Effect of fear of hypoglycaemia on sleep quality of patients with type 2 mellitus diabetes: The mediating role of alexithymia

Background

Patients with type 2 diabetes mellitus (T2DM) commonly experience poor sleep quality. This study aimed to investigate whether alexithymia mediates the association between fear of hypoglycaemia (FoH) and sleep quality in patients with T2DM.

Methods

From September 2021 to November 2021, a cross-sectional survey was conducted on 407 patients with T2DM in China. Data collection was made possible through the administration of the Chinese Version of the Worry Scale, Toronto Alexithymia Scale and Chinese version of the Pittsburgh Sleep Quality Index (CPSQI). Multiple linear regression analyses were also performed.

Results

A total of 65.6% of the participants were male, and 75.7% were aged 18-40 years. FoH showed a moderate and positive correlation with CPSQI scores (r = 0.308, p < 0.001). Alexithymia was weakly and positively correlated with CPSQI scores (r = 0.185, p < 0.001). Meanwhile, FoH exhibited a moderate and positive correlation with alexithymia (r = 0.422, p < 0.001), and difficulty in identifying (r = 0.414, p < 0.001) and describing feelings (r = 0.416, p < 0.001) and a weak and positive correlation with externally oriented thinking (r = 0.221, p < 0.001). The total effect (β = 0.408, p < 0.001) of FoH on CPSQI comprised not only the direct (β = 0.293, 95% confidence interval: 0.174-0.411, p < 0.001) but also the indirect effect (β = 0.115, p < 0.001) of alexithymia.

Conclusions

Alexithymia can mediate the association between FoH and sleep quality. Clinicians should recognize the potential effect of alexithymia and incorporate it in intervention planning and care. Addressing the affective disturbances arising from FoH can enhance emotional expression and sleep quality among T2DM patients.

The impact of hypoglycaemia on quality of life among adults with type 1 diabetes: Results from "YourSAY: Hypoglycaemia"

AIMS

Research on hypoglycaemia and quality of life (QoL) has focused mostly on severe hypoglycaemia and psychological outcomes, with less known about other aspects of hypoglycaemia (e.g., self-treated episodes) and impacts on other QoL domains (e.g., relationships). Therefore, we examined the impact of all aspects of hypoglycaemia on QoL in adults with type 1 diabetes (T1DM).

METHODS

Participants completed an online survey, including assessment of hypoglycaemia-specific QoL (using the 12-item Hypoglycaemia Impact Profile). Mann-Whitney U tests examined differences in hypoglycaemia-specific QoL by hypoglycaemia frequency, severity, and awareness. Hierarchical linear regression examined associations with QoL.

RESULTS

Participants were 1028 adults with T1DM (M ± SD age: 47 ± 15 years; diabetes duration: 27 ± 16 years). Severe and self-treated hypoglycaemia and impaired awareness negatively impacted on overall QoL and several QoL domains, including leisure activities, physical health, ability to keep fit/be active, sleep, emotional well-being, spontaneity, independence, work/studies, and dietary freedom. Diabetes distress was most strongly associated with hypoglycaemia-specific QoL, followed by generic emotional well-being, fear of hypoglycaemia, and confidence in managing hypoglycaemia. Hypoglycaemia frequency and awareness were no longer significantly associated with QoL once psychological factors were considered.

CONCLUSIONS

Hypoglycaemia negatively impacts on several QoL domains. Psychological factors supersede the effect of hypoglycaemia frequency and awareness in accounting for this negative impact.

Effect of diabetes technologies on the fear of hypoglycaemia among people living with type 1 diabetes: a systematic review and meta-analysis

Background

Fear of hypoglycaemia (FOH) significantly disrupts the daily management of type 1 diabetes (T1D) and increases the risk of complications. Recent technological advances can improve glucose metrics and reduce hypoglycaemia frequency, yet their impact on FOH is unclear. This systematic review and meta-analysis (SRMA) aimed to synthesize the current literature to understand the impact of diabetes technologies on FOH in T1D.

Methods

In this SRMA, we searched PubMed, Medline, Scopus, and Web of Science from inception up to May 21st, 2023 for studies assessing the effect of using real-time or intermittently scanned continuous glucose monitors (rtCGM or isCGM); insulin pumps (CSII); and their combinations on FOH as the primary outcome, measured using the Hypoglycaemia Fear Survey (HFS; including total, worries [HFS-W], and behaviours [HFS-B] scores), in non-pregnant adults with T1D. Data was extracted by the first and second authors. Results were pooled using a random-effects model based on study design (RCT and non-RCT), with subgroup analysis based on the type of technology, reported change in hypoglycaemia frequency, and duration of use. Risk of bias was evaluated with Cochrane and Joanna Briggs Institute tools. This study is registered with PROSPERO, CRD42021253618.

Findings

A total of 51 studies (n = 8966) were included, 22 of which were RCTs. Studies on rtCGM and CSII reported lower FOH levels with ≥8 weeks of use. Studies on CSII and rtCGM combinations reported lower FOH levels after ≥13 weeks of automated insulin delivery (AID) use or 26 weeks of sensor-augmented pump (SAP) use. The meta-analysis showed an overall lower FOH with technologies, specifically for the HFS-W subscale. The RCT meta-analysis showed lower HFS-W scores with rtCGM use (standard mean difference [95%CI]: -0.14 [-0.23, -0.05], I2 = 0%) and AID (-0.17 [-0.33, -0.01], I2 = 0%). Results from non-RCT studies show that SAP users (-0.33 [-0.38, -0.27], I2 = 0%) and rtCGM users (-0.38 [-0.61, -0.14], I2 = 0%) had lower HFS-W.

Interpretation

We found consistent, yet small to moderate, effects supporting that diabetes technologies (specifically rtCGM, SAP, and AID) may reduce hypoglycaemia-related worries in adults with T1D. Current literature, however, has limitations including discrepancies in baseline characteristics and limited, mainly descriptive, statistical analysis. Thus, future studies should assess FOH as a primary outcome, use validated surveys, and appropriate statistical analysis to evaluate the clinical impacts of technology use beyond just glucose metrics.

Funding

Canadian Institutes of Health Research, Juvenile Diabetes Research Foundation Ltd.

Potential mechanisms for poor glycaemic control in patients with type two diabetes and fear of hypoglycaemia

Purpose

The current study aimed to explore the potential effect of diabetes-related distress on the association between fear of hypoglycaemia and poor glycaemic control. We evaluated the specific aspects of fear of hypoglycaemia that affect glycaemic control among Saudi patients with type 2 diabetes (T2D).

Methods

Descriptive cross-sectional survey of patients with T2D attending a specialist diabetes clinic in Taif, Saudi Arabia. We used the Hypoglycaemia Attitudes and Behaviour Scale (HABS) for assessing fear of hypoglycaemia among our sample. We used Structural Equation Modelling to evaluate the moderators and correlates of fear of hypoglycaemia.

Results

We surveyed 365 patients with T2D. Cronbach's alpha for the HABS assessment was 0.84, an indication of excellent internal consistency. The composite reliability for hypoglycaemic anxiety was 86.8%; hypoglycaemic avoidance was 85.2%; and hypoglycaemic confidence was 92.6%. The mean HABS score was 32.7 points (out of 70 points; SD = 9.8 points). Fear of hypoglycaemia was associated with increased levels of glycated haemoglobin (HbA1c), presence of eye disease, heart disease, and stroke. Fear of hypoglycaemia was associated with poor glycaemic control. No significant moderating effect of diabetes-related distress was observed. However, only hypoglycaemic anxiety and avoidance were associated with poor glycaemic control. Confidence in the ability to control low glucose levels was not associated with elevated HbA1c levels.

Conclusion

A significant finding of this study highlighted the considerable and direct effect of fear of hypoglycaemia on poor glycaemic control among patients with T2D. However, only fear-related anxiety and avoidance-and not confidence in the ability to control low glucose levels-had an effect on poor glycaemic control.

Effectiveness of a flash glucose monitoring systems implementation program through a group and telematic educational intervention in adults with type 1 diabetes

OBJECTIVES

Verifying the clinical effectiveness and the impact on quality-of-life parameters, fear of hypoglycaemia and satisfaction with the treatment obtained with a flash glucose monitoring (MFG) devices implantation program that includes a telematic and group educational intervention in adults with type 1 diabetes.

PATIENTS AND METHODS

Prospective quasi-experimental study, carried out during the COVID-19 pandemic period with a 9-month follow-up at the Virgen Macarena University Hospital, Sevilla.

RESULTS

Eighty-eight participants were included (men: 46.6%; mean age (years) 38.08, SD: 9.38); years of DM1 evolution: 18.4 (SD: 10.49); treatment with multiple doses insulin (MDI) 70.5% vs 29.5% subcutaneous insulin infusion therapy (CSII)). Baseline HbA1c was 7.74% (1.08). After the intervention, the global decrease in HbA1c was -0.45% (95% CI [-0.6, -0.25], P < 0.01), increasing to -1.08% in the group that started with HbA1c ≥ 8% (P < 0.01). A mean decrease in the Fear of Hypoglycemia 15 (FH15) test score of -6.5 points was observed (P < 0.01). In the global score of the Spanish version of Diabetes Quality Of Life (DQOL-s) test, the decrease was -8.44 points (P < 0.01). In Diabetes Treatment Satisfaction Questionnaire test (DTQ-s), global score increased in + 4 points (P < 0.01).

CONCLUSIONS

The incorporation of an educational program in group and telematic format within the development of MFG devices implantation strategies is an effective option, with associated benefits in quality of life and fear of hypoglycemia in adult patients with DM1. This option can be implemented in usual clinical practice.

Impact of fear of hypoglycaemia on self-management in patients with type 2 diabetes mellitus: structural equation modelling

AIMS

This study aimed to explore the effect of fear of hypoglycaemia (FOH) on self-management and its specific action path in patients with type 2 diabetes mellitus (T2DM) to provide a basis for developing targeted nursing interventions.

DESIGN

A cross-sectional study.

METHODS

From June to October 2019, we recruited 258 patients with T2DM from the endocrinology department of three hospitals to complete questionnaires, including the Hypoglycaemia Fear Survey-II, Diabetes Distress Scale, Self-Stigma Scale, Social Support Rating Scale and Summary of Diabetes Self-Care Activities, in Jiangsu Province, China. Pearson's correlation analyses and structural equation modelling were conducted to explore the relationship and influence path among the above variables.

RESULTS

The correlation analysis of FOH, distress, self-stigma, social support and self-management showed that, except for social support not being correlated with FOH and distress (P > 0.05), all variables were correlated in pairs (r = - 0.19-0.77, P < 0.01). The final model fit well, and the fitting indexes of the model were as follows: χ²/df = 2.191, GFI = 0.934, CFI = 0.954, TLI = 0.934, RMSEA = 0.068, and SRMR = 0.0649. The effects of FOH on self-management in patients with T2DM included one direct path and two indirect paths: (a) FOH had a direct impact on self-management (P < 0.05); (b) FOH had an indirect impact on self-management through distress (P < 0.05); and (c) FOH had an indirect impact on self-management through self-stigma and social support (P < 0.05).

CONCLUSIONS

FOH could directly influence self-management in patients with T2DM. Furthermore, distress, self-stigma and social support were important mediating variables of FOH influencing self-management. Researchers can develop personalized interventions to improve the self-management of patients with T2DM by regulating distress, self-stigma and social support levels.

Quality of life in people with type 2 diabetes in the 3 years following initiation of second-line therapy: The DISCOVER study

AIMS

To assess changes in health-related quality of life (HRQoL) in DISCOVER, a 3-year, longitudinal, observational study of patients with type 2 diabetes initiating a second-line glucose-lowering therapy.

METHODS

HRQoL was assessed using the physical and mental component summary (PCS and MCS) scores of the 36-item Short-Form Health Survey version 2 (score ranges: 0-100; higher denotes better HRQoL) and the Hypoglycaemia Fear Survey II (HFS-II; score range: 0-132 scale; higher indicates greater fear of hypoglycaemia). Latent class growth modelling (LCGM) was used to identify patients with similar score trajectories.

RESULTS

Mean baseline PCS (n = 7428), MCS (n = 7453), and HFS-II (n = 5005) scores were 48.0, 45.4, and 15.4, respectively, and remained stable during follow-up. LCGM revealed subgroups with low or decreasing HRQoL. Patients in these subgroups tended to be older, had more comorbidities, and a lower socioeconomic status than in other subgroups. Use of insulin and sulfonylureas was highest in the subgroup with the highest fear of hypoglycaemia.

CONCLUSIONS

Overall, HRQoL remained stable in DISCOVER patients during follow-up. However, LCGM suggests that some patient characteristics and use of sulfonylureas or insulin are associated with low or decreasing HRQoL, potentially warranting the use of alternative therapies.

Association between sleep disturbances, fear of hypoglycemia and psychological well-being in adults with type 1 diabetes mellitus, data from cross-sectional VARDIA study

AIM

To assess the relationship between sleep quality, fear of hypoglycemia, glycemic variability and psychological well-being in type 1 diabetes mellitus.

METHODS

Our data were provided by the VARDIA Study, a multicentric cross-sectional study conducted between June and December 2015. Sleep characteristics were assessed by the Pittsburgh Sleep Quality Index (PSQI). Fear of hypoglycemia and psychological well-being were measured with the Hypoglycemia Fear Survey version II (HFS-II) and the Hospital Anxiety and Depression Scale (HADS), respectively. Glycemic variability (GV) was determined using the CV of three 7-point self-monitoring blood glucose profiles and the mean amplitude of glycemic excursion (MAGE).

RESULTS

315 patients were eligible for PSQI questionnaire analysis: 54% women, mean age 47 ± 15, mean diabetes duration of 24 ± 13 years, HbA1c of 7.6 ± 0.9% (60 ± 7,5mmol/mol). Average PSQI score was 6.0 ± 3.3 and 59.8% of the patients had a PSQI score > 5. HFS-II score and HADS were significantly higher among "poor" sleepers (p < 0.0001) and PSQI score was positively associated with HADS (β = 0.22; 95% CI = 0.08;0.35). GV evaluated by CV or MAGE did not differ between "poor" and "good" sleepers (p = 0.28 and 0.54, respectively).

CONCLUSIONS

Adult patients with type 1 diabetes have sleep disturbances which correlate with psychological well-being. This study suggests that psychological management can be a target to improve sleep quality in adults with type 1 diabetes mellitus.

The relationships among fear of hypoglycaemia, diabetes-related quality of life and psychological well-being in Norwegian adults with Type 1 diabetes

AIMS

To examine the associations among fear of hypoglycaemia, diabetes-related quality of life and psychological well-being, and determine whether diabetes-related quality of life is a mediator of the relationship between fear of hypoglycaemia and psychological well-being in adults with Type 1 diabetes.

METHODS

A total of 235 of 319 invited adults (18-69years) with Type 1 diabetes agreed to participate. Hierarchical linear regression was applied to 188 individuals with complete data. Mediation analysis was used to determine whether diabetes-related quality of life mediated the relationship between fear of hypoglycaemia and psychological well-being.

RESULTS

Fear of hypoglycaemia was significantly associated with diabetes-related quality of life and psychological well-being. The behaviour and worry components of fear of hypoglycaemia were significantly associated with diabetes-related quality of life (behaviour component: unstandardised coefficient=-0.04, p<0.001, standardised coefficient=-0.40; worry component: unstandardised coefficient=-0.01, p=0.041, standardised coefficient=-0.18). Fear of hypoglycaemia worry had a significant independent association with psychological well-being (unstandardised coefficient=-0.28, p=0.009, standardised coefficient=-0.25), whereas fear of hypoglycaemia behaviour did not. Diabetes-related quality of life mediated approximately half of the association between fear of hypoglycaemia worry and psychological well-being.

CONCLUSIONS

Hypoglycaemic episodes can have serious consequences, and assessing fear of hypoglycaemia might help health care providers offer suitable care strategies to individuals with Type 1 diabetes.

Fear of hypoglycaemia and self-management in type 1 diabetes

Aims

We studied the association between fear of hypoglycaemia (FoH) and various diabetes self-management practices.

Methods

Data from 798 individuals with type 1 diabetes participating in the FinnDiane Study were included. Self-reported questionnaires were used to assess FoH and self-management practices (e.g. dietary intake, insulin administration, physical activity). For glycaemic control, we used both the latest HbA_1c measurements and the serial HbA_1c measurements from the medical files. Factor analysis was used to reveal underlying constructs within the food frequency section of the diet questionnaire.

Results

In all, 44% and 63% of men and women reported FoH, respectively. In men, FoH was associated with higher mean serial HbA_1c levels, higher number of reported self-monitoring of blood glucose (SMBG), higher carbohydrate intake, and lower scores in the "high-fat" factor. In women, FoH was associated with a higher number of reported SMBGs and higher energy intake. No difference was observed in physical activity and insulin administration.

Conclusions

FoH has various implications for the self-management of diabetes. More studies are however needed to assess on one hand the association between FoH and diabetes self-management, and on the other hand, FoH and its long term consequences, such as the emergence of diabetic complications and mortality.

Severe hypoglycaemia and its association with psychological well-being in Australian adults with type 1 diabetes attending specialist tertiary clinics

AIM

To investigate severe hypoglycaemia (SH) in adults with type 1 diabetes and its associations with impaired awareness of hypoglycaemia (IAH), clinical, psychological and socio-demographic factors.

METHODS

Attendees of three specialist diabetes clinics in Melbourne, Australia completed questions about frequency of SH in the past six months; impaired awareness of hypoglycaemia (Gold score); and measures of general emotional well-being (WHO-5), diabetes-specific positive well-being (subscale of W-BQ28), diabetes-related distress (PAID) and fear of hypoglycaemia (HFS).

RESULTS

Of 422 participants (mean ± SD age 37.5 ± 15.0 years; 54% women), 78 (18.5%) reported at least one SH event and 86 (20.5%) had IAH. SH and IAH frequencies were similar at all clinics. In total, 194 SH events were reported, with 10 people experiencing 40% of events. Compared with those without SH, participants with SH had longer diabetes duration, were younger at diabetes onset and more likely to have IAH (p<0.01). Those with SH had greater fear of hypoglycaemia and diabetes-related distress, poorer general emotional well-being, and lower diabetes-specific positive well-being, (p<0.01). There were no associations with age, gender, insulin regimen or HbA1c.

CONCLUSIONS

This study has identified that SH and IAH in Australian adults with type 1 diabetes exist at similar levels to those reported in US and European research. SH was significantly associated with IAH and fear of hypoglycaemia. Assessment of hypoglycaemia, IAH and psychological well-being as part of a routine diabetes clinic visit was well accepted by attendees and enabled identification of those who may benefit from medical, educational or therapeutic interventions.