While the physical complicactions of are well known and devastating, it is important to remember the humanistic-side of this disease and the consequences that may result from hypoglycemia. Besides the symptoms of hypoglycemia, social embarrassment, mental disruption, interpersonal conflict, unconsciousness or seizures, accidents/injury, and even death may occur. In addition, hypoglycemia is associated with many psychological characteristics of major stressors such as unpredictability, perceived or actual lack of control, high levels of vigilance, and potentially serious or even life-threatening consequences. Fear of hypoglycemia is also significant as it can increase specific stress, worry, and anxiety, as well as have a negative impact on quality-of-life and relationships.

Fear of hypoglycemia is experienced by many of those who are touched by diabetes such as adults, adolescents, and children with type 1 diabetes, adults with type 2 diabetes, and family members or significant others of those that struggle with the disease. This fear is not limited to insulin-users alone as patients with type 2 diabetes not on insulin can also experience anxiety about hypoglycemia episodes which may lead to decreased well-being and emotional distress.¹ Hypoglycemic episodes are recorded differently in different studies. For the purposes of this review, hypoglycemia events can be construed as having 1 or more of the following:

• Severe hypoglycemia (single or recurrent episode)
• Frequent mild/moderate hypoglycemic events
• Unconsciousness or seizure
• Emergency room visits
• Other episodes associated with physical or psychological trauma
• Impaired awareness of hypoglycemia.

In an Australian study of type 1 diabetes patients, severe episodes of hypoglycemia resulted in an increased fear of hypoglycemia and diabetes-related distress as well as a decrease in emotional well-being.² The MILES study from the Netherlands noted that depressive symptoms were a predictor of fear of hypoglycemia as was any history of severe hypoglycemia.³ In a study from Spain with over 4000 patients, any history of hypoglycemia was associated with fear of hypoglycemia and a decreased quality-of-life.⁴ Predictors of fear of hypoglycemia in adults with type 1 and type 2 diabetes, adolescents, and children with type 1 diabetes included a history of hypoglycemia, and fear of hypoglycemia itself was a predisposition factor to anxiety. Saudi Arabia had similar findings for their adolescents (13-18 years) in factors that predicted fear of hypoglycemia. These included female sex, multiple daily insulin injections, older age, and duration of diabetes.⁵ Hypoglycemia history also played a role in the fear of hypoglycemia, with history including frequency of hypoglycemia, fainting, nocturnal hypoglycemia, and hypoglycemia while asleep, at school, or in front of friends.⁵ In a United States study specific to fear of hypoglycemia in adolescents, severe hypoglycemia and trait anxiety were predictors of fear of hypoglycemia. Parents of these patients also had limited confidence in the adolescent to carry emergency glucose on their person in case of an emergent need.⁶ Interestingly, there is a relationship between hypoglycemia and post-traumatic stress disorder (PTSD) in which patients who experienced fear of hypoglycemia and had a perceived threat of death were predicted to have a PTSD diagnosis.⁷

Nondiabetic spouses and partners of type 1 diabetes patients have higher levels of fear of hypoglycemia than the patients themselves. This can greatly impact the dynamics of a relationship as the non-diabetic partner needs to become responsible for caretaking concerns such as carrying snacks, checking glucose during lows, and prearranging for emergencies.⁸ These partners experience significant worry, stress, and anxiety about hypoglycemia as well as the potential complications of an episode.⁸ When compared to spouses/partners of patients with diabetes who did not experience hypoglycemia, partners/spouses of patients who did experience severe hypoglycemia reported greater conflict with their diabetic spouse, greater fear of hypoglycemia, and greater sleep disturbances as a result of remaining vigilant during sleeping hours.⁹

Parents of children with type 1 diabetes may suffer fear of hypoglycemia and mental health symptoms as a result of their child’s illness. Some of the known mental health issues identified in this population include:^10-14

• Anxiety symptoms
• Emotional distress
• Reduced quality-of-life
• Reduced sense of self-efficacy in taking care of their child
• Depressive symptoms
• Parental stress
• Coping difficulty
• Sleep problems.

In addition, patients fear of hypoglycemic episodes can be worse than the episode itself as demonstrated by an Australian study.¹⁵ In this study, the parents’ fear of hypoglycemia led to a reduced quality-of-life for their children. The child’s fear also led to higher HbA_1c levels.¹⁵ Unfortunately, these fears of hypoglycemia by parents have led to higher than average blood glucose levels, higher HbA_1c levels, and higher blood glucose readings.^6,12,15