title: A critical review of the literature on fear of hypoglycemia in diabetes: Implications for diabetes management and patient education.
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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Oxford Outcomes Ltd., Seacourt Tower, West Way, Oxford, United Kingdom. Diane.wild@oxfordoutcomes.com
authors.forename: Diane
authors.initials: D
authors.lastname: Wild
authors.forename: Robyn
authors.initials: R
authors.lastname: von Maltzahn
authors.forename: Elaine
authors.initials: E
authors.lastname: Brohan
authors.forename: Torsten
authors.initials: T
authors.lastname: Christensen
authors.forename: Per
authors.initials: P
authors.lastname: Clauson
authors.forename: Linda
authors.initials: L
authors.lastname: Gonder-Frederick
mesh_terms: D000223:Adaptation, Psychological; D001007:Anxiety / Q000209:etiology / Q000517:prevention & control / Q000523:psychology; D001294:Attitude to Health; D015928:Cognitive Behavioral Therapy; D003922:Diabetes Mellitus, Type 1 / Q000150:complications* / Q000378:metabolism / Q000517:prevention & control; D003924:Diabetes Mellitus, Type 2 / Q000150:complications* / Q000378:metabolism / Q000517:prevention & control; D019468:Disease Management; D005239:Fear; D007722:Health Knowledge, Attitudes, Practice; D006301:Health Services Needs and Demand; D006801:Humans; D007003:Hypoglycemia / Q000209:etiology / Q000517:prevention & control / Q000523:psychology*; D010353:Patient Education as Topic / Q000458:organization & administration*; D012307:Risk Factors; D012648:Self Care; D016896:Treatment Outcome