Editorial Board: Editor: George H. Conklin, North Carolina Central University Board: Bob Davis, North Carolina Agricultural and Technical State University Richard Dixon, UNC-Wilmington Ken Land, Duke University Miles Simpson, North Carolina Central University Ron Wimberley, N.C. State University Robert Wortham, North Carolina Central University
Shannon O'Connor North Carolina Central University
Volume 4, Number 2
The Social Side of Diabetes: The Influence Of Social Support on the Dietary Regimen of People With Diabetes*
Roger Y. Klomegah
Fayetteville State University
Diabetes mellitus is a chronic endocrine disorder characterized by dysfunctions in glucose metabolism due to problems with the production and utilization of the hormone insulin. Diabetes is one of the biggest health care problems facing the United States with regard to prevalence, cost, and the onus it places on patients and its high morbidity and mortality rates (Marzilli, 1999).
Treatment of diabetes involves developing a management plan with a goal of controlling blood glucose (BG) levels and thereby decrease the chances of developing complications such as circulatory problems, renal failure, blindness, and peripheral neuropathy (Goodal & Halford, 1997). To achieve this goal, patients are advised to follow a complex management regimen, which usually consists of self-monitoring of blood glucose, diet, body weight, education, exercise, medications, and attitude (Kereiakes and Wetherill, 2002).
Diabetes is about sugar in the blood and because sugar comes from the food we eat, adherence to dietary regimen becomes very important in self-care aspect of diabetes management and it is central to diabetes treatment. Nonetheless, dietary regulation is one of the challenges in diabetes management, because it extends over a long period of time, it involves progressive adjustments and changes in lifestyles, and it also involves different self-care behaviors in terms of appropriate food choices, limiting carolic intake, and timing meals appropriately (Glasgow et al, 1984, 1987).
Diet, unlike the pharmacological aspect of diabetes self-care, has to do with social behavior, which is subject to the influence of other people. Previous studies linking diet adherence to behavior of others and those who live with them support this fact. However, previous authors have also noted that additional research is needed in the specific types of social support that diabetic patients receive, as well as with culturally diverse populations (Epple, 2003; La Greca and Bearman, 2002; Marzilli, 1999).
This study is a response to the above call for further studies on types of social support that people with diabetes receive. The purpose is to examine the association between the perceived nutritional social support and diabetic patients' eating behavior.
The study has the following objectives:
1. To examine two social support factors (emotional and instrumental) that influence adherence to dietary regimen. An example of emotional support is making supportive comments and an example of instrumental support is eating the same way, cooking, or doing grocery for the diabetic patient.
2. To identify gender and racial/ethnic differences in the observed relationship. Since most previous studies focused on children and adolescents, I am limiting my study to adults with diabetes who reside in Cumberland, Lee, and Robeson counties in North Carolina.
The following questions were addressed:
1. Is there a significant relationship between a) perceived emotional (verbal) support and adherence to dietary regimen and b) perceived instrumental (active) support and adherence to dietary regimen?
2. To what extent do index scores of emotional and instrumental support predict dietary adherence? How much variance in dietary adherence can be explained by scores on these scales?
3. Which variable in the study is the best predictor of dietary adherence?
4. Is there a variation in adherence to food regimen by gender and by race/ethnicity?
The mind-frame of people with type 2 diabetes influence how they will react to their rate of compliance and treatment (Flynn, 2004). The factors that influence compliance to treatment are the person’s health beliefs, locus of control, polypharmacy, and social support. It has been noted that between 30% and 60% of people with diabetes do not comply with their treatment, and diabetic patients who enjoy good social support have stability and are more likely to adhere to management regimen (Flynn, 2004). In fact, studies have suggested that social support plays a part in predicting food adherence (Sherman et al., 2000; Gonder-Frederick et al., 2002). However, social support has been mentioned broadly without any specification of type of support.
Fisher and others (1998) have identified four categories of factors that are associated with diabetes management - patient characteristics, stress, provider-patient relationship, and social support. They have found out that the association of social support with objective indicators of metabolic control of diabetes has been less demonstrative and results have been mixed. They also have noted that social support is the least studied among the four categories. Because of the importance of social support, many have called for increased research into the social aspects of diabetes management.
In a study of the role of the family in management of type 2 diabetes among the Dine (Navajo), Epple (2003) discovered that active support of family members is related to clinical measures of metabolic control for Dine diabetic patients. To be sure, when family members involve themselves in cooking meals for the respondent, the individual was more likely than not to have lower triglyceride, cholesterol, and hemoglobin A1c (Hb A1c) levels. A1c test determines how controlled (close to normal) a diabetic’s blood sugar has been over the last 3 months.
Adhering to diabetes regimen, which involves a combination of diet, medication, and exercise, is a tough act to follow. At times, lack of proper planning and local food habits obstruct implementing diets. If the regimen is perceived as merely to stop the disease from worsening and not to cure it totally, or if it involves big changes in lifestyles to be followed over an extended period of time, adherence is usually low. Coupled with these psychological challenges, lack of social support can engender non-compliance to dietary regimen and diabetes control.
In a study of individuals with diabetes resident along the US/Mexico border, Concha and others (2004) found that individuals who receive non-directional social support such as expressions of intimacy or esteem and tangible assistance such as money or shelter were more likely to show better quality of adherence. Marzilli (1994) has shown that eating behaviors of others can influence eating behaviors of diabetic patients, especially if they live together. The study has demonstrated that eating well with others is more challenging than eating well alone. Moreover, it is easier to eat healthily when those one associates with also eat healthily compared with when they do not. Marzilli found out that there is a correlation between self-efficiency, social support, and glucose control. Those with higher Hb A1c and lower self-efficacy levels have more difficult time eating well both alone and with others, than those with lower Hb A1c and higher degree of self-efficacy.
Gender and ethnicity may also affect the benefits of support differently, but previous results are conflicting. In some instances, socially supported women tend to lose more weight or better Hb A1c control than do socially supported men; whereas in other cases, the results show the opposite (Epple, 2003). Marzilli’s study, for example, has shown that there is higher self-efficacy in women than in men. However, it is not clear why this is so. The need for further research in gender and ethnic difference in the social correlates of diabetic management and adherence to dietary regimen is apparent. Even though there is general evidence to support the association between social support and diabetes self-care, it is unclear what specific types of support affect adherence to dietary regimens (Gonder-Frederick et al., 2002; Brawley & Culos-Reed, 2000; and Sherman et al., 2000).
With considerations from the literature in mind, a hypothesis was tested that eating choices and behaviors of a diabetic person is significantly associated with eating choices or behaviors of family members or significant others. People are more or less likely to make good or bad dietary choices that will promote or prevent blood sugar control based on the choices of those around them.
Data collection method was a survey. In designing the measuring instrument, survey questions on demographics and dietary management from Diabetes Care Profile (Fitzgerald et al., 1996) and The Diabetes Social Support Questionnaire-Family Version (LaGreca & Bearman, 2002) were extracted and modified respectively. The questionnaires (reproduced below) were administered to 151 participants (diabetic patients) who were selected by convenience sampling method through diabetic clinics and diabetic education centers in Cumberland, Lee, and Robeson counties in North Carolina. Because the sample was selected by a non-probability method, the results of the study cannot be generalized beyond this unique sample.
The variables involved in the study were as follows: Independent variables –emotional social support and instrumental social support. Dependent variable – adherence to diet regimen. I adjusted for the effects of age of respondents, number of people who live with respondent, membership of diabetes support group, gender, and race/ethnicity.
Emotional support was measured by an index of the following questions: How often does a family member encourages you to eat the right foods? How often does a family member ask if certain foods are okay for you to eat before serving them? How often does a family member tell you not to eat something you shouldn’t? How often does a family member remind you about sticking to your meal plan? Instrumental support was measured by an index of the following questions: How often does a family member do grocery shopping for your meals? How often does a family member suggest foods you can eat on your meal plan? How often does a family member join you in eating the same food as you? How often does a family member cook meals for you that fit you meal plan? Diet adherence was measured by an index of these items: How often do you follow a meal plan or diet? In general, how often do you try to choose foods that best help you maintain good blood sugar level?
Reliability analysis was done to check for the reliability of these scales. The outcomes showed Cronbach's alpha coefficients of .92 for the emotional support scale, .87 for the instrumental support scale, and .79 for the dietary adherence scale, indicating that all scales showed internal consistency. That is, for each index, the items measured the same underlying construct.
Two limitations are noted in this study. First, the special population involved in the study had an effect on sample size, as it was challenging recruiting participants with diabetes; consequently responses had been slow. Second, some ethnic/racial groups were underrepresented because either they were unavailable in the locations (clinics) chosen for the study or they were underrepresented with the disease.
The sample comprised 151 respondents (32% males and 68% females) who were recruited from diabetic clinics and diabetic education centers. All participants were between ages 18 and 92 (M = 55, SD = 18.3). Most of the respondents (88.6%) reported that, upon being diagnosed with diabetes, they had been told to follow a meal plan. Twenty three percent of the respondents also reported belonging to diabetes support group. Most of them (71.8%) lived with up to 5 people and the minority (28.2%) lived alone.
48% of the sample were married and 19.2% were never married, 13.9% were separated/divorced or widowed. The ethnic/racial breakdown was as follows: Whites constituted 46.4% of the sample, Blacks 41.1%, Hispanics 2.6%, Native Americans 7.9% and Asians, Arabs, and others .21%. Almost 7% had graduate degrees, 19.5% had bachelors degree, 61% had attained some high school, high school GED, some college, or technical school diplomas, and 12.8% had attained 8th grade or less. With regard to current employment status, 33.8% of the respondents worked full time, 11.3% worked part time, and the balance of the sample (54.9%) were unemployed, homemakers, in school, retired, or disabled.
A question was posed about respondent’s perceived importance of receiving emotional and instrumental support from family and friends in a way that helps maintain blood glucose control. Generally, the majority of the participants thought it was important to receive social support, emotionally or instrumentally, in a way that helped one to control blood glucose level. This observation is consistent for males (93.5%) and females (95%) as well as married (95.8%) and unmarried people (93.4%). There is no difference in this perception between males and females, and married and unmarried people.
Another question was posed on whether or not it was difficult for respondents to eat in a way that helped to control their blood glucose if others they were eating with chose to eat healthily. The greater proportion of both demographic groups found it easy to eat healthily if others around them do so. Eighty seven percent of both males and females reported that they ate in a manner that helped them control their blood sugar level if others around them chose to eat healthily. Similar pattern can be seen among married and unmarried people. Ninety percent of unmarried and 81% of married people would eat healthily if those eating with them do so. However, statistically, there was no significant associations between gender and degree of difficulty in eating healthily [X2 (1, n = 147) = .001, p > .05] and marital status and degree of difficulty in eating healthily [X2 (1, n = 148) = 2.475, p > .05].
The relationship between the dependent variable (diet adherence) and the independent variables (emotional and instrumental support) was evaluated using Spearman's correlation coefficient. The analysis (summarized in Table 1) revealed that
both independent variables (emotional and instrumental support) have a positive association with the dependent variable (diet adherence) with increasing social support associating with increasing adherence to dietary regimen. Instrumental support had the stronger association with diet adherence (rs = .55, p < .05). Emotional support has the next strongest correlation with diet adherence (rs = .52, p < 05). Other variables included in the study also had a significant association with adherence to diet. Age had a moderately strong and positive association with diet adherence with increasing age associating with increasing dietary adherence (rs = .28, p < .05). Healthy eating with others also had a correlation with diet adherence (rs = .21, p < .05).
To examine the gender variation in adherence to food regimen, Mann Whitney U test was done and the outcome showed no difference in adherence to food regimen between males (n = 47) and females (n = 102), z = -1.20, p > .05. Similarly, a Kruskal-Wallis test indicated that there was no variation [H (3, n = 150) = 4.45, p > .05] in adherence to food regimen among the various ethnic/racial groups (White = 70, Black = 61, Native American = 12, Other = 7).
To address the rest of the research questions posed in the introduction, standard multivariate regression analysis was performed.
As indicated in Table 2 the R2 equals .53 meaning that the model, which includes emotional and instrumental support, healthy eating with others, age of respondents, number of people living with respondents, and membership of diabetes support group, was able to explain 53% of the variance in the dependent variable -- adherence to diet. If we were to consider the Adjusted R2 = .51 instead, due to the sample size (n = 151) and as the better estimate of the true population value, the variance explained by the model would be 51% which is very similar to the R2.
Adjusted Rsquare = .505
Constant = .501
*p < .01
In Table 2, eating healthily with others had the strongest beta coefficient of .33, indicating that it has the strongest contribution to explaining the dependent variable (adherence to food regimen) when the effect of other variables in the equation were adjusted for. The next strongest explanatory variable was instrumental support (beta = .31). The more active support respondents receive from their relatives, friends, and significant others, the more frequent they adhere to their dietary regimen. Following instrumental support in explaining adherence to diet is Age of respondents (beta = .25). Older respondents adhere to diet regimen more frequently than younger respondents. Next in line of explanatory power is membership of diabetes support group (beta = .20). The coefficient of membership of diabetes support group is approximately .20, which is the difference in the predicted values of those who belong to a support group compared with those who do not when the influence all other variables are held constant. In effect, belonging to diabetes support group is a good predictor of adherence to food regimen. Emotional support and number of people living with respondent had beta coefficients of .10 each, making them the least contributors to explaining the variation in adherence to diet.
Of the variables in the analysis, eating healthily with others, instrumental support, age, and membership of diabetes support group made statistically significant contributions to the prediction of the dependent variable, adherence to dietary regimen. On the other hand, emotional support, and number of people living with respondents did not make statistically significant contribution to the prediction of adherence to dietary regimen.
Discussion and Conclusion
In this study, I have replicated findings about the relationship between social support and diabetic patients’ adherence to dietary regimen, but this time, with emphasis on the influence of emotional (verbal) and instrumental (active) supports. I have also examined this relationship in the context of males and females and ethnic/racial categories. Generally, the majority of the respondents recognized the importance of social support to their dietary management and control of blood glucose level. The majority of the respondents also found it easy to eat healthily if family members, friends and others around them eat healthily.
It is very clear from the above findings that most diabetic patients acknowledge the importance of social support in managing their condition. Their perception of the degree of difficulty in adhering to food management was contingent on eating behaviors of others, whether or not they eat healthily. Most of the respondents believed that it would be easier to eat in a fashion that helped them control blood sugar if others around them choose to eat healthily. This information lends support to Marzilli’s (1999) earlier finding that diabetic patient’s found it easier to eat healthily when those they associated with also eat healthily compared with if they did not.
In examining the specific types of social support people with diabetes received, it was discovered that while both emotional (verbal) and instrumental (active) support are correlated with dietary adherence, instrumental support appears to be more important as it has a stronger association to dietary adherence than does emotional support. When these variables were examined in a multivariate analysis, the difference between them become clearer. Even though both emotional and instrumental support had predictive powers, instrumental support has a stronger predictive power. Moreover, whereas instrumental support made a statistically unique contribution to the prediction of adherence to food regimen, emotional support did not. This finding supports and refines earlier findings that suggest that social support plays a role in predicting adherence to food regimen (Sherman et al., 2000; Gonder-Frederick et al., 2002) and contributes more information about the type of support that is vital in helping people with diabetes manage their disease.
Another important finding from the study is the contagion effect of healthy eating. Almost every respondent reported that when people around them ate healthily, they also ate healthily and in a fashion that helped them control their blood glucose. In fact, the variable eating healthily with others had the highest predictive value among the valuables considered in the regression model as depicted in Table 2.
The social interaction and behavioral implication of this finding underscores the value of active involvement of family members, friends, and significant others in the lives of people living with diabetes. Active support such as helping in doing the grocery, helping in choosing and cooking healthy foods, and eating healthily around diabetes patients would help in managing what and how they eat. Just as Marzilli (1999) has shown, eating behaviors of others can influence eating behaviors of diabetic patients, especially if they live together.
The study did not find any differences in dietary adherence between males and females nor among ethnic/racial categories. Future research is needed to include ethnic and racial categories and to estimate their association with social support and eating behaviors (dietary adherence), because this research was limited by adequate representation of these categories. Further study should be designed in manner to resolve this limitation.
The Diabetes Social Support Questionnaire
We want to know how often your family members and friends
do things to help or support your dietary regimen. We also want to know
how you feel about their supportive behavior. There are no right or wrong
answers. Just circle the number that best describes what each supportive
behavior means to you.
1. (age) What is your age? ______
2. (gender) Gender
3. (marital) What is your marital status?
4. (ethorigin) What is your ethnic origin/race?
5. (pplivewith) How many people live with you?
6. (schooling) How much schooling have you had?
7. (employsta) Which of the following best describes your
current employment status?
Emotional Support Questions
8. (famrightfoo) How often does a family member encourage
you to eat the right foods?
9. (okaytoeat) How often does a family member ask if certain
foods are okay for you to eat, before serving them?
10. (remind) How often does a family member remind you
about sticking to your meal plan?
11. (notoeat) How often does a family member tell you
not to eat something you shouldn’t?
Instrumental (or Active) Support Questions
12. (dogrocery) How often does a family member do grocery
shopping for your meals?
13. (suggestfoods) How often does a family member suggest
foods you can eat on your meal plan?
14. (joineating) How often does a family member join you
in eating the same food as you?
15. (cookmeals) How often does a family member cook
meals for you that fit your meal plan?
16. (hsemotionfrien) When eating out or eating at
other people’s houses, how often do your friends provide emotional (verbal)
support to help you eat in a way that helps you maintain good blood sugar
17. (hseactivfrien) When eating out or eating at other
people’s houses, how often do your friends provide active support by choosing
to eat healthily along with you?
18. Do you belong to Diabetes Support Group?
Other Dietary Questions
19. (pplwchose) If the people I am eating with choose
to eat healthily, eating in a way that helps me maintain my blood glucose
control is …
20. (receimosuport) Receiving emotional support from other
people about eating in a way that helps me control my blood sugar is …
21. (receinstrsuport) Receiving active (instrumental)
support such as having people eat healthily with me that helps me maintain
control of my blood sugar is …
Diet Adherence Scale
22. (mealpl) Has any health care provider or nurse told
you to follow a meal plan or diet?
23. (mealplan) How often do you follow a meal plan or
24. (genfoods) In general, how often do you try
to choose foods that best help you maintain good blood sugar level?
*This study was supported by Grant Number P20 MD001089 from the National Center of Minority Health and Health Disparities, National Institutes of Health. Its contents are solely the responsibility of the author and do not necessarily represent the official views of National Institutes of Health.
The author gratefully acknowledges support received in
administering questionnaire from Melissa Brady and Judy Klinck of Better
Health of Cumberland County, John Paszton of Regional Diabetes & Endocrine
Center in Fayetteville, Susan Morgan of NC Cooperative Extension Service
in Bolivia, Susan Condlin of NC Cooperative Extension Service in Sanford,
Gladys Paul of Diabetes Community Center in Lumberton, and Susan Noble
of NC Cooperative Extension in Lumberton.
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