Fear of hypoglycemia: Influence on glycemic variability and self-management behavior in young adults with type 1 diabetes

Abstract

Purpose

The purpose of this study was to examine how fear of hypoglycemia (FOH) is associated with glycemic variability (GV) and self-management behavior in young adults (aged 18–35) with type 1 diabetes (T1DM).

Procedures

Using a prospective repeated-measures design, in 35 young adults, within- and between-person and temporal associations of FOH, specific self-management behaviors, and GV were measured. The data were collected using questionnaires and real-time measures using daily diaries, insulin pump downloads, actigraphy, and continuous glucose monitoring.

Findings

FOH was associated with greater glycemic variability. Significant temporal associations emerged. Concurrent day (glucose SD, p = .011) and previous-evening fear levels were associated with GV (glucose SD, p = .007). FOH was also associated with greater calorie intake (r = .492, p = .003) and less physical activity (light activity, r = − .341, p = .045).

Conclusions

The significant associations of FOH with GV, dietary patterns, and physical activity provide evidence for FOH as an important psychological factor associated with diabetes care.

Introduction

Near-normal glucose levels can reduce the occurrence and progression of diabetes-related complications (Diabetes Control and Complications Trial (DCCT) Research Group, 1994). However, as blood glucose approaches near-normal levels, the risk increases for hypoglycemia. Hypoglycemia is life-threatening and can lead to serious physical and psychological sequelae and can in turn lead to profound fear of future hypoglycemic episodes (Vallis, Jones, & Pouwer, 2014). These distressing negative experiences influence health behaviors used in diabetes self-management (Lawton et al., 2013). Vigilance to avoid hypoglycemia is necessary; however, fear of hypoglycemia (FOH) can lead to perceived concerns of a mismatch between food intake (Richmond, 1996, Wu et al., 2011), insulin dose (Richmond, 1996), or physical activity (Brazeau, Rabasa-Lhoret, Strychar & Mircescu, 2008), resulting in over- or under-compensatory behaviors.

As a result of the over- or under-compensatory behaviors in response to FOH, blood glucose levels can vary greatly, leading to increased glycemic variability (GV; Gonder-Frederick et al., 2013). GV is defined as the intraday fluctuation in blood glucose (Cameron, Donath, & Baghurst, 2010). Emerging evidence supports the role that GV plays in the generation of oxidative stress (Quagliaro et al., 2003), endothelial dysfunction (Ceriello et al., 2012), and diabetes complications (Soupal et al., 2014). High degrees of GV are associated with more frequent episodes of hypoglycemia (Kilpatrick, Rigby, Goode, & Atkin, 2007) and glucose extremes (i.e., hypo- to hyperglycemic levels), which may occur with overtreatment of a hypoglycemic episode. GV is influenced by self-management behavior (Kildegaard, Christensen, & Hejlesen, 2009) and is amenable to change with appropriate intervention. The use of continuous glucose monitoring (CGM) allows measurement of 24-h GV to better explore this problem. To our knowledge, the relationship of FOH to GV has not been examined using CGM technology. Young adults may be at particular risk for GV because they report higher FOH levels than adolescents (Bohme, Bertin, Cosson, & Chevalier, 2013); thus, it is critical to develop strategies to assist young adults in coping with FOH.

Changing dietary intake is a frequent strategy used in response to FOH (Richmond, 1996). Dietary modifications may include excessive eating (Ahola et al., 2016, Richmond, 1996), overcorrecting a hypoglycemic episode (Savard et al., 2016), or snacking at night (Desjardins et al., 2014, Weiner and Skipper, 1978). Stress-induced eating has been linked to diabetes distress (Martyn-Nemeth, Quinn, Hacker, Park, & Kujath, 2014), and binging in response to hypoglycemia is commonly reported (Lawton et al., 2013). In terms of medication management, insulin doses may be inappropriately reduced in anticipation or fear of future hypoglycemia (Di Battista, Hart, Greco, & Gloizer, 2009).

FOH has been reported to be a major barrier to engaging in a regular physical activity/exercise program (Brazeau et al., 2008, Pinsker et al., 2016). Certain types of activity may be limited due to the perception of a greater risk of hypoglycemia and difficulty managing it (Lascar et al., 2014). Many struggle to adhere to the recommended guidelines due to anxiety, FOH, and habituated responses to FOH (Lawton et al., 2013).

The purpose of this study was to examine how FOH is associated with GV and self-management behavior in young adults (aged 18–35) with T1DM. Young adults are an important group to study because they have reported high FOH levels (Bohme et al., 2013) and are in a critical developmental stage when they are entering the workforce, planning their families, and becoming financially independent (Arnett, 2001), all within the context of managing a chronic illness.

The specific aims were to examine: (1) the association of FOH with GV and (2) associations of FOH with self-management behaviors (dietary patterns, carbohydrate intake, insulin dosing, and physical activity); and to examine temporal associations of each.