The major aims of this study were to examine (1) the association between fear of hypoglycemia (FOH) in adults with type 1 diabetes with demographic, psychological (anxiety and depression), and disease-specific clinical factors (hypoglycemia history and unawareness, A1c), including severe hypoglycemia (SH), and (2) differences in patient subgroups categorized by level of FOH and risk of SH.
Research design and methods
Questionnaires were mailed to 764 patients with type 1 diabetes including the Swedish translation of the Hypoglycemia Fear Survey (HFS) and other psychological measures including the Perceived Stress Scale, Hospital Anxiety and Depression Scale, Anxiety Sensitivity Index, Social Phobia Scale, and Fear of Complications Scale. A questionnaire to assess hypoglycemia history was also included and A1c measures were obtained from medical records. Statistical analyses included univariate approaches, multiple stepwise linear regressions, Chi-square t tests, and ANOVAs.
Regressions showed that several clinical factors (SH history, frequency of nocturnal hypoglycemia, self-monitoring) were significantly associated with FOH but R 2 increased from 16.25 to 39.2 % when anxiety measures were added to the model. When patients were categorized by level of FOH (low, high) and SH risk (low, high), subgroups showed significant differences in non-diabetes-related anxiety, hypoglycemia history, self-monitoring, and glycemic control.
There is a strong link between FOH and non-diabetes-related anxiety, as well as hypoglycemia history. Comparison of patient subgroups categorized according to level of FOH and SH risk demonstrated the complexity of FOH and identified important differences in psychological and clinical variables, which have implications for clinical interventions.
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Anderson RJ, Freedland KE, Clouse RE, Lustman PJ (2001) The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care 24(6):1069–1078
Collins MM, Corcoran P, Perry IJ (2009) Anxiety and depression symptoms in patients with diabetes. Diabet Med 26(2):153–161
Lloyd CE, Dyer PH, Barnett AH (2000) Prevalence of symptoms of depression and anxiety in a diabetes clinic population. Diabet Med 17(3):198–202
Grigsby AB, Anderson RJ, Freedland KE, Clouse RE, Lustman PJ (2002) Prevalence of anxiety in adults with diabetes: a systematic review. J Psychosom Res 53(6):1053–1060
Katon W, von Korff M, Ciechanowski P, Russo J, Lin E, Simon G et al (2004) Behavioral and clinical factors associated with depression among individuals with diabetes. Diabetes Care 27(4):914–920
Amsberg S, Anderbro T, Wredling R, Lisspers J, Lins PE, Adamson U et al (2009) A cognitive behavior therapy-based intervention among poorly controlled adult type 1 diabetes patients—a randomized controlled trial. Patient Educ Couns 77(1):72–80
Forlani G, Nuccitelli C, Caselli C, Moscatiello S, Mazzotti A, Centis E et al (2013) A psychological support program for individuals with type 1 diabetes. Acta Diabetol 50(2):209–216
Taylor EP, Crawford JR, Gold AE (2005) Design and development of a scale measuring fear of complications in type 1 diabetes. Diabetes Metab Res Rev 21(3):264–270
Olsen M, Anderbro T, Amsberg S, Leksell J, Moberg E, Lisspers J, Gudbjörnsdottir S, Johansson U-B (2014) Psychometric properties of the Swedish version of the fear of complications questionnaire. Open J Endocr Metab Dis 4(4):69–76
Cox DJ, Irvine A, Gonder-Frederick L, Nowacek G, Butterfield J (1987) Fear of hypoglycemia: quantification, validation, and utilization. Diabetes Care 10(5):617–621
Irvine AA, Cox D, Gonder-Frederick L (1992) Fear of hypoglycemia: relationship to physical and psychological symptoms in patients with insulin-dependent diabetes mellitus. Health Psychol 11(2):135–138
Wild D, von Maltzahn R, Brohan E, Christensen T, Clauson P, Gonder-Frederick L (2007) A critical review of the literature on fear of hypoglycemia in diabetes: implications for diabetes management and patient education. Patient Educ Couns 68(1):10–15
Pramming S, Thorsteinsson B, Bendtson I, Binder C (1991) Symptomatic hypoglycaemia in 411 type 1 diabetic patients. Diabet Med 8(3):217–222
Clarke WL, Gonder-Frederick A, Snyder AL, Cox DJ (1998) Maternal fear of hypoglycemia in their children with insulin dependent diabetes mellitus. J Pediatr Endocrinol Metab 11(Suppl 1):189–194
Cox DJ, Gonder-Frederick L, Antoun B, Clarke W, Cryer P (1990) Psychobehavioral metabolic parameters of severe hypoglycemic episodes. Diabetes Care 13(4):458–459
Cox DJ, Gonder-Frederick L, Polonsky W, Schlundt D, Kovatchev B, Clarke W (2001) Blood glucose awareness training (BGAT-2): long-term benefits. Diabetes Care 24(4):637–642
The Diabetes Control and Complications Trial Research Group (1993) The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 329(14):977–986
Nathan DM, Cleary PA, Backlund JY, Genuth SM, Lachin JM, Orchard TJ et al (2005) Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. N Engl J Med 353(25):2643–2653 PMCID: 2637991
Anderbro T, Amsberg S, Adamson U, Bolinder J, Lins PE, Wredling R et al (2010) Fear of hypoglycaemia in adults with type 1 diabetes. Diabet Med 27(10):1151–1158
Gonder-Frederick LA, Schmidt KM, Vajda KA, Greear ML, Singh H, Shepard JA et al (2011) Psychometric properties of the hypoglycemia fear survey-ii for adults with type 1 diabetes. Diabetes Care 34(4):801–806 PMCID: 3064031
Schopman JE, Geddes J, Frier BM (2011) Frequency of symptomatic and asymptomatic hypoglycaemia in type 1 diabetes: effect of impaired awareness of hypoglycaemia. Diabet Med 28(3):352–355
Polonsky WH, Davis CL, Jacobson AM, Anderson BJ (1992) Correlates of hypoglycemic fear in type I and type II diabetes mellitus. Health Psychol 11(3):199–202
Mollema ED, Snoek FJ, Ader HJ, Heine RJ, van der Ploeg HM (2001) Insulin-treated diabetes patients with fear of self-injecting or fear of self-testing: psychological comorbidity and general well-being. J Psychosom Res 51(5):665–672
Di Battista AM, Hart TA, Greco L, Gloizer J (2009) Type 1 diabetes among adolescents: reduced diabetes self-care caused by social fear and fear of hypoglycemia. Diabetes Educ
Rogers HA, de Zoysa N, Amiel SA (2012) Patient experience of hypoglycaemia unawareness in type 1 diabetes: are patients appropriately concerned? Diabet Med 29(3):321–327
Anderbro T, Amsberg S, Wredling R, Lins PE, Adamson U, Lisspers J et al (2008) Psychometric evaluation of the Swedish version of the Hypoglycaemia Fear Survey. Patient Educ Couns 73(1):127–131
Cohen S, Kamarck T, Mermelstein R (1983) A global measure of perceived stress. J Health Soc Behav 24(4):385–396
Mattick RP, Clarke JC (1998) Development and validation of measures of social phobia scrutiny fear and social interaction anxiety. Behav Res Ther 36(4):455–470
Lisspers J, Nygren A, Soderman E (1997) Hospital Anxiety and Depression Scale (HAD): some psychometric data for a Swedish sample. Acta Psychiatr Scand 96(4):281–286
Reiss S, Peterson RA, Gursky DM, McNally RJ (1986) Anxiety sensitivity, anxiety frequency and the prediction of fearfulness. Behav Res Ther 24(1):1–8
Babor TF, Dolinsky ZS, Meyer RE, Hesselbrock M, Hofmann M, Tennen H (1992) Types of alcoholics: concurrent and predictive validity of some common classification schemes. Br J Addict 87(10):1415–1431
Engström L-M, Ekblom B, Forsberg A, von Koch M, Seger J (1993) Motionsvanor, fysisk prestationsförmåga och hälsotillstånd bland svenska kvinnor och män i åldrarna 20–65 år. Stockholm; Contract no.: document number
Wredling R (1991) On the management of insulin dependent diabetes mellitus. Karolinska Institutet, Stockholm
Hommel E, Olsen B, Battelino T, Conget I, Schutz-Fuhrmann I, Hoogma R et al (2014) Impact of continuous glucose monitoring on quality of life, treatment satisfaction, and use of medical care resources: analyses from the SWITCH study. Acta Diabetol 51(5):845–851 PMCID: 4176956
Briscoe VJ, Davis SN (2006) Hypoglycemia in type 1 and type 2 diabetes: physiology, pathophysiology, and management. Clin Diabetes 24(3):115–121
Byrne M, Newell J, Coffey N, OH MC, Cooke D, Dinneen SF (2012) Predictors of quality of life gains among people with type 1 diabetes participating in the Dose Adjustment for Normal Eating (DAFNE) structured education programme. Diabetes Res Clin Pract 98(2):243–248
de Zoysa N, Rogers H, Stadler M, Gianfrancesco C, Beveridge S, Britneff E et al (2013) A psychoeducational programme to restore hypoglycemia awareness: the DAFNE-HART pilot study. Diabetes Care 37(3):863–866
This study was funded by Sophiahemmet University College, the Foundation for Medical Research at Sophiahemmet, the Swedish Diabetes Federation, and the Bert von Kantzow Foundation. The authors would like to thank Katarina Selling, Statisticon for statistical support. No potential conflicts of interest relevant to this article were reported. T.A. researched and interpreted the data and wrote the manuscript. J.L., E.M, L.G-F, and U-B.J. interpreted the data and reviewed/edited the manuscript, J.B, P-E.L., and R.W contributed to discussion and reviewed/edited the manuscript. All authors reviewed, commented on, and accepted the manuscript. T.A. is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Conflict of interest
Therese Anderbro, Linda Gonder-Frederick, Jan Bolinder, Per-Eric Lins, Regina Wredling, Erik Moberg, Jan Lisspers and Unn-Britt Johansson declare that they have no conflict of interest.
All human studies have been reviewed by the appropriate ethics committee and have therefore been performed in accordance with the ethical standards laid down in an appropriate version of the 1964 Declaration of Helsinki.
Human and animal rights disclosure
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 (5).
Informed consent disclosure
Informed consent was obtained from all patients for being included in the study.
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Anderbro, T., Gonder-Frederick, L., Bolinder, J. et al. Fear of hypoglycemia: relationship to hypoglycemic risk and psychological factors. Acta Diabetol 52, 581–589 (2015). https://doi.org/10.1007/s00592-014-0694-8
- Type 1 diabetes
- Fear of hypoglycemia
- Severe hypoglycemia
- Psychological factors