Fear of hypoglycemia is common in people with diabetes. Linda Gonder-Frederick, PhD, associate professor of psychiatry and neurobehavioral sciences at the University of Virginia School of Medicine, discusses how fear of hypoglycemia can affect people with diabetes as well as their caregivers and what health care professionals can do to support these patients.

Q: What is fear of hypoglycemia?

A: Fear of hypoglycemia is the anxiety that people with diabetes and their loved ones can experience about low blood glucose levels, also called hypoglycemia.

Hypoglycemia can vary in severity. Typically, a blood glucose level below 70 milligrams per deciliter (mg/dL) is considered hypoglycemia. A blood glucose reading at that level is a signal to the person with diabetes that they may need to consume some sort of fast-acting carbohydrate, such as fruit juice or something similar, to bring blood glucose levels back up. An episode like this would be considered a mild episode of hypoglycemia.

However, when blood glucose levels drop below 54 mg/dL, people may begin to experience short- and long-term negative effects, such as mental confusion and an increased risk of developing heart problems. Some people also develop hypoglycemia unawareness, also called impaired awareness of hypoglycemia, which is when they are no longer able to feel the symptoms of low blood glucose levels. How often and how severely people experience hypoglycemia varies greatly from person to person.

Hypoglycemic episodes are physically unpleasant for most people. People can experience waves of nausea, dizziness, and trembling. These episodes can be scary, too. For example, imagine if someone is driving or caring for a young child, and then suddenly, they can’t think clearly or move their body well. Hypoglycemia can even become so severe that people are no longer able to give themselves treatment. People can be afraid of experiencing these episodes, especially if they’ve had a severe episode before. Caregivers of someone with diabetes can also be afraid that the person they’re caring for may experience severe episodes of hypoglycemia.

Q: Is fear of hypoglycemia common in people with diabetes? How can fear of hypoglycemia affect caregivers or family members?

A: Fear of hypoglycemia is common. A healthy level of fear—also called adaptive fear—about hypoglycemia is necessary. People with adaptive fear are aware that hypoglycemia could happen, how damaging it can be, and how to treat it if it happens. However, the level of fear can be unhealthy if it grows to a point that provokes extreme anxiety.

Caregivers may have an even greater fear of hypoglycemia than the person with diabetes. This is especially true for parents and other caregivers of children who have diabetes. Having low blood glucose levels during sleep, or nocturnal hypoglycemia, is common. Parents and other caregivers often feel they must get up several times during the night to check their child’s blood glucose level. Diabetes technology, such as continuous glucose monitors (CGMs), may be helpful for many families with children who have diabetes. Caregivers may be able to have an alarm in their room that will go off if the child’s blood glucose level gets too low.

Q: Are there certain behaviors or signs that may indicate fear of hypoglycemia? What should health care professionals look for when talking with their patients?

A: Some people who are extremely fearful may try to avoid low blood glucose by keeping their blood glucose levels in a higher range. Often, these people have had a traumatic or socially embarrassing experience with hypoglycemia that affects how they manage their diabetes.

Another thing that health care professionals can look for is how people with diabetes treat an episode of hypoglycemia. Sometimes, people with fear of hypoglycemia will overtreat low blood glucose. They may eat or drink too many carbohydrates and then have high blood glucose levels, which can be hard to bring back down.

Q: What questions can health care professionals ask their patients to see if they may experience fear of hypoglycemia? Are there any tools or questionnaires that can help?

A: I think health care professionals should always ask patients with diabetes if they’ve had any episodes of hypoglycemia. Unfortunately, some people may not want to admit that they’ve had an episode, especially if it was severe. Many people are fearful of having some sort of negative consequence from admitting that they’ve had a severe episode, such as losing their ability to drive.

Health care professionals should not only ask about whether an episode of hypoglycemia has occurred, but also what the impact was. What were the circumstances, and what happened? Were there other people around? Did it happen during an important social occasion? Were they alone with no food available? Several social and environmental factors can affect how traumatic the episode was, and asking these questions can help give a full picture of the incident.

From a clinical perspective, it might be helpful to do a quick assessment before giving people a longer questionnaire. I think health care professionals should ask something like, “If I asked you how worried you are about hypoglycemia on a zero- to five-point scale, with zero being not worried at all and five being extremely worried, what would you say?” Then, if someone answers with a four or five, perhaps it’s time to do a longer questionnaire.

The tool health care professionals most commonly use to assess fear of hypoglycemia is the Hypoglycemia Fear Survey (PDF, 372 KB) . This tool is available in more than 60 languages, and health care professionals all over the world have used it.

Q: What can health care professionals do to help support people with fear of hypoglycemia?

A: Most of the time, fear of hypoglycemia is tied to actual hypoglycemia, so it’s important to address hypoglycemia first. The health care team should review the person’s insulin regimen, how often they’re checking their blood glucose levels, and whether they could benefit from a continuous glucose monitoring system or other medical intervention.

Some people who are afraid of hypoglycemia may also benefit from some form of anxiety-reduction therapy. Several different interventions—such as cognitive behavioral therapy, stress relaxation training, or mindfulness training—can help people lower their overall levels of anxiety. Certain versions of diabetes-specific interventions—such as blood glucose awareness training—have also been shown to reduce fear of hyperglycemia.

Q: What are we learning, or hoping to learn, from research about fear of hypoglycemia?

A: People who have hypoglycemia unawareness and are no longer able to feel the symptoms of low blood glucose levels are at the highest risk of having a severe episode. Several studies are looking into possible interventions for people with hypoglycemia unawareness, such as diabetes technologies and patient education programs. The sooner a person with diabetes knows their blood glucose is low, the sooner they can do something about it, and the less likely they are to experience a severe episode.