Fear of hypoglycemia: relationship to hypoglycemic risk and psychological factors



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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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.

Ethical standard

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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Correspondence to Therese Anderbro.

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Managed by Antonio Secchi.

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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

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  • Type 1 diabetes
  • Hypoglycemia
  • Fear of hypoglycemia
  • Severe hypoglycemia
  • Psychological factors