Hypoglycaemic-related fear in parents of children with poor glycaemic control of their type 1 diabetes is associated with poorer glycaemic control in their child and parental emotional distress
- Correspondence to Susana R Patton
Division of Child Behavioral Health, CS Mott Children's Hospital, 1924 Taubman Center, Box 5318, Ann Arbor, MI 48109-5318, USA;
Hypoglycaemia is a common complication of type 1 diabetes treatment.1 It is typically the result of incorrect matching of insulin to carbohydrate intake and/or mismanagement of insulin when exercising. Symptoms of mild hypoglycaemia can include confusion, faintness, irritability, trembling and nausea. However, in cases of moderate to severe hypoglycaemia, low blood glucose levels can sometimes lead to seizures, coma or even death. The availability of new analogue insulin and improvements in intensive therapy have decreased the rate of severe hypoglycaemia in patients with type 1 diabetes.1 However, because the symptoms of hypoglycaemia are uncomfortable and potentially dangerous, fear of hypoglycaemia remains a widespread problem among youth with type 1 diabetes and their families.
In a population-based study, Haugstvedt and colleagues report on fear of hypoglycaemia in parents of youth with type 1 diabetes, and whether fear of hypoglycaemia is associated with diabetes treatment factors and parental emotional distress. The parents of 115 youth with type 1 diabetes participated in this study. Parents completed Norwegian versions of the Hypoglycaemia Fear Survey-Parent (HFS-P) and the Hopkins Symptom Checklist-25 (HSCL-25). Information specific to youths' diabetes treatment were reported by parents via questionnaire. To estimate glycaemic control, glycated haemoglobin values (HbA1c) obtained nearest to the date of survey distribution were extracted from youths' medical chart. The results demonstrated associations between higher worry scores on the HFS-P and higher HbA1c values and parent-reported frequency of hypoglycaemia among youth. Examining the HFS-P Behaviour subscale, higher scores were found for youth on insulin injections, and youth who checked blood glucose seven or more times daily. Overall, mothers were reported higher HFS-P scores than fathers. However, when examining parental emotional distress, there was a direct association between HFS-P and HSCL-25 scores for both mothers and fathers.
The study methodology is largely sound. The authors recruited a large sample of youth on intensive therapy which is important as the risk of hypoglycaemia may be higher for youth on older conventional regimens.1 The study used validated measures to examine fear of hypoglycaemia and emotional distress. However, there are some limitations. First, the patient sample was very homogenous, and thus the results may not generalise to more diverse samples. Second, most of the outcome measures were measured via self-report, which may introduce a response bias. A more objective report of frequency and severity of hypoglycaemia and youths' daily blood glucose monitoring are extracted from youths' medical record. Finally, variation in the timing when HbA1c values were collected may have introduced some bias. Collecting all HbA1c values ahead of study enrolment would have minimised any impact study participation could have had on parents' daily diabetes management and youths' subsequent HbA1c.
With respect to clinical practice, the results suggest that physicians and nurses should assess for fear of hypoglycaemia in parents of youth who have experienced hypoglycaemic events as well as youth with higher average blood glucose levels. While caution is clearly needed to avoid episodes of hypoglycaemia, parents who are overly afraid could make daily treatment decisions that lead to higher than optimal blood glucose levels in youth. Thus, another important implication is the need to teach parents and youth appropriate self-management strategies to prevent hypoglycaemia.
Although interesting, the results of this study are not truly novel. Past studies have demonstrated associations between parental fear of hypoglycaemia and youths' blood glucose levels and hypoglycaemia frequency.2,–,4 Parental fear of hypoglycaemia has been related to parenting stress and anxiety.5 6 Moreover, a comparison of HFS-P scores for mothers and fathers has been previously reported.3 Haugstvedt and colleagues report findings for parental fear of hypoglycaemia that are consistent with the existing literature. Going forward, researchers should focus on the development of evidence-based intervention materials for parents of youth with type 1 diabetes.
Competing interests None.