Prevalence And Psychological Mechanism Of Impaired Awareness Of Hypoglycemia In People With Diabetes Undergoing Insulin Therapy

Objectives To investigates the prevalence and psychological mechanism of impaired awareness of hypoglycemia(IAH)in people with diabetes treated with insulin.On the one hand,to understand the prevalence of IAH and to analyse the contribution of general demographic factors and disease progression factors to IAH,which provides an evidence-based basis for the early identification of individuals at high risk.On the other hand,to validate the psychological impact mechanisms of IAH with reference to the revised common-sense model,which provides an entry point for the subsequent development of proven interventions to facilitate the regression of adverse outcomes.Methods This study conducts a cross-sectional survey study in people recruited for insulin-treated diabetes.This study component was conducted in two phases.In phase1,421 people with insulin-treated diabetes were recruited from January to June 2022 from endocrine wards and diabetic physical examination centres in one of two tertiary general hospitals in Anhui Province.General information questionnaire,Gold score and Clarke questionnaire were used for assessment.Independent influences on IAH were analysed using multivariate logistic regression based on univariate analysis.In phase 2,260 patients with insulin-treated diabetes were recruited from July to November 2022 from the endocrine wards and diabetic physical examination centres of two tertiary general hospitals in Anhui Province.General information questionnaire,Clarke questionnaire,Edinburgh symptom scale,diabetes distress scale,hypoglycemia fear suveryⅡ,attitudes to awareness of hypoglycemia(A2A)questionnaire,hypoglycemia confidence scale(HCS)and ways of coping questionnaire were used for assessment.The IAH and key psychological variables were clustered using the K-means clustering algorithm based on the results of univariate analysis,correlation analysis and common method bias tests.Coping procedure-mediated mediating effects,and moderating effects of illness characteristics were tested using PROCESS.Results(1)The prevalence of IAH in persons with insulin-treated diabetes was 30.6%,with median scores of 1.00(0.00,4.00)and 2.00(1.00,4.00)on the Clarke questionnaire and Gold,respectively.(2)Logistic regression analysis showed that history of severe hypoglycemia(OR=3.23,95% CI 1.78 to 5.89,P<0.001),frequency of hypoglycemic events in the last week(OR=1.44,95% CI 1.20 to 1.73,P<0.001),Hb A1 c <7%(OR=0.42,95% CI 0.23 to 0.76,P = 0.004),self-monitoring regularity of blood glucose(OR = 0.51,95% CI 0.29 to 0.89,P = 0.017)and retirement(OR = 2.08,95% CI 1.12 to 3.87,P = 0.021)as well as unemployed(OR = 2.69,95% CI 1.53 to4.72,P = 0.001)were independent influencers of IAH.(3)Pathway analysis reported a significant partial mediating effect of HCS-mediated A2 A on hypoglycemic awareness(β = 0.22,95% CI 0.05 to 0.43),with a mediating effect of 27.4% of the total effect.The direct effect showed that hypoglycemic worry was a significant negative predictor of hypoglycemic awareness(β =-0.61,t =-3.00,P = 0.001),with the HCS acting as a’masking effect’ for the effect of the worry on hypoglycemic awareness,accounting for53.7% of the direct effect.Hypoglycemic symptom experience significantly moderated the effect of A2A(moderation index =-0.29,95% CI-0.50 to-0.10)and the worry(moderation index = 0.22,95% CI 0.08 to 0.42)on HCS.(4)Exploratory k-means clustering analysis yielded optimal tri-cluster clusters,named normal(n = 119);vulnerable(n = 69)and impaired(n = 72)groups.The vulnerability group(1.71 ± 0.37)and the normal group(1.68 ± 0.35)had higher levels of active coping compared to the impaired group(1.42 ± 0.34)(P < 0.001).In addition,hypoglycemic symptom scores were significantly higher in the normal group(P = 0.002)vs the impaired group.Conclusion(1)The awareness status of hypoglycemia of insulin-treated people with diabetes deserves attention,in view of their high prevalence of IAH.History of severe hypoglycemia,frequency of hypoglycemia in the last week,Hb A1 c <7%,unemployed and retired were the key screening factors,along with the patients’ daily glucose monitoring,and these meaningful factors deserve further study.(2)There is significant heterogeneity in the hypoglycemic awareness of individuals with insulin-treated diabetes.Health care providers should assess the current state of hypoglycemic awareness and the dynamic trend of the individual,take into account the individual’s coping process(especially coping effectiveness)and illness distress,and provide scientific and practical strategies to support the management of blood glucose in a timely manner.(3)The psychological mechanisms of IAH in people with insulin treated diabetes are multiple and complex,with coping efficacy playing a substantially important role.It is suggested that follow-up intervention protocols be tailored from cognitive and emotional multidimensional disease representations to promote patients’ hypoglycemic coping abilities and ultimately improve adverse outcomes in IAH.