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The distress experienced by people with type 2 diabetes

Article  in  British journal of community nursing · January 2003

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 RESEARCH STUDY
The distress
experienced by people
with type 2 diabetes
Christina West, Joan McDowell
iabetes mellitus is a chronic condition
D
Christina West is
Diabetes Liaison Nurse, affecting the metabolism of glucose as a
Lomond and Argyll
Primary Care NHS
result of under production of or resistance
Trust, Mid-Argyll to insulin. It is recognized as a major worldwide
Hospital, Lochgilphead public health problem. At present about 100 million
and Joan McDowell is
Senior Lecturer, Nursing
people worldwide have diabetes and it is estimated
& Midwifery School, that by the year 2010 this will have increased to
University of Glasgow, over 220 million (Amos et al, 1997).
Scotland
There are several types of diabetes. Type 1 dia-
betes is characterized by a lack of production of
insulin and is seen predominantly in people under
the age of 40. Type 2 diabetes (which constitutes
approximately 80% of people with diabetes) is
characterized by resistance to insulin production,
usually due to obesity. Though previously seen in
people over the age of 40, it is now increasingly
being seen in teenagers and young adults. Other
types of diabetes are related to pregnancy, genetic
ABSTRACT
With diabetes an ever-increasing problem across the developed world, a
great deal of research has been carried out into the effects of the disease
on the patient. Yet despite the fact that type 1 diabetes accounts for only a
relatively small proportion of worldwide cases, it has been the focus of
research attention. This study aimed to investigate the distress associated
with type 2 diabetes, whether gender differences existed in the impact of
type 2 diabetes and how men and women viewed dietary management. A
multi-method, two-stage research approach was taken. Quantitative data
were obtained using the Problem Areas in Diabetes (PAID) questionnaire,
and no statistically significant gender difference was identified. Worrying
about the future, the possibility of complications and feelings of guilt or
anxiety when ‘off-track’ with diabetes management were sourcces of signif-
icant distress. Treatment mode, length of time diagnosed with diabetes
and age were significant factors which impacted on the emotional distress
experienced by the individual. A subsample of respondents took part in
gender-specific focus group interviews which explored issues identified in
the survey. Behavioural impact, emotional impact and fear of complica-
tions were major themes identified in the interviews. Views of the dietary
management of diabetes were also explored within the focus groups and
three broad categories identified: dietary restrictions, value judgments and
the influence of others. Awareness by health-care professionals of factors
influencing adaptation to diabetes is recommended.
606
disorders and disease aetiologies. The prevalence of
diabetes in the UK has traditionally been estimated
at 2% or more of the population, with undiagnosed
diabetes accounting for a further 2% (Mackinnon,
1995). There is a higher incidence among ethnic
groups who have migrated to the UK, e.g. South
Asians, as a result of a combination of genetic pre-
disposition to diabetes and changes in diet and
lifestyle. Ageing is associated with a deterioration
in blood glucose tolerance, and therefore an
increased risk of developing diabetes: the preva-
lence of the disease rises to 5% or greater in those
over the age of 65 (Peters and Davidson, 1992).
Type 2 diabetes is reaching epidemic proportions.
First line management of people with type 2 dia-
betes is by dietary measures, although medication
or insulin may be indicated at a later date.
Encouraging people with diabetes to stick to a
healthy eating programme is generally believed to
have a positive impact on overall diabetic control, so
influencing the development of complications
(Diabetes Control and Complications Trial, 1993).
The United Kingdom Prospective Diabetes Study
(UKPDS) confirmed the importance of intensive
nutrition therapy for people with type 2 diabetes
(Franz et al, 2000).
Treatment of people with type 2 diabetes and its
complications has been estimated to take up 5–10%
of NHS resources (Alberti, 1997), predominantly
for inpatient care. With the escalating incidence of
diabetes, this is likely to increase. The current phi-
losophy of care is to prevent the early onset of dia-
betic complications, which can be effectively
screened for and managed in a primary care setting.
Hence, it is anticipated that there will be increasing
demands on health-care professionals to help peo-
ple adjust to the impact of diabetes. In view of this,
it was felt that it would be useful to carry out a study
to investigate the impact of type 2 diabetes.
Literature review
Clinical opinion on what constitutes appropriate psy-
chological adjustment to diabetes is conflicting and
the equation ‘good adjustment equals good diabetic
British Journal of Community Nursing, 2002, Vol 7, No 12
control’ is overly simplistic. Emotional adjustment,
by definition, is dynamic and fluctuating. It is an
ongoing process that is shaped by the ups and downs
of the disease and the events of everyday life.
A qualitative, descriptive study carried out by
Handron and Leggett-Frazier (1994) investigated
stressors that impact on a person’s ability to cope
with type 2 diabetes. Data were accumulated from a
series of in-depth counselling sessions with six par-
ticipants with type 2 diabetes and their families.
Factors impacting on diabetes management that
emerged included: a sense of isolation from the
family; co-dependency; experience of loss; overuse
of defence mechanisms; low self-esteem; irritabili-
ty; depression; and secondary stressors not related
to diabetes, e.g. financial concerns, marital prob-
lems. A significant loss of freedom was identified
in relation to food and the ability to eat what, where
or when individuals chose.
Limitations were identified by the authors.
Although the sample consisted of men and women,
the study did not examine differences in their experi-
ences. Using counselling sessions for data collection
could have presented some difficulties due to the
subjective nature of the relationship formed between
counsellor and client. Bias during data analysis was
avoided through the use of a second investigator
to support the validity of the coding, although the
small sample size means the findings cannot be
generalized to all individuals with type 2 diabetes.
In an attempt to identify the factors influencing
the attitudes of women with type 2 diabetes and its
treatment, Dietrich (1996) used a previously tested
interview guide. This allowed comprehensive and
systematic data gathering. However, only seven par-
ticipants could be recruited, resulting in several lim-
itations to the study, which are acknowledged by the
author. Nevertheless, the analytic methods used
resulted in categories for investigation being deter-
mined by the research participants, so minimizing
researcher bias (Polit and Hungler, 1999).
The subcategory of food, cooking and exercise
accumulated the most responses (Dietrich, 1996).
Giving up certain foods and incorporating national
guidelines for healthy eating were seen as challenges
to self-care. These findings support the work of Koch
et al (1999) who found that the women in their study
felt restricted by dietary guidelines. Dietary restric-
tions and meal schedules also caused difficulties
within the family, with some women having to bal-
ance personal needs with family preferences
(Maclean, 1991; Handron and Leggett-Frazier, 1994;
Dietrich, 1996). However, some women may view
increased flexibility within an otherwise unhealthy
family diet as a positive outcome.
British Journal of Community Nursing, 2002, Vol 7, No 12
Paterson et al (1998) carried out an ethnograph- ‘The literature
ic meta-analysis, in which the results of qualita-
tive studies were synthesized to provide informa- available identifies
tion and insights into how people with diabetes that diabetes and
adapt to and manage their illness. A literature its management
search identified 43 research reports, which
addressed 38 discrete studies and fulfilled explic- can have a
it inclusion criteria. A single researcher carried considerable
out the initial analysis. Trustworthiness was impact on people’s
achieved through the use of multiple researchers
to review this analysis, identify negative or non- lives. In some
confirming cases and test rival hypotheses cases this may
(Paterson et al, 1998). even result in
These findings demonstrated ‘balance’ as the
predominant metaphor of living with diabetes. distress.’
Balancing requires an individual to assume an
active self-care role and is achieved through expe-
rience (Paterson et al, 1998). It involves knowing
the body, learning how to manage diabetes and
fostering supportive, collaborative relationships
(Paterson et al, 1998). Learning to balance is a
developmental process in which one learns to
assume control of diabetes management.
The strength of the study lay in its methodology.
The limitations, which were acknowledged by the
authors, are that most of the participants were well
educated, white women with type 1 diabetes
(Paterson et al, 1998). The findings therefore
may only be applied with caution to others. The
findings reflect the lack of research investigating
the experience of people, particularly men, living
with type 2 diabetes.
The literature available identifies that diabetes
and its management can have a considerable impact
on people’s lives. In some cases this may even
result in distress. Gender has been highlighted as
a variable that may influence this experience,
but individuals with type 2 diabetes have not been
studied to any great depth. After reviewing the lit-
erature, therefore, our investigation into the impact
of type 2 diabetes was refined to include the
secondary questions:
● What is the diabetes-related distress of type 2
diabetes on men and women?
● How do women and men view the dietary man-
agement of type 2 diabetes?
Methodology
A multi-method research design (Polit and Hungler,
1999) was employed to answer the research ques-
tions. A two-stage approach allowed for the collec-
tion and analysis of quantitative data, which formed
the basis of questions for deeper exploration in
focus group interviews. Clinical experience seemed
to indicate that there were gender differences in
607
 RESEARCH STUDY

relation to the impact of diabetes and that this hypothesis could only be fully
tested in a multi-method design.
A questionnaire was used to gather quantitative data and focus group inter-
views provided qualitative information. The questionnaire used was the
Problem Areas in Diabetes survey (PAID) (Polonsky et al, 1995), which had
been previously tested for validity and reliability in other studies (Polonsky et
al, 1995; Welch et al, 1997; Snoek et al, 2000), although none of the studies was
without its limitations. The questionnaire is a 20-item measure of emotional
adjustment to life with diabetes, covering topics including – among others –
goals of treatment, family support, worry about complications and eating and
drinking. Each item is rated on a 5-point Likert scale, reflecting the degree to
which the item is perceived as a problem. The scale ranges from 0 (not a prob-
lem) to 4 (serious problem). It is scored 0–100, with higher scores indicating
greater emotional distress.
The open questions developed for the focus group interviews were derived
from the literature and initial analysis of the PAID questionnaire. A panel of
people with diabetes who were excluded from the study reviewed the focus
group questions.

Acquiring the study participants

The sample population was taken from one rural primary care trust. Data pro-
tection legislation (HMSO, 1998) meant that the researchers were unable to
access the diabetes registers for the whole trust. Three general practices were
approached and informed about the study, and were unanimous in their support.
Permission was given by the GPs to access the diabetes registers at their gener-
al practices. Patient population parameters indicated that sufficient numbers
of people with type 2 diabetes were obtainable from these three practices.
People with type 2 diabetes registered with the practices were selected using
stratified random sampling (Polit and Hungler, 1999) which guaranteed the
appropriate representation of men and women. Exclusion criteria were people
who were blind or partially sighted as they would have had difficulty complet-
ing a questionnaire. A sample of 50 men and 50 women were identified. Ethics
approval was obtained from the health board’s ethics committee.
A letter was sent out from the GPs to individuals in the identified sample
describing the study and inviting them to participate. People could participate in
two ways: they could return the enclosed anonymous questionnaire and/or offer
to take part in a focus group interview.

500 British Journal of Community Nursing, 2002, Vol 7, No 10

Data collection
Sixty people (36 women and 24 men) returned the
completed questionnaire. This gives a response
rate of 60% which is acceptable within this
methodological design (Burns, 2000). A total of
51 people (32 women and 19 men) returned the
form offering to take part in the focus group inter-
views. Sampling was undertaken by selecting
names at random from those who volunteered until
eight men and eight women were identified. Five
women and five men actually participated in two
gender-specific groups. The focus group interviews
were held in a central location that was readily
accessible for all participants.
Results from the questionnaires
The questionnaires were analysed using the
Statistical Package for the Social Sciences (SPSS).
Non-parametric statistics (Diamantopoulus and
Schlegelmilch, 2000) were used to examine the
scores from the different groups of participants –
the Mann-Whitney U test (Diamantopoulus and
Schlegelmilch, 2000) for gender and the Kruskal-
Wallis one-way analysis of variance (ANOVA)
(Diamantopoulus and Schlegel-milch, 2000) for
other variables. A significance level of 5% was
used to conduct the hypothesis testing, i.e. a p-
value of 0.05 or less would indicate statistical
significance. It was possible to calculate PAID
scores for only 57 of the returned questionnaires
since the others were incomplete.
Eleven respondents (19%) had a PAID score of 0,
illustrating an absence of diabetes-related distress.
The remaining 46 respondents (81%) therefore did
experience some degree of distress attributable to
diabetes. Total PAID scores for men and women
were compared (Table 1) and showed that
British Journal of Community Nursing, 2002, Vol 7, No 10
a greater number of women had PAID scores
of 1–25.
Gender differences
No significant difference between the PAID scores
for men and women was found in this sample (two-
tailed p = 0.80). This result is similar to Sanden-
Eriksson (2000) who found an absence of gender
difference to the impact of diabetes. However, sever-
al other studies (Bradley and Lewis, 1990; Fitzgerald
et al, 1995; Snoek et al, 2000) did identify gender
differences in PAID scores.
Treatment modes
Table 2 shows the number of participants using dif-
ferent modes of treatment. A significant difference
was found between these groups (two-tailed
p = 0.002). The group of respondents managing their
diabetes with diet and insulin demonstrated signifi-
cantly higher total PAID scores when compared
with the other treatment modes (Table 2). This is in
keeping with the results of Via and Salyer (1999)
who noted that people using oral medication had a
greater ability to cope with feelings and to motivate
themselves compared with those using insulin.
Length of time diagnosed
Length of time diagnosed also had a significant
relationship to the levels of stress of the participants
(two-tailed p = 0.001). Respondents who had been
diagnosed for up to 5 years had significantly lower
total PAID scores compared with respondents diag-
nosed for longer periods of time (Table 3). This
may be due to the fact that these individuals are
still accessing information about diabetes and may
not yet have grasped the long-term implications
of the illness. Those diagnosed for 6–10 years
501
 RESEARCH STUDY

demonstrated significantly higher PAID scores

Table 1. Total PAID scores for men and women than any other group which may imply that the
reality of diabetes has impacted on them, but, with
PAID PAID PAID PAID duration and survival through time, distress related
score of score of score of score of to diabetes decreases. Another explanation may be
Gender 0 1–25 26–50 51–75 Total that increasing levels of knowledge about diabetes
Female Count 7 24 2 2 35 decrease diabetes-related distress, as previously
% 20% 68.6% 5.7% 5.7% 100% reported (Via and Salyer, 1999).

Male Count 4 14 2 2 22
% 18.2% 63.6% 9.1% 9.1% 100% Relevance of age
Age was another significant factor in diabetes-relat-
Total Count 11 38 4 4 57 ed stress levels, with older respondents, aged 80
% 19.3% 66.7% 7.0% 7.0% 100%
years and over, demonstrating significantly lower
PAID scores compared with younger respondents
(two-tailed p = 0.003) (Table 4). A possible explana-
Table 2. Mean rank of total PAID scores by treatment tion is that the older adult may have an expectation
mode of ill health and so take a more pragmatic approach
to diabetes, as age is a factor that influences emo-
tional distress attributable to type 2 diabetes
Number of Mean Rank of
Treatment mode respondents PAID score (Polonsky et al, 1995).
There were other insights gained from the ques-
Diet only 10 16.45
tionnaire. Twenty respondents identified feelings of
Diet and tablets 35 27.99 deprivation regarding food and meals as a minor
Diet and insulin 11 41.09 problem. The questions pertaining to worrying
about the future and the possibility of complica-
Missing 1
tions, feelings of guilt or anxiety when one gets ‘off
Total 57 track’ with one’s diabetes management accrued the
largest number of respondents with 33 and 31
respondents, respectively. Initial analysis of the
questionnaires demonstrated large numbers of
Table 3. Mean rank of total PAID scores by length of
time diagnosed responses for six questions and these were used in
the focus groups as a set of open questions (Box 1).

Length of time Number of Mean rank of Results of the focus

diagnosed respondents PAID score
group interviews
Up to 5 yrs 32 20.92 The analysis of the qualitative findings used the
6-10 yrs 13 39.46 processes identified by Morse (1991): compre-
hending, synthesizing, theorizing and recontextual-
11-20 yrs 7 27.93
izing. The transcripts were read and meaningless or
Missing 5 unrelated material was discarded. If there was any
Total 57 doubt about a portion of text, it remained.
Remaining text was reread and sorted into mean-
ingful segments or units that dealt with a theme or
idea. These meaningful units were repeatedly
Table 4. Mean rank of total PAID scores by age (n=57) reviewed to ensure appropriateness and were then
coded. The codes were used to sort and organize
Age Number of respondents Mean rank of PAID score the text so that patterns and structures connecting
the thematic categories could then be identified.
<40-59 yrs 13 39.42
The focus group interviews identified three main
60-69 yrs 22 25.20 themes in relation to diabetes-related distress:
70-79 yrs 14 31.64 behavioural impact, emotional impact and fear of
complications (Figure 1). These broad categories
>80 yrs 7 12.29
were identified in relation to the aim of the study
Missing 1 and the secondary research questions. Three further
themes were identified in relation to the secondary

610 British Journal of Community Nursing, 2002, Vol 7, No 12

research question on views regarding dietary man-
agement: dietary restrictions, value judgements,
influence of others.
Behavioural impact
Within the category of behavioural impact, four
subcategories were identified (Figure 1). The sub-
category of being ‘ever vigilant’ was identified by
both women and men. Women applied this to their
dietary management and it had a major impact on
their lives. In comparison the men felt the need to be
ever vigilant in relation to their blood monitoring:
‘You’ve got to watch what you are eating all
the time.’ (Woman 3)
‘I’m at work – I don’t want to stop to test.’
(Man 3)
Women rationalized ‘bad’ behaviour such as
binge eating, thereby eliminating the feelings of
guilt:
‘Stress is probably what causes you to
binge.’ (Woman 2)
Men did not demonstrate similar rationalization.
A typical comment was:
‘I think about eating sweets as looking for
energy from sugar.’ (Man 4)
Both women and men identified that due to their
diabetes their behaviour had been altered in positive
and negative ways. Examples of altered behaviour
are buying alternative foods and increasing exer-
cise.
‘I go to the pub every day and I drink diet
Coke.’ (Man 4)
‘I’ve bought an exercise bike.’ (Woman 5)
For the man, the local pub had taken to buying in
his favourite diet drink to encourage his attendance
at the pub.
For women the influence of family members was
most relevant. In contrast, the men denied any influ-
ence by others in the management of their diabetes.
Emotional impact
Within the category of emotional impact of dia-
betes, three subcategories were identified (Figure
1). Women in particular felt a loss of control in rela-
tion to being diagnosed with diabetes and the fact
that, for them, diabetes became all-consuming.
‘It takes over your life. It does really, to a
certain extent … it shouldn’t but it does.’
(Woman 2)
In contrast, the men emphasized the inevitability
British Journal of Community Nursing, 2002, Vol 7, No 12
Box 1. Topics for focus group interviews
Feelings of deprivation regarding food and meals
Not knowing if your mood or feelings are related to your diabetes
Worrying about low blood sugar
Feeling constantly concerned about food and eating
Worrying about the future and the possibility of serious complications
Feelings of guilt or anxiety when you get off track with your diabetes
management.
of associated complications and the unpredictabili-
ty of diabetes.
‘Once you get it there is nothing you can do
about it.’ (Man 1)
The men identified a need for consistency by
health-care professionals in relation to management
targets to reduce ambiguity and uncertainty. This
may explain why the men described feelings of
helplessness regarding their diabetes outcomes and
their perceived failure to meet management targets.
‘It depends on who you speak to … the levels
alter.’ (Man 3)
There were gender differences in the use of denial
as a coping mechanism. The men frequently denied
diabetes had any impact on their lives, in contrast to
the women:
‘I don’t notice it. I don’t really think of
myself as being diabetic at all.’ (Man 5)
The women relayed fears in relation to their blood
glucose levels that included both hypoglycaemia
and hyperglycaemia. The men did not identify fear Figure 1. Themes from focus
as an independent emotion but rather linked fear to group interviews regarding
the fear of complications. diabetes-related distress.
Ever vigilant
Rationalizing behaviour
Behavioural impact Altered behaviour
Influence of others
Loss of control
Impact of diabetes Emotional impact Denial
Fear
Fear of complications
611
 RESEARCH STUDY
‘Educators need Fear of complications
While women also expressed this fear it tended
to ask individuals to be triggered by the knowledge of another person
about their experiencing difficulties with their diabetes and
concerns and how therefore overlaps with the theme of influence
of others.
management of
‘Just what sort of long-term damage is it
their diabetes doing?’ (Woman 3)
impacts on their life
Dietary management
so that gender The women identified dietary restrictions as an area
differences can of their management that caused them concern.
be identified These restrictions resulted in feelings of deprivation
and resentment.
and appropriate
‘I am sitting looking to see what someone
education provided.’ else is eating. It annoys me.’ (Woman 1)
The men similarly identified dietary restrictions
as having an impact but did not tend to view the
changes as restrictively as the women.
‘What you actually eat has changed but I
still very much enjoy my food.’ (Man 2)
The reason for any gender difference may be
related to food preparation in the home. Women
with diabetes appeared to prepare separate meals
for the family and themselves or simply did not
participate in certain courses if deemed unaccept-
able. The female participant who lived alone did
not appear to experience dietary restrictions to the
same extent as others in the group, perhaps illus-
trating the importance of family meal preparation
to this category.
The women, as opposed to the men, specifically
illustrated the subcategory of value judgments in
relation to dietary management:
‘Then again, it depends if you have been
good or bad.’ (Woman 1)
This may have been as a result of food behaviour
being linked to the women’s self-esteem, as reported
by Maclean (1991).
The women identified the influence of others as
problematic due to their concerns about fulfilling
family requirements and their own dietary needs.
Similar findings by Koch et al (1999) and Handron
and Leggett-Frazier (1994) support these findings.
One woman expressed feelings of guilt in relation
to admissions about dietary indiscretions. The men
identified dietary-related situations that might
impact on their experience of diabetes. The situa-
tions mentioned were related to eating in someone
else’s house and therefore afforded the men little or
no control over what they ate, so identifying a link
with the loss of control category identified earlier.
612
Limitations of the study
The study was limited by time as one of the authors
was undertaking this study as part of a higher
degree programme. It is also limited due to the
small sample size. In addition, the sample com-
prised several participants who were known by one
of the researchers in her capacity as a diabetes nurse
specialist and this may have influenced responses.
Conclusions
This study identified the presence and absence of
diabetes-related distress in people with type 2 dia-
betes in a rural community. Quantitative data did
not identify any statistically significant results in
relation to gender.
Statistically significant results were found in rela-
tion to the age of the person with diabetes, treatment
modality and length of time since diagnosis. People
aged over 80 years had less diabetes-related distress
than younger people. Respondents who had been
diagnosed for up to 5 years demonstrated signifi-
cantly lower total PAID scores when compared with
respondents who had been diagnosed for longer.
People whose diabetes was managed with both diet
and insulin had higher PAID scores than those on
diet/or oral hypoglycaemic agents alone.
Although it cannot be generalized, the data show
that people who have had diabetes for more than
5 years, were treated with diet and insulin and who
were younger than 80 years demonstrated the high-
est PAID scores. This has implications for the uti-
lization of resources and support mechanisms
required by people with type 2 diabetes.
Qualitative findings identified some gender dif-
ferences in behaviour and emotional impact, fear
and views of dietary management. These findings
too cannot be generalized, but demonstrate that gen-
der differences should be explored by qualitative
research as opposed to quantitative design.
Recommendations
Further research with a larger sample would produce
more statistically significant results. Studies that
explore rural/urban differences and whether the
availability of food choices impacts on views in rela-
tion to dietary management would be useful. Focus
group interviews could further explore some of the
identified gender differences. This would involve
further refinement of the interview schedule.
The findings highlight several important issues
for practice. Educators need to ask individuals about
their concerns and how management of their dia-
betes impacts on their life so that gender differences
can be identified and appropriate education provid-
ed. There is a need for health-care professionals to
British Journal of Community Nursing, 2002, Vol 7, No 12
recognize that quality-of-life issues may impact on
the individual’s adherence to dietary recommenda-
tions. These need to be explored in conjunction with
the individual so that they can be addressed. For
women there is a need to emphasize the importance
of healthy eating for the family, as opposed to the
preparation of separate foods for women with dia-
betes. This may help to reduce the frustration and
anger experienced by some women.
The setting of mutually acceptable goals must be
a priority in order to reduce confusion and anxiety
in relation to inconsistent management targets.
Older people who have had diabetes for a long time
may have a more pragmatic approach to the man-
agement of their illness. Health-care professionals
should discuss management goals with the individ-
ual with an awareness that these may be less than
ideal. The provision of psychological support,
which enables adjustment to diabetes, may prevent
the use of inappropriate coping mechanisms and a
more positive view of the future. Health-care pro-
fessionals have a responsibility to promote support-
ive relationships that enhance both openness and
honesty with the individual.
Health-care professionals should be aware that a
change in the treatment mode can have a major
impact on the emotional distress experienced by
the individual. Increasingly people with long-
standing diabetes have regimes that are complex
and often involve the use of insulin therapy. Health
care professionals should not assume that long-
standing diabetes equates with emotional adjust-
ment and a need for less education. There is still a
need, if not an increased need, for support among
this group of people. ■
The authors acknowledge Dr G Welch and wish to thank
him for permission to use the PAID questionnaire.
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KEY POINTS
● Treatment mode, length of time diagnosed with diabetes and age were
all statistically significant factors, which impacted on the diabetes-
related emotional distress experienced by the individual with Type 2
diabetes.
● Gender-specific focus groups identified a behavioural impact, an
emotional impact and a fear of complications in relation to Type 2
diabetes.
● Views of the dietary management of diabetes explored within the
focus groups identified three broad categories: dietary restrictions,
value judgments and the influence of others.
● Educators need to ask individuals about their concerns and how
management of their diabetes impacts on their life in order that
gender differences can be identified and appropriate education
provided.
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