Diabetes is characterized by hyperglycemia and can cause vascular and neurological damage, which seriously threatens the health of patients and contributed significantly to the global disease burden (Ali, Pearson-Stuttard, Selvin, & Gregg, 2022; Rizzo et al., 2022). As reported by the International Diabetes Federation, the prevalence of diabetes in the total population is 8.8% (Yu et al., 2022) and 415 million adults in the world had diabetes mellitus in 2015, which is projected to rise to 642 million by 2040. Type 2 diabetes mellitus (T2DM) accounts for over 90% of the total diabetes mellitus cases, with a prevalence of 11.6% among the Chinese adult population based on a recent large-scale population-based survey (Han et al., 2022; Kanaley et al., 2022). Type 2 diabetes has seriously affected people's health and quality of life, and this impact has a trend of expansion among people of all ages (Wu et al., 2021). Recent studies have shown that the age of diagnosis of type 2 diabetes is gradually expanding and the trend of youth is obvious (Gardner et al., 2022; Wang, Mao, Wang, Liu, & Huang, 2022).
Among the complications of type 2 diabetes, hypoglycemia is a common and potentially serious complication of diabetes (Echouffo-Tcheugui, Kaze, Fonarow, & Dagogo-Jack, 2022; Steinbrenner, Duntas, & Rayman, 2022) which can lead to cognitive dysfunction, hemiplegia, blurred vision, decreased renal function, arrhythmia, coma, and even death (Andersen et al., 2021). The frequencies of severe hypoglycemia in diabetes patients substantially vary across studies and a systematic review of 46 population-based studies estimated that was 6% (Yun, Han, & Ko, 2022), and the incidence of hypoglycemia was much higher. Hypoglycemia can cause dizziness, syncope, and even a sense of dying (Lambert-Obry, Lafrance, Savoie, & Lachaine, 2022). Hypoglycemic experience can cause patients to fear hypoglycemia. This negative emotional experience can lead patients to take "overcompensation behavior", such as overly vigilant blood glucose monitoring, limiting physical activity, intentionally reducing the required drug dosage, or ingesting excessive carbohydrates to maintain blood glucose at a high level (Heller et al., 2018; Siamashvili & Davis, 2021). This has become a major obstacle to the control of blood sugar, which can lead to the occurrence or aggravation of complications in patients and have a negative impact on the management of diabetes (Muneer, 2021; Zhang et al., 2020).
‘Hypoglycemia worries’ is an important aspect of hypoglycemia fears, which is the patient's concern about hypoglycemia after experiencing hypoglycemia, and fear of hypoglycemia again. Research shows that fear of hypoglycemia is closely related to worry, that is, the more fear of hypoglycemia, the more serious the anxiety of diabetes patients (Ng, Moore, Clemente, Pintus, & Soni, 2019). Besides worry, diabetes patients also have other negative emotions such as anxiety and depression, which seriously affect their subjective well-being (Pate, Klemenčič, Battelino, & Bratina, 2019). ‘Excessive avoiding hypoglycemia behavior’ is another important aspect of hypoglycemia fears (Grammes et al., 2018). In a survey of diabetes patients with hypoglycemia, results show that patients often take actions to maintain high blood sugar levels in order to avoid hypoglycemia again (O'Donnell et al., 2022). The behavior of avoiding hypoglycemia is caused by the fear of hypoglycemia, which is not conducive to maintaining normal blood sugar of diabetes patients, and is closely related to hypoglycemic worries (Polonsky et al., 2020; Roberts, Yi-Frazier, Carlin, & Taplin, 2020).
Hypoglycemia worries and avoiding hypoglycemia behavior are two important aspects of hypoglycemic fear, one is ideological, the other is behavioral. However, previous studies investigating the relationship between hypoglycemia worries and avoiding hypoglycemia behavior in T2DM patients with hypoglycemia through scale measurements have tended to consider hypoglycemia fear as a whole, such as T H Wieringa's (Wieringa, de Wit, Twisk, & Snoek, 2018) research results shows that hypoglycemia is associated with lower quality of life in terms of hypoglycemia fear and diabetes symptom distress (Wieringa et al., 2018). In this way, the determination of correlation based on the total score disguises the relationship between different dimensions of variables and the traditional statistical model cannot evaluate the relative importance of different interrelated nodes in the network by calculating indicators. The existing researches regards hypoglycemic fear as a whole and studies the relationship between it and other variables (Nakhleh & Shehadeh, 2021; Przezak, Bielka, & Molęda, 2022) which will lead to spurious correlations among variables easily appear when there are more variables. We do not know how the items in the two dimensions of hypoglycemic fear, hypoglycemic worries and hypoglycemic avoidance, interact with each other.
Network analysis can reduce these problems by fitting data with Gaussian image model (Serra et al., 2020). It is based on mathematical analysis and visual representation of the interaction between complex variables. The advantage of network analysis is that it does not rely on previous assumptions about the relationship between variables, and allows visualization of the association patterns of different variables (Askar, Cañadas, & Svendsen, 2021). Community is always used to represent a group of psychological variables. The bridge centrality index helps to accurately capture variables that play a key role in connecting communities in the whole network (Stevens, Lydon, Marshall, & Taylor, 2020; Vanzhula, Kinkel-Ram, & Levinson, 2021).
In summary, our study was conducted based on a network analysis approach to analyze the relationship between hypoglycemia worries and avoiding hypoglycemia behavior in T2DM patients with hypoglycemia. We constructed the network model and estimated the bridge centrality to detect the important role of some specific aspects of the effect of hypoglycemic worries on avoiding hypoglycemic behavior and identified the variables connecting these two communities to reduce hypoglycemic worries and avoid hypoglycemic behavior excessively in T2DM patients with hypoglycemia.