Psychosocial Aspects Of Diabetes Research Paper

1. Diabetes Mellitus

1.1 Background

Diabetes mellitus is characterized by abnormality in the production or utilization of insulin to regulate blood sugar levels. It has a complex etiology and pathogenesis (Mandrup-Poulsen 1998), and affects about five percent of the population, with variation by age, gender, ethnicity, and geographic location. It is grouped crudely into two forms, Type 1 and Type 2, with some rarer forms such as gestational diabetes and maturity onset diabetes of the young. Type 1 diabetes (insulin-dependent diabetes or IDDM) is an autoimmune disease characterized by insulin deficiency, accounting for about 15 percent of diagnoses, typically in people less than 30 years of age. Type 2 diabetes (noninsulin-dependent diabetes or NIDDM) is more complex and is characterized by resistance to insulinmediated glucose disposal or impaired insulin secretion. It accounts for about 85 percent of diagnoses, typically in people aged 40 or older. The disease has serious long-term consequences caused by elevated blood sugar levels, or hyperglycemia, and can result in blindness, limb amputation, liver failure, and increased risk of stroke and heart disease.

1.2 Management

The diabetic individual must attempt to maintain strict glucose control to avoid low blood sugar levels, or hypoglycemia, which is very aversive, and to minimize long-term complications. Obesity is a major issue in Type 2 diabetes, and management initially focuses on control through diet and exercise, which is usually supplemented with oral medication, and sometimes with insulin, as the disease progresses. Type 1 diabetics, and Type 2 diabetics with little insulin production, must receive insulin through daily self-injection to survive. Treatment also involves dietary change, eating foods containing complex rather than simple sugars and distributing food intake over the day. Regulation of exercise levels and balancing these with food intake is also required to maintain blood sugar levels within a normal range. Management thus involves regular attention to a range of daily self-care tasks, attending to diet, exercise, medication, and blood glucose level monitoring.

Most research into psychosocial factors in diabetes has focused on successful control of blood glucose levels. A major longitudinal study, the Diabetes Control and Complications Trial, established that strict metabolic control can sharply reduce long-term complications from diabetes, and it set standards for glycated hemoglobin levels considered as adequate control. However, strict control is not always achieved as diabetics juggle the demands of the disease against the demands of daily life. This has prompted a move from compliance to adherence (Jenkins 1995) and for educational programs to incorporate local cultural understandings, increase knowledge, motivation and goal-setting, and empower diabetics to self-adjust their regime.

2. Psychosocial Aspects Of Diabetes

2.1 Knowledge, Attitudes, And Beliefs

Understandings of diabetes and attitudes towards it can influence how it is managed. Diabetics with greater knowledge of the disease have been found to deal with issues of glycemic control more appropriately than patients with less knowledge. Knowledge and beliefs about insulin function has also been linked to the pattern of insulin use adopted, and indirectly to control. Hence, knowledge and beliefs are considered important components in diabetic education programs aimed at enhancing adherence. However, their effects on control are generally indirect and mediated by other psychosocial factors.

Comparison of the understandings of diabetes held by patients and health professionals reveal considerable differences between them in responsibility for control and explanations for the disease. Professionals’ disease models emphasize pathological and physical aspects whereas patients’ models emphasize social aspects and the impact of the disease on their lives, leading to issues of adherence and control being valued differently by these groups.

2.2 Stress, Coping, And Adjustment

Stress is widely considered to have effects on diabetes onset and management, but the evidence for this is mixed, and dependent upon the assessment of stress and outcome measures. Cox and Gonder-Frederick (1992) concluded that:

(a) relationships between stress and diabetes are bidirectional, and stress can affect diabetes directly (through hormone release) and indirectly (by disrupting self-care behavior),

(b) with regard to onset, no research has linked stress to onset of Type 2, but there is evidence for increased incidence of stressful life events before Type 1 onset, and

(c) the effects of stress on blood glucose levels after onset are variable. Laboratory studies produce mixed findings and indicate marked individual differences, suggesting that some subgroups are more reactive than others. Field studies generally support a relationship between increased stress and increased blood glucose levels, but differ as to whether this is mediated by self-care behaviors.

Subsequent research provides little evidence for changing these conclusions. Recent research has moved to focus on daily stressors rather than major life events, to use repeated daily records rather than retrospective ratings, and to examine individual variability in stress response. These directions, combined with prospective designs and better controls, may lead to improved models of stress effects in diabetes.

Adjustment to diabetes follows a similar course to other chronic illnesses. Diagnosis can lead to a sense of loss, grieving, and concerns about the future, followed by a period of adaptation to a new life situation and readjustment of goals and life understandings. Successful negotiation of this leads to the development and use of skills to manage the changed situation successfully. Research into diabetic coping strategies is limited and has generally been confined to the postdiagnosis period, and focused on Type 1 diabetes. Most studies demonstrate problem-focused or task-oriented strategies to be better, at least in relation to glycemic control. However, some studies have shown denial or avoidance coping to be adaptive, and this is a continuing area of debate. Gender differences in the use of strategies have also been documented.

2.3 Social Support

Social support is a complex construct, but generally is found to have positive effects on diabetes management. Research has demonstrated positive effects on adherence and control for both structural support (e.g., family, friends, workers as sources, density of support networks) and for functional support (e.g., diabetes-specific help, communication style, cohesiveness). As much of this research is cross-sectional, directional relationships between support and outcome are not clear. Gender differences have been documented for both level and type of support and for its relation to outcome. Adolescence has been a particular focus of this research (Burroughs et al. 1997), and has documented the importance of a supportive family, particularly following diagnosis. Functional support, especially involving open, empathic communication within families, is also important for achieving good adherence with adolescents.

Evaluation of interventions designed to enhance support, such as social skills training for diabetics, and diabetic understanding for families, has revealed positive effects on adherence and control. Several trials have demonstrated that group instruction to impart diabetes knowledge and coping skills produces better results than individualized instruction. Support provided through self-help groups or through a mentor (a well-adjusted patient) has been promoted but not researched in the context of diabetes.

2.4 Quality Of Life

Diabetes, with daily requirements for self-monitoring and management in order to avoid the short-term consequences of hypoglycemia and the long-term complications associated with hyperglycemia, has a substantial impact on daily life. This has led to considerable interest in diabetic quality of life (QoL), assessed through a wide range of concerns including morale, well-being, depression, and role functioning. The relationship between glycemic control and QoL for Type 2 diabetics is mixed; for Type 1 diabetics, most research finds glycemic control and QoL to be related, cross-sectional and prospectively. Recent research has also found intensive insulin therapy to be associated with better QoL outcomes, attributed to making management more compatible with the demands of daily living.

Psychiatric morbidity is higher for both Type 1 and Type 2 diabetics than in matched controls, and this is compounded by diabetic complications: those with complications have higher levels of morbidity than those without. Depression has been a specific focus of studies, and prevalence rates between 8 and 27 percent are reported in diabetic patients. Depression appears not to be directly related to glycemic control.

QoL is multidimensional, and only some aspects of it relate to disease-specific outcomes such as control. The development of diabetes-specific measures of QoL (Bradley 1994) provides a means to standardize measurement in this area, and to assess the impact of diabetes on aspects of life other than control.

2.5 Diet And Eating Disorders

Dietary factors are specifically relevant in diabetes: food choice for Type 1 and reducing body weight for Type 2. Limited research here suggests that breaches of dietary self-management show high individual variability, and are associated with reactions to hypoglycemic symptoms and social cues about eating.

Research on dietary issues has focused on younger female diabetics and the relationship between diabetes and eating disorders. Diabetic women are reported to have higher levels of body dissatisfaction and desire for thinness than age-matched healthy controls, and women who omit insulin injections (to lose weight) are found to be more sensitive to external cues to eating. Many reports suggest an increase of eating disorders in Type 1 diabetics, and also an increase of Type 1 diabetes amongst patients with eating disorders. However, recent controlled research does not support this. Intentional insulin admission is, however, potentially indicative of eating disorder in Type 1 patients.

2.6 Sexual Dysfunction

Diabetes is associated with disorders of sexual function, but this varies by gender. Diabetic men report lower levels of erotic drive, sexual arousal, enjoyment, and satisfaction than controls. Up to one-third of diabetic men experience erectile disorder: three times the rate for healthy controls but similar to rates for other chronic diseases. For diabetic women, sexual dysfunction rates appear not to differ substantially from general population rates, although there is limited evidence for loss of libido, enjoyment, and satisfaction. Apart from an association between neurological disorder and erectile dysfunction for men, it appears that psychosocial factors, such as disease acceptance or depression, rather than disease-related factors, such as glycemic control or disease duration, are more predictive of sexual dysfunction, particularly for women (Thomas and LoPiccolo 1994).

3. Future Directions

Psychosocial factors are implicated in almost all aspects of diabetes, but research findings in this area are often inconclusive, fragmented, or limited methodologically. To overcome this, future research should: develop improved theoretical accounts of psychosocial influence; make more systematic use of standard measures such as those described by Bradley (1994); extend research to examine other outcomes alongside glycemic control; conduct more controlled trials and longitudinal studies; and conduct more research, absolutely and comparatively, on the more common Type 2 diabetes.

Bibliography:

1. Bradley C (ed.) 1994 Handbook of Psychology and Diabetes. Harwood, Chur, Switzerland
2. Burroughs T E, Harris M A, Pontious S L, Santiago J V 1997 Research on social support in adolescents with IDDM: A critical review. The Diabetes Educator 23: 438–48
3. Cox D J, Gonder-Frederick L 1992 Major developments in behavioral diabetes research. Journal of Consulting and Clinical Psychology 60: 628–38
4. Jacobson A M 1996 The psychological care of patients with insulin-dependent diabetes mellitus. New England Journal of Medicine 334: 1249–53
5. Jenkins C D 1995 An integrated behavioral medicine approach to improving care of patients with diabetes mellitus. Behavioral Medicine 21: 53–65
6. Mandrup-Poulsen T 1998 Diabetes. British Medical Journal 316: 1221–25
7. Thomas A M, LoPiccolo J 1994 Sexual functioning in persons with diabetes: Issues in research, treatment and education. Clinical Psychology Review 14: 61–86
8. Warren L, Hixenbaugh P 1998 Adherence and diabetes. In: Myers L B, Midence K (eds.) Adherence to Treatment in Medical Conditions. Harwood, Amsterdam, The Netherlands