OBJECTIVE

To evaluate the relation between household food insecurity (HFI) and fear of hypoglycemia among young adults with type 1 and type 2 diabetes and adolescents with type 1 diabetes and their parents.

RESEARCH DESIGN AND METHODS

We analyzed cross-sectional data of 1,676 young adults with youth-onset diabetes (84% type 1, 16% type 2) and 568 adolescents (<18 years old; mean age 15.1 years) with type 1 diabetes from the SEARCH for Diabetes in Youth study. Adult participants and parents of adolescent participants completed the U.S. Household Food Security Survey Module. Adults, adolescents, and parents of adolescents completed the Hypoglycemia Fear Survey, where answers range from 1 to 4. The outcomes were mean score for fear of hypoglycemia and the behavior and worry subscale scores. Linear regression models identified associations between HFI and fear of hypoglycemia scores.

RESULTS

Adults with type 1 diabetes experiencing HFI had higher fear of hypoglycemia scores (0.22 units higher for behavior, 0.55 units for worry, 0.40 units for total; all P < 0.0001) than those without HFI. No differences by HFI status were found for adolescents with type 1 diabetes. Parents of adolescents reporting HFI had a 0.18 unit higher worry score than those not reporting HFI (P < 0.05). Adults with type 2 diabetes experiencing HFI had higher fear of hypoglycemia scores (0.19 units higher for behavior, 0.35 units for worry, 0.28 units for total; all P < 0.05) than those in food secure households.

CONCLUSIONS

Screening for HFI and fear of hypoglycemia among people with diabetes can help providers tailor diabetes education for those who have HFI and therefore fear hypoglycemia.

In 2019, 10.5% of U.S. households (6.5% of households with children) experienced household food insecurity (HFI), the “limited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain ability to acquire acceptable foods in socially acceptable ways” (1,2). HFI is even more prevalent among adults with cardiometabolic diseases (3) and families with a child who has diabetes (4), as it affects 20% of Americans with diabetes (3). Epidemiologic research specific to food insecurity among adolescents and young adults with diabetes is limited (4). However, we recently reported that 18% of youth and young adults with type 1 diabetes and 31% with type 2 diabetes experienced HFI in the previous year (5). This research suggests that food insecurity is a considerable problem, particularly among adolescents and young adults with diabetes.

Hypoglycemia is a common acute complication of diabetes and is characterized by abnormally low blood glucose levels that can trigger sweating, shaking, heart palpitations, dizziness, lethargy, slurred speech, and mental confusion (6). Severe hypoglycemia can be life-threatening due to loss of consciousness, seizure, accidents, physical injury, and in the most severe cases, death (7). Consequently, many people with diabetes attempt to avoid hypoglycemia by treating early signs and ingesting fast-acting carbohydrate-rich snacks (8,9). Although some level of concern is normal, individuals with diabetes or parents may develop a more significant, anxiety-like fear of hypoglycemia that negatively impacts quality of life and diabetes management (7,10). This more severe fear of hypoglycemia is typically expressed as worrying about hypoglycemia or through avoidant behaviors (10).

For individuals with diabetes experiencing HFI, the uncertain availability of food may increase fear of hypoglycemia. Fast-acting carbohydrate foods may be insufficient in quantity or unhealthy (11), compromising the ability to treat early signs of hypoglycemia. Food may also be completely unavailable. There is research to support that people with diabetes who have HFI must sometimes choose between food, medication, and living expenses (11,12). Among people with diabetes who use community food resources such as food banks or kitchens, at least one in three opt to purchase medication before food (12).

To our knowledge, there are no studies with exploration of a relation between HFI and fear of hypoglycemia among people with diabetes. If such a relation exists, providers may be encouraged to screen for HFI and fear of hypoglycemia, as well as modify conversations about fear of hypoglycemia if a patient experiences HFI. Therefore, the purpose of this study was to evaluate the relation between HFI and fear of hypoglycemia in young adults with youth-onset type 1 or type 2 diabetes as well as among adolescents with youth-onset type 1 diabetes and their parents. We hypothesized that people who experience HFI would have more fear of hypoglycemia than those in food secure households.

The SEARCH for Diabetes in Youth (SEARCH) study is a multicenter observational study with assessment of incidence and prevalence of youth-onset diabetes. The overarching goal of SEARCH is to advance the understanding of the epidemiology of nongestational diabetes among youth and young adults diagnosed with diabetes before age 20 years. Initially designed as a surveillance effort, SEARCH has expanded into a multicenter cohort study (13,14). Data collection sites include CA, CO, OH, SC, and WA (14). Institutional review board approval to conduct this study was granted at each of the participating funded centers. Participants provided informed consent (if ≥18 years old) or assent (if <18 years old) and parents provided consent before data collection began. Methods for SEARCH have previously been described (14).

In this study, we used cross-sectional data collected during the SEARCH phase 4 cohort study in years 2015–2019.

HFI

HFI was assessed with the 18-item U.S. Household Food Security Survey Module, which includes queries about the previous 12 months. Parents/guardians of SEARCH participants under age 18 years and young adults ≥18 years of age completed the survey. The first 10 questions pertain to all households (with or without minors), and the last 8 questions are specific to households with children ages 0–17 years (1). Both households with and households without children were classified as food insecure if three or more food insecure conditions or behaviors were affirmed and as food secure otherwise (2). For the purpose of assessing the prevalence of HFI among U.S. households, the U.S. Household Food Security Survey Module has been shown to be a stable, robust, valid, and reliable measurement tool (1).

Fear of Hypoglycemia

The Hypoglycemia Fear Survey-II (HFS-II) contains two question sets for people with diabetes: one on behaviors to avoid or mitigate hypoglycemia and its consequences and another on worries concerning hypoglycemia (15). These two question sets can be combined to produce an overall fear of hypoglycemia score.

The adult behavior subscale includes assessment of 15 behaviors (e.g., keeping blood glucose levels >150 mg/dL, making sure other people are around, and limiting exercise or physical activity) and the worry subscale addresses 18 concerns about experiencing hypoglycemia (e.g., being alone, episodes occurring during sleep, or having an accident) (15). In the current study, adult participants (ages 18–35 years) completed this survey. For each item, a participant indicated his/her response on a Likert scale of 0–4 as never, rarely, sometimes, often, or almost always. We used an average score for each subscale and an average score for the full survey (16). Therefore, scores of the subscales and full survey ranged from 0 to 4. A 0.5-unit change in the score indicates movement from one response to the midpoint of another response. Findings of a large study among adults with type 1 diabetes (mean age 41.9 years) showed that the HFS-II had good validity and reliability, demonstrated by positive correlations between the survey and other measures of distress (15).

The Hypoglycemia Fear Survey for Children (HFS-C) and the Hypoglycemia Fear Survey for Parents (HFS-P) are adapted from the original adult version to be appropriate for children with type 1 diabetes and their parents (17,18). In our study, adolescent participants ages 10–17 years completed the HFS-C and their parents completed the HFS-P. The HFS-C was created for youth ages 6–18 years and has demonstrated adequate internal consistency and reliability (18,19). Additionally, the HFS-P has been well validated among parents of youth with type 1 diabetes (20).

The parent and adolescent versions of the survey include 10 behavior subscale questions and 15 worry subscale questions that vary slightly from the adult version in wording and do not have questions that would not pertain to adolescents. As with the adult survey, adolescents and parents answered questions on a Likert scale of 0–4. An average score was calculated for the behavior subscale, the worry subscale, and the full survey so that scores ranged from 0 to 4.

Covariates

Continuous variables used for this analysis include the participant’s age and diabetes duration at the cohort visit. Categorical variables included sex (female/male), race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, other), SEARCH clinic site (CA, CO, OH, SC, WA), highest parental education (less than high school graduate, high school graduate, some college/associate degree, bachelor’s degree or higher), household income (<$25,000, $25,000–49,000, $50,000–75,000, ≥75,000), insurance type (state/federal, private, other/unknown, none), diabetes medication regimen (insulin pump, long-acting and rapid-acting insulin, 3+ injections per day, any other combo of insulin injections, oral hypoglycemic medication, no pharmacological treatment), and continuous glucose monitoring use (yes/no).

Statistical Analysis

Cohort visits were completed for 2,669 participants (699 adolescents <18 years old and 1,970 young adults). Because this sample had been part of a longitudinal study with three to six prior data collection points, missing demographic characteristics (household income, parent education, and insurance type) were obtained from the most recent data collection time point for 89 adolescents and 447 young adults. Among 1,970 young adults, 1,892 completed the HFS-II. Young adults missing a single question (n = 20) were included in the analysis. Of people who completed the HFS-II, 16 did not have household food security information. After restriction of the data set to those with all covariates, 1,676 were left in the sample. Young adults were divided into groups of those with type 1 diabetes (n = 1,401) and type 2 diabetes (n = 275) for the analyses.

The sample of 676 adolescents with type 1 diabetes was restricted to those for whom there was both an HFS-C and HFS-P (n = 623). Adolescents missing a single question from the survey (n = 4 adolescents, n = 3 parents) were included in the analysis. Four additional adolescents were excluded because they did not have household food security data. Using only complete data sets limited the analysis to 568 adolescents with type 1 diabetes and their parents. Due to the mean age at type 2 diabetes diagnosis and the minimum diabetes duration of 5 years to be eligible for a cohort visit, there was only a small number of adolescents with type 2 diabetes (n = 23), and this group was excluded because it was too small for statistical analysis.

All analyses were conducted separately for young adults with type 1 diabetes and type 2 diabetes and adolescents with type 1 diabetes and parents of these adolescents. We examined the association between HFI and fear of hypoglycemia using linear regression analysis. A partially adjusted model included adjustment for the participant’s age, diabetes duration, sex, race/ethnicity, and SEARCH clinic site. The fully adjusted model additionally included parent education, household income, health insurance type, diabetes medication regimen, and continuous glucose monitoring use, as these variables are modifiable.

The mean fear of hypoglycemia score, behavior subscale score, and worry subscale score showed slightly skewed distributions. We repeated the linear regression analyses after a square root transformation of the mean scores. This yielded similar results and is not reported.

For adults with type 2 diabetes, risk of hypoglycemia is higher for those who include insulin in their medication regimen than for those who do not (21,22). Therefore, we repeated the analysis for adults with type 2 diabetes with stratification by those who use any form of insulin and those who do not. All analyses were completed with SAS 9.4.

The study sample was comprised of 568 adolescents <18 years old with type 1 diabetes (mean ± SD age 15.1 ± 2.1 years [range 10.0–17.9]), 1,401 young adults with type 1 diabetes (23.6 ± 3.7 years [18.1–35.9]), and 275 young adults with type 2 diabetes (25.8 ± 3.8 years [range 18.2–35.6]). Of these participants, 16%, 19%, and 35%, respectively, were from food insecure households. Additional descriptive information is provided in Table 1.

Table 1

Demographic and clinical characteristics of adults participating in SEARCH for Diabetes in Youth study (2015–2019), by household food security status

Adolescents with type 1 diabetes (n = 568)Young adults with type 1 diabetes (n = 1401)Young adults with type 2 diabetes (n = 275)
TotalHousehold food security statusTotalHousehold food security statusTotalHousehold food security status
Food secure (n = 477)Food insecure (n = 91)Food secure (n = 1,141)Food insecure (n = 260)Food secure (n = 180)Food insecure (n = 95)
Age 15.1 ± 2.1 15.1 ± 2.1 15.0 ± 2.1 23.6 ± 3.7 23.5 ± 3.7 24.1 ± 3.5 25.8 ± 3.8 25.7 ± 3.9 26.1 ± 3.7 
Sex          
 Female 50.2 48.6 58.2 54.3 53.8 56.2 66.5 65.6 68.4 
 Male 49.8 51.4 41.8 45.8 46.2 43.9 33.5 34.3 31.6 
Race/ethnicity          
 NH White 71.1 74.4 53.9 74.6 75.6 70.4 22.2 18.3 29.5 
 NH Black 11.8 9.0 26.4 10.6 9.0 17.3 43.3 43.9 42.1 
 Hispanic 13.4 13.0 15.4 12.4 13.0 10.0 23.6 26.7 17.9 
 Other 3.7 3.6 4.4 2.4 2.5 2.3 10.9 11.1 10.5 
Household income          
 <$25,000 10.0 7.3 24.2 21.2 16.7 40.8 50.9 45.6 61.1 
 $25,000–49,999 18.3 15.5 33.0 23.4 21.2 33.1 33.5 32.2 35.8 
 $50,000–74,999 17.3 14.5 31.9 17.1 17.4 15.8 7.6 10.6 2.1 
 ≥$75,000 54.4 62.7 11.0 38.3 44.7 10.4 8.0 11.7 1.1 
Clinic          
 SC and NC 19.9 18.5 27.5 18.8 17.8 23.5 34.6 32.8 37.9 
 OH 14.8 15.5 11.0 19.8 20.7 16.2 20.0 20.6 19.0 
 CO 37.5 37.7 36.3 33.9 33.9 33.9 20.0 18.9 22.1 
 CA 10.7 11.5 6.6 12.5 12.9 10.8 19.6 23.9 11.6 
 WA 17.1 16.8 18.7 14.9 14.7 15.8 5.8 3.9 9.5 
Parent education          
 <HS graduate 2.1 2.1 2.2 4.4 4.2 5.0 12.0 12.2 11.6 
 HS graduate 9.0 7.6 16.5 15.3 13.7 22.3 33.1 35.6 28.4 
 Some Col./Asso. 32.0 28.9 48.4 26.0 23.8 35.4 37.8 36.1 41.1 
 ≥Bachelor’s degree 56.9 61.4 33.0 54.4 58.3 37.3 17.1 16.1 19.0 
Insurance status          
 State/federal 23.4 18.0 51.7 12.4 9.8 23.9 37.5 35.0 42.1 
 Private 75.0 80.3 47.3 81.4 84.5 68.1 44.4 47.2 39.0 
 Other/unknown 0.9 0.8 1.1 2.2 2.5 1.2 2.9 3.3 2.1 
 None 0.7 0.8 0.0 3.9 3.2 6.9 15.3 14.4 16.8 
Diabetes duration, months 116.8 ± 36.9 117.1 ± 37.2 115.2 ± 34.9 148.2 ± 33.9 148.0 ± 33.7 148.9 ± 34.9 135.2 ± 39.5 136.1 ± 38.1 133.3 ± 42.3 
Diabetes regimen          
 Insulin pump 75.0 76.5 67.0 55.0 57.9 42.3 3.6 3.9 3.2 
 Long-acting and rapid-acting insulin, 3+ injections per day 22.2 20.8 29.7 38.5 36.4 47.7 16.4 13.3 22.1 
 Any other combination of insulin injections 2.8 2.7 3.3 5.4 4.8 7.7 34.6 37.2 29.5 
 Oral hypoglycemic medication 0.0 0.0 0.0 0.6 0.4 1.5 16.7 15.6 19.0 
 No treatment 0.0 0.0 0.0 0.6 0.5 0.8 28.7 30.0 26.3 
CGM2 use, % 49.3 51.4 38.5 34.9 38.7 18.5 16.7 15.0 20.0 
Participant fear scores          
 HFS score* 1.3 ± 0.5 1.3 ± 0.5 1.3 ± 0.5 1.1 ± 0.7 1.0 ± 0.6 1.4 ± 0.7 0.7 ± 0.6 0.6 ± 0.6 0.9 ± 0.7 
 Behavior subscale 1.8 ± 0.6 1.8 ± 0.6 1.8 ± 0.6 1.0 ± 0.6 1.0 ± 0.5 1.2 ± 0.6 0.7 ± 0.6 0.6 ± 0.6 0.9 ± 0.7 
 Worry subscale 1.0 ± 0.6 0.9 ± 0.6 1.0 ± 0.7 1.1 ± 0.9 1.0 ± 0.8 1.5 ± 1.0 0.7 ± 0.8 0.5 ± 0.8 0.9 ± 0.9 
Parent fear scores          
 HFS score 1.6 ± 0.6 1.5 ± 0.6 1.6 ± 0.6       
 Behavior subscale 2.0 ± 0.6 2.0 ± 0.6 1.9 ± 0.6       
 Worry subscale 1.3 ± 0.7 1.3 ± 0.7 1.4 ± 0.8       
Adolescents with type 1 diabetes (n = 568)Young adults with type 1 diabetes (n = 1401)Young adults with type 2 diabetes (n = 275)
TotalHousehold food security statusTotalHousehold food security statusTotalHousehold food security status
Food secure (n = 477)Food insecure (n = 91)Food secure (n = 1,141)Food insecure (n = 260)Food secure (n = 180)Food insecure (n = 95)
Age 15.1 ± 2.1 15.1 ± 2.1 15.0 ± 2.1 23.6 ± 3.7 23.5 ± 3.7 24.1 ± 3.5 25.8 ± 3.8 25.7 ± 3.9 26.1 ± 3.7 
Sex          
 Female 50.2 48.6 58.2 54.3 53.8 56.2 66.5 65.6 68.4 
 Male 49.8 51.4 41.8 45.8 46.2 43.9 33.5 34.3 31.6 
Race/ethnicity          
 NH White 71.1 74.4 53.9 74.6 75.6 70.4 22.2 18.3 29.5 
 NH Black 11.8 9.0 26.4 10.6 9.0 17.3 43.3 43.9 42.1 
 Hispanic 13.4 13.0 15.4 12.4 13.0 10.0 23.6 26.7 17.9 
 Other 3.7 3.6 4.4 2.4 2.5 2.3 10.9 11.1 10.5 
Household income          
 <$25,000 10.0 7.3 24.2 21.2 16.7 40.8 50.9 45.6 61.1 
 $25,000–49,999 18.3 15.5 33.0 23.4 21.2 33.1 33.5 32.2 35.8 
 $50,000–74,999 17.3 14.5 31.9 17.1 17.4 15.8 7.6 10.6 2.1 
 ≥$75,000 54.4 62.7 11.0 38.3 44.7 10.4 8.0 11.7 1.1 
Clinic          
 SC and NC 19.9 18.5 27.5 18.8 17.8 23.5 34.6 32.8 37.9 
 OH 14.8 15.5 11.0 19.8 20.7 16.2 20.0 20.6 19.0 
 CO 37.5 37.7 36.3 33.9 33.9 33.9 20.0 18.9 22.1 
 CA 10.7 11.5 6.6 12.5 12.9 10.8 19.6 23.9 11.6 
 WA 17.1 16.8 18.7 14.9 14.7 15.8 5.8 3.9 9.5 
Parent education          
 <HS graduate 2.1 2.1 2.2 4.4 4.2 5.0 12.0 12.2 11.6 
 HS graduate 9.0 7.6 16.5 15.3 13.7 22.3 33.1 35.6 28.4 
 Some Col./Asso. 32.0 28.9 48.4 26.0 23.8 35.4 37.8 36.1 41.1 
 ≥Bachelor’s degree 56.9 61.4 33.0 54.4 58.3 37.3 17.1 16.1 19.0 
Insurance status          
 State/federal 23.4 18.0 51.7 12.4 9.8 23.9 37.5 35.0 42.1 
 Private 75.0 80.3 47.3 81.4 84.5 68.1 44.4 47.2 39.0 
 Other/unknown 0.9 0.8 1.1 2.2 2.5 1.2 2.9 3.3 2.1 
 None 0.7 0.8 0.0 3.9 3.2 6.9 15.3 14.4 16.8 
Diabetes duration, months 116.8 ± 36.9 117.1 ± 37.2 115.2 ± 34.9 148.2 ± 33.9 148.0 ± 33.7 148.9 ± 34.9 135.2 ± 39.5 136.1 ± 38.1 133.3 ± 42.3 
Diabetes regimen          
 Insulin pump 75.0 76.5 67.0 55.0 57.9 42.3 3.6 3.9 3.2 
 Long-acting and rapid-acting insulin, 3+ injections per day 22.2 20.8 29.7 38.5 36.4 47.7 16.4 13.3 22.1 
 Any other combination of insulin injections 2.8 2.7 3.3 5.4 4.8 7.7 34.6 37.2 29.5 
 Oral hypoglycemic medication 0.0 0.0 0.0 0.6 0.4 1.5 16.7 15.6 19.0 
 No treatment 0.0 0.0 0.0 0.6 0.5 0.8 28.7 30.0 26.3 
CGM2 use, % 49.3 51.4 38.5 34.9 38.7 18.5 16.7 15.0 20.0 
Participant fear scores          
 HFS score* 1.3 ± 0.5 1.3 ± 0.5 1.3 ± 0.5 1.1 ± 0.7 1.0 ± 0.6 1.4 ± 0.7 0.7 ± 0.6 0.6 ± 0.6 0.9 ± 0.7 
 Behavior subscale 1.8 ± 0.6 1.8 ± 0.6 1.8 ± 0.6 1.0 ± 0.6 1.0 ± 0.5 1.2 ± 0.6 0.7 ± 0.6 0.6 ± 0.6 0.9 ± 0.7 
 Worry subscale 1.0 ± 0.6 0.9 ± 0.6 1.0 ± 0.7 1.1 ± 0.9 1.0 ± 0.8 1.5 ± 1.0 0.7 ± 0.8 0.5 ± 0.8 0.9 ± 0.9 
Parent fear scores          
 HFS score 1.6 ± 0.6 1.5 ± 0.6 1.6 ± 0.6       
 Behavior subscale 2.0 ± 0.6 2.0 ± 0.6 1.9 ± 0.6       
 Worry subscale 1.3 ± 0.7 1.3 ± 0.7 1.4 ± 0.8       

Data are means ± SD or %. Asso., associates; CGM, continuous glucose monitoring; Col., college; HS, high school; NH, non-Hispanic.

*

Including the HFS-C and the HFS-P.

HFS score range 0–4, behavior subscale range 0–4, worry subscale range 0–4.

The mean fear of hypoglycemia scores overall and stratified by food security status are presented in Table 1 for each group. Fear of hypoglycemia scores were highest for parents of adolescents with type 1 diabetes and were lowest for young adults with type 1 diabetes. Unadjusted models for assessment of the association between HFI and fear of hypoglycemia scores are presented in Tables 2 and 3. HFS-II scores were significantly higher for young adults with type 1 diabetes and type 2 diabetes experiencing HFI compared with their counterparts who lived in food secure households. There was no difference in HFS-C and HFS-P scores between food secure and food insecure households of adolescents with type 1 diabetes and parents.

Table 2

Association of household food security with hypoglycemia fear scores and subscales among young adults, adolescents, and the parents of adolescents with type 1 diabetes: SEARCH for Diabetes in Youth study

OutcomesModel 1*Model 2Model 3Adjusted meanMean difference
β ± SEPβ ± SEPβ ± SEPFSFI
Young adults (n = 1,401)          
 HFS-II score 0.39 ± 0.04 <0.05 0.37 ± 0.04 <0.05 0.40 ± 0.05 <0.05 0.75 1.15 0.40 
 Behavior subscale score 0.21 ± 0.04 <0.05 0.20 ± 0.04 <0.05 0.22 ± 0.04 <0.05 0.85 1.07 0.22 
 Worry subscale score 0.53 ± 0.06 <0.05 0.51 ± 0.06 <0.05 0.55 ± 0.06 <0.05 0.67 1.22 0.55 
Adolescents (n = 568)          
 HFS-C score 0.05 ± 0.06 >0.05 0.04 ± 0.06 >0.05 0.05 ± 0.06 >0.05 0.98 1.03 0.05 
 Behavior subscale score −0.02 ± 0.06 >0.05 0.00 ± 0.07 >0.05 0.01 ± 0.07 >0.05 1.44 1.46 0.02 
 Worry subscale score 0.10 ± 0.07 >0.05 0.07 ± 0.07 >0.05 0.07 ± 0.08 >0.05 0.67 0.75 0.08 
Parents of adolescents (n = 568)          
 HFS-P score 0.05 ± 0.06 >0.05 0.05 ± 0.07 >0.05 0.11 ± 0.07 >0.05 1.42 1.54 0.12 
 Behavior subscale score −0.04 ± 0.07 >0.05 −0.04 ± 0.07 >0.05 0.01 ± 0.07 >0.05 1.64 1.65 0.01 
 Worry subscale score 0.11 ± 0.08 >0.05 0.11 ± 0.08 >0.05 0.18 ± 0.09 <0.05 1.28 1.46 0.18 
OutcomesModel 1*Model 2Model 3Adjusted meanMean difference
β ± SEPβ ± SEPβ ± SEPFSFI
Young adults (n = 1,401)          
 HFS-II score 0.39 ± 0.04 <0.05 0.37 ± 0.04 <0.05 0.40 ± 0.05 <0.05 0.75 1.15 0.40 
 Behavior subscale score 0.21 ± 0.04 <0.05 0.20 ± 0.04 <0.05 0.22 ± 0.04 <0.05 0.85 1.07 0.22 
 Worry subscale score 0.53 ± 0.06 <0.05 0.51 ± 0.06 <0.05 0.55 ± 0.06 <0.05 0.67 1.22 0.55 
Adolescents (n = 568)          
 HFS-C score 0.05 ± 0.06 >0.05 0.04 ± 0.06 >0.05 0.05 ± 0.06 >0.05 0.98 1.03 0.05 
 Behavior subscale score −0.02 ± 0.06 >0.05 0.00 ± 0.07 >0.05 0.01 ± 0.07 >0.05 1.44 1.46 0.02 
 Worry subscale score 0.10 ± 0.07 >0.05 0.07 ± 0.07 >0.05 0.07 ± 0.08 >0.05 0.67 0.75 0.08 
Parents of adolescents (n = 568)          
 HFS-P score 0.05 ± 0.06 >0.05 0.05 ± 0.07 >0.05 0.11 ± 0.07 >0.05 1.42 1.54 0.12 
 Behavior subscale score −0.04 ± 0.07 >0.05 −0.04 ± 0.07 >0.05 0.01 ± 0.07 >0.05 1.64 1.65 0.01 
 Worry subscale score 0.11 ± 0.08 >0.05 0.11 ± 0.08 >0.05 0.18 ± 0.09 <0.05 1.28 1.46 0.18 

Food secure is the reference level. FI, food insecure; FS, food secure.

*

Model 1: unadjusted association between household food security and hypoglycemia fear scores and subscales.

Model 2: adjustment for age, diabetes duration, sex, race/ethnicity, and clinic.

Model 3: model 2 adjustments plus parent education, household income, insurance type, medication regimen, and continuous glucose monitoring use.

Young adults with type 1 diabetes from food insecure households had significantly higher HFS-II scores, behavior subscale scores, and worry subscales scores than those without HFI, independent of age, diabetes duration, sex, race, and clinic (Table 2). These associations remained significant after additional adjustment for demographic and clinical covariates. Specifically, young adults with type 1 diabetes experiencing HFI had mean ± SD HFS-II score 0.40 ± 0.046 units higher than those from food secure homes (P < 0.0001). They also had a behavior subscale score 0.22 ±0.040 units higher (P < 0.0001) and a worry subscale score 0.55 ± 0.061 units higher (P < 0.0001) than those without HFI.

For adolescents with type 1 diabetes and their parents, no differences in the self-reported fear of hypoglycemia scores were observed between adolescents living in food secure households and those in food insecure households (Table 2). Among parents of adolescents with type 1 diabetes, parents’ average worry subscale scores were 0.18 units higher (P < 0.05) among those experiencing HFI compared with parents in food secure households in the fully adjusted model.

Among young adults with type 2 diabetes, HFI was associated with HFS-II score, the worry subscale score, and the behavior subscale score (Table 3). These associations remained in the fully adjusted models, in which food insecurity was associated with the average fear of hypoglycemia score (0.28 units higher; P < 0.05), the behavior subscale score (0.19 units higher; P < 0.05), and the worry subscale score (0.35 units higher; P < 0.05). Of the 275 individuals in our study with type 2 diabetes, 150 (55%) used insulin in their medication regimen. In analyses stratified by insulin use, HFI was significantly associated with the HFS-II score and worry subscale score in both groups. However, the magnitude of the associations was higher among those who use insulin. For the behavior subscale score, those who did not use insulin had no association between food insecurity and hypoglycemia fear after adjustment for covariates. Those who used insulin had a higher behavior subscale score (0.28 units higher; P < 0.05) if they were food insecure compared with those who were food secure. The results of the stratified analysis can be found in Table 4.

Table 3

Association of household food security with hypoglycemia fear scores and subscales among young adults with type 2 diabetes: SEARCH for Diabetes in Youth study

Outcomes in young adults (N = 275)Model 1*Model 2Model 3Adjusted meanMean difference
β ± SEPβ ± SEPβ ± SEPFSFI
HFS-II score 0.32 ± 0.08 <0.05 0.37 ± 0.08 <0.05 0.28 ± 0.08 <0.05 0.61 0.88 0.27 
Behavior subscale score 0.24 ± 0.08 <0.05 0.29 ± 0.08 <0.05 0.19 ± 0.08 <0.05 0.66 0.85 0.19 
Worry subscale score 0.39 ± 0.10 <0.05 0.43 ± 0.10 <0.05 0.35 ± 0.10 <0.05 0.56 0.91 0.35 
Outcomes in young adults (N = 275)Model 1*Model 2Model 3Adjusted meanMean difference
β ± SEPβ ± SEPβ ± SEPFSFI
HFS-II score 0.32 ± 0.08 <0.05 0.37 ± 0.08 <0.05 0.28 ± 0.08 <0.05 0.61 0.88 0.27 
Behavior subscale score 0.24 ± 0.08 <0.05 0.29 ± 0.08 <0.05 0.19 ± 0.08 <0.05 0.66 0.85 0.19 
Worry subscale score 0.39 ± 0.10 <0.05 0.43 ± 0.10 <0.05 0.35 ± 0.10 <0.05 0.56 0.91 0.35 

Food secure is the reference level. FI, food insecure; FS, food secure.

*

Model 1: unadjusted association between household food security and hypoglycemia fear scores and subscales.

Model 2: adjustment for age, diabetes duration, sex, race/ethnicity, clinic.

Model 3: model 2 adjustments plus parent education, household income, insurance type, medication regimen, and continuous glucose monitoring use.

Table 4

Association of household food security with hypoglycemia fear scores and subscales among young adults with type 2 diabetes, stratified by insulin use: SEARCH for Diabetes in Youth study (n = 275)

OutcomesNo insulin use, n = 125Insulin use, n = 150
β ± SEPβ ± SEP
HFS-II score 0.24 ± 0.09 0.01 0.35 ± 0.14 0.01 
Behavior subscale score 0.10 ± 0.10 0.32 0.28 ± 1.12 0.03 
Worry subscale score 0.35 ± 0.13 0.01 0.41 ± 0.17 0.02 
OutcomesNo insulin use, n = 125Insulin use, n = 150
β ± SEPβ ± SEP
HFS-II score 0.24 ± 0.09 0.01 0.35 ± 0.14 0.01 
Behavior subscale score 0.10 ± 0.10 0.32 0.28 ± 1.12 0.03 
Worry subscale score 0.35 ± 0.13 0.01 0.41 ± 0.17 0.02 

Food secure is the reference level. Models adjusted for age, diabetes duration, sex, race/ethnicity, clinic, parent education, household income, insurance type, and continuous glucose monitoring use.

The results of this study demonstrated that HFI in the past year was associated with increased fear of hypoglycemia, expressed as both engaging in behaviors to avoid hypoglycemia and worries of experiencing hypoglycemia in people with type 1 and type 2 diabetes. The nature of the food insecurity experience makes it likely that people with diabetes in food insecure households are keenly aware that preventing and overcoming hypoglycemia may be difficult for them because they do not always have immediate access to food because of monetary constraints. This is consistent with other research where investigators found that higher income was associated with less fear of hypoglycemia (23).

Parents with HFI worried about their child with type 1 diabetes experiencing hypoglycemia more than parents whose households were food secure. Parental concern about the child’s hypoglycemia is well documented (17,18,2426), with mothers reporting greater fear than fathers (24,25). In our study we extend this research by differentiating by household food security status. Parents who are experiencing food insecurity may be more aware of the dangers of not having enough food and therefore more inclined to worry about the child having a hypoglycemic episode. Literature also documents that very worried mothers of adolescents with type 1 diabetes may accept elevated glucose levels to reduce risk of hypoglycemia (26). Long-term, glucose levels higher than the recommendations (hyperglycemia) can have serious negative health consequences such as poor cognitive function (27), cardiac autoimmunity leading to increased risk of cardiovascular disease later in life, and chronic diabetes complications (9). In future research investigators should focus on parents who fear hypoglycemia for their children and explore how to help those in food insecure households manage the child’s diabetes.

Among adolescent participants with type 1 diabetes, we did not observe an association between HFI and self-reported fear of hypoglycemia. This lack of association may be because children are often shielded from HFI as parents try to maintain a near-normal diet for their children even if they themselves are not able to eat (28). In 2019, only 0.6% of U.S. households with youth experienced food insecurity so severe that caregivers reported there was not enough money for food so that their children experienced hunger, could not eat all daily meals, or did not eat for 24 h (2). Parents have also reported that if their children experience food insecurity, they are usually older (2,28).

Young adults with type 1 diabetes or type 2 diabetes who lived in households with food insecurity experienced more worry, engaged in more avoidant behaviors, and overall had higher fear of hypoglycemia scores than those living in food secure households. By and large, the most common predictor of fear of hypoglycemia is the experience of previous hypoglycemic episodes (10,16,18,2931). Reports document consistently that adults with HFI have a higher prevalence and increased risk of experiencing hypoglycemia (32,33). Adults who fear hypoglycemia oftentimes consume excessive carbohydrates and simple sugars to prevent a hypoglycemic episode (34,35). The latter is problematic for two reasons. First, long-term consequences of hyperglycemia result in chronic complications of diabetes (3638).

Second, fearing hypoglycemia may further exacerbate the difficult task of balancing food and diabetes medicine in a stretched budget, as overeating carbohydrates requires administration of more medication to counter elevated blood glucose levels, which in turn requires purchasing of more medication. People who have diabetes and HFI struggle to balance acquiring food, medicine, and supplies for diabetes, along with their day-to-day expenses (12). Consequently, integrating fear of hypoglycemia screening as well as food security screening into diabetes clinical visits will provide relevant information for tailored diabetes education. Tailored education is needed for households that are food insecure, as innovative rather than conventional strategies to maintain glycemic control are necessary for people with diabetes and HFI (11). This conclusion is in line with the Americans Diabetes Association’s recommendation to screen for food insecurity in all patients with diabetes (9).

For adults with type 2 diabetes, the magnitude of the associations of HFI, HFS-II score, and worry subscale score was higher for those using insulin than for those who do not use insulin. Additionally, adults with type 2 diabetes using insulin had a higher behavior subscale score if they were food insecure compared with those who were food secure. This association was not significant for those who do not use insulin, which is what we expected to observe. The belief that hypoglycemia is uncommon in people with Type 2 diabetes is a myth. In a systematic review, Alwafi et al. (22) found that the prevalence of hypoglycemia among people with type 2 diabetes is as high as 73.0%, and the risk is highest among those using insulin-based therapy. Diabetes providers should pay special attention to patients with type 2 diabetes using insulin, especially since the prevalence of HFI is typically higher in those with type 2 diabetes than in those with type 1 diabetes (5). In our study, 35% of adults with type 2 diabetes experienced HFI compared with 19% of adults with type 1 diabetes and 16% of adolescents with type 1 diabetes.

A strength of this study is the use of validated and widely accepted instruments to measure HFI and fear of hypoglycemia, which allow for comparison and future replication in other populations (1,1618). Moreover, our study included a large diverse set of perspectives of adolescents with type 1 diabetes, parents of adolescents with type 1 diabetes, and young adults with type 1 and type 2 diabetes, whereas most previous work examining fear of hypoglycemia focused on either adults or adolescents with type 1 diabetes and parents of adolescents with type 1 diabetes (7,10,18,24,25,39). A weakness of this study is the sample size of adolescents with type 2 diabetes.

In conclusion, young adults with type 1 diabetes and type 2 diabetes who lived in households with food insecurity experienced more fear of hypoglycemia than those living in food secure households. Parents of adolescents with type 1 diabetes living in food insecure households experienced more worry about hypoglycemia than parents in food secure households. More research is needed that explores how to help young adults manage fear of hypoglycemia and manage glucose levels in the presence of HFI. Additionally, providers should consider tailored strategies that take into account social determinants of health such as HFI status in discussing how to manage low blood glucose levels and fear of hypoglycemia with patients. Innovations are clearly needed because conventional methods to prevent or overcome hypoglycemia, such as carrying snacks, is problematic for people who are food insecure.

See accompanying articles, pp. 245 and 278.

This article contains supplementary material online at https://doi.org/10.2337/figshare.20031944.

Acknowledgments. SEARCH is indebted to the many youths and their families and their health care providers, whose participation made this study possible.

Funding. SEARCH is funded by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (1R01DK127208-01 and 1UC4DK108173), and supported by the Centers for Disease Control and Prevention.

The Population Based Registry of Diabetes in Youth Study (1U18DP006131, U18DP006133, U18DP006134, U18DP006136, U18DP006138, and U18DP006139) is funded by the Centers for Disease Control and Prevention (DP-15-002) and supported by the National Institute of Diabetes and Digestive and Kidney Diseases. National Institutes of Health. SEARCH (phases 1, 2, and 3) is funded by the Centers for Disease Control and Prevention (program announcement nos. 00097, DP-05-069, and DP-10-001) and supported by the National Institute of Diabetes and Digestive and Kidney Diseases. SEARCH sites include Kaiser Permanente Southern California (U48/CCU919219, U01 DP000246, and U18DP002714), University of Colorado Denver (U48/CCU819241-3, U01 DP000247, and U18DP000247-06A1), Cincinnati Children’s Hospital Medical Center (U48/CCU519239, U01 DP000248, and 1U18DP002709), University of North Carolina at Chapel Hill (U48/CCU419249, U01 DP000254, and U18DP002708), Seattle Children’s Hospital (U58/CCU019235-4, U01 DP000244, and U18DP002710-01), and Wake Forest University School of Medicine (U48/CCU919219, U01 DP000250, and 200-2010-35171). This work is also funded by the SEARCH Food Security Cohort Study (NIDDK grant 5R01DK117461).

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention or the National Institute of Diabetes and Digestive and Kidney Diseases.

Duality of Interest. No potential conflicts of interest relevant to this article were reported.

Author Contributions. L.A.R. researched data, completed the analysis, and wrote the manuscript. S.Z. analyzed data and edited the manuscript. B.A.R. provided guidance for the analysis, reviewed and edited the manuscript, and contributed to discussion. J.A.M., A.J.R., K.A.S., J.M.L., E..J., L.H., K.F., L.M.K., C.P., L.M.D., and E.M.A. reviewed and edited the manuscript, contributed to discussion, and gave final approval of the manuscript. A.D.L. conceptualized the objective, guided the analysis, reviewed and edited the manuscript, contributed to discussion, and gave final approval of the manuscript. L.A.R. and A.D.L. are the guarantors of this work and, as such, had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Prior Presentation. Parts of this study were presented in abstract form at the 80th Scientific Sessions of the American Diabetes Association, 12–16 June 2020.

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