Breaking the Barrier: How to Manage Hypoglycaemia Fear in Diabetes Care
Impact of Hypoglycaemia Fear
Fear of hypoglycaemia affects approximately one in seven people with diabetes1 (PwD) and can significantly impact treatment adherence and outcomes.1 For healthcare professionals, understanding and addressing this fear is necessary to ensure timely initiation of insulin therapy when appropriate. When PwD are hesitant to start insulin therapy due to concerns about hypoglycaemia, applying practical, PwD-centered strategies can make a meaningful difference in their diabetes treatment journey.2 This article provides evidence-based approaches to help you confidently navigate challenging conversations.
Recognising Fear of Hypoglycaemia
Early identification of hypoglycaemia concerns in PwD enables more effective intervention.1 The following are some behavioural indicators to monitor:
- Over-compensatory behaviours: Maintaining higher blood glucose levels by taking less insulin than needed, frequent "preventative" snacking between meals1,3,4
- Avoidance behaviours: Limiting physical or social activities, avoiding being alone1
- Treatment resistance: Reluctance to discuss insulin and implement agreed treatment changes1
- Blood glucose management: Acceptance of persistently high blood glucose levels, excessive daily blood glucose checks1
These behaviours are particularly common in PwD with a history of severe hypoglycaemic episodes, a longer duration of insulin treatment, high blood glucose variability, anxiety traits or disorders, those who live alone, and older adults.4,5
The impact of untreated hypoglycaemia fear extends beyond glycaemic control—PwD often experience guilt, frustration, perceived loss of control, and increased stress, all of which significantly reduce quality of life6 and can lead to more diabetes-related complications.1
Assessment Strategies
Validated Tools
The Hypoglycaemia Fear Survey-II Worry scale (HFS-II W) or the Hypoglycaemic Fear Scale (HFS) can be used for assessing fear of hypoglycaemia and guiding conversations.1,4 This validated tool measures both behavioural responses (avoidance behaviours) and emotional concerns (worry) related to hypoglycaemia on a five-point scale.4
Effective Conversation Starters
Those who view their diabetes more negatively may have a greater fear of hypoglycaemia.6 Understanding these perceptions can help tailor your approach.
Approaches to Managing Fear of Hypoglycaemia
This evidence-based approach addresses both practical and psychological aspects of hypoglycaemia management2:
Practical Management Components
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Optimize Medications: Review current medications to identify those increasing hypoglycaemia risk. Consider discontinuing older hypoglycaemic agents or switching to newer agents with a lower hypoglycaemic risk when appropriate and carefully evaluate insulin types and dosages. |
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Ensure Proper Treatment Preparation: Help PwD plan for suitable, fast-acting carbohydrates and ensure they are pre-positioned where they may be needed. |
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Leverage Diabetes Technology: Continuous glucose monitoring (CGM) can help decrease severe hypoglycaemic events and alleviate fear of hypoglycaemia. When appropriate, consider the use of automated insulin delivery systems for enhanced management. |
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Identify Times of Increased Risk: Review glucose patterns and hypoglycemia history to pinpoint key contributors to past events and predict potential future occurrences. Collaborate with PwD to develop targeted interventions such as strategic snacking, basal insulin adjustments, or CGM implementation to mitigate the identified risks. |
Psychological Management Components
Effective Communication Approaches
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COLLABORATION Adopt collaborative communication with PwD in treatment decisions, which has been shown to improve insulin persistence compared to authoritarian styles.7 |
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DEMONSTRATION Demonstrate the injection process by showing actual needle size, proper technique, and provide in-office practice opportunities to reduce delay in insulin initiation.7 |
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INVOLVEMENT Involve PwD’s support network, as family members may provide valuable information about hypoglycaemic episodes that PwD might not report. Support persons may also need education, as they might encourage higher glucose levels due to their own fears.4 |
Building Confidence in People With Diabetes
Enhance knowledge and skills in hypoglycaemia management by reviewing symptom recognition, appropriate treatment, and the interactions between insulin, food, physical activity, and other contributing factors.1 Focus on practical education, including preventative measures such as carrying fastacting carbohydrates and recognising early warning signs.4
Fear of nocturnal hypoglycaemia (dying at night) is particularly common and can be reduced by providing knowledge of preventive actions, such as having frequent blood glucose checks.8 Discuss nighttime monitoring options and develop specific strategies to reduce overnight lows.
Rather than focusing on deficits, adopt a strengths-based approach to build confidence in PwD.8 Fostering hope can enhance their confidence in managing hypoglycaemia and support improved self-management.8
Addressing Hypoglycaemia Fears: A Key to Successful Insulin Therapy
Fear of hypoglycaemia represents a significant barrier to insulin initiation and optimal diabetes management.5 By recognising this fear, assessing its severity, and implementing targeted strategies, you can help PwD overcome their concerns and move forward with appropriate treatment. Remember that timely insulin initiation, when appropriate, is crucial for long-term health outcomes, and addressing hypoglycaemia fears directly can make this transition smoother and more successful for PwD.
By building confidence in PwD and providing appropriate support, you can help transform fear into effective self-management.8,9
Conclusion
The practical strategies outlined in this article—from structured assessment frameworks to collaborative communication approaches—provide you with tools to confidently address these concerns in your clinical practice.
Fear of hypoglycaemia represents a significant yet manageable barrier in diabetes care that requires thoughtful clinical attention. By implementing the practical and psychological strategies outlined in this article, healthcare professionals can transform PwD’s experiences with insulin therapy. The combination of medication optimisation, technology utilisation, targeted education, and strengths-based approaches creates a comprehensive framework for addressing these fears effectively. When PwD receive appropriate support to overcome hypoglycaemia concerns, they gain confidence in their self-management abilities and become more engaged partners in their treatment journey.
The successful management of hypoglycaemia fears may lead to improved treatment adherence, better glycaemic control, and enhanced quality of life for PwD1. Healthcare professionals who recognize these fears early and address them with empathy and evidence-based strategies can help make a profound difference in PwD outcomes, including levels of A1C and long-term diabetes complications1. By fostering open communication, building on PwD’s strengths, and providing practical tools for hypoglycaemia management, caregivers can create an environment where PwD can move beyond fear to embrace effective diabetes care. This PwD-centred approach may not only improve the aforementioned clinical outcomes but may also restore a sense of control and well-being essential for living successfully with diabetes1.
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Hendrieckx C, Halliday JA, Beeney LJ, Speight J. Fear of Hypoglycemia (and Other Diabetes-Specific Fears). Diabetes and emotional health: a practical guide for health professionals supporting adults with type 1 or type 2 diabetes. American Diabetes Association; 2021:53-63.
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Polonsky WH, Guzman SJ, Fisher L. The Hypoglycemic Fear Syndrome: Understanding and Addressing This Common Clinical Problem in Adults With Diabetes. Clin Diabetes. 2023;3-7. doi:10.2337/cd22-0131
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Huang J, Peng W, Ding S, Xiong S. Fear of hypoglycemia and associated factors in hospitalized patients with type 2 diabetes: a crosssectional study. Scientific Reports. 2022;3. doi:10.1038/s41598-022-24822-1
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Wild D, von Maltzahn R, Brohan E, Christensen T, Clauson P, Gonder- Frederick L. A critical review of the literature on fear of hypoglycemia in diabetes: Implications for diabetes management and patient education. Patient Educ Couns. 2007;2-6. doi:10.1016/j.pec.2007.05.003
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Sakane N, Kotani K, Tsuzaki K, et al. Fear of hypoglycemia and its determinants in insulin-treated patients with type 2 diabetes mellitus. J Diabetes Investig. 2015;6(5):2. doi:10.1111/jdi.12340
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Fariba A, Amerzadeh M, Banazadeh M, Rashidi S, Myaneh ZT. Fear of hypoglycemia and illness perception in type II diabetes patients. BMC Endocrine Disorders. 2024;2-4. doi:10.1186/s12902-024-01548-x
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Polonsky WH, Fisher L, Hessler D, et al. Identifying solutions to psychological insulin resistance: An international study. J Diabetes Complications. 2019;1-4. doi:10.1016/j.jdiacomp.2019.01.001
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Brown JB, Reichert SM, Valliere Y, et al. Living With Hypoglycemia: An Exploration of Patients' Emotions: Qualitative Findings From the InHypo- DM Study, Canada. Diabetes Spectr. 2019;3-6. doi:10.2337/ds18-0074
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Winkley K, Upsher R, Stahl D, et al. Psychological interventions to improve glycemic control in adults with type 2 diabetes: a systematic review and meta-analysis. BMJ Open Diabetes Res Care. 2020;1. doi:10.1136/bmjdrc-2019-001150
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