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LIVED EXPERIENCE OF MIDDLE-AGED WOMEN WITH TYPE 2 DIABETES MELLITUS IN OZAMIZ CITY

A Research Paper
Presented to the
Faculty of the College of Nursing and School of Midwifery
Misamis University
Ozamiz City

In Partial Fulfillment
Of the Requirement for the Degree
Bachelor of Science in Nursing

by
GRANT ROBERT LABASTIDA
MERYJEAN MIRO
ANNA MARGARETT B. MUTIA
October 2013
Chapter 1
THE PROBLEM

Background of the Study Filipino people love holidays, where they can partake freely on foods without thinking on the immediate threats to their health. In a moment of weakness or in the face of temptations, could cause a dramatic downward spiral in overall health, resulting in both short-term and long-term complications. For young and adults information, Diabetes Mellitus has increased widely, approximately 360 million people were affected in the year 2011 and it was thought that half of them were unaware that they have this diagnosis (ESC Guidelines, 2011). Diabetes Mellitus is a chronic medical condition that stems from the body’s inability to sufficiently produce or properly use insulin, a hormone that is necessary for the appropriate use of glucose as a source of energy for the body. Without insulin, glucose cannot enter cells in the peripheral tissue and becomes trapped in the bloodstream, leading to elevated blood glucose levels or hyperglycemia. Over time, chronic hyperglycemia can lead to life-threatening and debilitating complications such as heart disease, kidney failure, and blindness (Silverthron, 2001) at present there is still no profound remedy to such condition. For now, these individuals must rely upon a strict regimen of antidiabetic medication, daily insulin injections, controlled diet, exercise and close monitoring of blood glucose levels in order to lead a relatively normal life.
Diabetic patients are having difficulty in functioning on their daily lives. In the verge of hunger, they won’t be able to control their food consumption and this might lead to eating disorders. Some will become overly conscious about their blood glucose level that they would tend to abstain from eating or worse. People who are diabetic commonly experience the 3P’s; polyphagia (excessive hunger), polyuria (excessive urination) and polydypsia (excessive thirst) which are very incommoding. These individuals may develop depression and low-self-esteem; it is because of the fact that they know that their health are deviating from the normal function. Not only adults are being affected by this disease, children and adolescents are no exemption. Adolescent and children might think that they are different from others as they have been always being reprimanded about their eating habits and to always control their food consumption. As a result serious complications might arise such as cardiovascular disease, chronic renal failure, and diabetic retinopathy (WHO, 1999) and these debilitating complications might lead to organ failure and death. However, many researchers nowadays are concerned about this disease because of its hereditary trait; they are still searching for possible cure even with the availability of regimens and management that may be used as a treatment to lessen their discomfort.
It is for this reason that the researcher will look into the lived experiences of diabetic patients to understand

Review of Related Literature and Studies This study was anchored by the theory of Bury’s (1982) notion of Chronic Illness as a biographical disruption along with Paterson’s (2001) shifting perspectives model of chronic illness as the theoretical frameworks in the research study. According to Bury, chronic illness can be viewed as a critical situation causing disruption in three distinct areas of the ill person’s life; their taken-for-granted assumptions, their biography and the person’s mobilization of resources. How the person experiences his/her illness and makes meaning of it will depend on the resulting levels of disruption to each of these three areas. As the affected person’s symptoms become more prevalent, the disease begins to structure his/her everyday life, and then very foundations of the individual’s pre-illness conceptions and beliefs are toppled. The loss of taken-for-granted assumptions can in turn alter the individual’s biography. A new understanding of the illness, the consequences it has on the person, as well as the effect it has on love ones are all incorporated into chronically ill person’s life stories, changing how they view themselves as individuals. While struggling to deal with the emotional and psychological implications of their disease, the affected individuals may simultaneously experience a disruption in the mobilization of resources (Bury, 1982).
The type of support received by the affected person, his or her social interaction with others, as well as the cultural, medical and financial resources that are available to the chronically ill individual all play a role in shaping the affected person’s new sense of identity. In Paterson’s shifting perspective model of illness, a person with a chronic illness can assume one of two perspectives; the illness in the foreground perspective, or the wellness in the foreground perspective (Paterson, 2003). Although individuals may have a preferred outlook, they are likely to shift between the two several times over the course of their illness experience. While assuming the illness in the foreground perspective, the individual focuses on his/her sickness, and the burdens, suffering, and loss associated with it. They viewed chronic illness as destructive to the self, and to others in their lives. While the second perspective is assuming a wellness in the foreground perspective, chronically ill people view their illness as being meaningful, and as serving purpose in changing their relationship with the environment and with others. In relation to my study, the theory of Bury and Paterson is the appropriate since this persons that I need to focus are the ones who suffered diabetes mellitus which is a chronic illness that not only physical aspect is affected but psychologically, emotionally and spiritually. Being diagnosed with a chronic condition such as type 1 and 2 diabetes mellitus can be life altering at any age. For children and adolescents in particular, this metabolic illness can have resounding effects on their psychological well-being (Hood et al, 2006). From the time they are diagnosed, individuals with diabetes must assume numerous roles, bouncing among the roles of nurse, physician, mathematician, and dietitian. They must take over the responsibilities of pancreas, performing tasks that in a healthy human being occur subconsciously; balancing the level of insulin to carbohydrate in an attempt to achieve glucose homeostasis. At first, these individuals may receive support from parents and medical teams in managing the complex everyday tasks of diabetes regimen; however, as they become more familiar with treatment demands, the responsibility of maintaining their health falls completely on their own shoulders (Seiffge-Krenke, 1998). As Dovey- Pearce, Doherty and May (2007) said that also children and adolescents struggling to deal with the lifelong demands of self-care, they also must face the same challenges that plague others their age or they mature and find their place in the world. From changes in their social lives, to changes in their knowledge levels, to physical changes, they must also need to relearn how to manage their diabetes upon entering puberty. This sudden loss of control of their health can bring various psychological effects such as stress, anxiety, depression and eating disorders.
Medical Complications of Diabetes Mellitus
Throughout their lives, individuals with diabetes will experience numerous periods of poor metabolic control (Gould, 2002). From short-lived blood glucose fluctuations caused by imbalances among food intake, exercise, and insulin, to more long-term instabilities initiated by hormonal changes, numerous aspects of the individual’s biology and environment influence his or her ability to maintain blood glucose levels within the desired range. While physicians suggest that people with diabetes should sustain blood glucose levels of between 4-6 mmol/L, many people may have blood sugars that lie outside of this range. When blood sugars stray out of the ideal range, a variety of acute and long-term complications may ensue. In the short-term, fluctuations may cause feelings of anxiety, aggression, or antisocial conduct. In the long-term, these fluctuations if left unresolved can lead to more serious complications such as kidney failure, blindness, stroke, and possibly death (Bryden et al., 2001).
In diabetes there are three types of metabolic crises: hyperglycemia, hypoglycemia, and diabetic ketoacidosis. All three of these conditions can be detrimental to the health and functioning of the individual with diabetes, and must be recognized and treated as soon as possible to prevent further complications from arising.
Hyperglycemia is a condition in which levels of glucose in the blood are elevated. Hyperglycemia occurs as a result of insufficient levels of insulin in the body, which may be caused by inadequate dosages of injected insulin, increased intake of food, or decreased levels of exercise. The symptoms of hyperglycemia develop slowly, and include feelings of malaise, fatigue, and excessive thirst. People who are in a hyperglycemic state may show signs of deep breathing, rapid heart rate, and, if the symptoms remain untreated, may go into a coma (DePaepe, Garrison-Kane, &Doelling, 2002).
At the opposite end of the spectrum is the condition known as hypoglycemia, or low blood glucose. Unlike hyperglycemia, hypoglycemia or insulin shock develops rapidly in a person with diabetes who is treated with insulin. This glucose deficiency is caused by excessive insulin, strenuous energy output, insufficient food, or failing to eat after taking insulin. Individuals in a low may complain of headaches, nausea, and vomiting, restlessness, fatigue, excessive hunger, sudden changes in behaviour, and, under serious circumstances, may experience convulsions or coma (DePaepe et al., 2002). If a person presents with symptoms of hypoglycemia, he or she can prevent further deterioration by ingesting foods that are rich in sugar such as fruit juice or candy (Gould, 2002). When a person in a low slips into unconsciousness, he or she can be given a glucagon needle which increases the amount of glucose released by the liver. This needle is only a short-term solution, and the individual with diabetes must seek medical attention immediately to properly treat the hypoglycemia.
The final type of metabolic crisis that can occur in individuals with diabetes is diabetic ketoacidosis. This condition occurs when there is a buildup of ketones in the body as a result of high levels of blood glucose, and insufficient supplies of insulin. A person who is experiencing ketoacidosis will exhibit a higher breathing rate, acidification of the urine, and high levels of potassium in the blood. If ketoacidosis goes untreated for a prolonged period of time, it can lead to circulatory collapse, and cause coma or even death (Touchette, 2002). A person experiencing ketoacidosis should be taken immediately to the hospital for insulin replacement, and fluid and electrolyte therapy (Gould, 2002).
Treatment of Diabetes in Children and Adolescents
Prior to the discovery of insulin by Dr. Frederick Banting in 1921, individuals with diabetes were destined to a life of suffering, their bodies dying of starvation amidst a cornucopia of glucose in the blood (Gould, 2002). Today, through a strict regimen of daily insulin injections, regulated diet, and close monitoring of blood glucose levels, people diagnosed with diabetes are able to lead long and relatively healthy lives (Daley, Wodrich, & Hasan, 2006). The development of numerous varieties of insulin and insulin administration devices has facilitated the diabetic individual’s ability to achieve and maintain glucose homeostasis. Hypodermic needles, insulin pens, and insulin pumps can be used by individuals with type 1 and type 2 diabetes, and each have their own assets and drawbacks.
Typically when individuals begin insulin therapy they are placed on short-acting and long-acting insulin that is most often administered using a hypodermic needle or insulin pen. The amount of insulin injected and the frequency of administration is highly individual, and depends on a variety of factors including the current level of insulin production by the pancreas, the person’s weight, and his or her activity level (Canadian Diabetes Association, 2007). Based on these considerations, the physician or endocrinologist is able to calculate insulin to carbohydrate ratio that is appropriate for that particular person.
Once the diabetic individual becomes accustomed to using hypodermic needles or the insulin pen to treat his or her diabetes, he or she may choose to switch to a more recent invention, the insulin pump. This device administers a constant flow of insulin to the body through an injection site that is embedded in the stomach, and functions in a similar manner to a healthy human pancreas. While the pump provides more freedom from the strict diet and eating schedule that is imposed upon needle and insulin pen users, it requires more training and attention to ensure proper usage and prevention of infection (Canadian Diabetes Association, 2007).
Children and adolescents with diabetes will undergo several changes in diabetes regimens as their activity levels change, and as they grow and enter puberty. To increase the level of metabolic control and decrease the incidence of long-term complications, researchers from the Diabetes Control and Complications Trial (DCCT, 1993) suggest that physicians should prescribe a more intensive diabetic therapy of 3-4 injections a day. While a more intense insulin regimen may decrease the incidence of future diabetic complications, it places the individual at an increased risk of acute episodes of severe hypoglycemia, and may cause unwanted weight gain, making it more difficult for individuals to achieve glucose homeostasis (DCCT, 1993).
Diabetes in the School
Because of the rapidly increasing prevalence of type 1 and type 2 diabetes among children and adolescents, all schools are likely to encounter a student with diabetes at some point (Nichols, 2002). Children spend on average 30 to 35 hours a week in the school setting, and often depend on the support of school staff to help them manage the medical, social, and emotional aspects of their diabetes (Lightfoot, Mukherjee, &Sloper, 2001). This section addresses some of the issues related to the academic experience of children and adolescents with diabetes, first examining Ontario law and the legal responsibilities of the school toward the diabetic student, then looking at the knowledge base of teachers pertaining to diabetes. The final sections examine research on the cognitive abilities and needs of individuals with type 1 diabetes, and discuss barriers in the school environment that may impede the full inclusion of students with diabetes.
The Teacher and Diabetes
The proper management of diabetes is a complex process that requires collaboration among the child with diabetes, parents, peers, school staff, and medical practitioners. While teachers are not responsible for providing medical treatments to the student with diabetes, they should be aware of the signs and symptoms of medical emergencies such as hypoglycemia and hyperglycemia. Failure to recognize the early signs of medical distress could result in the student losing consciousness, going into a diabetic coma, or, in extreme cases, death (Gould, 2002).
Unfortunately, many teachers do not have an adequate understanding of diabetes, and are unable to recognize the medical and educational needs of these students (Mukherjee, Lightfoot, &Sloper., 2000; Nabors et al., 2003; Wagner, Heapy, James, &Abbot, 2005). A survey of 463 elementary school teachers in Arkansas showed that 90% of the teachers had never received training on diabetes, and only a few could identify the symptoms or appropriate treatment of hypoglycemia (Gormanous et al., 2002). Since acute hypoglycemia can rapidly deteriorate into a life-threatening condition, these results are frightening.
The trend of inadequate diabetes knowledge among educators has been reported by both parents and students in numerous studies (e.g., Asprey& Nash, 2006; Lightfoot et al., 2001; Wagner et al., 2005). According to the 58 parents in Wagner and colleagues’ study (2005), very few teachers who were responsible for assisting students in the management of their diabetes at school had actually received formal training from a medical professional. When asked what type of preparation the school personnel had received, most parents indicated that the training varied from informal conversations, to review of educational material, with very few actually receiving training directly from a healthcare provider. Parents often assumed the responsibility of educating staff members on their child’s condition and on how to manage a medical crisis. Children whose parents reported having a trained professional on staff at the school had better levels of metabolic control when compared to students who did not have a trained individual at their educational institution. Because this study was cross-sectional in design, it was not possible for the researchers to determine the direction of association between training, glycemic levels, and quality of life. Measures of self-report data may have led to an inaccurate portrayal of the level of diabetes knowledge of school staff, since the parents and children may not have been aware of all forms of diabetes education received by school employees. Despite the limitations of Wagner and colleagues’ study, Nabors and colleagues (2003) and Asprey and Nash (2006) received similar feedback during interviews with parents and students who had type 1 diabetes; that teachers often lacked a clear understanding of T1DM and thus were unable to provide adequate levels of support to diabetic students in the classroom.
Students with diabetes and their parents are not the only people to have questioned the ability of educators to manage diabetes in the school. Teachers often share this same concern, indicating that they are not adequately trained to deal with medical emergencies should they arise. Mukherjee, Lightfoot, and Sloper (2000) interviewed 34 teachers who had experience working with chronically ill children. The researchers conducted focus group sessions with these educators which examined the teachers’ perceptions of their abilities to handle students with chronic illnesses in the school. Many educators felt that they were uninformed about a wide range of illnesses including diabetes, cancer, leukemia, epilepsy, and asthma, and often worried that they would not respond appropriately during medical emergencies. Other worries that were mentioned during focus group sessions included the possibility of pushing chronically ill children too hard to keep up with schoolwork, dealing with the reactions of other students in the class, and being unable to provide chronically ill children with the academic and emotional support they required. Teachers reported a sincere desire to learn more about type 1 diabetes; however, they would rather that the information came from a healthcare professional than a parent. Since communication with healthcare providers often involved a significant time delay, many teachers were unable to obtain the medical and academic information they required in a timely fashion. Many educators were reluctant to seek out medical information from parents, since they did not want to overburden parents, did not want parents to think of them as incapable of caring for their child, and believed that healthcare providers were better able to give medical advice. Of the teachers who reported approaching parents for medical advice, some described the parents as being either unwilling or unable to pass on valuable medical and academic information to the teacher. Participants in this study were also concerned about a general lack of medical knowledge among all staff members, stating that if only one individual on staff was trained to deal with medical emergencies, children would be unnecessarily placed at risk should that staff member be absent. These teachers also noted the importance of informing all occasional staff of the child’s medical conditions and of any symptoms or signs of medical problems for which they should be looking.
If teachers are to exert a positive influence over the outcome of a student’s diabetes, they must first have a well-developed understanding of the condition. By recognizing the diverse needs of diabetic students, making appropriate accommodations, and providing medical and emotional support, teachers can help make the student’s school experiences more positive, rewarding, and safe (Hayes-Bohn et al., 2004).
The Student and Diabetes: Academic Abilities and Student Needs
Although the impact of diabetes on the body is well known, the impact it has on the brain and cognitive functioning has only been recognized recently (Rovet& Alvarez, 1997). When researchers initially began examining the effects of diabetes on neurocognitive functioning in children and adolescents, they consistently reported satisfactory levels of intelligence and academic achievement among this small group of individuals. These findings produced a false sense of hope, and further studies in the area were abandoned (Rovet, Ehrlich, Czuchta, &Akler, 1993). It was not until several years later when new methods for measuring metabolic control were developed that researchers began to revisit the possibility of neurocognitive impairment in children with diabetes. As more studies were conducted, it became apparent that, although children with diabetes tended to be of average intelligence as measured by IQ tests, they often suffered from deficits in verbal intelligence, visual spatial abilities, and attention.
Kovacs, Goldston, and Iyengar (1992) were among the first researchers to demonstrate long-term deficits in academic and neurocognitive ability in children and adolescents with T1DM. Following 87 children between the ages of 8-13 years from the initial time of diagnosis for a total of 6 years, these researchers found that the participants’ academic abilities, as determined by grade point averages and marks on report cards, decreased significantly over time. Upon examining annual scores achieved by individuals on the Vocabulary and Block Design subtests of the WISC-R, Kovacs and colleagues noticed that children with T1DM had lower verbal intelligence than a control group of healthy individuals who were matched on the basis of age, socioeconomic status, and ethnicity. Although the homogeneity of the sample limited the generalizability of this study (all participants were white, middle to upper class, with good metabolic control), Kovacs and colleagues’ longitudinal study played a pivotal role in demonstrating the potential long-term effects of diabetes on the intellectual functioning of children and adolescents.
As many researchers continued to investigate the notion of intelligence and diabetes, some began searching for other areas that could potentially be affected by instabilities in glycemic levels. One area of functioning that was of particular interest to Rovet and Alvarez (1997) was attention. To examine how various aspects of attention were affected in children and adolescents with T1DM, the researchers recruited 103 individuals between the ages of 9-18 years who had type 1 diabetes, and 100 healthy individuals. Upon administering several tests of attention, including the WISC-R, Modified Matching Familiar Figures Test, and StroopColour-Word Test, the researchers discovered that children and adolescents with type 1 diabetes experienced significantly more difficulties with the focus, select, and inhibit aspects of attention when compared to the healthy control group. While Rovet and Alvarez demonstrated that diabetes could potentially affect numerous aspects of attention, they only administered each test to the participants once, and all tests were completed on the same day. At the time of the experiment, most participants had blood glucose levels within the normal range. Because the researchers did not test the participants when their blood sugar was higher or lower than normal, they did not show how fluctuations in glycemic levels might influence a person’s attention. Further studies examining attention in individuals over a prolonged period of time would be useful in determining what types of accommodations should be provided to students with type 1 diabetes in the classroom.
In a study assessing the effects of mild hypoglycemia on cognitive functioning in diabetic children, Ryan and colleagues (1990) discovered that when they induced a hypoglycemic state in 11 participants, a significant decline in mental efficiency occurred. These researchers assessed the participants’ mental efficiency using three measures: the simple choice visual reaction time test, the trail making test, and the StroopColour-Word Test. The participants completed each measure prior to receiving the insulin glucose clamp at a euglycemic state, once they started showing symptoms of hypoglycemia, and once their blood glucose levels had returned to normal. At the hypoglycemic state, participants showed significantly slower reaction times, a decrement in functioning on the trail making test, and poorer word-reading scores on the StroopColour-Word test. These cognitive changes appeared shortly after the initiation of hypoglycemia, indicating that even a moderate state of hypoglycemia could significantly affect a child’s ability to perform in the classroom. Even following a return to a euglycemic state, the participants showed some difficulties on the tests when compared to the initial euglycemic measurements.
In a similar study, Sommerfield, Deary, McAulay, and Frier (2003) induced hypoglycemic states in 16 healthy adults using a hyperinsulinemic glucose clamp. Employing tests of immediate and delayed verbal memory, immediate and delayed visual memory, and working memory, the researchers discovered that all memory systems were impaired during acute hypoglycemia, with working memory and delayed memory being particularly affected. These two studies suggest that the detrimental effects of acute hypoglycemia on memory and mental efficiency could impair a student’s ability to learn while in a state of low blood sugar, and immediately following the return to normal glycemic levels.
Not only can fluctuations in blood glucose levels affect cognitive functioning, but they can also cause changes in behaviour. Both hyperglycemia and hypoglycemia have been found to initiate changes in moods, at times resulting in problem behaviour (e.g., Valdovinos&Weyand, 2006; Warren, Deary, &Frier, 2003). Individuals experiencing hyperglycemia are prone to feelings of irritability, restlessness, and agitation (Warren, Deary, &Frier, 2003). Similarly, individuals in a hypoglycemic state show evidence of impaired judgment, emotional lability, moodiness, irritability, belligerence, and fatigue (Gould, 2002). Since diabetes can influence the cognitive functioning, behaviour, and attention of children and adolescents, it is important that teachers are aware of these effects, and properly attribute them to fluctuations in blood glucose instead of attributing them to the students’ willingness to cooperate and learn.
Children and adolescents with diabetes have a diverse range of needs, and may require differing levels of support and accommodations while in the school setting (Mukherjee et al., 2000; Nabors et al., 2003). Studies that rely on qualitative methods such as interviews and focus group sessions with diabetic youth and their parents have identified some areas in which individuals may need support from teachers and other school officials (e.g., Mukherjee et al., 2000; Nabors et al., 2003). Although some participants in these studies reported receiving adequate support from teachers, most individuals suggested that teachers and other school employees needed to make more of an effort to satisfy the medical and academic requirements of people with diabetes. In a study by Nabors and colleagues (2003), the researchers interviewed 105 children (60 boys, 45 girls) in a group setting during diabetes summer camp sessions. Children completed the ‘how is school scale’ which addressed their perceptions about the amount of support they needed from teachers, nurses, and friends while at school for monitoring their blood glucose, administering insulin, and following their meal plan. Several of the participants described ways in which teachers could help them to deal with their condition in the classroom. These suggestions included allowing students to check blood glucose whenever they felt that their levels were high or low, having their test kits in an accessible area, ensuring that there were snacks in the classroom in case the children experienced hypoglycemia, and allowing the students to take breaks when they felt low, even if the teacher was in the middle of a lesson or test. These students wanted their teachers to understand their condition, and to refrain from drawing too much attention to them when they were not feeling well. Younger children wanted reminders to test their blood sugars and to snack; however, teachers had to be careful not to overstep the line between reminding and nagging. Despite variations in the requirements for medical assistance, all participants reported needing a certain level of emotional support from teachers or peers in order to adhere to the diabetic regimen at school.
Diabetes in the School Environment
Although the low level of diabetes awareness that exists among teachers and students in the classroom places the student at risk for poor diabetes management, there are several other barriers in the general school environment that may further threaten the student’s overall metabolic control. The scarcity of healthy food in the cafeteria, stringent school rules, and difficulties associated with participating in extra-curricular activities may influence the overall school experiences of students with diabetes.
Hayes-Bohn and colleagues (2004) conducted a study with 30 adolescent females 13-20 years old who had T1DM. Through semi-structured interviews, the researchers learned about the girls’ perceptions of the barriers and resources for diabetes management that existed in their schools. One of the issues brought up by several participants was the lack of healthy food choices available in the cafeteria. According to the girls, there was a high prevalence of junk food in the cafeteria and in the vending machines. Cafeterias often did not provide the nutritional information about the food they prepared, which made it more difficult for participants to accurately monitor their carbohydrate intake. Other studies that have examined meals offered in cafeterias throughout the United States have called similar attention to the fact that very few cafeterias provide healthy food options (e.g., Shannon, Story, Fulkerson, & French, 2002; Wechsler, Brener, Kuester, & Miller, 2001).
Although the participants were mainly concerned with the lack of healthy food choices offered by the cafeteria, several girls also commented on the difficulty of adhering to the diabetic regimen when friends or teachers offered them treats (Hayes-Bohn et al., 2004). According to several of these individuals, teachers often brought in candy or other sweets as a reward for their class. This practice made the girls feel excluded and singled out, as their classmates noticed when the girls refused to eat the treats. For participants who preferred to keep their diabetes a secret, the teacher’s act of generosity resulted in feelings of discomfort and humiliation.
When schools are inflexible with their rules, students with diabetes may be placed at a disadvantage. Rules that prohibit the presence of syringes at school mean that students with diabetes must go to the nurse’s office where they can be supervised administering their insulin. For individuals who prefer to keep their condition hidden from their peers, this process of leaving the classroom so that they can be supervised by an adult is embarrassing. Studies by Hayes-Bohn and colleagues (2004), and Wagner and colleagues (2005) indicate that many students are required to leave the classroom before checking their blood glucose levels or administering doses of insulin. According to Wagner and colleagues (2005), 56% of children who participated in their study had to go to the nurse’s office, main office, or their locker when giving an injection during school hours. These children who were required to leave the classroom had poorer metabolic control than those who were allowed to monitor their condition in the classroom. Leaving the room to manage their diabetes meant that the students would miss class time, a fact which many students described to be an inconvenience (Hayes-Bohn et al., 2004). Some teachers also refused to allow students to eat or drink in the class, or to go to the bathroom as needed, because they did not believe it was fair to the other students in the class who had to follow rules established by the school. As such, many individuals with type 1 diabetes experienced difficulties maintaining a consistent level of metabolic control while at school (Hayes-Bohn et al., 2004; Nabors et al., 2003). By refusing the students their rights to fulfill diabetes-related needs, schools were unnecessarily placing students with diabetes at risk.
Because of the general lack of diabetes knowledge among school staff, children with diabetes are often unnecessarily denied the opportunity to participate in extra-curricular activities (Mukherjee et al., 2000; Nabors et al., 2003; Wagner et al., 2005). Many people believe that individuals with diabetes are unable to partake in excessive physical activity, since it would undoubtedly result in hypoglycemia (e.g., Raile et al., 1999). These beliefs, however, are flawed. With proper monitoring of blood glucose, altering of insulin dosage, and snacking when blood glucose levels drop, students with diabetes are able to participate fully in a wide variety of extracurricular activities (Hopkins, 2004). Exercise can even reduce the risk of future diabetes complications by increasing the level of cardiovascular fitness (Raile et al., 1999). Despite the ability of children and adolescents with diabetes to participate in extracurricular activities, many barriers exist that discourage them from joining after-school programs. Participants in Nabors’ (2003) study told of instances where there was no longer an individual on staff after school hours that could help them manage their disease. They complained that coaches often did not understand their condition, and refused to let them participate in different sports even though they were capable of playing. Other participants noted that their diabetes supplies were often locked in the nurse’s office after school, and could not be accessed easily in the case of an emergency. All of these factors impeded the child’s ability to participate in extracurricular activities, and may have deprived the student of feelings of support, belonging, and connectedness to the school.
Social Implications of Diabetes
The relationships that children and adolescents with diabetes have with their parents and friends can have a large influence over their psychological and physical well-being. These relationships can either provide a source of support to the diabetic individual, increasing the likelihood that they will be able to deal with the stresses of diabetes management, or can act as a negative enforcement, influencing the individual to abandon his or her regimen. This section examines relationships between the diabetic individual and his or her parents, as well as the relationships with friends.
Parental Support and the Adolescent Need for Autonomy
As a child enters the world of adolescence, the role of the family in diabetes management changes (Seiffge-Krenke, 1998). During early childhood, parents frequently take on the daunting task of monitoring blood glucose, exercise, and diet (Schroff-Pendley et al., 2002). However, as the child becomes older and enters the school system, he or she begins to accept more responsibility for the management of diabetes (Wiebe et al., 2005). In some cases, parents are reluctant to relinquish control, and as a result, are perceived by their children as being overbearing (Wiebe et al., 2005). Constant scrutiny and concern from parents diminishes opportunities for adolescents with diabetes to participate in normal teenage activities, since doing so might lead to conflict with parents or would require that the youth check in with family members on a regular basis (Schroff-Pendley et al., 2002).
Upon entering adolescence, support from parents is typically viewed as less positive (Furman &Buhrmester, 1992). At this time in their lives, adolescents are striving for a sense of autonomy, a goal which is often difficult for youths living with chronic illnesses to achieve. Attempting to meet the expectations of society, many parents allow their children full control of diabetes management at an early age (Palmer et al., 2004). Although children are typically able to participate in most aspects of diabetes management by the age of 13, Wysocki (1993) suggests that many parents are transferring the responsibility of diabetes management to their child too early. According to Schroff-Pendley et al. (2002), parents who surrender complete control of diabetes management to their teenager and no longer offer assistance to their son or daughter are unintentionally placing their loved one at risk for poor diabetes compliance and increased hospital admittance.
In their 2001 study, Wiebe and colleagues examined how adolescents’ appraisals of maternal involvement in coping with diabetes were associated with metabolic control and quality of life. The researchers administered a series of questionnaires to 127 adolescents’ ages 10-15 years and their mothers to obtain measures of regimen adherence, parental support, appraisal of parental involvement, and quality of life. Wiebe and colleagues found that mothers of children who had been diagnosed at an earlier age were frequently less involved in the management of their child’s diabetes, and that the lack of parental involvement was associated with poorer metabolic control and lower life satisfaction. Maternal collaboration was seen most often with parents of teenagers who had more recently been diagnosed with diabetes, and who were on more intense interventions. Parental collaboration was associated with better adherence and metabolic control, yet was still associated with lower life satisfaction among the youths. The researchers concluded that optimal diabetes care is more likely to occur when children view their mothers as collaboratively involved in dealing with issues surrounding disease management. Wiebe and colleagues’ finding that having a controlling parent leads to poorer life satisfaction is consistent with the findings of other researchers (Ott, Greening, Palardy, Holdreby, &DeBell, 2000; Williams, Freedman, & Deci, 1998; Wysocki, 1993). Having a controlling parent may lead adolescents to believe that their parents do not trust them to manage their own condition, resulting in decreased levels of self-efficacy (Carroll & Marrero, 2006; Seiffge-Krenke, 1998). In an attempt to exercise their autonomy, teenagers may revolt against the desire of the parents, and refuse to follow the diabetes treatment (Carroll & Marrero, 2006). To reduce levels of parental anxiety and to avoid conflict, other adolescents may refrain from diabetes management tasks such as testing their blood glucose, especially when they believe it is low or high (Carroll & Marrero, 2006).
Relationships with Friends
While struggling to cope with normal issues that confront others their age, children and adolescents with type 1 diabetes are faced with the additional stress of managing a chronic illness. Although individuals with T1DM and T2DM would benefit from increased levels of peer support during these tumultuous times, many do not receive the assistance they require. This lack of peer support has been attributed to a variety of factors, including the diabetic person’s self-consciousness, the strict requirements of the diabetes medical regimen, and the lack of diabetes knowledge among peers (Boice, 1998; Schroff-Pendley et al., 2002).
During the childhood years, peers play a significant role in the individual’s adherence to the diabetic regimen. The influence of friends and classmates continues to increase throughout childhood, reaching a peak during adolescence. Adolescents begin to spend more time in the presence of their peers as they seek to gain insight into the normal rules of behaviour, and the process for identity formation (Cheung et al., 2006). The guidance, emotional support, and understanding that were once bestowed upon the individual by parents are now sought out from peers (Cheung et al., 2006). Although social relationships are important in determining the quality of life of most individuals, these relationships with friends are particularly influential for adolescents with diabetes, affecting not only their quality of life, but also their overall state of health (Faro, 1999). Studies examining the role of social influences and peers on diabetes adherence have consistently shown that peers can exert a great amount of influence over the individual with diabetes, whether the influence be positive or negative (e.g., Cheung et al., 2006; Faro, 1999; Hains, Berlin, Davies, Parton, &Alemzadeh, 2006).
In a qualitative interview study conducted by Bearman and La Greca (2002), participants with type 1 diabetes reported that friends were the main source of emotional support during adolescence, and that they provided companionship when the adolescent was experiencing difficulty adhering to the diabetic regimen. Greco, Pendley, McDonnell, and Reeves (2001) echoed this concept of emotional support, finding that peers were more likely than family members to provide adolescents with the emotional support that they required over the course of their disease.
Seeking to gain a better understanding of peer support during adolescence, Cheung and colleagues (2006) examined adolescent perceptions of the quality of support obtained from peers. The researchers selected 29 participants between the ages of 13-17 who had attended at least one diabetes camp, and 10 participants who had never attended camp. The adolescents completed a series of questionnaires that included a quality of life survey, and a survey to assess the nature of their friendships with others. Over half of the participants in the study felt that diabetes limited their social relationships and friendships. Those who reported having several close friends also obtained higher scores on the Quality of Life survey. The benefits of friendship were amplified when adolescents with T1DM were granted the opportunity to interact with other people suffering from diabetes in the camp setting, since it provided them with mutual and sincere support as they struggled to manage their disease. Because of the nature of the study, it is not possible to determine the direction of the relationship between number of friends and level of metabolic control. While it is possible that having more close friends would increase adherence to the diabetic regimen, it is also possible that people had more positive relationships because of better moods associated with good glycemic control. Because of the small sample size, Cheung and colleagues’ findings may be limited in generalizability.
Despite an increased need for support among adolescents with chronic illness, several researchers have found that chronically ill adolescents spend more time in isolation, and have fewer friendships than healthy individuals (e.g., Boice, 1998). Fears of appearing different from peers and feelings of self-consciousness often overwhelm the chronically ill individual, leading to decreased efforts and motivation to initiate friendships with healthy individuals (Cheung et al., 2006). Social interactions may be further limited by the unwillingness of the adolescent to test blood glucose in a public setting for fear of blood-borne disease, and the possibility of contracting an illness (Cheung et al., 2006). When adolescents do choose to engage in social activities, they often decide not to check blood glucose levels, administer insulin, or eat foods that are different than their peers in an attempt to appear normal (Falsetti et al., 2003; Hains et al., 2006). The restrictive nature of the diabetes regimen might also interfere with the teenager’s participation in a variety of social activities, including sports, driving, and dining out with friends (Carroll & Marrero, 2006).
Although adolescents with diabetes may actively choose not to engage in many social activities, the reactions of their peers may also dictate whether or not they will participate. Most healthy adolescents lack knowledge on the subject of diabetes (Canadian Diabetes Association, 2007; Seiffge-Krenke, 1998). This lack of knowledge can be problematic, since it may cause them to view the diabetic individual as being different or even scary. According to a study by Faro (1999), many adolescents with diabetes felt that their peers behaved differently towards them, and one third of the participants stated that they frequently needed to explain to non-diabetic peers that diabetes was not contagious. Many participants chose to keep their diabetes a secret, since they feared that this knowledge might lead their friends to abandon or disown them.
Even though many adolescents with diabetes report having positive relationships with non-diabetic peers, their friends often negatively influence the teenagers’ diabetic regimen adherence. Engaging in activities that are appropriate for their developmental level often conflicts with good diabetes management practices (Frey, Guthrie, Loveland-Cherry, Park, & Foster, 1997). Schroff-Pendley and colleagues illustrated this issue in their 2002 study. Attempting to examine the level of social support offered by peers to adolescents with chronic illnesses, Schroff-Pendley and colleagues recruited 68 children ages 8-17 that had been diagnosed with T1DM. The participants selected a minimum of 3 people from their extended family, peer-group, or school to act as a support team over the course of the study. As part of the study, the researchers presented diabetic individuals with a series of hypothetical social situations in which they had to decide between diabetes adherence and peer desires. The researchers discovered that most individuals when presented with such a problem were more likely to comply to peer desires than to maintain their diabetes regimen. Schroff-Pendley and colleagues also discovered that although peers may treat the individual with diabetes like everyone else, the peers were actually encouraging non-adherent behaviour.
While the reactions of friends may directly influence the diabetic individual’s desire to adhere to a specific regimen, Hains and colleagues (2006) argue that it may instead be the diabetic person’s appraisal of peer beliefs that exerts the greatest amount of control over his or her decision to abandon the treatment regimen. Adolescents often choose to filter out certain aspects of a particular situation, and may view a friend’s reaction as being negative when it is actually not (Hains et al., 2006). In an attempt to avoid such negative reactions, people with diabetes may decide to avoid aspects of their diabetes management. These false attributions are not only concerning due to their negative health implications, but also because the adolescent may be missing out on opportunities for valuable friend support (Hains et al., 2006). In their 2006 study, Hains and colleagues examined the relationships among negative attributions of friend reactions, anticipated adherence difficulties, diabetic stress, and metabolic control. In all, 104 participants with T1DM between the ages of 11-18 took part in this study. The researchers gave each individual a package of questionnaires which assessed friend attributions and diabetic stress. The researchers discovered that individuals who showed greater levels of negative friend attributions also demonstrated higher levels of diabetic stress, lower metabolic control, and anticipated more adherence difficulties. Although Hains and colleagues have shown that negative friend attributions are associated with decreased metabolic control and adherence, it is not possible to determine whether or not it is a causal relationship. Hains and colleagues employed vignettes that were similar to those used by Schroff-Pendley and colleagues (2002) in which the adolescents were presented with a social situation which required them to decide between peers or adherence to the diabetic regimen. The problem with using an instrument such as this is that it may not be an accurate reflection of how the adolescent would act if placed in the situation. The use of alternative instruments in future studies is important to see if these trends are indeed observable in everyday life.
In recent studies, high levels of social support have been linked to greater regimental adherence, fewer diabetes-related complications, and greater quality of life in children and adolescents living with diabetes (e.g., Cheung et al., 2006; Mayou, Bryant, & Turner, 1990). Because an increased level of social support has been linked to better health and psychological outcomes among diabetic individuals, it is important that children and adolescents with diabetes have ample opportunities to form friendships within the school setting. Recognizing the benefits of social support in the school, Wagner and colleagues (2006) have suggested that schools implement a “diabetes buddy” program. This program would permit one or a few classmates to accompany the student with diabetes over the course of the day as he or she goes about managing his or her condition in the school. Not only would this “diabetes buddy” program be a cost-effective intervention for promoting diabetes care in the school, but could also increase the level of peer awareness surrounding diabetes, and promote the formation of friendships between the diabetic student and his or her peers (e.g., Greco, SchroffPendley, McDonnell, & Reeves, 2001; Wagner et al., 2005).
In addition to encouraging the formation of friendships between diabetic students and their classmates, LaRusso, Romer, and Selman (2007) believe that teachers can reduce the occurrence of risky health-related behaviours in students by creating a positive and respectful school environment. In providing support when students need it, and valuing the students’ perspectives and decision-making capabilities, teachers can establish a respectful class environment that increases students’ feelings of social belonging.
While several suggestions have been made as to how diabetes educators can increase the level of social support given to the individual with diabetes, very few of these suggestions have been tested in the school setting. Future research in the area of social support and diabetes should include program evaluations of “diabetes buddy” programs and other peer interventions to determine the effectiveness of increased social support on the diabetic student’s adherence, academic performance, and overall quality of life.
Depression and Diabetes Mellitus
Diabetes is considered to be one of the most psychologically and behaviorally demanding of the chronic illnesses (Cox & Gonder-Frederick, 1992). The stress associated with managing a chronic illness, the restrictions imposed by the diabetic regimen, as well as bodily changes resulting from the disease all play a role in determining how an individual responds to his or her condition. Although many children and adolescents who have been diagnosed with type 1 and type 2 diabetes are able to adjust well to life with a chronic illness, others may experience greater difficulty adjusting to this new way of living. A perceived loss of control, low self-esteem, and disease complications may lead to feelings of negative affect in the child or adolescent with diabetes and in some cases may manifest as full-blown depression.
Although there have been several studies examining the co-occurrence of depression and diabetes, the majority have focused on depression in adults. Studies of adults with type 1 and type 2 diabetes have shown an increased risk of associated depression, with 20%-30% of participants with diabetes meeting the criteria for major depression (e.g., Anderson, Freedland, Clouse, & Lustman, 2001; De Groot, Anderson, Freedland, Clouse, &Lustman, 2001). Although estimates of depression in youths with diabetes are thought to be lowering than those seen in adults, they are believed to be higher than the depression rates seen in the general population (Lustman & Clouse, 2005).
In one of the few studies examining the prevalence of depressive symptoms in youths with diabetes, Hood and colleagues (2006) administered a series of questionnaires to 145 participants. Using the Children’s Depression Inventory to assess depression, the researchers found that 15.2% of the participants scored at or above the clinical cut-off for depression. The number of individuals with depression in this study was nearly double that of the highest estimate of depression in youth in general (Anderson & McGee, 1994; Lewinsohn, Clarke, Seeley, & Rohde, 1994). Other studies that used different tools to measure depression in diabetes obtained mixed results; showing both higher and lower incidences of depression (e.g., Egede& Zheng, 2003). Reasons for the mixed results include differences in methodologies used to assess depression, small sample sizes, and unrepresentative groups of participants (Ciechanowski, Katon, & Russo, 2000; Korbel, Wiebe, Berg, & Palmer, 2007).
Similar to trends seen in healthy adolescent populations, females with diabetes appear to be at a higher risk of developing depression than their male counterparts (Korbel et al., 2007). This gender difference is thought to emerge between the ages of 10-15 years, when the prevalence of depression among girls increases to twice that of boys (Nolen-Hoeksema, 2001).
Although studies have differed on estimates of the prevalence of depression in diabetes, one thing remains certain; that the co-occurrence of these diseases is particularly dangerous for children and adolescents. In youths with diabetes, depression is associated with a 10-fold increase in suicide and suicidal ideation (Goldston et al., 1997; Goldston, Kovacs, Ho, Parrone, & Stiffler, 1994). Children and adolescents who take insulin have a ready method of performing suicide, since an overdose of this hormone will inevitably lead to severe hypoglycemia and probable death if left untreated. Depression in children and adolescents with diabetes is also associated with negative diabetes-related health control outcomes such as poorer glycemic control (Kovacs, Iyengar, et al., 1990; La Greca, Swales, Klemp, Madigan, & Skyler, 1995), and recurrent diabetic ketoacidosis (Stewart, Rao, Emslie, Klein, & White, 2005), both of which increase the likelihood of future diabetes-related complications.
Several researchers have noticed a link between depression and hyperglycemia in both adults and youths with diabetes (e.g., Engum, Mykletun, Midthjell, Holen, &Dahi, 2005; La Greca et al., 1995). Because of the cross-sectional designs of these studies, it has not been possible to determine the direction or cause of this relationship. While some suggest that the resultant high blood glucose levels might be a manifestation of poor diabetic regimen adherence, others suggest that it may be the physiology of depression that is to blame. Because 95% of diabetes management is conducted by the patient, comorbid depression in diabetes may lead to poorer outcomes and increased risks of complications by lowering adherence to glucose monitoring, exercise, diet, and medication regimens (Ciechanowski et al., 2000). In a study by Hood and colleagues (2006) of 145 youths with diabetes, the researchers found that the individuals who scored higher on the Children’s Depression Inventory reported checking their blood glucose levels less frequently, had higher HbA1c levels, and a higher level of diabetes-related stress. Another proposed mechanism for the hyperglycemia that is seen in depressed diabetic individuals is that cortisol abnormalities that are associated with depression may have hyperglycemic effects, as might the insulin resistance that accompanies depression (Lustman& Clouse, 2005).
Disturbed Eating Behaviour and Eating Disorders
Adolescence has been found to be one of the most critical times in a diabetic individual’s life. According to the Diabetes Control and Complications Trial (1994), adherence to intensive diabetes therapy during the adolescent years can lower blood glucose levels, and reduce the risk of long-term diabetic complications significantly. Although the period of adolescence is one of great promise for the successful treatment of diabetes, many adolescents experience extreme difficulty adhering to the diabetes regimen (Du Pasquier-Fediaevsky, Chwalow, &Tubiana-Rufi, 2005; Madsen, Roisman, & Collins, 2002). This deterioration of self-care behaviours and glycemic control can have lasting effects on the individual, resulting in the development of long-term diabetes-related complications such as retinopathy, nephropathy, and neuropathy (White et al., 2001).
One of the developmental tasks that all adolescents face is to accept one’s body and the changes that have occurred as a result of puberty (Seiffge-Krenke, 1998). For individuals living with diabetes, this task can be particularly troublesome (Carroll & Marrero, 2006; Dabadghao, Vidmar, & Cameron, 2001). During puberty, boys and girls experience major hormonal changes, often resulting in weight gain particularly among females. The increases in body fat that occur during puberty come at a particularly critical point in the female’s life when she is becoming increasingly concerned about her body shape and appearance. The resultant weight gain and changes in body size may result in a heightened level of body dissatisfaction, and place young females at an increased risk of developing disturbed eating behaviours and eating disorders (Jack, 2003).
Females who have diabetes are at an even higher risk of developing disturbed eating behaviours due to several interacting factors related to diabetes and its treatment (Rodin et al., 2002). Prior to beginning insulin therapy, many males and females with undiagnosed diabetes experience a period of rapid weight loss as a result of chronic hyperglycemia and glucosuria (Kelly, Howe, Hendler, &Lipman, 2005). Upon commencing insulin therapy, these individuals will gain weight as their body begins to effectively use the glucose that is ingested through dietary means (Kaufman, 2006). Through the combination of pubertal weight gain and insulin-mediated weight gain, females with diabetes have been typically found to have a higher Body Mass Index (BMI) than their healthy peers (e.g., Bryden et al., 1999; Rodin et al., 2002). According to Rodin and colleagues (2002), this increased BMI may heighten body dissatisfaction in the female with diabetes, triggering a cycle of dieting and subsequent bingeing and purging. In recent years there has been a heightened interest in the comorbidity of diabetes and eating disorders. Some studies have found an increased incidence of anorexia nervosa, bulimia nervosa, binge-eating, purging, excessive exercising, and food deprivation in female adolescents with type 1 diabetes (e.g., Bryden et al., 1999; Rodin et al., 2002) while others have found no such relationship (e.g., Meltzer et al., 2001). Researchers who have examined studies which show no increase in incidence have pointed to several flaws in the studies that may be responsible for the conflicting results. Studies such as that conducted by Meltzer and colleagues (2001) typically employed small sample sizes of females who are in the age of highest risk for eating disturbances (i.e., older adolescence and young adulthood), did not use age-matched control groups, had low statistical power, and lacked structured diagnostic interviews for the assessment of eating disorders (Rodin et al., 2002).
Recognizing the importance of examining small age groups separately, Colton and colleagues (2004) conducted a cross-sectional, case-controlled study of 101 girls with type 1 diabetes between the ages of 9-14 years, and 303 age-matched female non-diabetic control subjects. The researchers collected information on the participants’ height, weight, BMI, and level of glycemic control. Participants completed a private semi-structured standardized interview, the Children’s Eating Disorder Examination interview. Upon analysis the researchers found that the same percentage of diabetic and non-diabetic girls reported at least one disturbed eating behaviour in the previous month; however, significantly more diabetic girls reported currently engaging in two or more disturbed eating behaviours. The most common behavioural combination reported by females in this age group was strict dieting with intense, excessive exercise for weight control. Binge-eating was also more common in diabetic than in non-diabetic girls. The researchers concluded that although disturbed eating behaviour was moderately common in preteen and early teenage girls, the severity was most often mild. Only 2% of the diabetic females in this study employed insulin omission as a weight-loss tool.
Colton and colleagues (2007) later extended their study to a 5-year prevalence study. A total of 98 females with type 1 diabetes completed the 5-year follow up. At the end of the 5-year period, 49% of the females reported current disturbed eating behaviour, 43.9% actively restrained their diet, 6.1% engaged in binge-eating episodes, 3.1% reported self-induced vomiting, 3.1% omitted insulin, and 25.5% employed excessive exercise for weight control. Of the women who participated in this study, 13.3% met the diagnostic criteria for an eating disorder.
Despite variations in the estimated comorbidity of diabetes and eating disorders, researchers agree that these patterns of disturbed eating are particularly hazardous to the health of individuals with diabetes. Disordered eating behaviour has been associated with recurring hypoglycemic episodes, more frequent episodes of diabetic ketoacidosis, poor metabolic control, and higher incidence of diabetes related complications including retinopathy and nephropathy (Jones, Lawson, Daneman, Olmsted, & Rodin, 2000; Rydall, Rodin, Olmstead, Devenyi, &Daneman, 1997).
In young women with body dissatisfaction, diabetes provides a unique but dangerous opportunity to control weight by deliberate insulin omission. By reducing or omitting doses of insulin, individuals with diabetes can induce hyperglycemia and glucosuria, effectively starving their body of the food they ingest. This dangerous method of purging, referred to as diabulimia, is reported by 1% of girls in preteens, rising to 11-14% by the mid-teens, and 34% by older adolescence and adulthood (Kelly, Howe, Hendler, &Lipman, 2005; Rodin et al., 2002). According to Rydall et al. (1997), between1/3 and 1/2 of all young women with type 1 diabetes frequently take less insulin than they need for good glycemic control in order to control their weight. Bryden and colleagues (1999) found similar incidences of diabulimia, with 30% of the 76 women admitting to intentionally reducing or omitting insulin to control their weight during the adolescent years. The duration of insulin purging by the women in this study ranged from 3 months to an average duration of 2 years.
Often eating disorders in people with diabetes go unrecognized and untreated. Because the treatment of diabetes requires individuals to focus a great amount of attention on proper diet, it is often difficult to differentiate between the normal concerns with food and body image and pathological ones (Adili et al., 2006). Frequent episodes of diabetic ketoacidosis, suboptimal or erratic blood glucose control, significant weight loss without illness, and frequent and severe episodes of hypoglycemia are all warning signs that an individual may be suffering from an eating disorder. In order to prevent life-threatening complications, it is important that parents, teachers, friends, or healthcare professionals recognize the presence of disturbed eating behaviours in individuals with diabetes, and seek proper medical attention.
Despite recognizing an association between diabetes, depression, and eating disorders, very little is known about the actual prevalence of these psychological conditions in children and adolescents with diabetes (e.g. Bryden et al., 1999; Hood et al., 2006). While the actual comorbidity of these conditions is unknown, one thing remains certain; the co-occurrence of diabetes, depression, and eating disorders can have resounding effects over the diabetic individual’s health, social experiences, and academic performance (e.g., Hilsman& Garber, 1995). Because children and adolescents spend on average 30 hours a week in school, it has been suggested that schools might be the primary setting for the identification of depression and eating disorders in children and adolescents (Moor et al., 2007). While teachers are considered to be one of the primary agents in the detection of depression and disordered eating in schools, many teachers are unable to accurately identify students exhibiting signs of these psychological conditions (e.g., Verhulst, Koot, & Van Der Ende, 1994). Moor and colleagues (2007) suggest that even following training sessions involving videos, case vignettes, and general management strategies, teachers are not able to effectively identify depressed students. The design and implementation of more effective depression and eating disorder identification tools in schools may help teachers and school personnel to catch early signs of eating disorders and depression, reducing the risk of future health complications, and increasing the diabetic individual’s quality of life (Van Tilburg et al., 2001).
Statement of the Problem This study will look into the lived experience of middle-aged women with Type 2 Diabetes Mellitus in Ozamiz City.

Significance of the Study
This study may undertake with the hope that its outcome could benefit the following:
Healthcare providers/workers. May be provided with data of the health behavior describe by the diabetic patients and would aid them in their health assessment during hospital admission. This would provide appropriate intervention to health problems manifested by diabetic patients as an effect to their lifestyles. Furthermore, this study results would enable the health workers to reevaluate and improve their health teaching strategies towards the negative effects of unhealthy lifestyles and strengthen those that contribute to optimal health.
Diabetes Patients. The study results could raise awareness regarding the vast implication of diabetes mellitus. They would also appreciate the need to assess or reflect their selves in regards with their behavior to help realize the need of change in lifestyle that can cause them to become ill and to promote wellness.
Future Researcher. This could serve as their one of their basis in conducting another research regarding diabetes mellitus. As we all know that this kind of chronic illness has still no cure but there are regimens and precautions that will help lessen their symptoms and to further prevent complications.

Scope and Limitations of the Study This study will look into the lived experience of middle-aged women with Type 2 Diabetes Mellitus in Ozamiz City. This study will be conducted in the selected barangays of Ozamiz City such as Brygy.Tinago, Brgy. Aguada, Brgy. Bañadero and Brgy. Annex. There will be seven (7) selected participants who served as the participants of the study selected through purposive sampling, in which the participants 1.) have been diagnosed recently with diabetes mellitus type 2, 2.) is aged of 35-50years-old female and is residing in Ozamiz City and 3.) is willing to participate in the investigation. To gather pertinent data and information, a researcher-made questionnaire will be employed to look into the lived experience of middle-aged women with type 2 diabetes mellitus. This research will utilize phenomenological type of study in which the live experiences of diabetic patients will be looked into. The study will be conducted from month of January to March 2014. A colaizzi method of analysis will be utilized.

Definition of Terms: For the purposes of understanding the variables used in the study, the terms are defined according to their operational unit.
Diabetes Mellitus. This refers to the chronic disease experience mostly by women characterized by 3P’s- polyuria, polydipsia, and polyphagia. There are 2 types of Diabetes Mellitus. Type 1 diabetes mellitus are persons experiencing insulin deficiency younger than 30 years old while type 2 diabetes mellitus are the persons having diabetes mellitus (insulin abnormality) older than 30 years old.
Live Experience. This refers to the description made by the participant’s life experience having a chronic disease.

Chapter 2
RESEARCH METHODOLOGY This particular chapter represents the research design, research setting, respondents’ of the study, research instrument and its validation, data-gathering procedure and statistical techniques that will be used.

Research Design This study will utilize the qualitative method particularly phenomenological research design. This method of research aims to gather an in-depth understanding of human behavior and the reasons that govern such behavior. A structured interview guide will be used to collect the needed data. The qualitative-phenomenological method of research is the primary design that will be utilized in this study. This design is the most appropriate in this investigation since the study survey facts and conditions exists in a particular locale.
Research Setting This study will be conducted in Ozamiz City. The city is formerly known as Misamis a name believe to have been derived from the subanen word “kuyamis”, a variety of coconut. However, suggest that the name Misamis came from “Misa” after the Catholic Mass. The origin and the growth of the old Spanish town, Misamis, was due to the presence of the Spanish garrison stationed at the stone fort named Nuestra Señoradela Concepcion del Triunfo which was constructed sometimes the 18th century in order to control the piratical activities originating in the nearby Lanao area. In 1850, the town of Misamis became the capital of the District of Misamis founded by Mr. Jose Ozamis. The city is urbanized and the 3rd largest city.
Research Respondents The respondents in this study will be the seven (7) diabetes patients who were currently residing at Ozamiz city. A purposive sampling will be used in the selection of possible respondents. The respondents will be chosen because 1.) have been diagnosed recently with diabetes mellitus type 2, 2.) is aged of 35-50years-old female and is residing in Ozamiz City and 3.) is willing to participate in the investigation.
Research Instrument A researcher-made questionnaire, unstructured interview guide will be utilized in gathering data. Questions will be directed towards gaining information regarding the respondents’ quality of life after having diagnosed with diabetes mellitus which will focused on their physical capability, the general state of health, the social aspects, and the emotional response towards present condition.
Validation of Instrument In this study questionnaire will be developed by the researchers after an extensive literature review. Content validity test for the development of questionnaire will be done by the researchers. After revising for the draft according to the suggestions and comments from the adviser, the questionnaire will undergo a field test foe reliability of the actual data collection.
Data Gathering Procedure Before the actual distribution of the research instrument, the researchers will secure permission from the College Dean, Dr. Cynthia S. Superable that the researchers will be allowed to conduct the study. After having the approval of the letter of request, a researcher-made unstructured interview guide will be used to obtain data from the respondent’s life experiences having diabetes mellitus. The researchers will obtain the information on the agreed schedule. The researcher will explain to the participants that the findings would be kept confidential and they could withdraw anytime. The researcher will explain the nature of the research such as the interview and the time involved. The researcher will also inform the participants that the participation would be voluntary. The participants will be asked to fill out an informed consent. After getting the identification of the final participants, an interview will be scheduled. The interview will be digitally recorded and will then be transcribed. The interviews will occur throughout the course of four weeks and each one lasted approximately 45 minutes to one hour. A face-to-face interview format will be used to add the benefit of being able to clarify questions, ask further probing questions and observe non-verbal communications. The researcher will take notes during the interview and will make notes of participant’s behavior observed, and then will add the memos to their journal. Moreover, a tape recorder will also be used for the researchers to review what transpired during the interview questions. To start the interview, the researcher will greet the identified participant and will review the purpose of the interview. The participants will be informed again of the right to withdraw at any time and that confidentiality would be maintained. Participants will be asked to review drafts of the written report of the study and to give additional feedback to establish the accuracy of the findings. This kind of member checking is one of the procedures for verifying the accuracy of the data (Creswell, 1998). An interview protocol will be followed. The questions will be open-ended. As in the characteristics of phenomenological interviews, the subjects will be encouraged to share with the researcher the details of their experiences. Probing questions will be asked when necessary to gain the rich description needed for the study and to clarify meaning of participant’s statements. The recorded interviews will be transcribed. The researcher’s reflective notes on their observations of the interviews will be collected and added to the interview data. To come up with the findings, the researcher will follow the seven step method of data analysis of Colaizzi (1978). The steps are: 1.) making sense or acquiring feelings from the interview protocol 2.) extracting significant statements, 3.) organizing the cluster themes, 5&6.) integration of results and exhaustive description and 7.) validation.
Ethical Consideration Before doing the distribution of the research instrument, the researcher will secure permission from the research adviser that she may allow the researcher to conduct study. The researcher will approach the Dean of the College of Nursing to give the researcher opportune time to conduct the study using clinical instructor and student nurse as respondents of the study. While waiting for the approval of the request letter, the researcher will give an informed consent form with an explanation about the purpose of the study and detailed benefits, risk and procedure about the study involving the target respondents.

Interview Protocol

Before the interview begins the participants will be informed that:
The interview will be digitally recorded.
Their identity will be remained confidential during the whole course of the study and in the written report of the study.
They can discontinue their participation at any time.
If they have not done yet, so they will be asked to sign an informed consent form.

Opening Questions.
1. How long have you been diagnose with diabetes mellitus?
2. What was your feeling when you first heard it to your doctor?
3. Does your doctor explain this kind of disease to you? How much do you understand about this disease?
Core Questions.
1. With your situation, can you tell me a story about your present condition and how it affects you and your family?
Closing Question.
1. How do you cope up with the situation having with diabetes mellitus?

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