The relationship between components of hypoglycemia worries and avoiding hypoglycemia behavior in type 2 diabetes mellitus with hypoglycemia: a network analysis

Abstract

Background: The fear of hypoglycemia in type 2 diabetes mellitus (T2DM) patients with hypoglycemia has seriously affected their quality of life. They are always afraid of hypoglycemia and often take excessive action to avoid it. Yet, researchers have investigated the relationship between hypoglycemia worries and excessive avoiding hypoglycemia behavior using total scores on self-report measures. However, network analysis studies of hypoglycemia worries and excessive avoiding hypoglycemia behavior in T2DM patients with hypoglycemia are lacking.

Purpose: The present study investigated the network structure of hypoglycemia worries and avoiding hypoglycemia behavior in T2DM patients with hypoglycemia and aimed to identify bridge items to help them correctly treat hypoglycemia and properly deal with hypoglycemia fear.

Methods: A total of 283 T2DM patients with hypoglycemia were enrolled in our study. Hypoglycemia worries and avoiding hypoglycemia behavior were evaluated with the Hypoglycemia Fear Scale. Network analyses were used for the statistical analysis.

Results: B9 "Had to stay at home for fear of hypoglycemia" and W12 "I am worried that hypoglycemia will affect my judgment" have the highest expected influences in the present network. In the community of hypoglycemia worries, W17 "I worry about hypoglycemia during sleep" has the highest bridge expected influence. And in the community of avoiding hypoglycemia behavior, B9 "Had to stay at home for fear of hypoglycemia" has the highest bridge expected influence.

Conclusion: Complex patterns of associations existed in the relationship between hypoglycemia worries and avoiding hypoglycemia behavior in T2DM patients with hypoglycemia. From the perspective of network analysis, B9 "Had to stay at home for fear of hypoglycemia" and W12 "I am worried that hypoglycemia will affect my judgment" have the highest expected influence, indicating their highest importance in the network. W17 "I worry about hypoglycemia during sleep" aspect of hypoglycemia worries and B9 "Had to stay at home for fear of hypoglycemia" aspect of avoiding hypoglycemia behavior have the highest bridge expected influence, indicating they have the strongest connections with each community. These results have important implications for clinical practice, which provided potential targets for interventions to reduce hypoglycemia fear and improve the quality of life in T2DM patients with hypoglycemia.

Keywords: Avoiding hypoglycemia behavior; Hypoglycemia fear; Hypoglycemia worries; Network analyses; T2DM patients.

Fig. 1

Network structure of hypoglycemia worries and avoiding hypoglycemia behavior. Green edges represent positive correlations, red edges represent negative correlations. The thickness of the edge reflects the magnitude of the correlation. The circles around nodes depict its predictability. W1: I am afraid that I will have hypoglycemia, but I do not realize it; W2: I am worried that there is no food, fruit, or drink within my reach; W3: I am afraid I’ll faint in public; W4: I am worried that hypoglycemia will embarrass me or my friends in public; W5: I am worried about hypoglycemia when I’m alone; W6: I am afraid I will be in a trance when hypoglycemia occurs; W7: I am afraid I lose control after hypoglycemia; W8: I am afraid that when I have hypoglycemia, there is no one around to help me; W9: I am worried about hypoglycemia when I’m driving or cycling; W10: I am afraid of causing mistakes or accidents due to hypoglycemia; W11: I am worried about being criticized by others because of hypoglycemia; W12: I am worried that hypoglycemia will affect my judgment; W13: I am afraid hypoglycemia makes me feel dizzy; W14: I am worried that hypoglycemia may hurt me or others; W15: I am worried that hypoglycemia will cause permanent damage to my health; W16: I am worried that the occurrence of hypoglycemia will disrupt some important things I am doing; W17: I worry about hypoglycemia during sleep; W18: I am worried that hypoglycemia will make me suddenly feel restless and difficult to calm down; B1: When I feel signs of hypoglycemia, I will eat something; B2: I will keep my fasting blood sugar above 8 mmol/L to avoid hypoglycemia; B3: When my blood sugar is low, I will reduce the dose of insulin or drugs; B4: I will increase the frequency of blood glucose monitoring; B5: Worried about hypoglycemia, I will ensure that I am accompanied when I go out; B6: Worried about hypoglycemia, I will reduce my outing or travel; B7: Worried about hypoglycemia, I dare not drive a car or bicycle; B8: Worried about hypoglycemia, I’m afraid to visit relatives and friends; B9: Had to stay at home for fear of hypoglycemia; B10: Restricted exercise and physical activity due to fear of hypoglycemia; B11: Make sure there are people around who can help me; B12: Take candy or carbohydrates to avoid hypoglycemia.; B13: Keep blood sugar higher than usual when participating in some activities; B14: When doing important work, keep the blood sugar higher than usual; B15: Seek the attention of others

Fig. 2

Centrality plot depicting the expected influence and bridge expected influence of each variable selected in the present network (z-score). W1: I am afraid that I will have hypoglycemia, but I do not realize it; W2: I am worried that there is no food, fruit, or drink within my reach; W3: I am afraid I’ll faint in public; W3: I am afraid I’ll faint in public; W4: I am worried that hypoglycemia will embarrass me or my friends in public; W5: I am worried about hypoglycemia when I’m alone; W6: I am afraid I will be in a trance when hypoglycemia occurs;; W7: I am afraid I lose control after hypoglycemia; W8: I am afraid that when I have hypoglycemia, there is no one around to help me; W9: I am worried about hypoglycemia when I’m driving or cycling; W10: I am afraid of causing mistakes or accidents due to hypoglycemia; W11: I am worried about being criticized by others because of hypoglycemia; W12: I am worried that hypoglycemia will affect my judgment; W13: I am afraid hypoglycemia makes me feel dizzy; W14: I am worried that hypoglycemia may hurt me or others; W15: I am worried that hypoglycemia will cause permanent damage to my health; W16: I am worried that the occurrence of hypoglycemia will disrupt some important things I am doing; W17: I worry about hypoglycemia during sleep; W18: I am worried that hypoglycemia will make me suddenly feel restless and difficult to calm down; B1: When I feel signs of hypoglycemia, I will eat something; B2: I will keep my fasting blood sugar above 8 mmol/L to avoid hypoglycemia; B3: When my blood sugar is low, I will reduce the dose of insulin or drugs; B4: I will increase the frequency of blood glucose monitoring; B5: Worried about hypoglycemia, I will ensure that I am accompanied when I go out; B6: Worried about hypoglycemia, I will reduce my outing or travel; B7: Worried about hypoglycemia, I dare not drive a car or bicycle; B8: Worried about hypoglycemia, I’m afraid to visit relatives and friends; B9: Had to stay at home for fear of hypoglycemia; B10: Restricted exercise and physical activity due to fear of hypoglycemia; B11: Make sure there are people around who can help me; B12: Take candy or carbohydrates to avoid hypoglycemia.; B13: Keep blood sugar higher than usual when participating in some activities; B14: When doing important work, keep the blood sugar higher than usual; B15: Seek the attention of others