent home glucose monitoring and among those not having support from friends, healthcare providers, or at their workplace. Another survey, of 288 Dutch people with T1D, showed FoH to be associated with depressive symptoms as well as with a prior history of hypoglycemia. Fear of hypoglycemia is associated with excessive food intake, particularly carbohydrates. Education aimed at avoidance of overtreatment of hypoglycemia with excessive ingestion of simple sugars has been found to be of limited benefit, perhaps because the symptoms of panic, disorientation, hunger, and anxiety make following such approaches quite difficult. Fear of hypoglycemia is also a major barrier to regular physical activity and, in some studies, tracks with lower daily mean glucose levels and increased glucose variability. Another analysis observed that women with T1D often experience feelings of failure, being overwhelmed, and fatalism concerning complications, and that these women exhibit a variant of what has been termed the “external eating style”, namely the tendency to eat in response to factors other than hunger, “. eating in response to insulin dose and time effects, capillary blood glucose levels, and/or planned physical activity, which have little to do with typical stimuli such as hunger and sensation”. This critical effect of FoH on eating pattern was also noted in analysis of food intake and glucose and insulin logbooks over a 2-day period from 121 people with T1D, 94 of whom experienced at least one hypoglycemic event (there was a total of 271 events during the period, further illustrating how commonly this issue occurs). On average, 73% of respondents overtreated their hypoglycemia with excess food ingestion. Similarly, FoH is a barrier to regular physical exercise. Fear of hypoglycemia can be readily ascertained in the clinical setting. Recently, a condensed version of the doi: 10.1111/1753-0407.12491 Journal of Diabetes 9 (2017), 108–110