Associations among fear of hypoglycemia, cognitive fusion and diabetes self- care activities in elderly patients with type 2 diabetes: a cross-sectional study

Associations among fear of hypoglycemia, cognitive fusion and diabetes self- care activities in elderly patients with type 2 diabetes: a cross-sectional study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Associations among fear of hypoglycemia, cognitive fusion and diabetes self- care activities in elderly patients with type 2 diabetes: a cross-sectional study Fangli Liu, Meng Wang, Luwen Zhang, Jianpei Niu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7110540/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 21 Nov, 2025 Read the published version in BMC Nursing → Version 1 posted 16 You are reading this latest preprint version Abstract Background Fear of hypoglycemia (FOH), considered an underestimated issue in clinical care, is not only related to patients' negative psychological states but also adversely affects the metabolic control of diabetes patients. This study aims to investigate the current status and influencing factors of FOH in elderly patients with type 2 diabetes, and to examine its relationships with cognitive fusion and self-care activities using structural equation modeling. Methods This study adopts a cross-sectional design. From November 2023 to October 2024, elderly patients with type 2 diabetes admitted to the endocrinology department of two tertiary hospitals in Zhengzhou were selected as subjects. The research tools are general data questionnaires, cognitive fusion questionnaire (CFQ-F), the Chinese Version Hypoglycemia Fear Survey II-Worry Scale (CHFSII-WS), and the Summary of Diabetes Self-Care Activities (SDSCA). Data entry was performed using Epidata 3.1, statistical analysis was performed on SPSS 20.0, and structural model analysis was performed on AMOS 24.0. Results A total of 200 elderly patients with type 2 diabetes were included in this study. The total score of FOH in elderly patients with type 2 diabetes was (25.81 ± 10.81). Age, the number of hypoglycemia, medical payment methods (free medical service/own expense), cognitive fusion and self-care activities were the influencing factors of FOH ( P < 0.05). The path factor model showed that age, the number of hypoglycemia, self-pay, self-management, and cognitive fusion had an indirect effect on the FOH. At the same time, age, the number of hypoglycemia, free medical service, self-management, and cognitive fusion had a direct effect on the FOH. Conclusion Elderly patients with type 2 diabetes often experience FOH, which is influenced by multiple factors such as the disease, cognitive fusion, and self-care. Healthcare professionals should balance glycemic targets with patients' psychological burden, avoiding excessive prevention of hypoglycemia that may heighten anxiety. Type 2 diabetes Fear of hypoglycemia Cognitive fusion Self-care Elderly people Path analysis Figures Figure 1 1. Introduction Diabetes Mellitus (DM) is a chronically progressive disease that affects various organs and tissues of the body. Together with coronary heart disease and hypertension, it is called the three major killers of elderly health [ 1 ]. The International Diabetes Federation (IDF) [ 2 ] reported in 2021 that the global diabetic population reached 537 million. It is predicted to reach 783 million in 2045 [ 2 ]. At present, the number of diabetic patients in China has reached 117 million with an overall prevalence rate is 12.8%, and patients with type 2 diabetes account for more than 90% of the total [ 3 ]. Most DM patients in China are elderly, mainly exhibiting type 2 diabetes [ 4 ]. Diabetes patients are accompanied by an unavoidable risk of hypoglycemia while maintaining stable blood glucose levels. Compared with non-elderly patients, the relevant organs of elderly DM patients have been damaged to some extent and the complications of cardiovascular and cerebrovascular diseases are relatively more [ 5 ], which increases the likelihood of hypoglycemia. Hypoglycemia can also impose a severe psychological burden on patients, causing them to feel fear, which is especially apparent in the elderly. This fear of hypoglycemia (FOH), considered an underestimated issue in clinical care, is not only related to patients' negative psychological states but may also adversely affects disease management and metabolic control of DM patients [ 6 ]. In recent years, research on the fear of hypoglycemia has been focused on translations of different scale versions, and more research has been applied to patients with type 1 diabetes than to type 2 diabetes [ 7 – 9 ]. Cognitive fusion, a key component of the Acceptance of Commitment Therapy (ACT) model of psychopathology, refers to the tendency for people's behaviors to be overly controlled by the laws of language and the content of their thoughts [ 10 ]. Specifically, individuals get caught up in their thoughts and have actions dominated by them, which leads to their immersion in negative thoughts, causing the creation and aggravation of negative emotions [ 11 ]. At present, the relationship between cognitive fusion and mental health has attracted the attention of scholars. Relevant studies have shown that cognitive fusion is closely related to negative emotions such as anxiety, depression and post-traumatic stress disorder [ 12 , 13 ]. FOH also belongs to a negative psychological state. But whether cognitive fusion affects the FOH is still unclear. Self-care for diabetic patients is key to the comprehensive management of diabetes, which is not only directly related to their health condition but also affects their quality of life and psychological status [ 14 ]. However, to the best of our knowledge, the relationship between FOH, cognitive fusion, and self-care activities has not been explored. In addition, no researchers have explored whether cognitive fusion affects patients' FOH. In addition, most studies on FOH have focused on type 1 diabetes, with limited research on older patients with type 2 diabetes and on the specific factors through which FOH affects patients' health behaviors. Therefore, the purpose of this study was to assess the status of FOH in elderly patients with type 2 diabetes, and to explore its influencing factors. We then analyzed the association between FOH, cognitive fusion and diabetes self-care activities by using path analysis. The findings of our research have the potential to provide a reference for improving patients' psychological well-being and quality of life. 2. Materials and methods 2.1 Design This survey was used in a cross-sectional design. 2.2 Participants In this study, from April 2023 to January 2024, elderly patients with type 2 diabetes were selected from the endocrinology department of two hospitals in Zhengzhou, Henan. Inclusion criteria: ①age is greater than or equal to 60 years old [ 15 ]; ②diagnosed as type 2 diabetes(4); ③experienced hypoglycemia in the past six months; ④can correctly answer questions and complete the required questionnaires independently or with the help of researchers; ⑤voluntary participation. Exclusion criteria: ①diabetic patients with other chronic diseases, such as primary liver and kidney disease;②diabetic patients with malignant tumors; ③people with mental illness. 2.3 Instruments 2.3.1 General information questionnaire By reviewing the literature and combining expert opinions, the researcher designed a questionnaire of socio-demographic and clinical characteristics, including: gender, age, occupation, education level, way of residence, marital status, medical payment method, monthly income per capita, family genetic history, blood sugar control, and the amount of hypoglycemia in a month. 2.3.2 Fear of hypoglycemia Fear of hypoglycemia was assessed using the CHFSII-WS. This scale is widely used in patients with type 2 diabetes and was initially discovered by Cox et al [ 16 ] in 1987 for determining the FOH levels of diabetic patients in the past six months. It contains behavior scale (HFSII-BS) and worry scale (HFSII-WS), with Cronbach's α coefficients of 0.85 and 0.94, respectively. In 2015, Mu C et al [ 17 ] translated the English version of the scale into Chinese, and the Chinese version of the scale contains 13 items, with the internal consistency of 0.89. Each item uses the Likert 5 rating, ranging from 0 to 4 points, with "never = 1 point, " "very few = 2 points, " "sometimes = 3 points, " "often = 4 points, " and "always = 5 points. " The total score ranges from 0 to 52 points; the higher score indicates the higher level of the FOH [ 18 ]. 2.3.3 Cognitive fusion Cognitive fusion questionnaire (CFQ-F): In 2010, GillaIlders et al [ 19 ] constructed a cognitive fusion questionnaire containing 13 items. In 2015, Zhang Weichen et al [ 20 ] translated it into Chinese version. It contains a total of 9 items, representing 1ཞ7 for different levels, with the following scoring: "not at all = 1 point," "does not meet = 2 points," "apparently does not meet = 3 points," "interposed between = 4 points," "some match = 5," "conformity = 6 points," and "obvious match = 7 points." The higher the score, the higher the level of cognitive fusion. The Cronbach’ α was 0.92(20), demonstrating strong reliability and validity. 2.3.4 Self-Care Activities Summary of Diabetes Self-Care Activities (SDSCA): More versions of the Self-Management Questionnaire for Diabetes. After reviewing the literature, the self-management questionnaire designed and widely used by Toobea et al [ 21 ] was selected. This questionnaire contains 13 items across 6 dimensions, covering diet, exercise, medication, foot care, monitoring of blood sugar and smoking. The number of days spent on questionnaire-related activities in the past week as a score (except smoking). The higher the average score of the items contained in each subscale, the higher the level of self-management. The content validity index (CVI) is 1.00. 2.4 Data Collection The data were collected from April 2023 to January 2024. Elderly type 2 diabetic patients admitted to the endocrinology department of two tertiary-grade hospitals in Henan Province were investigated. With the approval of the hospital and department heads, patients were screened rigorously according to the inclusion and exclusion criteria and the questionnaires were distributed in person by researchers. It was necessary to communicate with the patients before distribution, explaining the significance and research purpose of this survey and promising to keep the questionnaires confidential. After patients agreed to participate in the survey, they were required to sign an informed consent form. The filling time was controlled within 10ཞ15 minutes, and researchers ensured that the questionnaires were returned without error. According to Kendall’s [ 22 ] sample size estimation method, this study approximated the number of questionnaire variables by 10 to 15 times and then considered about 20% of the loss rate and invalid questionnaires. The required sample size ranged from 160 to 240, with a total of 200 cases included in the study. A total of 210 questionnaires were issued, and 200 valid questionnaires were collected, with an effective recovery rate of 95.2%. 2.5 Statistical analysis Database was established by Epidata 3.1, analyzed by SPSS 22.0 and AMOS 24.0. During the statistical description, the continuous data was first tested for normality. The normal data were described with frequencies, means, standard deviations, while the non-normal data were described with median and quartile. The data following a normal distribution were used for independent-samples T test and analysis of variance, while the non-normal distribution data and grade data were used for rank sum test. The multiple linear regression analysis was carried out to explore its influencing factors. AMOS24.0 was used for structural model analysis. 3. Results 3.1 Participants Characteristics This study investigated 200 elderly patients with type 2 diabetes, including 104 males (64.4%) and 96 females (48.0%). The average age was (71.56 ± 8.19) years old, with the minimum age was 60 years, and the maximum age was 92 years. Of the participants, 77.0% are married and 23.0% are without spouse; education level is 30.0% with elementary school and below, 21.0% with junior high school, 31.5% with high school or junior college, 17.5% with college and above. In monthly income per capita, 48.5% of the patients had more than 2,000 yuan, 14.5% had less than 1,000 yuan, and 37.0% had between 1,000 and 2,000 yuan. (Table 1). Table 1 General information on elderly patients with type 2 diabetes ( n =200) Project Classification n Proportion（﹪） Age 60～70 99 49.5 70～80 69 34.5 ≥81 32 16.0 Gender Male 104 52.0 Female 96 48.0 Marital status Married 46 77.0 No spouse 154 23.0 Education level Elementary school and below 60 30.0 Junior high school 42 21.0 High school or technical secondary school 63 31.5 College and above 35 17.5 Medical payment method Self-pay 15 7.5 Free medical service 9 4.5 Medical insurance 176 88.0 Monthly income per capita 2000 97 48.5 Working condition On duty 28 14.0 Off duty 172 86.0 Medical payment method At your own expense 15 7.5 Public expense 9 4.5 Medical insurance 176 88.0 3.2 Status of FOH in elderly patients with type 2 diabetes This survey involved a total of 200 elderly patients with type 2 diabetes. The items of the FOH scale were summed up. The minimum score was 3 points and the highest was 49 points. The results of this study show that the total score of FOH (25.81 ± 10.81), indicating patients had a moderate degree of FOH. The scores of each item on the scale were ranked (Table 2). Table 2 The fear of hypoglycemia score in elderly patients with type 2 diabetes ( n =200) Project （ ） Sequence Hypoglycemia alone 2.69 ± 0.90 1 No one helps when hypoglycemia occurs 2.64 ± 1.13 2 Hypoglycemia during sleep 2.57 ± 1.03 3 Hypoglycemia affects normal judgment 2.44 ± 1.24 4 Hypoglycemia in social situations embarrassing yourself and others 2.41 ± 1.01 5 Didn't realize when you had hypoglycemia 2.27 ± 1.12 6 Receive bad reviews from others 2.08 ± 1.27 7 Stupid or drunk when hypoglycemia occurs 1.57 ± 1.29 8 Negligence or accident 1.50 ± 1.08 9 Out of control 1.40 ± 1.20 10 Fainting from hypoglycemia in public 1.24 ± 1.08 11 Hurt yourself or others 1.23 ± 0.87 12 Cause permanent harm to one's health 0.84 ± 0.96 13 Total score 25.81 ± 10.81 3.3 Single factor of FOH in elderly type 2 diabetic patients Single factor analysis showed that there were statistically significant differences in the FOH among patients with different age(F=15.837, P <0.001), genders(F=-2.204, P =0.029), medical payment methods(F=15.067, P <0.001), years of diabetes(F=5.353, P <0.001), exercise(F=3.218, P =0.042), blood glucose stability (F=6.382,P=0.002), and frequency of hypoglycemia (F=12.626, P <0.001) (Table 3). Table 3 Analysis of the effects of the fear of hypoglycemia on participants with different demographic characteristics ( n =200) Project Classification n FOH ( ) t/F P Age 60～70 99 21.09 ± 11.52 23.152 < 0.001 71～80 69 29.87 ± 7.56 ≥81 32 31.63 ± 7.89 Gender Male 104 24.20 ± 10.79 -2.204 0.029 Female 96 27.54 ± 10.61 Medical Payment Method Self-pay 15 39.07 ± 5.47 15.067 < 0.001 Free medical service 9 19.78 ± 13.74 Medical insurance 176 24.98 ± 10.20 Diabetes Years ≤ 10 72 22.86 ± 11.42 5.353 0.005 11 < year < 20 68 26.12 ± 10.56 ≥ 20 60 28.40 ± 9.45 Exercise Situation No exercise 50 27.76 ± 9.37 3.218 0.042 Mild exercise 138 25.68 ± 11.02 Moderate exercise 12 19.08 ± 11.93 Blood Glucose Stability Unstable 147 26.78 ± 10.47 6.382 0.002 More stable 37 25.81 ± 10.11 Very stable 15 16.88 ± 11.93 The number of hypoglycemia occurrences in the past month 0 times 38 22.11 ± 12.00 12.626 < 0.001 1～2 times 96 23.26 ± 10.25 3～4 times 45 30.00 ± 8.18 ≥ 5 times 21 35.14 ± 7.83 3.4 Status of cognitive integration and self-care activities in elderly patients with type 2 diabetes The average score of cognitive fusion was (35.35 ± 10.07), which was higher than the domestic norm. The average score of self-care activities was (3.35 ± 1.18), and the lowest score was foot care (Table4). Table 4 Elderly participants with type 2 diabetes self-care activities behavior and its each dimension score ( n =200) Project Dimension Min Max （ ） Self-care activities 1.33 5.75 3.35 ± 1.18 Diet 0.75 7 3.32 ± 1.38 Sport 0 7 3.39 ± 1.91 Blood glucose monitoring 0 7 3.08 ± 2.08 Medical care 0 7 4.64 ± 1.68 Foot care 0 7 2.44 ± 1.46 Smoking (branch) 0 35 9.28 ± 9.59 3.5 Correlation analysis of FOH, cognitive fusion and self-care activities in elderly type 2 diabetic patients The result of Pearson correlation analysis shows that a significant positive correlation between FOH and cognitive fusion (r=0.704, P <0.01); and a significant negative correlation between FOH and self-care activities (r=0.588, P <0.01) (Table 5). Table 5 Correlation analysis of the fear of hypoglycemia, cognitive fusion and self-care activities in participants (n=200) Project Fear of hypoglycemia Cognitive fusion Self-care activities FOH 1 Cognitive fusion 0.704** 1 Self-care activities -0.485** -0.577** 1 Note:* P ＜0.05;** P ＜0.01 3.6 Multivariate analysis of the impact of FOH in elderly patients with type 2 diabetes In this study, FOH in elderly patients with type 2 diabetes was taken as the dependent variable, and the variable with statistical significance ( P <0.05) in single results of factor analysis was used as independent variable. The multivariate stepwise regression analysis was performed. The assignment method was as follows. Gender: male=1, female=2; Exercise situation: no exercise=1, mild exercise=2, moderate exercise=3; Blood glucose control situation: not good=1, general=2, good=3; The number of hypoglycemia occurrences in the past month:0 times=1, 1 to 2 times=2, 3 to 4 times=3, >5 times=4; Medical payment method: self-pay = 0, Free medical service=0, medical insurance=1; self-pay=0, Free medical service=1, medical insurance=0; self-pay=1, free medical service=0, medical insurance=0. Age, number of years of diabetes, cognitive integration and self-care activities scores were all included in the equation with the original values (Table 6). Table 6 The fear of hypoglycemia and multiple stepwise regression analysis of their respective variables Model B Std.Error Beta t P Constant -8.384 5.646 - -1.507 0.134 Age 0.214 0.069 0.162 3.095 0.002 Time 1.962 0.619 0.160 3.169 0.002 Free medical service -5.670 2.325 -0.115 -2.439 0.016 Own expense 6.713 2.316 0.142 2.899 0.004 Cognitive fusion 0.515 0.068 0.480 7.613 <0.001 Self-care activities -1.132 0.525 0.123 -2.156 0.032 Note： F =44.889, P <0.001; R 2 =0. 583, Adjusted R 2 =0.570 3.7 Path analysis of POH in elderly patients with type 2 diabetes In order to further clarify the functional models between FOH and age, the number of hypoglycemia, the free medical service, self-pay, cognitive fusion, self-care activities, a preliminary path analysis model was established. The study model demonstrated a satisfactory fit, X 2 =0.946, p =0.814(P>0.05), X 2 /df=0.315(X 2 /df0.90), AGFI=0.987(AGFI>0.90), NFI=0.997(NFI=>0.90), IFI=0.980(IFI>0.90), TLI=0.920(TLI>0.90), CFI=0.989(CFI>0.90), RMSEA=0.006(RMSEA<0.08). The analysis model showed that age, the number of hypoglycemia, self-care activities, and cognitive fusion had an indirect effect on the FOH. At the same time, age, the number of hypoglycemia, self-care activities, and cognitive fusion had a direct effect on the FOH (Figure 1, Table 7). Table 7 The influence factor of the fear of hypoglycemia effect value Direct effect Indirect effect Total effect Self-pay -0.020 0.170 0.150 Age 0.200 0.216 0.416 Free medical service -0.090 — -0.090 Number of hypoglycemia 0.140 0.069 0.209 Self-care activities -0.160 — -0.16 Cognitive fusion 0.460 0.098 0.558 4. Discussion 4.1 Elderly patients with type 2 diabetes had FOH In this study, a total of 200 elderly patients with type 2 diabetes were investigated, and the total score of FOH was (25.81 ± 10.81), which was higher than Iranian scholar Fariba A [23] using the same scale. This may be related to the study subjects of elderly patients. The study showed that the top four factors that patients were most worried about were: when hypoglycemia occurs you are alone; no help; occurs during sleep; interferes with normal judgment. Huang SG [24] 's results were: in dizziness when hypoglycemia occurs; No help; when hypoglycemia occurs you are alone; occurs in public fainting. Golovchanova N et al [25] think older adults are more likely to feel anxious and fearful. There are similarities and differences between these studies and the results of this study, which may be related to the inconsistency of the study subjects and measurement tools. In summary, the FOH has been widespread, which not only affects the patient's physical and mental health and quality of life, but also impacts the mental health of their family [26, 27]. 4.2 Path analysis of influential factors of FOH in elderly patients with type 2 diabetes Age has direct and indirect effects on FOH: In this study, age was included as a positively correlated factor in a stepwise regression model. The older patients had a higher FOH, which was contrary to the results of Shi Min Ko M [28] and Huang SG [24]. This discrepancy may be related to differences in the study subjects, as the study subjects by these two scholars were mostly young people during their business period. The study by Sakane et al [29] is consistent with the results of this study. Elderly patients often suffer from multiple chronic diseases and have a relatively long medical history, so they usually use a combination of medications to control blood glucose, and the medications they use may have synergistic effects with hypoglycemic agents, increasing the risk of hypoglycemia [30, 31]. Moreover, organ function and anti-stress ability of the elderly decline with age, causing an increased susceptibility to hypoglycemia and, thus, a higher incidence of hypoglycemia [32]. Also, elderly people who have experienced hypoglycemia will be more aware of the FOH. In addition, when elderly adults struggle with chronic diseases (such as diabetes) for a long period of time, they are prone to negative emotions such as depression [33], anxiety [34] and fear [25], which can increase their psychological stress. Path analysis showd that age not only directly affected the FOH (path coefficient=0.20), but also indirectly through self-care activities. Healthcare professionals should pay more attention to the elderly who have experienced hypoglycemia, especially those with advanced age and in poor physical condition. Moffet HH et al [35] found that there is an inextricable link between hypoglycemia and falls in elderly patients with type 2 diabetes. When these elderly people fall due to hypoglycemia, the physical injuries and economic losses are more serious, which once again brings fear to the patient [36]. The frequency of hypoglycemia had direct and indirect effects on the FOH in elderly patients with type 2 diabetes: The results of this study demonstrate that the frequency of hypoglycemia can positively predict the severity of FOH in elderly patients with type 2 diabetes, which is consistent with the studies of scholars Nicolucci [37], Pang J [38], and Huang SG [24]. The frequency of hypoglycemia represents the condition of blood glucose control. As the number of hypoglycemia occurrences increases, the patient will think that his condition is aggravated, increasing their psychological burden. Additionally, high-frequency hypoglycemia can confuse patients and reduce their quality of life, similar to studies of patients with type 2 diabetes by scholar Shi LZ [39] and Rossi MC [40]. Path analysis showed that the frequency of hypoglycemia had a direct effect on the FOH (path coefficient=0.14) and also had an indirect effect on the FOH through cognitive fusion. It can be seen that the detection of blood glucose can effectively reduce the number of hypoglycemia occurrences and improve the negative emotions of patients. In future nursing processes, it is essential to effectively detect blood glucose and assess and intervene on negative emotions to effectively reduce the number of hypoglycemia and reduce the FOH [41]. Effect of medical payment methods on the FOH in elderly patients with type 2 diabetes: Research results indicate that the method of medical payment has a certain impact on the FOH, with both self-paying and public medical factors directly affecting this fear. Self-paying patients also have an indirect impact on the FOH through self-care activities and cognitive integration. Diabetes is a lifelong illness that requires long-term management. Most of the elderly in this study were already retired, with a single source of income. Compared to patients with medical insurance and self-paying, publicly-funded patients do not have to worry about medical expenses, which may result in the lowest FOH for them. Patients with medical insurance have relatively lower economic and psychological burdens compared to self-paying patients, which is consistent with a Chinese study of hospitalization costs for diabetic patients [42]. Some studies have shown that the medical payment method is an influential factor in controlling blood glucose in elderly patients with type 2 diabetes; the expenses for medical expenses, treatment fees, laboratory expenses, etc. have imposed significant financial burdens on self-paying patients [43]. Self-paying patients, due to limited financial conditions, sometimes lack access to comprehensive medical management, resulting in fear and anxiety. Healthcare professionals can promote standardized visits to help control blood glucose, alleviate negative emotions, and inform diabetes patients about medical insurance policies to encourage eligible diabetic patients to participate in medical insurance. Cognitive fusion and self-care activities have direct and mediating effects on FOH: For elderly patients with type 2 diabetes, cognitive fusion has a positive impact on the FOH. Consistent with the study by Chinese scholar Xu H et al [44], the higher the level of cognitive fusion, the more suffering diabetes patients experience. Some scholars believe that cognitive fusion can also affect medication adherence, leading to poor mental states in patients [45]. However, some scholars believe that only a small number of patients will have persistent adverse effects on cognitive function [46, 47]. Path analysis showed that cognitive fusion had a direct positive impact on the FOH (path coefficient=0.46), and it was also a mediating effect of age, self-paying, and the frequency of hypoglycemia affecting the FOH. This illustrates the importance of cognitive fusion for FOH. A study indicates that cognitive fusion is one of the difficulties for diabetic patients in managing diseases [48]. Mental health education and improved cognitive integration can improve management and reduce the FOH. In addition, path analyses showed that self-care activities had a mediating effect between age, self-payment, and FOH. Self-care activities had a direct negative effect on fear of hypoglycemia (path coefficient=-0.16). Studies have suggested that the level of self-management in patients with type 2 diabetes may be related to factors such as glycemic control, lack of knowledge, FOH etc [38, 49]. Because patients sometimes think the harm of hypoglycemia is higher than that of hyperglycemia, they will reduce the dose of hypoglycemic agents and insulin and eat excessive carbohydrates to avoid hypoglycemia. Nurses can provide patients with interventions such as blood glucose awareness training and cognitive-behavioral therapy to alleviate patients' fear and improve treatment outcomes of the disease. There are some limitations in this study. This study adopted a cross-sectional study, and the results may be affected by the participants' recall or reporting bias; The participants were not subjected to continuous dynamic observation; Due to the impact of time and funding, the participants in our study were from two hospitals of one city in China, therefore, may not be representative of all Chinese elderly participants with type 2 diabetes and not conducive to the promotion of the research results. Further expansion of the sampling scope and level is needed. 5. Conclusion Elderly population with type 2 diabetes commonly experience FOH. Participants are especially worried about hypoglycemia occurring when they are alone, without help, or during sleep. Age, frequency of hypoglycemia, self-care activities, and cognitive fusion have both direct and indirect effects on the FOH. In the future nursing process, in order to reduce the FOH and improve the quality of life, the following measures can be taken: effectively detect blood glucose, evaluate and intervene negative emotions, and control blood glucose; encourage qualified persons with diabetes to participate in medical insurance to make the treatment more comprehensive; choose interventions such as blood glucose awareness training or cognitive-behavioral therapy to improve the participants 's self-management level of the disease; provide participants with mental health education to improve their cognitive fusion levels, etc. Declarations Declarations Ethics approval and consent to participate: This study protocol received ethical approval from the Ethics Committee of Henan University (Approval No. HUSOM2024-259). We declare that the research was performed in accordance with relevant regulations and conformed to the provisions of the Declaration of Helsinki. Written informed consent was obtained from all participants prior to their inclusion in the study. Consent for publication: Not applicable. Competing interests: The authors declare that they have no competing interests. Funding: This research was supported by Henan Provincial Department of Science and Technology Key project (Grant NO. 232102311027). Author Contribution FLL: conception, design of the work, method and statistical analysis, revision of article. MW: data collection, analysis, interpretation of data and drafting the initial manuscript. LWZ: data collection, interpretation of data and revision of article. JPN: design of work, data collection, analysis, interpretation of data and revision of article. All authors reviewed the manuscript. Acknowledgements: We extend our sincere appreciation to all members that contributed to this research. Data Availability The datasets supporting the conclusions of this article are included within the article. References G MAW. 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Int J Nurs Pract. 2015, 21 Suppl 2: 115-24. doi: 10.1111/ijn.12388 Wild S, Roglic G, Green A, Sicree R, King H. Global Prevalence of Diabetes: Estimates for the Year 2000 and Projections for 2030. Diabetes Care. 2004, 27(5): 1047-1053. doi: 10.2337/diacare.27.5.1047 Cox DJ, Irvine A, Gonder-Frederick L, Nowacek G, Butterfield J. Fear of hypoglycemia: quantification, validation, and utilization. Diabetes Care. 1987, 10(5): 617-21. doi: 10.2337/diacare.10.5.617 Chun M 2015. Chinese version of hypoglycemic fear questionnaire revised and its application in patients with type 2 diabetes. Tianjin Medical University; 2015. Mu C, Bao D, Wang Mj, Xing QL. In patients with type 2 diabetes low blood sugar fear status and related factors of research. China Diabetes Journal. 2015, (4): 235-240. doi: 10.3761/j.issn.1672-9234.2018.07.012. Gillanders DT, Bolderston H, Bond FW, Dempster M, Flaxman PE, Campbell L, Kerr S, Tansey L, Noel P, Ferenbach C et al. The development and initial validation of the cognitive fusion questionnaire. Behav Ther. 2014, 45(1): 83-101. doi: 10.1016/j.beth.2013.09.001 Zhang WC JY, Li X. Cognitive fusion validity analysis questionnaire in Chinese letter. Chinese Mental Health Journal. 2014, 28(1): 40-44. Toobert DJ, Hampson SE, Glasgow RE. The summary of diabetes self-care activities measure: results from 7 studies and a revised scale. Diabetes Care. 2000, 23(7): 943-50. doi: 10.2337/diacare.23.7.943 Wolf EJ, Harrington KM, Clark SL, Miller MW. Sample Size Requirements for Structural Equation Models: An Evaluation of Power, Bias, and Solution Propriety. Educ Psychol Meas. 2013, 76(6): 913-934. doi: 10.1177/0013164413495237 Fariba A, Amerzadeh M, Banazadeh M, Rashidi S, Myaneh ZT. Fear of hypoglycemia and illness perception in type II diabetes patients. BMC Endocr Disord. 2024, 24(1): 24. doi: 10.1186/s12902-024-01548-x Huang S, Lu P, Zhang S, Ma X. Fear of Hypoglycemia in Patients with Type 2Diabetes Mellitusand Its Influencing Factors. Nursing Journal of Chinese People's Liberation Army. 2018, 35(7): 1-7. Golovchanova N, Evans B, Hellfeldt K, Andershed H, Boersma K. Older and feeling unsafe? Differences in underlying vulnerability, anxiety and life satisfaction among older adults. Aging Ment Health. 2023, 27(8): 1636-1643. doi: 10.1080/13607863.2023.2177255 Shi L, Shao H, Zhao Y, Thomas NA. Is hypoglycemia fear independently associated with health-related quality of life? Health Qual Life Outcomes. 2014, 12: 167. doi: 10.1186/s12955-014-0167-3 Turen S, Yilmazer RG. The relationship between fear of hypoglycemia and health-related quality of life in diabetic patients with heart disease. Eur Rev Med Pharmacol Sci. 2023, 27(4): 1592-1600. doi: 10.26355/eurrev_202302_31402 Shi Min Ko M, Kit Lee W, Chang Ang L, Goh SY, Mong Bee Y, Ming Teh M. A Cross-Sectional study on risk factors for severe hypoglycemia among Insulin-Treated elderly type 2 diabetes Mellitus (T2DM) patients in Singapore. Diabetes Res Clin Pract. 2022, 185: 109236. doi: 10.1016/j.diabres.2022.109236 Sakane N, Kotani K, Tsuzaki K, Nishi M, Takahashi K, Murata T, Yamada K, Okazaki K, Yanagisawa K, Yamada K et al. Fear of hypoglycemia and its determinants in insulin-treated patients with type 2 diabetes mellitus. J Diabetes Investig. 2015, 6(5): 567-70. doi: 10.1111/jdi.12340 Maines E, Urru SAM, Leonardi L, Fancellu E, Campomori A, Piccoli G, Maiorana A, Soffiati M, Franceschi R. Drug-induced hyperinsulinemic hypoglycemia: An update on pathophysiology and treatment. Rev Endocr Metab Disord. 2023, 24(6): 1031-1044. doi: 10.1007/s11154-023-09828-y Agrawal S, Makuch S, Dróżdż M, Dudzik T, Domański I, Poręba R, Mazur G. The Impact of Hypoglycemia on Patients with Diabetes Mellitus: A Cross-Sectional Analysis. J Clin Med. 2022, 11(3): 626. doi: 10.3390/jcm11030626 Aberdeen H, Battles K, Taylor A, Garner-Donald J, Davis-Wilson A, Rogers BT, Cavalier C, Williams ED. The Aging Vasculature: Glucose Tolerance, Hypoglycemia and the Role of the Serum Response Factor. J Cardiovasc Dev Dis. 2021, 8(5): 58. doi: 10.3390/jcdd8050058 Bai S, Wang J, Liu J, Miao Y, Zhang A, Zhang Z. Analysis of depression incidence and influence factors among middle-aged and elderly diabetic patients in China: based on CHARLS data. BMC Psychiatry. 2024, 24(1): 146. doi: 10.1186/s12888-023-05473-6 Lu X, Liu J, Tian L, Zhang Q. Research progress on the association of diabetes with anxiety and depression in the elderly. Chinese Journal of Geriatrics. 2023, 42(11): 1384-1388. Moffet HH, Liu JY, Parker MM, Lipska KJ, Laiteerapong N, Grant RW, Lee AK, Karter AJ. Severe hypoglycemia and falls in older adults with diabetes: The Diabetes & Aging Study. Diabet Epidemiol Manag. 2023, 12: 100162. doi: 10.1016/j.deman.2023.100162 Wei TS, Liu PT, Chang LW, Liu SY. Gait asymmetry, ankle spasticity, and depression as independent predictors of falls in ambulatory stroke patients. PLoS One. 2017, 12(5): e0177136. doi: 10.1371/journal.pone.0177136 Anarte MT, Carreira M, Machado A, Domínguez M, Tapia MJ, Valdés S, Ruiz de Adana MS, Soriguer F. Identification of risk factors for suffering fear of hypoglycemia in type 1 Diabetes Mellitus patients. Scand J Psychol. 2014, 55(6): 554-7. doi: 10.1111/sjop.12158 Pang J, Zhang L, Li XN, Sun FF, Qiu JH, Zhao YQ, Wang JP, Liu L, Wan XJ, Zhang Y. Identification of factors associated with fear of hypoglycemia using the capability, opportunity, motivation and behavior model in people with type 2 diabetes mellitus: a cross-sectional study. Acta Diabetologica. 2023, 60(10): 1405-1415. doi: 10.1007/s00592-023-02132-w Shi LZ, Fonseca V, Childs B. Economic burden of diabetes-related hypoglycemia on patients, payors, and employers. J Diabetes Complications. 2021, 35(6): 107916. doi: 10.1016/j.jdiacomp.2021.107916 Rossi MC, Nicolucci A, Ozzello A, Gentile S, Aglialoro A, Chiambretti A, Baccetti F, Gentile FM, Romeo F, Lucisano G et al. Impact of severe and symptomatic hypoglycemia on quality of life and fear of hypoglycemia in type 1 and type 2 diabetes. Results of the Hypos-1 observational study. Nutr Metab Cardiovasc Dis. 2019, 29(7): 736-743. doi: 10.1016/j.numecd.2019.04.009 Yang L, Fang L, Gao RH. Dynamic blood sugar monitoring to observe the incidence of hypoglycemia elderly diabetes patients and its influencing factors. Chinese Journal of Diabetes. 2016, 024(011): 986-989. Li X, Xu Z, Ji L, Guo L, Liu J, Feng K, Xu Y, Zhu D, Jia W, Ran X et al. Direct medical costs for patients with type 2 diabetes in 16 tertiary hospitals in urban China: A multicenter prospective cohort study. J Diabetes Investig. 2019, 10(2): 539-551. doi: 10.1111/jdi.12905 Boye KS, Bae JP, Thieu VT, Lage MJ. An Economic Evaluation of the Relationship Between Glycemic Control and Total Healthcare Costs for Adults with Type 2 Diabetes: Retrospective Cohort Study. Diabetes Ther. 2024, 15(2): 395-407. doi: 10.1007/s13300-023-01507-0 Xu H, Yu J, Ye M. Elderly patients with type 2 diabetes cognitive fusion evaluation research of psychological distress associated with diabetes. Occupation and Health. 2016, (8): 1073-1075. Li Ling, Zhang SS. Cognitive fusion in patients with coronary heart disease and treatment compliance correlation studies. Nursing Practice and Research. 2017, 14(16): 96-97. Strudwick SK CC, Gardiner J, Foster JK, Davis EA, Jones TW. Cognitive functioning in children with early onset type 1 diabetes and severe hypoglycemia. J Pediatr. 2005, 147: 680–685. doi: 10.1016/j.jpeds.2005.06.010 Zargar F, Monzavi P, Tarrahi MJ, Salehi SA. Medication Beliefs, Cognitive Defusion, and Valued Living in Hypertensive Patients with Varying Medication Adherence. ARYA Atheroscler. 2023, 19(1): 17-24. doi: 10.48305/arya.2022.11811.2471. Costa J A MJ, Pinto‐Gouveia J. Validation of the psychometric properties of cognitive fusion questionnaire. A study of the factorial validity and factorial invariance of the measure among osteoarticular disease, diabetes mellitus, obesity, depressive disorder, and general populations. Clin Psychol Psychother. 2017, 24(5): 1121-1129. doi: 10.1002/cpp.2077 Ji M, Ren D, Dunbar-Jacob J, Gary-Webb TL, Erlen JA. Self-Management Behaviors, Glycemic Control, and Metabolic Syndrome in Type 2 Diabetes. Nurs Res. 2020, 69(2): E9-E17. doi: 10.1097/NNR.0000000000000401 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7110540","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":501995716,"identity":"926d11c8-1363-48f6-b293-8923ce9131d2","order_by":0,"name":"Fangli Liu","email":"","orcid":"","institution":"Henan University","correspondingAuthor":false,"prefix":"","firstName":"Fangli","middleName":"","lastName":"Liu","suffix":""},{"id":501995719,"identity":"93ace7ad-bc6f-4523-ae31-cc54e16c51e7","order_by":1,"name":"Meng Wang","email":"","orcid":"","institution":"Universiti Putra Malaysia","correspondingAuthor":false,"prefix":"","firstName":"Meng","middleName":"","lastName":"Wang","suffix":""},{"id":501995720,"identity":"56809da3-2502-4f91-86c9-cadf0af58b86","order_by":2,"name":"Luwen Zhang","email":"","orcid":"","institution":"Henan University","correspondingAuthor":false,"prefix":"","firstName":"Luwen","middleName":"","lastName":"Zhang","suffix":""},{"id":501995721,"identity":"bfb5e368-469e-4745-a830-c7489f68ee1a","order_by":3,"name":"Jianpei Niu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA00lEQVRIiWNgGAWjYBACA3YeBsYGIIOxgfnAgQ8/iNHCDNfClnhwZg8pWhgYeIwPc7ARocWcmffwxxl/Ducxz+75cJiBh0GeX+wAfi2WzXwJhht40ooZ55zdcLjAgsFw5uwEAg47zGOQ+EDCJrFxRu6GwzN4GBIMbhOh5eADAwmglpwHh3nYiNNi2LghAWRLDgOxWviSGWccSEtsnHPMABjIEkT45Xjv4Y89fw4nbpzd/PjDhx828vzSBLTAgeEMMCVBpHIQkCdF8SgYBaNgFIwsAACs1kpJjj9zMwAAAABJRU5ErkJggg==","orcid":"","institution":"The Third People's Hospital of Zhengzhou","correspondingAuthor":true,"prefix":"","firstName":"Jianpei","middleName":"","lastName":"Niu","suffix":""}],"badges":[],"createdAt":"2025-07-13 01:08:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7110540/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7110540/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12912-025-04099-1","type":"published","date":"2025-11-21T15:58:48+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":89469323,"identity":"9e7179d0-ce45-4e56-9b1f-9ec666e12067","added_by":"auto","created_at":"2025-08-20 09:13:47","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":101646,"visible":true,"origin":"","legend":"\u003cp\u003epath factor model of the fear of hypoglycemia (FOH)\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7110540/v1/784408363e402a279aa1c470.png"},{"id":96651077,"identity":"e9229fc1-1006-4726-8aa4-0153bf0d183f","added_by":"auto","created_at":"2025-11-24 16:13:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1280045,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7110540/v1/7ccc9312-e128-48d3-bc53-8400ce51641b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Associations among fear of hypoglycemia, cognitive fusion and diabetes self- care activities in elderly patients with type 2 diabetes: a cross-sectional study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eDiabetes Mellitus (DM) is a chronically progressive disease that affects various organs and tissues of the body. Together with coronary heart disease and hypertension, it is called the three major killers of elderly health [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The International Diabetes Federation (IDF) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] reported in 2021 that the global diabetic population reached 537\u0026nbsp;million. It is predicted to reach 783\u0026nbsp;million in 2045 [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. At present, the number of diabetic patients in China has reached 117\u0026nbsp;million with an overall prevalence rate is 12.8%, and patients with type 2 diabetes account for more than 90% of the total [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Most DM patients in China are elderly, mainly exhibiting type 2 diabetes [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDiabetes patients are accompanied by an unavoidable risk of hypoglycemia while maintaining stable blood glucose levels. Compared with non-elderly patients, the relevant organs of elderly DM patients have been damaged to some extent and the complications of cardiovascular and cerebrovascular diseases are relatively more [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], which increases the likelihood of hypoglycemia. Hypoglycemia can also impose a severe psychological burden on patients, causing them to feel fear, which is especially apparent in the elderly. This fear of hypoglycemia (FOH), considered an underestimated issue in clinical care, is not only related to patients' negative psychological states but may also adversely affects disease management and metabolic control of DM patients [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In recent years, research on the fear of hypoglycemia has been focused on translations of different scale versions, and more research has been applied to patients with type 1 diabetes than to type 2 diabetes [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCognitive fusion, a key component of the Acceptance of Commitment Therapy (ACT) model of psychopathology, refers to the tendency for people's behaviors to be overly controlled by the laws of language and the content of their thoughts [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Specifically, individuals get caught up in their thoughts and have actions dominated by them, which leads to their immersion in negative thoughts, causing the creation and aggravation of negative emotions [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. At present, the relationship between cognitive fusion and mental health has attracted the attention of scholars. Relevant studies have shown that cognitive fusion is closely related to negative emotions such as anxiety, depression and post-traumatic stress disorder [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. FOH also belongs to a negative psychological state. But whether cognitive fusion affects the FOH is still unclear.\u003c/p\u003e\u003cp\u003eSelf-care for diabetic patients is key to the comprehensive management of diabetes, which is not only directly related to their health condition but also affects their quality of life and psychological status [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, to the best of our knowledge, the relationship between FOH, cognitive fusion, and self-care activities has not been explored. In addition, no researchers have explored whether cognitive fusion affects patients' FOH. In addition, most studies on FOH have focused on type 1 diabetes, with limited research on older patients with type 2 diabetes and on the specific factors through which FOH affects patients' health behaviors.\u003c/p\u003e\u003cp\u003eTherefore, the purpose of this study was to assess the status of FOH in elderly patients with type 2 diabetes, and to explore its influencing factors. We then analyzed the association between FOH, cognitive fusion and diabetes self-care activities by using path analysis. The findings of our research have the potential to provide a reference for improving patients' psychological well-being and quality of life.\u003c/p\u003e"},{"header":"2. Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003e2.1 Design\u003c/h2\u003e\n \u003cp\u003eThis survey was used in a cross-sectional design.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003e2.2 Participants\u003c/h2\u003e\n \u003cp\u003eIn this study, from April 2023 to January 2024, elderly patients with type 2 diabetes were selected from the endocrinology department of two hospitals in Zhengzhou, Henan.\u003c/p\u003e\n \u003cp\u003eInclusion criteria: ①age is greater than or equal to 60 years old [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e]; ②diagnosed as type 2 diabetes(4); ③experienced hypoglycemia in the past six months; ④can correctly answer questions and complete the required questionnaires independently or with the help of researchers; ⑤voluntary participation.\u003c/p\u003e\n \u003cp\u003eExclusion criteria: ①diabetic patients with other chronic diseases, such as primary liver and kidney disease;②diabetic patients with malignant tumors; ③people with mental illness.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003e2.3 Instruments\u003c/h2\u003e\n \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e\n \u003ch2\u003e2.3.1 General information questionnaire\u003c/h2\u003e\n \u003cp\u003eBy reviewing the literature and combining expert opinions, the researcher designed a questionnaire of socio-demographic and clinical characteristics, including: gender, age, occupation, education level, way of residence, marital status, medical payment method, monthly income per capita, family genetic history, blood sugar control, and the amount of hypoglycemia in a month.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e\n \u003ch2\u003e2.3.2 Fear of hypoglycemia\u003c/h2\u003e\n \u003cp\u003eFear of hypoglycemia was assessed using the CHFSII-WS. This scale is widely used in patients with type 2 diabetes and was initially discovered by Cox et al [\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e] in 1987 for determining the FOH levels of diabetic patients in the past six months. It contains behavior scale (HFSII-BS) and worry scale (HFSII-WS), with Cronbach\u0026apos;s \u0026alpha; coefficients of 0.85 and 0.94, respectively. In 2015, Mu C et al [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e] translated the English version of the scale into Chinese, and the Chinese version of the scale contains 13 items, with the internal consistency of 0.89. Each item uses the Likert 5 rating, ranging from 0 to 4 points, with \u0026quot;never\u0026thinsp;=\u0026thinsp;1 point, \u0026quot; \u0026quot;very few\u0026thinsp;=\u0026thinsp;2 points, \u0026quot; \u0026quot;sometimes\u0026thinsp;=\u0026thinsp;3 points, \u0026quot; \u0026quot;often\u0026thinsp;=\u0026thinsp;4 points, \u0026quot; and \u0026quot;always\u0026thinsp;=\u0026thinsp;5 points. \u0026quot; The total score ranges from 0 to 52 points; the higher score indicates the higher level of the FOH [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e\n \u003ch2\u003e2.3.3 Cognitive fusion\u003c/h2\u003e\n \u003cp\u003eCognitive fusion questionnaire (CFQ-F): In 2010, GillaIlders et al [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e] constructed a cognitive fusion questionnaire containing 13 items. In 2015, Zhang Weichen et al [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e] translated it into Chinese version. It contains a total of 9 items, representing 1ཞ7 for different levels, with the following scoring: \u0026quot;not at all =\u0026thinsp;1 point,\u0026quot; \u0026quot;does not meet\u0026thinsp;=\u0026thinsp;2 points,\u0026quot; \u0026quot;apparently does not meet\u0026thinsp;=\u0026thinsp;3 points,\u0026quot; \u0026quot;interposed between =\u0026thinsp;4 points,\u0026quot; \u0026quot;some match\u0026thinsp;=\u0026thinsp;5,\u0026quot; \u0026quot;conformity\u0026thinsp;=\u0026thinsp;6 points,\u0026quot; and \u0026quot;obvious match\u0026thinsp;=\u0026thinsp;7 points.\u0026quot; The higher the score, the higher the level of cognitive fusion. The Cronbach\u0026rsquo; \u0026alpha; was 0.92(20), demonstrating strong reliability and validity.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e\n \u003ch2\u003e2.3.4 Self-Care Activities\u003c/h2\u003e\n \u003cp\u003eSummary of Diabetes Self-Care Activities (SDSCA): More versions of the Self-Management Questionnaire for Diabetes. After reviewing the literature, the self-management questionnaire designed and widely used by Toobea et al [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e] was selected. This questionnaire contains 13 items across 6 dimensions, covering diet, exercise, medication, foot care, monitoring of blood sugar and smoking. The number of days spent on questionnaire-related activities in the past week as a score (except smoking). The higher the average score of the items contained in each subscale, the higher the level of self-management. The content validity index (CVI) is 1.00.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003e2.4 Data Collection\u003c/h2\u003e\n \u003cp\u003eThe data were collected from April 2023 to January 2024. Elderly type 2 diabetic patients admitted to the endocrinology department of two tertiary-grade hospitals in Henan Province were investigated.\u003c/p\u003e\n \u003cp\u003eWith the approval of the hospital and department heads, patients were screened rigorously according to the inclusion and exclusion criteria and the questionnaires were distributed in person by researchers. It was necessary to communicate with the patients before distribution, explaining the significance and research purpose of this survey and promising to keep the questionnaires confidential. After patients agreed to participate in the survey, they were required to sign an informed consent form. The filling time was controlled within 10ཞ15 minutes, and researchers ensured that the questionnaires were returned without error. According to Kendall\u0026rsquo;s [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e] sample size estimation method, this study approximated the number of questionnaire variables by 10 to 15 times and then considered about 20% of the loss rate and invalid questionnaires. The required sample size ranged from 160 to 240, with a total of 200 cases included in the study.\u003c/p\u003e\n \u003cp\u003eA total of 210 questionnaires were issued, and 200 valid questionnaires were collected, with an effective recovery rate of 95.2%.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003e2.5 Statistical analysis\u003c/h2\u003e\n \u003cp\u003eDatabase was established by Epidata 3.1, analyzed by SPSS 22.0 and AMOS 24.0. During the statistical description, the continuous data was first tested for normality. The normal data were described with frequencies, means, standard deviations, while the non-normal data were described with median and quartile. The data following a normal distribution were used for independent-samples T test and analysis of variance, while the non-normal distribution data and grade data were used for rank sum test. The multiple linear regression analysis was carried out to explore its influencing factors. AMOS24.0 was used for structural model analysis.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003e\u003cstrong\u003e3.1 Participants Characteristics\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study investigated 200 elderly patients with type 2 diabetes, including 104 males (64.4%) and 96 females (48.0%). The average age was (71.56\u0026nbsp;\u0026plusmn;\u0026nbsp;8.19)\u0026nbsp;years old, with the minimum age was 60 years, and the maximum age was 92 years. Of the participants, 77.0% are married and 23.0% are without spouse; education level is 30.0% with elementary school and below, 21.0% with junior high school, 31.5% with high school or junior college, 17.5% with college and above. In monthly income per capita, 48.5% of the patients had more than 2,000 yuan, 14.5% had less than 1,000 yuan, and 37.0% had between 1,000 and 2,000 yuan. (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e General information on elderly patients with type 2 diabetes (\u003cem\u003en\u003c/em\u003e=200)\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"662\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eProject\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 255px;\"\u003e\n \u003cp\u003eClassification\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eProportion（﹪）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e60～70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e49.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e70～80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e34.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e\u0026ge;81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e16.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e104\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e52.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e48.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eMarital status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e77.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eNo spouse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e154\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e23.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eEducation level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eElementary school and below\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e30.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eJunior high school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e21.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eHigh school or technical secondary school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e31.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eCollege and above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e17.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eMedical payment method\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eSelf-pay\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e7.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eFree medical service\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eMedical insurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e176\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e88.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eMonthly income per capita\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e\u0026lt;1000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e14.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e1000～2000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e37.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e\u0026gt;2000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e48.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eWorking condition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eOn duty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e14.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eOff duty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e172\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e86.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eMedical payment method\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eAt your own expense\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e7.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003ePublic expense\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eMedical insurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e176\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e88.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003e3.2 Status of FOH in elderly patients with type 2 diabetes\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis survey involved a total of 200 elderly patients with type 2 diabetes. The items of the FOH scale were summed up. The minimum score was 3 points and the highest was 49 points. The results of this study show that the total score of FOH (25.81\u0026nbsp;\u0026plusmn;\u0026nbsp;10.81), indicating patients had a moderate degree of FOH. The scores of each item on the scale were ranked (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u0026nbsp;\u003c/strong\u003eThe fear of hypoglycemia score in elderly patients with type 2 diabetes (\u003cem\u003en\u003c/em\u003e=200)\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"643\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 425px;\"\u003e\n \u003cp\u003eProject\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e（\u003cimg width=\"35\" height=\"23\" src=\"data:image/wmf;base64,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\" alt=\"image\"\u003e）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eSequence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 425px;\"\u003e\n \u003cp\u003eHypoglycemia alone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e2.69 \u0026plusmn; 0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 425px;\"\u003e\n \u003cp\u003eNo one helps when hypoglycemia occurs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e2.64 \u0026plusmn; 1.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 425px;\"\u003e\n \u003cp\u003eHypoglycemia during sleep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e2.57 \u0026plusmn; 1.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 425px;\"\u003e\n \u003cp\u003eHypoglycemia affects normal judgment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e2.44 \u0026plusmn; 1.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 425px;\"\u003e\n \u003cp\u003eHypoglycemia in social situations embarrassing yourself and others\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e2.41 \u0026plusmn; 1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 425px;\"\u003e\n \u003cp\u003eDidn\u0026apos;t realize when you had hypoglycemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e2.27 \u0026plusmn; 1.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 425px;\"\u003e\n \u003cp\u003eReceive bad reviews from others\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e2.08 \u0026plusmn; 1.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 425px;\"\u003e\n \u003cp\u003eStupid or drunk when hypoglycemia occurs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e1.57 \u0026plusmn; 1.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 425px;\"\u003e\n \u003cp\u003eNegligence or accident\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e1.50 \u0026plusmn; 1.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 425px;\"\u003e\n \u003cp\u003eOut of control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e1.40 \u0026plusmn; 1.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 425px;\"\u003e\n \u003cp\u003eFainting from hypoglycemia in public\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e1.24 \u0026plusmn; 1.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 425px;\"\u003e\n \u003cp\u003eHurt yourself or others\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e1.23 \u0026plusmn; 0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 425px;\"\u003e\n \u003cp\u003eCause permanent harm to one\u0026apos;s health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e0.84 \u0026plusmn; 0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 425px;\"\u003e\n \u003cp\u003eTotal score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e25.81 \u0026plusmn; 10.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.3 Single factor of FOH in elderly type 2 diabetic patients\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSingle factor analysis showed that there were statistically significant differences in the FOH among patients with different age(F=15.837, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001), genders(F=-2.204, \u003cem\u003eP\u003c/em\u003e=0.029), medical payment methods(F=15.067, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001), years of diabetes(F=5.353, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001), exercise(F=3.218, \u003cem\u003eP\u003c/em\u003e=0.042), blood glucose stability (F=6.382,P=0.002), and frequency of hypoglycemia (F=12.626, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001) (Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e Analysis of the effects of the fear of hypoglycemia on participants with different demographic characteristics (\u003cem\u003en\u003c/em\u003e=200)\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"643\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eProject\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eClassification\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eFOH ( \u003cimg width=\"35\" height=\"19\" src=\"data:image/wmf;base64,iVBORw0KGgoAAAANSUhEUgAAACMAAAATCAYAAAAao7T0AAAAAXNSR0ICQMB9xQAAAAlwSFlzAAAOxAAADsQBlSsOGwAAABl0RVh0U29mdHdhcmUATWljcm9zb2Z0IE9mZmljZX/tNXEAAAEcSURBVEjH7ZVBisJAEEXrAF5AsJYeQIssdSWhEA+gKVyNuJIC8QBldtnMIbyHJ/AGs/AGuYNOIy1N4oSMZgYXWXxIuvm/X1dVCKRpCu+itwFpYf4cZi80w3iza2H+BcaFAsDFiWQ/c2umPBginKDHx3WWdV6BSQg/fb5T0VMyZNm6kxAc3OGqkxGLTsuh3/tB6ENRcgg97lII+MVqA3cG9+DoL1zZJl8hZLGm2hTCuHeNaeWfK2HMll0COBfJX52ZTYw7AMyLELVgiqVuYoBvQHRemnVrwQjzhzDaT6bfwgiR+ZyqqpeMKtGcFzYOeywRb+tAPZIfVg97y4W8Esb3MxKdhyGAw9NCrf/s13Rv+X0Pc4p11f4oW5gmdAWsTMxAe6O8LgAAAABJRU5ErkJggg==\" alt=\"image\"\u003e\u0026nbsp;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cem\u003et/F\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e60～70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e21.09 \u0026plusmn; 11.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e23.152\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e71～80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e29.87 \u0026plusmn; 7.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026ge;81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e31.63 \u0026plusmn; 7.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e104\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e24.20 \u0026plusmn; 10.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-2.204\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.029\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e27.54 \u0026plusmn; 10.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eMedical Payment Method\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eSelf-pay\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e39.07 \u0026plusmn; 5.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e15.067\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eFree medical service\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e19.78 \u0026plusmn; 13.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eMedical insurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e176\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e24.98 \u0026plusmn; 10.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eDiabetes Years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026le; 10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e22.86 \u0026plusmn; 11.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e5.353\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e11 \u0026lt; year \u0026lt; 20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e26.12 \u0026plusmn; 10.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026ge; 20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e28.40 \u0026plusmn; 9.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eExercise Situation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eNo exercise\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e27.76 \u0026plusmn; 9.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e3.218\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.042\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eMild exercise\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e138\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e25.68 \u0026plusmn; 11.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eModerate exercise\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e19.08 \u0026plusmn; 11.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eBlood Glucose Stability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eUnstable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e147\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e26.78 \u0026plusmn; 10.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e6.382\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eMore stable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e25.81 \u0026plusmn; 10.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eVery stable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e16.88 \u0026plusmn; 11.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eThe number of hypoglycemia occurrences in the past month\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e0 times\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e22.11 \u0026plusmn; 12.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e12.626\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e1～2 times\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e23.26 \u0026plusmn; 10.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e3～4 times\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e30.00 \u0026plusmn; 8.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026ge; 5 times\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e35.14 \u0026plusmn; 7.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.4 Status of cognitive integration and self-care activities in elderly patients with type 2 diabetes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe average score of cognitive fusion was (35.35\u0026nbsp;\u0026plusmn;\u0026nbsp;10.07), which was higher than the domestic norm. The average score of self-care activities was (3.35\u0026nbsp;\u0026plusmn;\u0026nbsp;1.18), and the lowest score was foot care (Table4).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e Elderly participants with type 2 diabetes self-care activities behavior and its each dimension score (\u003cem\u003en\u003c/em\u003e=200)\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"643\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eProject\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eDimension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eMin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eMax\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e（\u003cimg width=\"35\" height=\"23\" src=\"data:image/wmf;base64,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\" alt=\"image\"\u003e）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eSelf-care activities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e1.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e5.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e3.35\u0026nbsp;\u0026plusmn;\u0026nbsp;1.18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eDiet\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e3.32\u0026nbsp;\u0026plusmn;\u0026nbsp;1.38\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eSport\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e3.39\u0026nbsp;\u0026plusmn;\u0026nbsp;1.91\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eBlood glucose monitoring\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e3.08\u0026nbsp;\u0026plusmn;\u0026nbsp;2.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eMedical care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e4.64\u0026nbsp;\u0026plusmn;\u0026nbsp;1.68\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eFoot care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e2.44\u0026nbsp;\u0026plusmn;\u0026nbsp;1.46\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eSmoking (branch)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e9.28\u0026nbsp;\u0026plusmn;\u0026nbsp;9.59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.5 Correlation analysis of FOH, cognitive fusion and self-care activities in elderly type 2 diabetic patients\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe result of Pearson correlation analysis shows that a significant positive correlation between FOH and cognitive fusion (r=0.704, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.01); and a significant negative correlation between FOH and self-care activities (r=0.588, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.01) (Table 5).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5\u003c/strong\u003e Correlation analysis of the fear of hypoglycemia, cognitive fusion and self-care activities in participants (n=200)\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"643\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eProject\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 179px;\"\u003e\n \u003cp\u003eFear of hypoglycemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eCognitive fusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eSelf-care activities\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eFOH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 179px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eCognitive fusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 179px;\"\u003e\n \u003cp\u003e0.704**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eSelf-care activities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 179px;\"\u003e\n \u003cp\u003e-0.485**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e-0.577**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eNote:*\u003cem\u003eP\u003c/em\u003e＜0.05;** \u003cem\u003eP\u003c/em\u003e＜0.01\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.6 Multivariate analysis of the impact of FOH in elderly patients with type 2 diabetes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this study, FOH in elderly patients with type 2 diabetes was taken as the dependent variable, and the variable with statistical significance (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05) in single results of factor analysis was used as independent variable. The multivariate stepwise regression analysis was performed. The assignment method was as follows. Gender: male=1, female=2; Exercise situation: no exercise=1, mild exercise=2, moderate exercise=3; Blood glucose control situation: not good=1, general=2, good=3; The number of hypoglycemia occurrences in the past month:0 times=1, 1 to 2 times=2, 3 to 4 times=3, \u0026gt;5 times=4; Medical payment method: self-pay = 0,\u0026nbsp;Free medical service=0, medical insurance=1; self-pay=0, Free medical service=1, medical insurance=0; self-pay=1,\u0026nbsp;free medical service=0, medical insurance=0. Age, number of years of diabetes, cognitive integration and self-care activities scores were all included in the equation with the original values (Table 6).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6\u003c/strong\u003e The fear of hypoglycemia and multiple stepwise regression analysis of their respective variables\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"652\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eModel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eStd.Error\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eBeta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003et\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eConstant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e-8.384\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e5.646\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e-1.507\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.134\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.214\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.069\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.162\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e3.095\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eTime\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e1.962\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.619\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.160\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e3.169\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eFree medical service\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e-5.670\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e2.325\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e-0.115\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e-2.439\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.016\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eOwn expense\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e6.713\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e2.316\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.142\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e2.899\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eCognitive fusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.515\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.068\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.480\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e7.613\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eSelf-care activities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e-1.132\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.525\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.123\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e-2.156\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.032\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eNote：\u003cem\u003eF\u003c/em\u003e =44.889, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001; \u003cem\u003eR\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e=0. 583, \u003cem\u003eAdjusted R\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e=0.570\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.7 Path analysis of POH in elderly patients with type 2 diabetes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn order to further clarify the functional models between FOH and age, the number of hypoglycemia, the free medical service, self-pay, cognitive fusion, self-care activities, a preliminary path analysis model was established. The study model demonstrated a satisfactory fit, X\u003csup\u003e2\u003c/sup\u003e=0.946,\u003cem\u003ep\u003c/em\u003e=0.814(P\u0026gt;0.05), X\u003csup\u003e2\u003c/sup\u003e/df=0.315(X\u003csup\u003e2\u003c/sup\u003e/df\u0026lt;2), GFI=0.999(GFI\u0026gt;0.90), AGFI=0.987(AGFI\u0026gt;0.90), NFI=0.997(NFI=\u0026gt;0.90), IFI=0.980(IFI\u0026gt;0.90), TLI=0.920(TLI\u0026gt;0.90), CFI=0.989(CFI\u0026gt;0.90), RMSEA=0.006(RMSEA\u0026lt;0.08). The analysis model showed that age, the number of hypoglycemia, self-care activities, and cognitive fusion had an indirect effect on the FOH. At the same time, age, the number of hypoglycemia, self-care activities, and cognitive fusion had a direct effect on the FOH (Figure 1, Table 7).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 7\u0026nbsp;\u003c/strong\u003eThe influence factor of the fear of hypoglycemia effect value\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"643\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eDirect effect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eIndirect effect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eTotal effect\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eSelf-pay\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e-0.020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e0.170\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e0.150\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e0.200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e0.216\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e0.416\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eFree medical service\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e-0.090\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e-0.090\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eNumber of hypoglycemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e0.140\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e0.069\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e0.209\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eSelf-care activities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e-0.160\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e-0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eCognitive fusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e0.460\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e0.098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e0.558\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003e\u003cstrong\u003e4.1 Elderly patients with type 2 diabetes had FOH\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this study,\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ea total of 200 elderly patients with type 2 diabetes were investigated, and the total score of FOH was (25.81\u0026nbsp;\u0026plusmn;\u0026nbsp;10.81), which was higher than Iranian scholar Fariba A [23] using the same scale. This may be related to the study subjects of elderly patients. The study showed that the top four factors that patients were most worried about were: when hypoglycemia occurs you are alone; no help; occurs during sleep; interferes with normal judgment. Huang SG [24]\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u0026apos;s\u003csup\u003e\u0026nbsp;\u003c/sup\u003eresults were: in dizziness when hypoglycemia occurs; No help; when hypoglycemia occurs you are alone; occurs in public fainting. Golovchanova N et al [25] think older adults are more likely to feel anxious and fearful. There are similarities and differences between these studies and the results of this study, which may be related to the inconsistency of the study subjects and measurement tools. In summary, the FOH has been widespread, which not only affects the patient\u0026apos;s physical and mental health and quality of life, but also impacts the mental health of their family [26, 27].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.2 Path analysis of influential factors of FOH in elderly patients with type 2 diabetes\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAge has direct and indirect effects on FOH:\u0026nbsp;\u003c/strong\u003eIn this study, age was included as a positively correlated factor in a stepwise regression model. The older patients had a higher FOH, which was contrary to the results of Shi Min Ko M [28] and Huang SG [24]. This discrepancy may be related to differences in the study subjects, as the study subjects by these two scholars were mostly young people during their business period. The study by Sakane et al [29] is consistent with the results of this study. Elderly patients often suffer from multiple chronic diseases and have a relatively long medical history, so they usually use a combination of medications to control blood glucose, and the medications they use may have synergistic effects with hypoglycemic agents, increasing the risk of hypoglycemia [30, 31]. Moreover, organ function and anti-stress ability of the elderly decline with age, causing an increased susceptibility to hypoglycemia and, thus, a higher incidence of hypoglycemia [32]. Also, elderly people who have experienced hypoglycemia will be more aware of the FOH. In addition, when elderly adults struggle with chronic diseases (such as diabetes) for a long\u0026nbsp;period of time, they are prone to negative emotions such as depression [33], anxiety [34] and fear [25], which can increase their psychological stress. Path analysis showd that age not only directly affected the FOH (path coefficient=0.20), but also indirectly through self-care activities. Healthcare professionals should pay more attention to the elderly who have experienced hypoglycemia, especially those with advanced age and in poor physical condition. Moffet HH et al [35] found that there is an inextricable link between hypoglycemia and falls in elderly patients with type 2 diabetes. When these elderly people fall due to hypoglycemia, the physical injuries and economic losses are more serious, which once again brings fear to the patient [36].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe frequency of hypoglycemia had direct and indirect effects on the FOH in elderly patients with type 2 diabetes:\u0026nbsp;\u003c/strong\u003eThe results of this study demonstrate that the frequency of hypoglycemia can positively predict the severity of FOH in elderly patients with type 2 diabetes, which is consistent with the studies of scholars Nicolucci [37], Pang J [38], and Huang SG [24]. The frequency of hypoglycemia represents the condition of blood glucose control. As the number of hypoglycemia occurrences increases, the patient will think that his condition is aggravated, increasing their psychological burden. Additionally, high-frequency hypoglycemia can confuse patients and reduce their quality of life, similar to studies of patients with type 2 diabetes by scholar Shi LZ [39] and Rossi MC [40]. Path analysis showed that the frequency of hypoglycemia had a direct effect on the FOH (path coefficient=0.14) and also had an indirect effect on the FOH through cognitive fusion. It can be seen that the detection of blood glucose can effectively reduce the number of hypoglycemia occurrences and improve the negative emotions of patients. In future nursing processes, it is essential to effectively detect blood glucose and assess and intervene on negative emotions to effectively reduce the number of hypoglycemia and reduce the FOH [41].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEffect of medical payment methods on the FOH in elderly patients with type 2 diabetes:\u0026nbsp;\u003c/strong\u003eResearch results indicate that the method of medical payment has a certain impact on the FOH, with both self-paying and public medical factors directly affecting this fear. Self-paying patients also have an indirect impact on the FOH through self-care activities and cognitive integration. Diabetes is a lifelong illness that requires long-term management. Most of the elderly in this study were already retired, with a single source of income. Compared to patients with medical insurance and self-paying, publicly-funded patients do not have to worry about medical expenses, which may result in the lowest FOH for them. Patients with medical insurance have relatively lower economic and psychological burdens compared to self-paying patients, which is consistent with a Chinese study of hospitalization costs for diabetic patients [42]. Some studies have shown that the medical payment method is an influential factor in controlling blood glucose in elderly patients with type 2 diabetes; the expenses for medical expenses, treatment fees, laboratory expenses, etc. have imposed significant financial burdens on self-paying patients [43]. Self-paying patients, due to limited financial conditions, sometimes lack access to comprehensive medical management, resulting in fear and anxiety. Healthcare professionals can promote standardized visits to help control blood glucose, alleviate negative emotions, and inform diabetes patients about medical insurance policies to encourage eligible diabetic patients to participate in medical insurance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCognitive fusion and self-care activities have direct and mediating effects on FOH:\u0026nbsp;\u003c/strong\u003eFor elderly patients with type 2 diabetes, cognitive fusion has a positive impact on the FOH. Consistent with the study by Chinese scholar Xu H et al [44], the higher the level of cognitive fusion, the more suffering diabetes patients experience. Some scholars believe that cognitive fusion can also affect medication adherence, leading to poor mental states in patients [45]. However, some scholars believe that only a small number of patients will have persistent adverse effects on cognitive function [46, 47]. Path analysis showed that cognitive fusion had a direct positive impact on the FOH (path coefficient=0.46), and it was also a mediating effect of age, self-paying, and the frequency of hypoglycemia affecting the FOH. This illustrates the importance of cognitive fusion for FOH. A study indicates that cognitive fusion is one of the difficulties\u0026nbsp;for diabetic patients in managing diseases [48]. Mental health education and improved cognitive integration can improve management and reduce the FOH. In addition, path analyses showed that self-care activities had a mediating effect between age, self-payment, and FOH. Self-care activities had a direct negative effect on fear of hypoglycemia (path coefficient=-0.16). Studies have suggested that the level of self-management in patients with type 2 diabetes may be related to factors such as glycemic control, lack of knowledge, FOH etc [38, 49]. Because patients sometimes think the harm of hypoglycemia is higher than that of hyperglycemia, they will reduce the dose of hypoglycemic agents and insulin and eat excessive carbohydrates to avoid hypoglycemia. Nurses can provide patients with interventions such as blood glucose awareness training and cognitive-behavioral therapy to alleviate patients\u0026apos; fear and improve treatment outcomes of the disease.\u003c/p\u003e\n\u003cp\u003eThere are some limitations in this study. This study adopted a cross-sectional study, and the results may be affected by the participants\u0026apos; recall or reporting bias; The participants were not subjected to continuous dynamic observation; Due to the impact of time and funding, the participants in our study were from two hospitals of one city in China, therefore, may not be representative of all Chinese elderly participants with type 2 diabetes and not conducive to the promotion of the research results. Further expansion of the sampling scope and level is needed.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eElderly population with type 2 diabetes commonly experience FOH. Participants are especially worried about hypoglycemia occurring when they are alone, without help, or during sleep. Age, frequency of hypoglycemia, self-care activities, and cognitive fusion have both direct and indirect effects on the FOH. In the future nursing process, in order to reduce the FOH and improve the quality of life, the following measures can be taken: effectively detect blood glucose, evaluate and intervene negative emotions, and control blood glucose; encourage qualified persons with diabetes to participate in medical insurance to make the treatment more comprehensive; choose interventions such as blood glucose awareness training or cognitive-behavioral therapy to improve the participants 's self-management level of the disease; provide participants with mental health education to improve their cognitive fusion levels, etc.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eDeclarations\u003c/h2\u003e\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003cp\u003e This study protocol received ethical approval from the Ethics Committee of Henan University (Approval No. HUSOM2024-259). We declare that the research was performed in accordance with relevant regulations and conformed to the provisions of the Declaration of Helsinki. Written informed consent was obtained from all participants prior to their inclusion in the study.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e\u003cp\u003eThis research was supported by Henan Provincial Department of Science and Technology Key project (Grant NO. 232102311027).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eFLL: conception, design of the work, method and statistical analysis, revision of article. MW: data collection, analysis, interpretation of data and drafting the initial manuscript. LWZ: data collection, interpretation of data and revision of article. JPN: design of work, data collection, analysis, interpretation of data and revision of article. All authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements:\u003c/h2\u003e\u003cp\u003eWe extend our sincere appreciation to all members that contributed to this research.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets supporting the conclusions of this article are included within the article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eG MAW. The global burden of disease study and Population Health Metrics. Popul Health Metr. 2024, 22(1): 35. 10.1186/s12963-024-00357-7.\u003c/li\u003e\n\u003cli\u003eMagliano DJ, Boyko EJ; IDF Diabetes Atlas 10th edition scientific committee. IDF DIABETES ATLAS [Internet]. 10th ed. 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J Diabetes Investig. 2019, 10(2): 539-551. doi: 10.1111/jdi.12905\u003c/li\u003e\n\u003cli\u003eBoye KS, Bae JP, Thieu VT, Lage MJ. An Economic Evaluation of the Relationship Between Glycemic Control and Total Healthcare Costs for Adults with Type 2 Diabetes: Retrospective Cohort Study. Diabetes Ther. 2024, 15(2): 395-407. doi: 10.1007/s13300-023-01507-0\u003c/li\u003e\n\u003cli\u003eXu H, Yu J, Ye M. Elderly patients with type 2 diabetes cognitive fusion evaluation research of psychological distress associated with diabetes. Occupation and Health. 2016, (8): 1073-1075. \u003c/li\u003e\n\u003cli\u003eLi Ling, Zhang SS. Cognitive fusion in patients with coronary heart disease and treatment compliance correlation studies. Nursing Practice and Research. 2017, 14(16): 96-97. \u003c/li\u003e\n\u003cli\u003eStrudwick SK CC, Gardiner J, Foster JK, Davis EA, Jones TW. Cognitive functioning in children with early onset type 1 diabetes and severe hypoglycemia. J Pediatr. 2005, 147: 680\u0026ndash;685. doi: 10.1016/j.jpeds.2005.06.010\u003c/li\u003e\n\u003cli\u003eZargar F, Monzavi P, Tarrahi MJ, Salehi SA. Medication Beliefs, Cognitive Defusion, and Valued Living in Hypertensive Patients with Varying Medication Adherence. ARYA Atheroscler. 2023, 19(1): 17-24. doi: 10.48305/arya.2022.11811.2471.\u003c/li\u003e\n\u003cli\u003eCosta J A MJ, Pinto‐Gouveia J. Validation of the psychometric properties of cognitive fusion questionnaire. A study of the factorial validity and factorial invariance of the measure among osteoarticular disease, diabetes mellitus, obesity, depressive disorder, and general populations. Clin Psychol Psychother. 2017, 24(5): 1121-1129. doi: 10.1002/cpp.2077\u003c/li\u003e\n\u003cli\u003eJi M, Ren D, Dunbar-Jacob J, Gary-Webb TL, Erlen JA. Self-Management Behaviors, Glycemic Control, and Metabolic Syndrome in Type 2 Diabetes. Nurs Res. 2020, 69(2): E9-E17. doi: 10.1097/NNR.0000000000000401\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Type 2 diabetes, Fear of hypoglycemia, Cognitive fusion, Self-care, Elderly people, Path analysis","lastPublishedDoi":"10.21203/rs.3.rs-7110540/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7110540/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eFear of hypoglycemia (FOH), considered an underestimated issue in clinical care, is not only related to patients' negative psychological states but also adversely affects the metabolic control of diabetes patients. This study aims to investigate the current status and influencing factors of FOH in elderly patients with type 2 diabetes, and to examine its relationships with cognitive fusion and self-care activities using structural equation modeling.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis study adopts a cross-sectional design. From November 2023 to October 2024, elderly patients with type 2 diabetes admitted to the endocrinology department of two tertiary hospitals in Zhengzhou were selected as subjects. The research tools are general data questionnaires, cognitive fusion questionnaire (CFQ-F), the Chinese Version Hypoglycemia Fear Survey II-Worry Scale (CHFSII-WS), and the Summary of Diabetes Self-Care Activities (SDSCA). Data entry was performed using Epidata 3.1, statistical analysis was performed on SPSS 20.0, and structural model analysis was performed on AMOS 24.0.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eA total of 200 elderly patients with type 2 diabetes were included in this study. The total score of FOH in elderly patients with type 2 diabetes was (25.81\u0026thinsp;\u0026plusmn;\u0026thinsp;10.81). Age, the number of hypoglycemia, medical payment methods (free medical service/own expense), cognitive fusion and self-care activities were the influencing factors of FOH (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The path factor model showed that age, the number of hypoglycemia, self-pay, self-management, and cognitive fusion had an indirect effect on the FOH. At the same time, age, the number of hypoglycemia, free medical service, self-management, and cognitive fusion had a direct effect on the FOH.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eElderly patients with type 2 diabetes often experience FOH, which is influenced by multiple factors such as the disease, cognitive fusion, and self-care. Healthcare professionals should balance glycemic targets with patients' psychological burden, avoiding excessive prevention of hypoglycemia that may heighten anxiety.\u003c/p\u003e","manuscriptTitle":"Associations among fear of hypoglycemia, cognitive fusion and diabetes self- care activities in elderly patients with type 2 diabetes: a cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-20 09:13:42","doi":"10.21203/rs.3.rs-7110540/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-22T06:46:38+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-20T10:51:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"265433355940583971575176236456818674382","date":"2025-08-17T13:28:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"21012514162598270358716555774439428799","date":"2025-08-17T08:57:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"236744072567923372320372939060308224260","date":"2025-08-15T02:47:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"80134320757681309936559544369568979610","date":"2025-08-14T06:59:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"56142037065954632373198480719195683709","date":"2025-08-14T06:54:42+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-13T12:42:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"111139075873105096991139257715006685284","date":"2025-08-13T04:57:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"49178323127783578029857510865921211692","date":"2025-08-12T12:11:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"229165264211054587556824022099593031506","date":"2025-08-12T08:46:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"26053618863718463665216908913425859815","date":"2025-08-12T07:54:00+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-12T06:43:41+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-21T04:41:40+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-18T01:14:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2025-07-18T00:59:31+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"395465ca-55e1-4a2b-8bb8-fb0bafdf55bb","owner":[],"postedDate":"August 20th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-24T16:11:57+00:00","versionOfRecord":{"articleIdentity":"rs-7110540","link":"https://doi.org/10.1186/s12912-025-04099-1","journal":{"identity":"bmc-nursing","isVorOnly":false,"title":"BMC Nursing"},"publishedOn":"2025-11-21 15:58:48","publishedOnDateReadable":"November 21st, 2025"},"versionCreatedAt":"2025-08-20 09:13:42","video":"","vorDoi":"10.1186/s12912-025-04099-1","vorDoiUrl":"https://doi.org/10.1186/s12912-025-04099-1","workflowStages":[]},"version":"v1","identity":"rs-7110540","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7110540","identity":"rs-7110540","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}