Patient Education and Counseling 68 (2007) 10–15

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Review
A critical review of the literature on fear of hypoglycemia in diabetes:
Implications for diabetes management and patient education
Diane Wild a,*, Robyn von Maltzahn a, Elaine Brohan a, Torsten Christensen b,
Per Clauson b, Linda Gonder-Frederick c
a
Oxford Outcomes Ltd., Seacourt Tower, West Way, Oxford, United Kingdom
b
Novo Nordisk, Copenhagen, Denmark
c
University of Virginia, VA, USA
Received 24 August 2006; received in revised form 3 May 2007; accepted 7 May 2007

Abstract
Objective: In many individuals with diabetes, the unpleasant symptoms and negative consequences associated with hypoglycemia may result in
significant anxiety or even a fear of hypoglycemia (FoH). This fear may have significant clinical implications for diabetes management. The aim of
this review is to integrate existing research on FoH (its measurement, predictors, correlates, impact and treatment) and discuss its implications for
diabetes management and patient education.
Methods: A literature search was conducted using Medline and Embase. The search was limited to journal articles published in English from 1985
to 2007 inclusive. Three hundred and one abstracts were reviewed and 273 were rejected on the basis of non-relevance. In addition to the 28 papers
included, six additional papers were identified by further searches and were added to this review.
Results: FoH appears to be a widespread phenomenon. It is measured primarily through the use of a specific scale, the Hypoglycemic Fear Survey
(HFS). There are a number of factors that relate to whether an individual is likely to develop FoH including whether there is a history of
hypoglycemia in an individual, length of time since first insulin treatment, and a higher level of variability in blood glucose level. FoH has been
linked to both state and trait anxiety although the relationship is complex.
Conclusions: There is evidence that FoH may have a significant negative impact on diabetes management, metabolic control and subsequent
health outcomes. There is evidence that blood glucose (BG) awareness training and CBT can reduce levels of fear and improve disease
management. More research is needed on how FoH arises and the individual variables which predict its development. In addition, well designed
research is required to better understand the behavioral and medical impact of FoH, and interventions to reduce it.
Practice implications: There is some evidence to suggest that interventions including BG awareness training and cognitive behavioral therapy can
reduce levels of fear and improve disease management. While many aspects of FoH require further well-designed research, it is evident that this
phenomenon can have a major impact on diabetes management and needs to be specifically addressed in patient education programs.
# 2007 Elsevier Ireland Ltd. All rights reserved.

Keywords: Hypoglycemia; Fear; Diabetes; Review; Diabetes management; Patient education

1. Introduction
The maintenance of normalised blood glucose (BG) levels
leads to a reduction in the onset and advancement of diabetic
complications in type 1 and type 2 diabetes [1,2]. However, this
is a difficult task to accomplish as the maintenance of
normalised BG levels also increases the incidence of episodes
of hypoglycemia [1]. If not for the problem of hypoglycemia, it
* Corresponding author. Tel.: +44 1865 324930; fax: +44 1865 324931.
E-mail address: Diane.wild@oxfordoutcomes.com (D. Wild).
would be much easier for people with diabetes to have normal
glycated hemoglobin (HbA1c) values throughout their life
[1,3].
Hypoglycemia is the most common adverse event associated
with insulin treatment in type 1 and type 2 diabetes. It can occur
suddenly and is characterized by unpleasant physical and
psychological symptoms such as shaking, sweating, drowsi-
ness, nausea, poor motor coordination, mental confusion,
negative mood, and unconsciousness.
Some authors point to the difficulty in distinguishing
between the symptoms of hypoglycemia and the symptoms of
anxiety which can complicate the delivery of psychological

0738-3991/$ – see front matter # 2007 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.pec.2007.05.003
 D. Wild et al. / Patient Education and Counseling 68 (2007) 10–15
interventions [4]. Whilst some of the symptoms of anxiety
mirror those of hypoglycemia, such as shaking, sweating,
nausea, and mental confusion, there are many symptoms that
are do not cross over. For example, hypoglycemia does not
cause a person to have diarrhea, dry mouth, tightness or pain in
the chest, muscle tension, or frequent urination.
Hypoglycemia is a major limiting factor in the glycemic
management of type 1 and type 2 diabetes mellitus [1,3].
Intensifying insulin treatment to lower HbA1c leads to an
increase in the number of hypoglycemic events. The Diabetes
Complications and Controls Trial (DCCT) found that strict
glycemic control resulted in a three-fold increase in the number
of hypoglycemic events in type 1 diabetes [1]. Similarly, in the
UK Prospective Diabetes Study (UKPDS), the maintenance of
tight glycemic control led to a significant increase in the
incidence of hypoglycemia in individuals with insulin treated
type 2 diabetes [2].
Severe hypoglycemia can result in physical injury, auto-
mobile accidents, and even death. In a preliminary report from
the DCCT, 817 patients with type 1 diabetes were followed for a
mean of 21 months. There were 714 episodes of severe
hypoglycemia in a subset 216 of these patients. Over one-half
of the episodes occurred at night, and over three-quarters in
patients receiving intensive insulin therapy [1]. Hypoglycemia
is somewhat less common in type 2 diabetes, because deficits in
glucagon and epinephrine secretion are much less prominent
and strict glycemic control (predisposing patients to low BG
concentrations) is much more difficult to achieve.
Patients actively trying to manage their diabetes are
balancing the need to avoid these acute effects and the long-
term complications of hyperglycemia, and immediate con-
sequences are often much more salient to patients than the
possibility of more vague future health problems. This may
especially be the case if they have first hand experience of the
immediate negative consequences of an acute episode of
hypoglycemia.
Given the unpleasant aspects of hypoglycemia and the
potentially life threatening nature of severe hypoglycemia, it is
not surprising that many people with type 1 diabetes or insulin
treated type 2 diabetes have a significant fear of developing
hypoglycemia. FoH appears to be particularly prevalent in
patients who have had severe hypoglycemic episodes, such as
ones that have involved loss of consciousness. This makes
intuitive sense, as the more unpleasant or traumatic the event,
the more likely someone is to develop anxiety about a repeat
episode. Steps taken to avoid this situation may then be
reinforced as they are associated with a reduction in the
person’s anxiety.
This avoidance may have significant clinical implications
for diabetes management. In order to avoid the aversive
symptoms of past hypoglycemia episodes, patients who have
FoH may engage in ‘over-compensatory behaviors’. This may
include taking less insulin than they need or overeating, in order
to avoid hypoglycemia. This type of coping response may result
in poor metabolic control and increase the risk of serious health
consequences associated with diabetes. People with diabetes
with a history of past severe hypoglycemic episodes (the ones
11
most adverse to FoH) are often the patients with more severe
diabetes and for whom appropriate disease management is
especially critical.
The aim of this review is to integrate a wide range of
research on FoH. This includes studies that have attempted to
measure the phenomenon, studies investigating predictors and
correlates of FoH, and the impact of FoH on behavior, and
studies exploring possible interventions to treat FoH. Finally,
the findings will be integrated and implications for patient
education and disease management will be discussed.
2. Methods
The electronic databases MEDLINE and EMBASE were
searched. The search was limited to journal articles published in
the English language between 1985 and 2007. The search terms
‘‘hypoglycemia’’ (OR ‘‘hypoglycaemia’’) AND ‘‘fear’’,
‘‘anxiety’’ OR ‘‘worry’’ OR ‘‘concern’’, were used. Cross
reference searching was engaged in articles of particular
relevance and whose references had not been picked up via the
keyword electronic search.
3. Results
The search resulted in 301 original papers. All abstracts
were reviewed and 273 were rejected on the basis of being non-
relevant. The reasons for exclusion included a focus on
hypoglycemia as opposed to fear of hypoglycemia, a reference
to pregnancy induced diabetes, or non-diabetic reasons for
hypoglycemia. A further 6 papers were identified through
cross-referencing and included in the review as they provided
relevant information for the introduction, the section on
measurement of hypoglycemia, or the conclusions.
3.1. The measurement of fear of hypoglycemia
The Hypoglycemic Fear Scale (HFS) is the most widely
used measure of FoH [5]. This scale is composed of a behavior
and a worry subscale. The behavior subscale comprises 10-
items describing diabetes self-management and other behaviors
to avoid hypoglycemia and its negative consequences. The
worry subscale includes 13 items describing different anxiety
provoking aspects of hypoglycemia. Responses are made on a
five point likert scale ranging from 1 = ‘‘never’’ to
5 = ‘‘always’’. The worry scale is frequently used alone [6].
Revised versions of the HFS assess FoH in children and
adolescents, and in the parents of children with type 1 diabetes,
as well as in spouses/partners of adults with type 1 diabetes
[7–9].
A comprehensive review of seven studies [10] using the HFS
shows that the behavior and worry scales have good internal
reliability (a = 0.89–0.96 and 0.60–0.84 for the behavior and
worry scales, respectively). Test–retest reliabilities were between
r = 0.64–0.76 for the worry scale and 0.59–0.68 for the behavior
scale. The HFS has also demonstrated validity as a sensitive
measure of change, showing reductions after interventions to
reduce frequency and fear of hypoglycemia [11].
12 D. Wild et al. / Patient Education and Counseling 68 (2007) 10–15
Results indicate that the HFS has good psychometric
properties and a good utility in treatment studies examining
educational or other interventions to reduce FoH.
Recently, Kamps et al. [12], developed an alternative scale to
measure FoH in children: The Children’s Hypoglycemia Index
(CHI). The CHI consists of 3 subscales: the general fears
subscale contains nine items that assess general fears related to
hypoglycemia and its consequences; the situation subscale
consists of seven items related to fears in specific situations; and
the behavior subscale contains nine items that assess how
children engage in behaviors to prevent hypoglycemia.
Responses to all items are rated on a five point likert scale
anchored at ‘‘Not afraid’’ and ‘‘Afraid all the time’’. The CHI
total score was positively correlated with the children’s HFS
total score (r = 0.69, p < 0.01), worry subscale score (r = 0.63,
p < 0.01), and behavior subscale score (r = 0.38, p < 0.01).
The CHI demonstrated good internal consistency and test–
retest reliability for the total score and each subscale,
suggesting that it is also an appropriate tool to measure FoH
in children.
Other measures of diabetes related stress such as the ATT39
[13] include an item which addresses fear of hypoglycemia, i.e.
‘Hypos are not as frightening as people think’. In addition, the
Problem Areas in Diabetes Survey (PAID) [14] includes items
such as ‘worrying about the future and the possibility of serious
complications’ which indirectly assess fear of hypoglycemia.
More recently Taylor [15] developed the Fear of Complications
questionnaire. This scale includes items relating to general
fears about diabetes complications, specific fears (e.g.
blindness, kidney problems, heart disease), lifestyle fears, fear
of hypoglycemia, and weight gain. The measure correlates
positively with the HFS but factor analysis shows that the HFS
and fear of complications scales load on separate factors
indicating that they are not both simply examining a general
diabetes anxiety [16]. Having a well validated scale of fear of
hypoglycemia (the HFS) means that it is possible to measure
the construct scientifically which increases understanding of
the problem and should allow health care professionals to work
with patients to find ways to reduce it [16].
3.2. Predictors and correlates of FoH
3.2.1. History of hypoglycemia and FoH
Although the measurement of FoH helps to describe the
experience of living with FoH, the question remains as to why
such fear develops in some individuals and not in others, and
why fear is greater in some individuals than others. One
important factor appears to be hypoglycemia history. A
relatively consistent relationship has been found between a
history of hypoglycemia, and development of FoH.
For example, Polonsky et al. found that the prediction of the
HFS-worry subscale score in T1DM patients was significantly
enhanced by the addition of hypoglycemic history [17]. Shiu
and Wong, found that three factors correlated significantly and
positively with FoH, including: time since first insulin-
treatment, frequency of hospitalization due to hypoglycemia,
and frequency of hypoglycemia affecting working life [18].
The above findings are consistent with a study conducted by
Irvine et al, who found that frequency of past hypoglycemia
episodes was significantly and positively related to high scores
on the HFS behavior subscale. They also found that participants
with a lower mean daily BG level, and higher mean BG level
variability (which can increase risk for hypoglycemia) reported
higher levels of FoH [10]. In sum, these studies suggest that
FoH is related to more frequent hypoglycemia and risk factors
for severe hypoglycemia, such as BG variability.
Other studies support the relationship between actual risk,
previous experience with hypoglycemia, and FoH. Ter Braak
et al. found that FoH was a heavier burden for patients with a
history of severe hypoglycemia than for those who did not
report any recent severe hypoglycemic event [19].
3.2.2. State-trait anxiety and FoH
FoH has been linked to both state and trait anxiety, but
several issues complicate these inter-relationships. First,
anxiety or arousal, is considered a neurogenic symptom of
hypoglycemia [20]. Secondly, elevated anxiety levels may also
lead to impairment in detection of hypoglycemia, which can
increase risk of episodes of severe hypoglycemia [21].
Measures of general anxiety have been administered in
several studies assessing FoH. Polonsky et al. found that FoH
was positively correlated with both trait anxiety, as measured
by the State Trait Anxiety Inventory (STAI), and general
fearfulness, as measured using the Fear Survey Schedule, for
both type 1 and type 2 patients. For type 1 patients, FoH was
also significantly correlated with self-reported difficulty in
distinguishing between anxiety and initial hypoglycemia
symptoms. This correlation was not significant in type 2
patients [17]. Certainly, this difficulty in discriminating
between anxiety and hypoglycemia could increase the risk
of a patient failing to respond appropriately to hypoglycemia. A
similar relationship between trait anxiety and FoH, as well as
between hypoglycemic history and FoH, was observed in an
adolescent population where trait anxiety was found to be a
predictor of FoH, together with the recent frequency of
hypoglycemic episodes [9].
Green, Feher and Catalan presented an illustrative case study
of a man whose FoH lead to the development of agoraphobia
and panic disorder [4], much in the way that a single fear can
become generalized as both anxiety and avoidant behavior
spread well beyond the initial triggering situation. However, it
appears at least equally possible that a pre-existing anxiety
disorder could contribute to the subsequent development of
FoH, as patients with high pre-existing levels of anxiety may be
more susceptible to developing specific fears and phobias when
they encounter stressful events.
Costea et al. also found that marked anxiety and panic
attacks were more prevalent in patients who reported frequent
hypoglycemic events. They found that 74% of those in the
frequent hypoglycemic events group had exacerbated anxiety
about hypoglycemia including anxious-obsessive processes or
phobic-type panic attacks [22]. Similarly, Irvine, Cox, and
Gonder-Frederick [10], showed that individuals with more
psychological symptoms, as measured using the Hopkins’
 D. Wild et al. / Patient Education and Counseling 68 (2007) 10–15
Symptom Checklist 90, experienced higher levels of overall
FoH.
Hepburn et al. [23] created a model using Structural
Equation Modeling (SEM) of symptoms, hypoglycemia
awareness, FoH, and personality factors in a study which also
used the HFS to measure FoH. They assessed 305 patients with
diabetes and found that patients with reduced hypoglycemia
awareness scored higher for neuroticism and lower for
extroversion, and had greater FoH. The authors also found
that the personality trait of neuroticism, which is highly related
to anxiety, was the major determinant of the variance in FoH.
Gold et al. [24] also conducted a study using SEM and found
that over 25% of the variance of ‘worry’ on the HFS was
accounted for by a history of previous severe hypoglycemia.
These findings again support the conclusion that both
personality traits, such as neuroticism and trait anxiety, and
actual experiences with traumatic episodes of hypoglycemia
contribute to the development and severity of FoH.
While these studies suggest interesting links between
anxiety and FoH, the direction of causality has not yet been
firmly established, and it is likely that the relationship is
bidirectional. For example, an anxious person may be more
likely to develop FoH after experiencing an episode of
hypoglycemia. Conversely, such an anxiety-provoking event
may trigger development of an anxiety disorder in someone
who did not have one before. More research is required in this
area. Longitudinal research that provides baseline assessment
of anxiety, FoH, and diabetes management and follows changes
in these factors over time and in reaction to hypoglycemia
episodes would be particularly useful.
3.3. Impact of FoH
Fear of hypoglycemia not only increases psychological
distress associated with diabetes, but it is also thought to have a
behavioral impact on diabetes management and metabolic
control. One of the major areas of exploration in this field is the
hypothesis that people who fear hypoglycemia may take
corrective, or counter active action to prevent hypoglycemia at
the expense of experiencing unhealthily high glucose levels [5].
This hypothesis has not received the scientific attention it
deserves and when studies have been conducted they have
highlighted complex interactions between psychological and
biological variables.
Evidence in support of this hypothesis is clearly seen in a
documented case study by Cox et al. [25]. In this report, a
male subject in a longitudinal study experienced an episode
of severe hypoglycemia, resulting in multiple physical
injuries and hospitalization. Subsequently, his HFS scores
and HbA1c increased significantly, and he acknowledged that
he was intentionally maintaining higher BG levels to avoid a
reoccurrence of severe hypoglycemia. Over time, his FoH
and metabolic control returned to baseline levels. Further
support of the impact of FoH on metabolic control is
provided by Clarke, Gonder-Frederick, Snyder and Cox [7]
who found a positive linear relationship between HFS scores
and HbA1c.
13
However, other studies have failed to find a relationship
between FoH and diabetes control. For example, when Irvine,
Cox and Gonder-Frederick [10] examined the interaction
between hypoglycemia and fear, they found no correlation
between HbA1c and either HFS subscale, indicating that FoH
was not affecting diabetes management or control. On the other
hand, higher risk for hypoglycemia (low mean BG and high BG
variability) did significantly relate to the HFS worry subscale in
this study, but not the behavior subscale. Lower risk (high mean
daily BG) was associated with less fear.
Further support of the original hypothesis is provided by
Shiu and Wong [26] where 19.2% of their sample admitted to
raising their glucose levels to avoid hypoglycemia. However,
when the sample was grouped according to glycemic control it
was found that the group with optimal control, and therefore a
higher risk for hypoglycemia, had the highest HFS scores
indicating that good diabetes control in this group sometimes
comes at the expense of emotional well being.
A logical conclusion from the above studies is that fear may
motivate some patients to try and prevent hypoglycemia
thereby compromising metabolic control. However, the
relationship is obviously a complex one involving the
interaction of many variables and is an area of particular
concern in the context of current recommendations for tighter
metabolic control by the Diabetes Control and Complications
Trial [1]. Further research is needed if this relationship is to be
better understood.
3.4. Interventions to reduce FoH
Psychological interventions and patient education to reduce
FoH and improve diabetes management are beginning to be
explored. Cognitive behavioral therapy (CBT) has been found
to successfully alleviate panic attacks related to FoH in a case
study. This study focused on the case of a woman who feared
that hypoglycemia would lead to a loss of behavioral control
resulting in humiliation and embarrassment. The intervention,
which included relaxation training and reframing catastrophic
cognitions was successful in significantly lowering the
participant’s anxiety, depression and FoH [27].
Interventions more focused on disease management have
also been studied. Blood Glucose Awareness Training (BGAT)
is specific training for diabetes patients, which is designed to
improve awareness of BG symptoms and factors leading to
extremes in glucose. BGAT may reduce both frequency and
fear of hypoglycemia [8] and the sense of loss of control or
uncertainty associated with hypoglycemia [28,29] while
increasing individuals’ confidence in their ability to recognise
and anticipate hypoglycemic episodes. Cox et al. reported very
promising results using BGAT in a recent study. In this study, 73
adults with type 1 diabetes participated in a 6-month study with
follow-up at 1, 6 and 12 months after BGAT. The intervention
resulted in improved recognition of hypoglycemia; improved
judgment in knowing when to lower high BG; a reduction in
occurrence of diabetic ketoacidosis, severe hypoglycemia, and
motor vehicle violations; and also improvement in terms of
worry about hypoglycemia [30].
14 D. Wild et al. / Patient Education and Counseling 68 (2007) 10–15
Weinger and Jacobson also found that FoH decreased after
intensive diabetes treatment which included BGAT [31]. These
findings suggest that specific educational interventions that
provide training for early recognition and avoidance of severe
hypoglycemia may be effective both in terms of reducing FoH
and increasing appropriate diabetes management behavior. This
likely occurs because fear tends to decrease once perceived or
actual control over the feared situation has been established.
4. Discussion and conclusions
4.1. Discussion
This review has attempted to integrate the growing literature
in the area of FoH. In summary, it is clear that episodes of
hypoglycemia are highly unpleasant events, with the potential
for negative emotional, social and behavioral consequences for
patients. 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.
There is also some evidence that this fear is a major barrier to
patients achieving optimal BG control, and fear of hypogly-
cemia may outweigh concerns about long-term consequences
of the effects of hyperglycemia.
The research reviewed here approaches FoH from a variety
of methodological and conceptual perspectives. Regardless of
the approach however, the experience of hypoglycemia is
universally presented as unpleasant and associated with
numerous negative effects, particularly when the individual
does not recognise the early symptoms. Psychologically, this
can lead to reliance on others, social stigma, and a deterioration
of self-concept. As noted, loss of control and uncertainty appear
central to the psychological burden of FoH.
In the literature, FoH has been measured mainly using the
HFS, which assesses both the emotional and behavioral impact
of FoH. A large range of emotional and psychological issues
were connected to the experience of hypoglycemia [30].
Links between trait anxiety, history of hypoglycemia,
experiencing severe hypoglycemia, and FoH have also been
established [10,17]. These studies demonstrate that FoH is
influenced both by an individual’s enduring personality traits,
as well as situational and transient factors such as negative
experiences with hypoglycemia. Psychological comorbidity
appears to be a problem specifically with anxiety and panic
disorder.
Psychological and behavioral interventions that reduce FoH
warrant further research, although there is some evidence that it
decreases after BGAT and that CBT for FoH-triggered panic
disorder may be effective.
4.2. Conclusion
There appears to be evidence that FoH has a significant
negative impact on diabetes management, metabolic control
and subsequent health outcomes. The factors that contribute to
poor glycemic control are multi-factorial. As noted in the
introduction, patients actively trying to manage their diabetes
are balancing the need to avoid the acute effects of
hypoglycemia and a desire to avoid long-term complications
of hyperglycemia [28]. Acute, immediate consequences are
often much more salient to patients than possible future
complications. This may by influenced by first hand experience
of the immediate negative consequences of an acute episode of
hypoglycemia. FoH may then increase risk for keeping BG
levels high to avoid episodes when fear is high, thereby
contributing to poorer metabolic control. Although there is
some indirect and case study evidence to indicate that this
occurs, much more research is needed to determine whether this
is the mechanism that best explains the impact that FoH has on
patients’ diabetes management behavior.
There is evidence that interventions including BG awareness
training and CBT can reduce levels of fear and improve disease
management. Many aspects of FoH require further well-
designed research to better understand how FoH arises, the
individual variables which predict development of FoH as well
as its severity and impact on diabetes management behavior and
quality of life, and what psychological approaches or focused
education work best in treating FoH. Although there is
increasing knowledge about the development of FoH, how it
impacts diabetes control, and what may be done to treat it, many
important questions remain for future exploration in well
designed research.
4.3. Practice implications
Although more studies are needed, the currently available
research demonstrates that FoH has a major impact on diabetes
management for some patients, and that it should be addressed
in patient education programs. Research suggests that patients
are often reluctant to discuss problems with hypoglycemia with
health care professionals, especially episodes of severe
hypoglycemia. For example, one study found that patients
did not report 50% of episodes that occurred during driving,
presumably due to concerns about driving privileges [32]. This
means that diabetes educators should query patients directly
about episodes of hypoglycemia, and their impact on FoH and
diabetes management.
The first step is to identify those patients for whom FoH is a
significant clinical issue. While ideally educators would use an
assessment tool with well-documented validity and reliability,
such as the HFS, if this is not possible then patients should at
least be questioned about the occurrence of any recent episodes,
and the negative sequelae of these episodes, including impact
on diabetes management habits.
However, research has also indicated that patient reports
regarding hypoglycemic episodes may not always be reliable
For this reason it can be extremely useful to query spouses,
partners or other relatives about recent episodes and their
impact [33]. These significant others may also be experiencing
FoH and in need of education, support and counseling.
Significant others may also play a role in encouraging
maintenance of higher BG levels to reduce their own anxiety,
such as parents who attempt to keep glucose higher when their
children with type 1 diabetes are away from them.
 D. Wild et al. / Patient Education and Counseling 68 (2007) 10–15
Patients who are most vulnerable to developing significant
FoH warrant special attention. These groups would include
those who have had recent traumatic episodes of hypoglycemia,
those who appear to be high in trait anxiety or have pre-existing
anxiety disorders, adults who live alone, patients with
hypoglycemic unawareness, and parents of children who have
experienced seizures. When patients with high levels of fear are
identified, intensive education about hypoglycemia and its
prevention should be provided. This education will likely be
most useful if it focuses on health-promoting coping
techniques, such as always carrying appropriate fast-acting
carbohydrates, attending more to early warning symptoms, and
more frequent BG monitoring.
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.
Acknowledgments
The work was performed at Oxford Outcomes Ltd., Oxford,
UK. The study was funded by NovoNordisk. The authors are
aware of no potential conflicts of interest that are directly
relevant to the content of this manuscript.
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