Sm. Sri. Med. Vol. 32. No. 6. pp, 689496.

1991
Printed in Great Britain. All rights reserved

PATTERNS

Copyright

OF DIET RELATED

SELF-CARE

0277.953691 $3.00 + 0.04

1991 Pergamon Press plc

IN DIABETES

HEATHER M. MACLEAN
Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, 150 College St. Toronto.
Ontario, M5S IAS, Canada
Abstractaur
understanding of self-care actions can be enhanced by examining both the meanings
attached to them and the context in which they take place. This article discusses patterns of diet-related
self-care in a group of people with insulin-dependent diabetes. The study, based on a phenomenological
perspective, consisted of 91 interviews with 34 people who discussed their everyday experience of living
with diabetes. Individuals response to the diabetes diet can be characterized on a continuum that includes
strict adherence to diet to no adherence. Factors influencing how individuals responded to the diabetes
diet can be grouped into three categories encompassing individual, diabetes-related and contextual influences. Many individuals sought an appropriate balance between health and well-being. When the
pursuit of health did not compromise well-being adherence to diet was not a problem. When the pursuit
of health conflicted with well-being individuals took liberties with the diet in order to minimize its impact.
Implications for promoting self-care in people with diabetes are discussed.
Key words-self-care,

diabetes, dietary change, compliance

identified factors that either constrained or enabled

people to successfully integrate diabetes into their
lives. Although diet-related actions are the focus of
this article they have been interpreted within a framework of understanding developed from prior analysis
of the entire experience of living with diabetes [16].

INTRODUCTION
was recently defined as representing the
range of behaviour undertaken by individuals to
promote or restore their health [I, p, 1171. This
broad definition encompasses self-care actions in
either the presence or absence of medical supervision
and recognizes its significance in both health and
illness. Chronic conditions are a major health problem in todays society and their management depends
on effective self-care. Self-care is equally important in
disease prevention and health promotion programs.
Self-care actions need to be understood in terms of
the meanings attached to them, the context in which
they take place, the norms they are subject to and the
power of decision making which is available to
individuals [2].
This article examines patterns of diet-related selfcare in a group of people with insulin-dependent
diabetes. Compliance with the diet is generally believed to help prevent the long terms complications
associated with diabetes. It would therefore be
expected that motivation to follow a healthy diet
should be high. Nonetheless, studies of dietary compliance in diabetes indicate that the majority of
people do not rigorously follow the recommended
diet [3-91. Compliance studies attribute non-compliance to a perception that the condition is not serious,
interference with habitual actions, complexity of
action, lack of information, and/or a deterioration of
knowledge and management skills [5, IO-121. Most
compliance studies seek causal linkages to explain
non-compliance.
They ignore the constellation of
meanings associated with living with diabetes and the
relationship of these meanings to social and cultural
contexts. To develop a more holistic understanding of
individuals response to diabetes a qualitative study,
based on a phenomenological
perspective [13-l 51,
was undertaken. The purpose of the study was to
understand the impact of diabetes on the everyday lives of individuals who have the condition. It
Self-care

STUDY DESCRIPTION

The data for this article were drawn from interviews with 34 people who have insulin-dependent
diabetes. This sample size is consistent with most
qualitative studies. The labour intensive nature of
data collection and analysis means that sample size is
usually much smaller than comparable quantitative
studies. As subjects must have both a willingness to
participate and an ability to articulate their thoughts
and experiences about the research topic, samples are
rarely drawn randomly. It is therefore likely that the
volunteers have a greater interest in the research topic
and may be more committed individuals than nonvolunteers. Nevertheless, findings from qualitative
studies can be useful in generating hypotheses for
survey research, for assessing the relevance of previous research, and for understanding
personal
meanings and contextual issues linked to behaviour.
A total of 91 interviews were held with the 34 study
participants who lived in Toronto, Canada. The
number of interviews ranged from 1 to 5 with an
average of 2.7 per participant. The average interview
length was close to one and three-quarter hours.
Volunteers were solicited in Toronto through advertisements on the radio, in a local newsletter of the
Canadian Diabetes Association and from diabetes
clinics and diabetes education programs of two teaching hospitals. The sample was balanced in terms of
age (from 20 to 76), gender (19 women, 15 men), and
number of years since diagnosis (from 1 to 39 years).
The interviews were semi-structured and the interviewee was encouraged to discuss issues that were

689

HUTHERM.

690

personally significant. All interviews were taperecorded and transcribed. Data were coded, analyzed
and interpreted using methods common to qualitative
research [ 17-2 I].
RESPONSES

TO DIABETES

DIET

The way in which study participants responded to

the diabetes diet can be characterized on a continuum
that ranges from strict adherence to diet to no
adherence. Thirty percent of the sample described an
orientation that implied strict adherence. Fifteen
percent were at the other extreme, making comments
that suggested that they did not make any effort
to follow the recommended meal patterns. The
remainder of the sample clustered in the middle of the
continuum with 35% describing a response that could
be characterized as moderately flexible and 20%
taking a very flexible approach.
The determination
of where individuals were
placed on the continuum was based on a detailed
analysis of their comments about their eating patterns, the types of food they consumed, their perceptions of their conformity to the recommended dietary
regimen, and their general philosophy of diabetes
management. References to food and diet were woven into commentaries on other aspects of their lives
with diabetes and these were utilized as well. There
were no discernible differences within each group
relative to gender, income or duration of diabetes
except where explicitly noted.
Strict diet

The category of strict adherence to diet consists

of two distinct groups. Half of this group is composed of individuals who had had diabetes for
8 years or longer. These people belived that compliance with diet was essential for good health and
viewed it as a form of insurance against the development of complications. They also described themselves as individuals with a preference for an orderly, methodical life. Most stated that they did
not have a sweet tooth and therefore did not find
the dietary restrictions onerous. The other half of
this group is composed of people who had had
diabetes less than a year and a half and they too
believed the diet with critical to maintaining their
health. Their vivid recollections of ill health prior to
diagnosis underscored the importance of health.
Many people, in other categories along the response
to diet continuum, described a period just following the diagnosis, when they too had been more
strict about their diets. However, over time, other
factors (which will be described below) came into
play which lessened their commitment to following
a strict diet. In retrospect, they saw this early period
as a honeymoon phase which, in many cases, did
not last.
Moderately

flexible

diet

The second grouping on the response to diet

continuum includes individuals who took a moderately flexible approach to diet. The need to live a
balanced (if somewhat shorter) life was the guiding
principle. They spoke of moderation, of exercising
limits within reason, of striking a balance between

MACLEAN

their need for flexibility and the demands of diabetes,

between what was required and what was feasible.
They all spoke of allowing indulgences (sometimes
labelled cheating). There were certain occasions when
they gave themselves permission to eat as they
pleased and they did not spoil the pleasure with guilt.
There was a range of behaviour within this group.
Some people were in close proximity to those who
followed a strict diet. Occasionally they ate restricted
foods but almost always they adhered to regular
timing of meals and snacks. Others displayed considerably more flexibility. They described a more
liberal pattern of eating and they adjusted their
insulin dosage and exercise patterns in accordance
with their consumption of restricted foods. Although,
they did not wish to unduly compromise their health,
they refused to allow the diet to dominate their lives.
All individuals in this group communicated a sense of
confidence about their approach. They had given it
considerable thought and were comfortable with their
choice of action.
Very flexible

diet

The third grouping on the continuum includes

those individuals who reported taking a very flexible approach to their diet. They ate restricted foods
more frequently than the moderately flexible group
and in general, gave little consideration to diet. A
minority of this group made a deliberate choice to
be so flexible. They believed their behaviour was
not overly risky because they monitored their blood
sugar and kept it somewhat in line by vigorous
exercise and by adjusting their insulin dosage. The
rest of this group, however, were dissatisfied with
their response. They spoke of being out of control
and of being upset by their lack of self-discipline.
They spoke of cravings and of being obsessed
with certain foods. On the continuum, these people
were very close to those who do not follow any
special diet.
No diet

The final grouping on the continuum consists of

those people who rarely or never adhered to a dietary
regimen. Most described themselves as miserably
obsessed with food. Gender would appear to be an
important issue because those who were obsessed
with food were women. Their talk of cravings mirrors
the comments of women who suffer from bulimia. In
fact, many of them recounted stories of uncontrolled
binges, usually on chocolate or other sweets. Succumbing to the cravings led to feelings of failure and
self-loathing, feelings which are also characteristic of
women who are bulimic.
Individuals in this group felt angry, resentful and
out of control. Most felt victimized by diabetes. They
were discouraged and distressed by their behaviour
and conveyed an air of dissatisfaction which seemed
to reflect their inability to accept diabetes. By contrast, those in the strict and moderately flexible diet
groupings, and the three described earlier in the
very flexible group appeared satisfied with how they
had integrated diabetes into their lives. They communicated a sense of peace; of diabetes being in its
place.

Patterns of diet related self-care in diabetes

factors
I

Severity

Famky

Duration

Peer

support

EXpWlenCe

ProfessIonal

Threat
of
comptacottons

SOClOl

support

Self-monitormq
occupat

Fig. 1. Factors

support

norms

influencing

lo

response

to diet.

FACTORSINFLUENCINGRESPONSETO DIET
Many factors influenced how individuals
responded to diabetes dietary recommendations
and
hence where they fell on the continuum. These factors
are grouped under three categories: individual influences, diabetes-related
influences, and contextual
influences. As illustrated in Fig. I, the categories are
viewed as interrelated rather than discrete entities.
Some factors figured prominently in a persons response to the diabetes diet, whereas others were less
salient. As well, the configuration of the various
factors differed in any given individual and some
factors were not relevant to every situation. Each
group of factors will be described and their influence
on responses to a diabetes diet will be discussed.
Individual influences

Individual influences encompass unique personality traits that reflect individual temperaments, dispositions, and/or attitudes, beliefs, and values. They
include such things as food preferences, the relative
importance of food and eating, preferred approaches
to life management, character traits such as selfdiscipline and self-esteem, and the ease with which
challenges posed by diabetes were met.
Food preferences. Personal history of food use
influenced reactions to the diabetes diet. People who
had always eaten a healthy diet adapted more easily
to the diabetes diet because it did not entail much
change. Others claimed very little interest in food,
eating simply for nourishment. These people had little
difficulty following a diet although snacks were a
problem for those who had little interest in eating. By
contrast, those who did not eat regular meals, who
had a sweet tooth, or who liked to be intemperate
when the spirit moved them found the changes
required by adherence to a diet very difficult. Those
who took pleasure from food preparation or enjoyed
eating in restaurants also found the diet restrictive.
Life management preferences. One of the most
striking influences on how a person responded to the

691

diabetes diet was a personal preference for approaching and managing everyday life. Some people described themselves as conformists by nature. They
valued expert advice and took it at face value. They
viewed preventive action to ward off future problems
as a worthwhile venture. They described themselves as
organized people who planned ahead and welcomed
routine. Managing a regimented diet quickly became
second nature and was usually embraced with little
resentment. It was quite another story for people who
preferred a more spontaneous approach to life. Because the limits imposed by diabetes were frustrating,
most opted to strike a balance between the demands
of diabetes and their preferences for managing their
daily lives. This usually meant a willingness to pick
and choose from whatever food was available even
if it did not fit strictly within the framework of the
diabetes diet. It almost always meant using multiple
insulin doses and adjusting the dosage according to
how the day evolved. For some, vigorous exercise was
attractive because they believed its blood glucose
lowering effect meant they could be more relaxed
about the diet.
Character traits. Individual temperament played a
role in adhering to diet. Some people attributed their
ability to follow the diabetes diet to their high level
of self-discipline. In turn, they linked their will-power
to other reinforcing factors such as poor health or the
threat of future complications.
For some people, particularly
women, food
behaviour appeared to be linked to self-esteem. The
women who spoke of being obsessed with food were
explicit about this connection. One woman described
her history of ignoring the diabetes diet during those
periods when she did not feel good about herself.
Another recognized that eating was a means of
feeding her emotional hunger. Women who had
grappled with their obsessive tendencies and, for the
most part, had overcome them, were particularly
articulate
about the links between emotional
deprivation and food.
Ease of adjustment. The majority of the men and
women who either infrequently or never followed a
diet attributed their difficulty to the fact that they had
been unable to accept having diabetes. They frequently felt angry, resentful, frustrated, and discouraged. Individuals who had overcome these strong
feelings believed that it was impossible to follow the
regimen until diabetes had been acknowledged and
accepted. Until this happened, constraints on eating
were a focus for some of the frustration and anger.
There was resentment about having to do so many
abnormal things to lead a normal life. It was
necessary to wake up at a set time to eat, to eat
whether or not you were hungry, to interrupt exercise
to eat, to avoid spontaneous activities where food
might not be available when needed, to abstain from
alcohol at parties, and to plan ahead for meals on all
trips, be it a canoe trip in the wilderness or an
airplane trip through time zones. Until this resentment was resolved it was difficult to embrace dietary
changes.
Diabetes-related

iny7uences

A second set of factors that influenced how individuals responded to the diabetes diet were related to the

692

HEATHERM. MACLEAN

specific medical condition, i.e. diabetes. These factors

included the severity and duration of diabetes, ones
unique history of living with the condition, and the
perceived impact of diabetes on the persons past,
present, and future health.
Severity. The severity of diabetes can vary quite
dramatically from one individual to the next. One
person may find that diabetes can be easily controlled
and that occasional indiscretions do not appear to
affect the condition to any significant degree. Another
person may have a form of diabetes that is very
difficult to manage. Straying too far from the recommended diet may result in widely Ructuating
blood sugars and poor physical and emotional health.
When the feedback was this direct it reinforced
following a diet.
Experience. The length of time since diagnosis, and
hence experience with diabetes, was a factor for
some in influencing how they managed the diet.
Almost half of the people who had had diabetes
for 5 years or less clustered in the group who adhered
to a strict diet. Judging from the experience of people
who had had diabetes for a much longer period of
time (10-39 yr) it is likely that at least some of these
people will ease up on their diet as they gain experience living with the condition. Many people recalled
their initial tendency to avoid taking risks by complying with the dietary recommendations.
As they
gained experience and the diet became second nature
they took more liberties. Instead of following rules,
they blended their knowledge base with an acquired
common sense and an awareness of their body to
solve problems that arose because of diabetes. This
wisdom, acquired from experience, enabled them to
pursue a more flexible course while maintaining a
sense of control. As these people were all healthy,
their accumulated experience reinforced their belief
that flexibility was not overly detrimental to their
health.
By contrast, a few individuals concluded, over
time, that stricter adherence to diet was essential
for improving their health and their chances for
long-term survival. At some point each had ignored
the diet but was now more careful. On the response
to diet continuum, these individuals each moved
to the left. All had eventually concluded that
following the diet more closely had improved their
health.
Threat of complications. The threat of complications was a diabetes-related factor that had an
important impact on some people. Many spoke of
being frightened by the thought of future complications but this did not necessarily motivate them to
follow a diet. Some were fatalistic about complications, stating there wasnt a damn thing they
could do about them. They used this fatalism to
rationalize their indifference to diabetes management. Others had faith that good management would
limit the potential damage. If complications did
develop they wanted to be sure they were not attributable to any personal transgressions. This motivation
was so powerful for one woman that she controlled
her food intake by imagining a skull and crossbones
on forbidden foods. Another woman, for whom
flexibility was important, had not consistently followed a diet. However, after developing minor com-

plications that subsequently improved, she felt she

had been granted a reprieve. Good health became
more important and following a diet became a higher
priority.
Contextual injuences

There are a variety of factors in the environment

of individuals with diabetes that influenced their
response to diet. These factors include social stigma
associated with chronic disease conditions. the degree
of family, peer, and professional support, access to
self-monitoring equipment, the influence of social
norms related to food and eating, and certain features
of the work environment.
Social stigma. A predominant concern for almost
all interviewees was how they would be treated by
others once they learned that they had diabetes. They
worried about being stereotyped as different or even
abnormal. Some reported actual incidents where they
had been subjected to unwanted attention because of
diabetes. As well, many regarded having diabetes as
a personal matter which need not be revealed to just
anyone. Consequently, most people tried to avoid
activities that would draw special attention to themselves, preferring instead to act in ways that would be
inconspicuous.
Eating is often a public activity
and many people were reluctant to display eating
behaviour that might expose them to scrutiny. They
reported feeling embarrassed and self-conscious if
others noted something unusual about their eating
pattern.
Family support. Family support was closely linked
to meal preparation which in turn was linked to
gender. If appropriate food was readily available and
inappropriate food was not, it was much easier to
follow a diet. In this regard, married men were at an
advantage because in almost all cases, their wives
prepared meals that generally conformed to the diabetes diet. Two unmarried men spoke about their
mothers playing a similar role. As it was rare for
husbands to prepare meals for women with diabetes,
the women faced more food-related decisions. They
also had to balance their personal needs with family
food needs and most leaned toward flexibility in the
diet. One exception was the woman who prepared
two meals each evening, a plain one for herself which
she ate alone in order to eat on a schedule that suited
her, and a second meal later for her family. She was
so committed to following the diet that she did not
appear to resent the extra work. There were some
instances where family members, particularly the
spouse, followed the same diet and this was viewed as
highly supportive behaviour.
Problems within the family system could have a
negative influence on diet. One young women described how, during her adolescence, she had no
family support for following a diet. As she had not
received emotional support in any other facet of her
life the family response to diabetes was predictable.
Another woman, who acknowledged a history of
marital tension, described how her husband, who did
the shopping, refused to buy foods that were appropriate for her diet. In these cases diabetes became one
more arena to play out family problems.
Peer support. Peer support was discussed at length,
particularly by the younger study participants. They

Patterns of diet related self-care in diabetes

described how gestures from friends that signified
caring reinforced the importance of caring for oneself. Many friends, for example, were willing to
prepare special food to accommodate the person with
diabetes. This action sometimes caused problems
however, because some people with diabetes resented
being singled out even when the gesture was wellintentioned. A lack of peer support was also significant. Some people who had difficulty following the
diet and accepting diabetes described their lives as
emotionally impoverished. They believed that support was essential for coping. This was particularly
true for those who were obsessed with food, using it
as a substitute for emotional nurturing.
Other people with diabetes played an important
support role. Those who coped well were an inspiration. Those who did not cope well were a source of
motivation to avoid the same mistakes. Self-help
groups offered the opportunity to exchange information, ask questions, and discuss topics such as
cheating, that might not be broached with health
professionals. Because they were viewed as a critical
resource, participants were concerned by the shortage
of self-help groups.
Professional support. A number of people attributed their success in adjusting to diabetes to
psychotherapy that helped them deal with the anger
and frustration that was frequently acted out through
eating. It also helped them identify and face features
of their personality and life situation that made
integrating diabetes into their daily life problematic.
Availability of general support from health professionals and formal diabetes education programs
were also factors in dietary self-care. In particular,
people discussed the value of having a physician who
listened to complaints and concerns about following
the diet, who was non-judgmental
about lapses in
behaviour, and who displayed an understanding of
the need for a balanced approach to life and health.
Diabetes education programs were viewed as important vehicles for providing essential knowledge
and skills. However, a number of people wanted these
programs to allow more time for group discussions
about the emotional aspects of living with diabetes,
Self-monitoring
equipment. The use of selfmonitoring
equipment,
especially computerized
blood glucose monitoring systems that give instant
feedback, can play a role in encouraging individuals
to pay more attention to their diet. Only a few people
had blood glucose monitors but those who did found
them invaluable in providing information about their
level of control and in helping motivate them to get
back in line if their readings were high. Before the
advent of home monitoring, information on blood
glucose levels was available only after visits to the
doctor. Psychologically,
home monitors are an
important symbol as they offer a means of reinforcing self-care. They are, however, expensive so their
usefulness may be limited because of accessibility
problems.
Cultural norms. Cultural norms related to eating
and drinking also played a role in the response to
diet. A number of people commented that the recent
emphasis on health and fitness has made it more
acceptable to abstain from alcohol and to choose
healthy foods without feeling conspicuous. Eating in

693

restaurants posed problems particularly for those

who followed a strict diet. They usually avoided
restaurants and thus missed much of the socializing
that accompanies eating out. Those who were less
strict were content to eat what was available and
viewed the pleasures of restaurant eating as a higher
priority than worrying about their diet.
One manifestation of a more health-conscious lifestyle has been the proliferation of cookbooks with
recipes suitable for people with diabetes. A number
of women reported on the usefulness of these books
in preparing tasty, healthy food.
Occupation. Occupation also played a role in influencing the response to diet. Some men described the
difficulty of keeping to any type of diet while involved
in the sales/marketing culture where business is frequently transacted over meals and includes heavy
drinking. One man ignored his diabetes for years in
order to conform to this culture. As his health
deteriorated he slowly came to the conclusion that he
had to change his habits. As he did so he encountered
a great deal of hostility from his colleagues and was
eventually fired. Although the intervening years were
filled with conflict and trauma his story had a happy
ending. He is now self-employed, feels fulfilled
and healthy, and counsels others on how to handle
diabetes-related job discrimination. Others described
similar job cultures but resolved the difficulties with
less trauma. Confronting corporate cultures that
entail entertaining, drinking, or working long hours
without meal breaks is a very real challenge for
individuals especially if they are reluctant to publicly
admit that they have diabetes.
The most common work-related problem was eating meals and snacks on time. Some carried snacks
from home while others purchased them from coffee
wagons or cafeterias. A bigger problem was deciding
how to handle meetings that went over the lunch
hour. People felt conspicuous eating during the meeting and most were reluctant to suggest breaking for
lunch. These reactions, which were linked to publicly
acknowledging diabetes, indicate the strength of the
concern about being stigmatized by others.
DISCUSSION

In this sample the majority of the people took a

middle of the road approach to the diabetes diet. The
central concept that governed their response was
balance. Balance was the key to a lifestyle that did
not unduly compromise ones health but was still
personally satisfying. A somewhat smaller group
were happy with a more controlled approach to the
diet because they believed it was essential to good
health, both now and in the future. The smallest
proportion of the sample took an impulsive approach
to the diet, in some cases ignoring it altogether. The
distinctive feature of this group was the sense, for
almost everybody, that they were not in control of
diabetes. They were obsessed with food yet felt angry
and frustrated when they gave into their cravings.
The influences identified in this study encompass
many of those found in existing models of health
behaviour such as beliefs about the severity of the
condition and ones susceptibility to it, the perceived
benefits of changing behaviour and attitudes toward

694

HEATHERM. MACLEAN

the condition [22-261. The importance of social and

structural factors emphasized in models by Anderson
[27] and Green [26] were equally emphasized in this
study. In addition, the diversity of factors identified in this study illustrates the complexity of selfcare actions. Although thematic influences could
be clearly identified across the data, the exact
configuration and weighting of the influencing factors was unique to each person. This unique pattern,
at the level of the individual, suggests that linear,
causal analysis compiled from aggregate data may
oversimply our understanding of behaviour.
The study findings have important implications for
promoting self-care and for the development of disease prevention and health promotion programs.
Two important and interrelated constructs emerged
from the analysis of meanings associated with diet
and diabetes. The first construct concerns the notion
of autonomy and control and the second relates to
personal interpretations of health.
This article has illustrated the links between a sense
of control, satisfaction with ones approach to diabetes, and acceptance of diabetes. Those who expressed satisfaction
about how they managed
diabetes also felt they had some control over their
situation. Their overall approach to diet resulted
from a conscious deliberation which took into account a variety of needs and preferences. This response is a sharp contrast to the approach of most of
those who rarely followed the diet. These people felt
buffeted by diabetes and had no sense of being in
charge of their food intake. Their comments indicated their unhappiness with this state of affairs. They
expressed strong, negative feelings about diabetes,
viewing it as an adversary who had the upper hand
and made them feel impotent and incapable.
Self-care actions may result in behaviour that
health professionals consider detrimental to health
(e.g. the case of individuals who opt for a very flexible diet). When such actions result from deliberate
autonomous choice, the decision must be respected.
Self-care must acknowledge individuals right to
make their own decisions, including the decision to
do nothing. When actions emerge from a sense of
powerlessness and are ultimately demoralizing then
interventions to enhance self-care are critical. However, the objectives of interventions by health professionals to promote self-care must be considered
carefully and must take into account personal
interpretations of health.
Interpretations of health varied among the participants in this study. A number of people held conventional views of health, seeing it as a desirable
end-point that would maximize their life expectancy.
Many more people had a view of health that was
more consistent with health promotion, i.e. that
health is closely linked to well-being and is created in
the process of living and working in everyday life [28].
Well-being has been identified as a subjective assessment of health which is less concerned with biological
function than with feelings such as self-esteem, and a
sense of belonging through social integration [29,
p. 1261. Many people in the study (implicitly) distinguished health from well-being. Their search for the
appropriate balance between health and well-being
was a key feature of negotiating a satisfactory life

with diabetes. When the pursuit of health did not

compromise well being, adherence to diet was not
problematic. However, when the pursuit of health
conflicted with other needs, individuals had to find
ways to enhance well-being. Criteria for well-being,
while unique to each individual, encompassed the
notion of a lifestyle that complements rather than
restricts the achievement of personal aspirations and
vitality. Dietary flexibility was an important strategy
in enhancing well-being for many of the subjects. It
was achieved by a variety of means including planned
cheating, multiple insulin doses, regular, vigorous
exercise, and taking a liberal but balanced approach
to food selection. The distinctions between health
and well-being have not been addressed in the diabetes literature. Health is assumed to be synonymous with the achievement of certain physiological
standards (such as ideal blood glucose and lipid
levels). As a result, little, if any attention is given to
the need to help individuals discover the degree to
which achieving such outcomes might compromise
well-being.
There is no question that efforts to achieve physiological health are crucial to the management of
diabetes. At the same time, it is impossible to ignore
issues of well-being. Ultimately, discovering the
healthy life patterns that support a sense of well-being
have to be viewed as a self-care behaviour that merits
as much attention as the management of diet, insulin
and exercise.
This research has a number of implications for
promoting self-care in people with diabetes. It
emphasizes the importance of diabetes education
programs that help individuals sort through their
response to diabetes (and the diet) by encouraging reflection and discussion of personal values,
preferences, and aspirations.
The research also highlights the significance of the
cycle of learning that evolves from the experience of
living with the diabetes over a period of months and
years. This process of reflecting and learning from
experience, which is surely the essence of self-care.
has received little attention in the literature. Diabetes
education programs can build on this process by
offering additional programs based on time since
diagnosis and/or on the particular stage of adjustment to the condition. While such programs might
provide updates on developments in the treatment of
biabetes they would focus primarily on participants
experiences and the challenges posed by the condition.
Institutions should ensure that participants and
family members have access to individual and group
therapy and to self-help groups if they express the
need.
Health professionals who wish to promote self-care
should have access to in-service training to familiarize
them with concepts of self-care and to contrast these
with concepts acquired during professional training.
They should develop approaches to clients based on
active listening, empathy, and mutuality.
Diet-related self-care can be fostered in a sociocultural context that makes healthy choices the easy
choices. In a more health conscious society more
stimulants for healthy eating are available. The
people in this study were aware of the changing

Patterns of diet related self-care in diabetes

climate
in health and nutrition-related
attitudes
and practices. It has, for example, become more
acceptable in social situations to avoid alcohol and
decline desserts. Resources such as cookbooks with
good recipes for sugar and fat reduced diets were
readily available. They are early indications that
restaurants and airlines are beginning to cater to
health conscious consumers. This shifting environment makes it easier for everyone to select a balanced
diet and lessens the chances that people with diabetes
will be singled out for unwanted attention when they
do so.
There is also a need for policy initiatives to
promote self-care. Blood-glucose monitoring devices
that enable individuals to asses, for themselves,
their level of control, should be subsidized by
insurance plans. Funding should be made available
for self-help groups and for demonstration projects
that add innovative educational
components
to
traditional programs. Diabetes organizations should
be funded to conduct advocacy activities that
lessen the stigma associated with diabetes. Human
rights legislation should pay particular attention to
discriminatory practices related to diabetes in the
workplace.
The findings of this study indicate that gender
is a factor that influences self-care. Feminist analysis has suggested that at this particular point in
history, some womens confusion about gender issues
is manifested in the guise of obsession with food
and the development of eating disorders such as
anorexia and bulimia [30]. It is therefore not surprising that some women with diabetes find themselves
enmeshed in a tangle of ambivalent reactions to the
diabetes diet. Addressing gender issues in diabetes
calls for a range of approaches. It may be useful
to provide self-help and/or therapy specifically for
women with diabetes. However, because the actions
of women are a reflection of their response to a
broad cultural phenomena, the solutions are bound
up with the status of women in society at large.
Thus, the difficulties that some women face in dealing with the diabetes diet offer yet another rationale
for initiatives in other policy arenas that address
gender issues.
Self-care actions
They are part of
and the meanings
Findings presented
to the diabetes diet
reflect individuals

occur within a social context.

a pattern
of overall behaviour
attached
to the behaviour
[2].
in this article show how responses
are not independent
actions but
overall reaction to diabetes and

to the life context in which they live. Diet-related

health care actions are influenced by a host of
interrelated factors that include individual differences, social and cultural influences and the nature
and experience of diabetes itself. Efforts to promote
self-care must take into account the breadth of
these factors and encompass both individual and
sociocultural initiatives.
Acknowledgemenrs-This

research received a contribution

from the Health Promotion Directorate, Health and Welfare Canada (No. 6652-2-90). I would like to thank Jan
Tanner for her help with data analysis and Gwen Chapman,
Barbara Davis, and Joan Eakin for their comments on this
manuscript.

695
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