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Hypoglycemia Subtypes in Type 1 Diabetes: An Exploration of the Hypoglycemia Fear Survey-II

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Rory H. Maclean, Peter Jacob, Pratik Choudhary, Simon R. Heller, Elena Toschi, Dulmini Kariyawasam, Augustin Brooks, Mike Kendall, Nicole de Zoysa, Linda A. Gonder-Frederick, Stephanie A. Amiel

Original languageEnglish
Pages (from-to)538-546
Number of pages9
JournalDiabetes Care
Issue number3
Published1 Mar 2022

Bibliographical note

Funding Information: Acknowledgments. This study was undertaken in conjunction with recruitment into the randomized controlled trial Hypoglycaemia Awareness Restoration Programme (HARPdoc). The authors acknowledge the support of Mustabshira Qayyum and Sean Haywood in the HARPdoc central office; of the researchers, clinical teams, and patient group involved in HARP-doc; and of the patient participants in HARPdoc and the Characterisation of cognitions, outcomes and behaviours around hypoglycaemia in adults with type 1 diabetes and preserved awareness of hypoglycaemia (COBrAware) studies. The authors also thank Dr. Ian Godsland, Wynn Reader in Human Metabolism at Imperial College London, for his very helpful discussion of the clustering analysis. Funding. The study was funded by the JDRF Project Grant no. 4-SRA-2017-266-M-N, with additional support from the U.K.’s National Institute for Health Research (NIHR) through the Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South London at King’s College Hospital NHS Foundation Trust. The study is sponsored jointly by King’s College London and King’s College Hospital NHS Foundation Trust. Publisher Copyright: © 2022 by the American Diabetes Association.

King's Authors


OBJECTIVE The Hypoglycemia Fear Survey-II (HFS-II) is a well-validated measure of fear of hypoglycemia in people with type 1 diabetes. The aim of this study was to explore the relationships between hypoglycemia worries, behaviors, and cognitive barriers to hypoglycemia avoidance and hypoglycemia awareness status, severe hypoglycemia, and HbA 1c. RESEARCH DESIGN AND METHODS Participants with type 1 diabetes (n 5 178), with the study population enriched for people at risk for severe hypoglycemia (49%), completed questionnaires for assessing hypoglycemia fear (HFS-II), hyperglycemia avoidance (Hyperglycemia Avoidance Scale [HAS]), diabetes distress (Problem Areas In Diabetes [PAID]), and cognitive barriers to hypoglycemia avoidance (Attitudes to Awareness of Hypoglycemia [A2A]). Exploratory factor analysis was applied to the HFS-II. We sought to establish clusters based on HFS-II, A2A, Gold, HAS, and PAID using k-means clustering. RESULTS Four HFS-II factors were identified: Sought Safety, Restricted Activity, Ran High, and Worry. While Sought Safety, Restricted Activity, and Worry increased with progressively impaired awareness and recurrent severe hypoglycemia, Ran High did not. With cluster analysis we outlined four clusters: two clusters with pre-served hypoglycemia awareness were differentiated by low fear/low cognitive barriers to hypoglycemia avoidance (cluster 1) versus high fear and distress and increased Ran High behaviors (cluster 2). Two clusters with impaired hypoglycemia awareness were differentiated by low fear/high cognitive barriers (cluster 3) as well as high fear/low cognitive barriers (cluster 4). CONCLUSIONS This is the first study to define clusters of hypoglycemia experience by worry, behav-iors, and cognitive barriers to hypoglycemia avoidance. The resulting subtypes may be important in understanding and treating problematic hypoglycemia.

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