10 Strategies to Overcome Severe Hypoglycemia Fear

By TCOYD on October 17, 2024   /   Case Studies, Emotional Health, Hypoglycemia, Support   /   4 Comments

Highlights:

• Fear about severe low blood sugar is totally normal, but when that fear becomes too invasive and affects someone’s diabetes control, it’s classified as Hypoglycemic Fear Syndrome.
• The main goal in treating HFS is on enhancing someone’s confidence about hypoglycemia and helping them regain a sense of comfort and safety. Two sets of treatment strategies can make a huge difference: the BE SAFE and FEEL SAFE strategies.
• These strategies may be insufficient for people who have deep-rooted core beliefs and/or an underlying anxiety disorder, but for many people struggling with hypoglycemic fears, these 10 strategies can be successful tools to help people return to a balanced and productive way of living with diabetes.

If you’ve ever been nervous about your blood sugar dropping too low, you’re not alone. Worries about hypoglycemia are completely normal for people with both type 1 and type 2 diabetes, but some people’s fear can become so daunting, it starts to negatively impact their day-to-day life. In this case study, Dr. Bill Polonsky of the Behavioral Diabetes Institute offers actionable tools to help one of his patients overcome her extreme fear of hypoglycemia.

The Patient

Maddie is a 48-year-old woman who is married with two kids. She’s had type 2 diabetes for 12 years and she’s been on MDI (multiple daily insulin injections) for the last six years.

The Problem

Several years ago, Maddie had a severe hypoglycemic event, resulting in a seizure. After that experience she was terrified of hypoglycemia, and her A1c rose from 7.5% to 9.9%. She described having frequent “minor panic attacks”, where errant body sensations signaled to her that she might be going low, though this was never the case when she checked her blood sugar. Still, she would often omit her basal and mealtime insulin, check her glucose levels constantly, avoid exercise, and binge eat before bed because she was so afraid she would go low while she was asleep. At the encouragement of her healthcare team she decided to seek support, and she connected with our team at the Behavioral Diabetes Institute.

Hypoglycemic Fear Syndrome

It’s very common for people with diabetes to be worried about hypoglycemia, but we characterized Maddie as having something called “hypoglycemic fear syndrome” (HFS). People like Maddie who are affected by HFS may dramatically cut back their insulin dosing, snack excessively to avoid possible lows, limit exercise and other activities, and check glucose levels much more frequently than is needed. They are locked into a pattern of anxiety and avoidance, and cope with their fear by keeping their glucose levels high and/or limiting their activities to avoid any possibility that a hypoglycemic event might occur.

At the core of HFS is a loss of confidence in one’s ability to avoid or address severe hypoglycemia. People with HFS may no longer trust that their tools and treatments for addressing lows will work correctly.

Strategies to Overcome Hypoglycemic Fear Syndrome

The main focus of treating HFS should be on enhancing someone’s confidence about hypoglycemia, and helping them regain a sense of comfort and safety. A team at BDI developed two sets of strategies that can make a huge difference: BE SAFE and FEEL SAFE strategies.

BE SAFE Strategies

The following six guidelines are key to the BE SAFE Strategies, all designed to reduce hypoglycemic risk:

1. Optimize Medications

Review your medications and their use with your healthcare provider (HCP) to identify medications that increase the risk for hypoglycemia, problematic polypharmacy (using multiple medications to treat one or more conditions) overbasalization of insulin, or over-bolusing insulin. You may also be inadvertently using insulin in a way that enhances hypoglycemia risk, such as frequent stacking of fast-acting insulin (administering a dose while the previous dose is still active).

2. Be Prepared to Treat Lows

Have easy-to-use carbs readily available in places like your car, purse, desk, nightstand, etc. Get ready-to-use glucagon and tell your friends and family where you have it stored and how they can use it.

3. Try a  CGM and/or AID System

CGMs can decrease the frequency of severe lows and increase hypoglycemic confidence. Automated insulin delivery systems (insulin pumps) can offer the same benefits. Most CGMs also allow real-time data to be shared with family and friends so they can be notified in the case of a hypoglycemic emergency.

4. Address IAH (Impaired Awareness of Hypoglycemia)

Although it was originally presumed that impaired awareness of hypoglycemia was irreversible, it is now known that the scrupulous avoidance of low glucose levels over a limited period of time can often restore awareness, at least to some degree.

5. Establish a No-Delay Glucose Value

Identify (ideally, with your HCP) a glucose value when you will take immediate action to treat hypoglycemia.

6. Identify Times of Elevated Risk

Review glucose patterns with your HCP to identify specific times or events associated with increased hypoglycemia risk, and collaborate to problem-solve solutions (like pre-exercise snacks, adjustments to basal insulin doses, or the introduction of CGM).

FEEL SAFE Strategies

Helping people who are struggling with HFS to BE SAFE often is not enough. Consider Maddie’s case. Given her avoidance strategies and elevated A1c, she was – practically speaking – at no risk of hypoglycemia. She was safe, but she still felt vulnerable and feared that lows could strike without warning.

In these cases, the needed intervention is fear management rather than merely glucose management. To regain confidence, people like Maddie need to FEEL SAFE. To address this aspect of HFS, the following four strategies are suggested:

1. Try a  CGM and/or AID System

Although mentioned as a BE SAFE strategy, CGMs and/or AID systems are also a FEEL SAFE strategy.  Thanks to low glucose alarms and trend arrows, people can be alerted to impending low glucose levels at an earlier stage and can respond faster.

2. Engage in Symptom Discrimination

It’s common for people to confuse certain body sensations with signs of hypoglycemia. Anxiety symptoms are often similar to early signs of hypoglycemia. Maddie’s “minor panic attacks” are a good example, when she found herself wondering, Am I having a low, or am I just frightened? Education about the similarities (and differences) between anxiety and hypoglycemic symptoms can be helpful.

3. Evaluate Hypoglycemia Treatments

People with HFS are likely to feel safer when they are assured their preferred treatment can be trusted to work. Conducting home or in-office “experiments” when someone is not hyperglycemic can be helpful. During these experiments, you select and consume your preferred treatment and note how long it takes for your glucose levels to increase >50 mg/dL.

4. Initiate Gradual Behavioral Exposure

At the heart of almost all successful treatments for fear and anxiety is a slow but steady return to the feared activity. This must not be done too quickly or before equipping people with needed resources. The aim is to enhance someone’s ability to safely tolerate lower glucose levels and gain a sense of confidence that hypoglycemic events can be avoided or addressed. To illustrate, if you are afraid that long walks should be avoided because of your hypo fear, you might begin by taking a very short walk with a friend, then slightly longer walks over the course of days.

The Solution for Maddie

Shortly after Maddie began HFS counseling and described her scare with severe hypoglycemia, she immediately noticed that her hands and feet began to sweat, her chest tightened, and she became winded. Fearing the onset of another low, she immediately reached for her glucose meter. Before she could reach it, her counselor intervened and asked her to practice a brief, one-minute relaxation exercise which had been taught to her in the prior session. Her symptoms quickly disappeared, which was a startling experience for Maddie; a quick reversal of her uncomfortable bodily sensations made her realize that she was not likely to be severely low. It was anxiety about hypoglycemia, not actual hypoglycemia, that was causing these symptoms.

She was encouraged to continue to practice the relaxation exercise at least once daily to strengthen her ability to quickly address and reverse early anxiety sensations and, when further “hypoglycemic” symptoms arose, to try the relaxation exercise again before pulling out her glucose meter or consuming fact-acting carbs.

The Takeaway

Some degree of hypoglycemic fear is normal and expected in people with diabetes.  However, problems occur when worries are excessive and drive unhealthy management choices.

BE SAFE and FEEL SAFE strategies may not be appropriate for everyone. Care should be individualized for each person. These 10 strategies may be insufficient for people who have deep-rooted core beliefs and/or an underlying anxiety disorder. However, for many people struggling with hypoglycemic fears, these strategies can be successful tools that help people return to a more balanced and productive way of living with diabetes.

If you find yourself struggling with any aspect of diabetes management, seek support. Here are a few organizations and therapists who specialize in helping people with diabetes:

• Behavioral Diabetes Institute
• Integrated Diabetes Services
• The Diabetes Psychologist
• Erika Forsyth Counseling

You can also search for a therapist in your area by visiting Psychology Today or the ADA Mental Health Provider Directory. Help is out there.