Study Emphasizes Importance of Screening for Fear of Hypoglycemia in T1D


Fear of hypoglycemia is associated with negative outcomes in people with T1D that may influence psychosocial well-being and diabetes management.

Man holding woman's hand | Credit: Priscilla Du Preez/unsplash

Credit: Priscilla Du Preez/unsplash

Fear of hypoglycemia is common in people with type 1 diabetes (T1D), affecting their psychological well-being and disease management, according to new research.1

The use of an actionable 9-item fear of hypoglycemia screener for in-clinic use could be a suitable and efficient way to identify those with a fear of hypoglycemia, indicated the investigative team, with 30% of study participants showing a high fear of hypoglycemia

“This ‘fit-for-purpose’ screener may aid healthcare providers to quickly identify people with fear of hypoglycemia who can be further evaluated for the root cause of fear of hypoglycemia risk with referrals to mental health professionals as needed,” wrote the investigative team, led by Megan E. Peter, T1D Exchange. “In the future, this newly developed screener may be incorporated in real-world clinical practice to help identify fear of hypoglycemia in people with diabetes.”

Adults with T1D and fear of hypoglycemia can experience a lower quality of life and diminished emotional well-being, and it can affect diabetes management. Guidelines from the American Diabetes Association (ADA) recommend screening for fear of hypoglycemia using standardized and validated tools and referring as necessary to mental health providers.2 Common constructs of fear of hypoglycemia include psychosocial distress, lack of confidence in managing hypoglycemia, and behavioral avoidance of hypoglycemia.

Although clinical instruments to measure fear of hypoglycemia are validated in the research setting, they are not routinely used by healthcare providers in clinical practice. As a result, an easy-to-use, 9-item screener was developed and validated for use in people with T1D. The aim of Peter and colleagues' study was to assess the prevalence of fear of hypoglycemia using this screener in a sample of adults with T1D and explore the perspective of healthcare providers on its implementation in clinical practice.

The multiphase observational study used mixed methods in 2 study phases. For the first part of the study, eligible participants were recruited from 3 T1D Exchange Quality Improvement Collaborative adult clinics. The second part of the study involved focus groups among healthcare providers from 9 clinics in the United States who cared for adults with T1D for ≥5 years.

Participants reported demographic characteristics, general health information, and diabetes management information, including frequency of healthcare visits, T1D duration, and history of hypoglycemia in the past year. Investigators measured impaired awareness of hypoglycemia using the Gold score (score from 1 [always aware] to 7 [never aware]). To assess the prevalence of fear of hypoglycemia, the 9-item screener used a 5-point Likert scale, ranging from a score of 1 (strongly disagree) to 5 (strongly agree).

The study included 553 people with T1D, with a mean age of 38.9 years and 30% reported a high fear of hypoglycemia total score. Regression analyses revealed that higher hemoglobin A1c and a higher number of comorbidities were significantly associated with high fear of hypoglycemia (P <.001).

Investigators found a high fear of hypoglycemia worry and behavior scores were significantly associated with 8-item Patient Health Questionnaire and 7-item Generalized Anxiety Disorder Scale scores. Analyses showed individuals with ≥1 severe hypoglycemia event and impaired awareness of hypoglycemia had higher odds of high fear of hypoglycemia.

Regarding the focus group, a total of 11 healthcare providers participated in focus group interviewers. The providers indicated that fear of hypoglycemia screener is clinically necessary and relevant, particularly in preclinical visits. They indicated those who screened high on the 9 items may benefit from additional education and/or referrals for mental healthcare.

Additionally, the lack of an actionable screening tool in clinical practice may lead to missed opportunities to identify potential fear of hypoglycemia in people with T1D. However, the healthcare providers also indicated that screening does pose challenges to implementation that will need to be addressed before wider use.

“Clinicians discussed the barriers in implementation of a new fear of hypoglycemia screener such as limited time, burden in modifying the electronic medical record system, staff shortages due to clinical responsibilities, and constraints with IT resources at the health institution,” investigators wrote


  1. Peter ME, Rioles N, Liu J, et al Prevalence of fear of hypoglycemia in adults with type 1 diabetes using a newly developed screener and clinician’s perspective on its implementation BMJ Open Diabetes Research and Care 2023;11:e003394. doi: 10.1136/bmjdrc-2023-00339
  2. Psychosocial care for people with diabetes: a position statement of the American diabetes Association. Diabetes Care 2017;40:287. doi:10.2337/dc16-2053

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