Fear of hypoglycemia   (September 15, 2007)

I recently read an article titled "A critical review of the literature on fear of hypoglycemia in diabetes: Implications for diabetes management and patient education", which reviewed 34 journal articles which evaluated fear of hypoglycemia ("FoH"). The development of FoH appears to be a fairly common phenomenon, particularly among type 1 diabetes patients with a history of more severe hypoglycemia episodes.

I think we all agree that hypoglycemia is unpleasant, and is associated with numerous negative effects, and is scary, at least when you think about "what might have happened if". In the past, before widespread use of home BG monitoring, the fear was omnipresent: physicians routinely advised patients to "run a little sweet" (have urine glucose all the time) to avoid the potential of hypoglycemia, which at that time could not be measured objectively without going to a lab to have blood drawn. Fortunately, those days are gone: if you monitor BG routinely, and at the first symptoms of a hypo attack, you need not have the fear.

The authors wondered as to why FoH develops in some people but not in others, and why fear is greater in some individuals than others. One important factor, they find, is hypoglycemia history: a relatively consistent relationship has been found between a history of hypoglycemia and development of FoH. Factors included time since first insulin-treatment, frequency of hospitalization due to hypoglycemia, and frequency of hypoglycemia affecting working life. They also noted that people with a lower average daily blood glucose (BG) level and with higher BG level variability (which can increase risk for hypoglycemia), reported higher levels of FoH.

FoH is also thought to have an impact on diabetes management and control. For instance, people who fear hypoglycemia may take corrective, or counteractive action to prevent hypoglycemia by maintaining high glucose levels. However, surprising to me, some studies have failed to find such a relationship between FoH and diabetes control.

Psychological interventions and patient education to reduce FoH and improve diabetes management are beginning to be explored. For instance, Blood Glucose Awareness Training (BGAT) is designed to improve awareness of BG symptoms. BGAT may reduce both frequency and fear of hypoglycemia, and the sense of loss of control or uncertainty associated with hypoglycemia while increasing individuals' confidence in their ability to recognize and anticipate hypoglycemia. Perhaps other specific educational interventions that provide training for early recognition and avoidance of severe hypoglycemia can also help prevent FoH.

The authors conclude that FOH should be addressed in patient education programs. They indicate that coping strategies that rely on avoiding hypoglycemia by maintaining high BG levels should also be addressed candidly, including the long-term negative impact of hyperglycemia on health. Preventative measures other than maintenance of high BG levels should be reviewed. The goal is to help patients gain an increased sense of control over hypoglycemia and its treatment, thereby reducing fear and anxiety.

And clearly the key to avoiding hypos, and avoiding FOH, is being willing and able to measure your BG, both when you start to feel lousy, and in scenarios where hypos could be disastrous -- which is why I advise people with diabetes to check their BG before driving a vehicle: see Times to check your blood sugar.