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Diabetes Distress: A Closer Look at T1D and Hypoglycemia Awareness

Diabetes Distress

Battling Diabetes Distress: A Closer Look at T1D and Impaired Hypoglycemia Awareness

Recent research has shed light on the enduring issue of diabetes distress among individuals with type 1 diabetes (T1D), particularly those grappling with impaired awareness of hypoglycemia (IAH). Despite the widespread use of continuous glucose monitoring (CGM) technology, this study suggests that the association between IAH and distress remains, indicating the need for further interventions to alleviate diabetes distress.

The Challenge of Hypoglycemia in T1D

For individuals with T1D, hypoglycemia is a common and often unavoidable complication of insulin therapy. Repeated episodes of hypoglycemia can lead to IAH, where individuals become less aware of their hypoglycemic episodes over time. This lack of awareness can result in heightened diabetes-specific distress, as individuals face the ongoing challenges and limitations associated with this chronic condition.

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The Study

The research team, led by Namam Ali from the Department of Internal Medicine at Radboud University Medical Center, sought to investigate diabetes-specific distress, including emotions, cognitions, and behaviors, in individuals with T1D who either had IAH or normal awareness of hypoglycemia (NAH). The study was conducted in a contemporary cohort with a high prevalence of glucose sensor usage.

This single-center cross-sectional study took place at Radboud University Medical Centre’s outpatient diabetes clinic between February 2020 and April 2021. The participants included individuals with T1D who were 16 years of age or older. Out of 702 individuals assessed for eligibility, 422 were enrolled in the study, with a median diabetes duration of 30 years. Various questionnaires and surveys were administered to assess hypoglycemia awareness, diabetes distress, hypoglycemia fear, attitudes toward hypoglycemia awareness, clinical screening, and hyperglycemia avoidance.

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Key Findings

Approximately 88% of the participants reported using a glucose sensor for a median duration of 12 months. Among the participants, 19.4% reported having IAH (n = 82). The analysis revealed that high diabetes distress, defined by a PAID-5 score of ≥ 8, was present in 24.2% of individuals. Notably, this distress was more prevalent in individuals with IAH compared to those with NAH (35.4% vs. 21.5%; P = .008). Moreover, individuals with IAH had higher total PAID-5 scores.

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Furthermore, participants with IAH exhibited higher scores across all subcategories of the Hypoglycemia Fear Survey-II (HFS-II), including behavior, worry, Hyperglycemia Avoidance Scale (HAS) worries, and Nijmegen Clinical Screening Instrument Survey (NCSI) hypoglycemia items. However, no significant differences were observed in HAS behavior, attitudes towards awareness of hypoglycemia, and NCSI hyperglycemia scores between individuals with and without IAH. Sensitivity analyses indicated similar results for diabetes-specific distress questionnaires when participants using CGM technology were considered.


Despite the widespread use of CGM technology, the study underscores the persistence of diabetes distress in individuals with T1D, particularly those dealing with impaired awareness of hypoglycemia. The research team suggests that further investigations into intervention strategies, whether psychological or technological, are essential to alleviate diabetes-specific distress, especially in individuals who continue to experience IAH despite using a sensor.