Hypoglycaemia can have long-term physical and mental consequences on people with diabetes. A recent systematic review by Chatwin et al. assessed the association between hypoglycaemia and quality of life in people with type 1 diabetes. In this opinion article, Dr Linda Gonder-Frederick provides her insight on this study, revealing the unanswered questions that require further research and describing the need for better interventions that address the psychological and behavioural impacts of hypoglycaemia in patients with diabetes.
Type 1 diabetes (T1D) affects a person’s life in a multitude of ways. People with T1D must carefully control their diet, while also ensuring that they have constant access to insulin. These considerations can impose a significant financial and psychological burden on people with T1D, and any complications that arise will further exacerbate these burdens. In addition, imbalances in blood sugar and insulin can lead to episodes of hypoglycaemia, which can cause acute and potentially long-term emotional distress. Although the impact of hypoglycaemia on quality of life (QoL) in people with T1D and their families has been the focus of much research, many questions remain, as highlighted by a recent literature review.
This systematic review, led by Hannah Chatwin and supported by members of the Hypo-RESOLVE Consortium1, detailed research findings over the past decade on how hypoglycaemia affects different aspects of quality of life. The authors did an excellent job in summarising the different metrics of QoL and trends observed in people with T1D. Their findings showed that in the 30 studies reviewed, 73% found a positive relationship between hypoglycaemia and a measure of QoL. In particular, severe hypoglycaemia was associated with:
- Increased fear of hypoglycaemia
- Increased diabetes-related distress
- Decreased generic emotional well-being
However, the review also found that hypoglycaemia did not appear to be positively associated with depression, anxiety or health status, and there was insufficient evidence to make conclusions about the relationship between hypoglycaemia and diabetes-specific positive well-being or sleep quality/quantity. Essentially, this review showed that experiencing episodes of hypoglycaemia is associated with some measures of negative psychological outcomes; however, for several aspects of QoL, there appeared to be no relationship or there was a lack of adequate research.
Discrepancies between Researched and Real-World Results
While the Chatwin et al.1 paper showed mixed results on how hypoglycaemia impacts QoL in T1D, physician experiences and anecdotal evidence tell a different story, reporting common and widespread negative consequences. There are many reasons why this discrepancy between the scientific literature and lived experiences of people with T1D and their families can occur.
Firstly, episodes of hypoglycaemia can vary in severity and frequency, and there are likely individual differences in how these episodes are perceived. When investigating the impact of hypoglycaemia, several characteristics of the episode should be considered including:
- The frequency of episodes
- The severity of episodes
- The consequences of an episode (eg, embarrassment, accident, or injury)
- The level of emotional distress and/or trauma resulting from an episode
Most scientific studies take into consideration the first two characteristics of hypoglycaemia, frequency and severity. However, research does not typically consider the last two which may, in fact, contribute as much, or more, to the impact of hypoglycaemia on emotional well-being and QoL. There is a qualitative and critical difference between hypoglycaemic episodes that, although unpleasant, are relatively easily treated and cause minimal disruption to the individual’s life compared to the experience of episodes that are deeply frightening, debilitating, and have significant negative consequences, such as physical injury. Although it is challenging enough to accurately measure the frequency and severity of hypoglycaemia, it is much more difficult to quantify the psychosocial characteristics, circumstances, and consequences of episodes.
For these reasons it may be that research into the impact of hypoglycaemia on QoL needs to shift the focus to the effects of problematic hypoglycaemia on the lives of people living with diabetes and their families. Of the 30 studies reviewed by Chatwin et al., only 3 studies specifically analysed individuals with a history of severe and problematic hypoglycaemia. Therefore, with the majority of patients analysed having non-problematic hypoglycaemia, it becomes clear why research may underestimate the impact of hypoglycaemia on QoL.
A Fear of Hypoglycaemia
In the Chatwin et al study, the most common psychological consequence of hypoglycaemia was higher incidence of fear of hypoglycaemia. Past research has shown that fear of hypoglycaemia is associated, not only with frequency and severity of episodes, but also with the level of trauma resulting from the episode.3,4 Only one study has directly compared the impact of a history of severe hypoglycaemia to that of fear of hypoglycaemia. This study showed that, in parents of children with T1D, fear of hypoglycaemia rather than the occurrence of severe hypoglycaemia itself, was the main factor associated with QoL reductions.2 Similar findings would likely be found for adults with T1D.
The Chatwin et al.1 paper provides insight into the different aspects of QoL that appear to be affected by hypoglycaemia and raises awareness concerning gaps in our scientific understanding and the need for more educational and psychobehavioral interventions to help individuals better manage and cope with hypoglycaemia. The IHSG is committed to working toward these goals and collaborating with groups like Hypo-RESOLVE to improve QoL for people living with diabetes and the threat of hypoglycaemia. The IHSG has developed tools to identify individuals who are at higher risk for severe hypoglycaemia and resources to educate and help health care providers and their patients to manage and reduce this risk. Clinicians and people with diabetes are invited to use these tools to improve quality of life and other complications that arise from hypoglycaemia incidents.
- Chatwin H, Broadley M, Speight J, Cantrell A, Sutton A, Heller S, de Galan B, Hendrieckx C, Pouwer F; Hypo-RESOLVE Consortium. The impact of hypoglycaemia on quality of life outcomes among adults with type 1 diabetes: A systematic review. Diabetes Res Clin Pract. 2021 Apr;174:108752. doi: 10.1016/j.diabres.2021.108752. Epub 2021 Mar 17. PMID: 33722700.
- Johnson SR, Cooper MN, Davis EA, Jones TW. Hypoglycaemia, fear of hypoglycaemia and quality of life in children with Type 1 diabetes and their parents. Diabet Med. 2013 Sep;30(9):1126-31. doi: 10.1111/dme.12247. Epub 2013 Jun 28. PMID: 23808967.
- Clarke WL, Gonder-Frederick A, Snyder AL, Cox DJ. Maternal fear of hypoglycemia in their children with insulin dependent diabetes mellitus. J Pediatr Endocrinol Metab. 1998 Mar;11 Suppl 1:189-94. doi: 10.1515/jpem.1998.11.s1.189. PMID: 9642659.
- Gonder-Frederick LA, Schmidt KM, Vajda KA, Greear ML, Singh H, Shepard JA, Cox DJ. Psychometric properties of the hypoglycemia fear survey-ii for adults with type 1 diabetes. Diabetes Care. 2011 Apr;34(4):801-6. doi: 10.2337/dc10-1343. Epub 2011 Feb 23. PMID: 21346182; PMCID: PMC3064031.