Conquering diabetes by overcoming psychological barriers and embracing health

Diabetes mellitus and insulin resistance

Diabetes mellitus (DM) is one of the major chronic diseases today^1,2. Data for 2021 show that 537 million people are currently living with DM around the world, with a 46% increase predicted by 2045 ¹. DM is an endocrine disease, a carbohydrate metabolism disorder, more specifically a glucose processing disorder^1,3,4,5. It is diagnosed by a significantly elevated blood glucose level^6,7. It is caused by the inadequate pancreatic β-cell function, which leads to a lack of or insufficient production of the insulin hormone^4,5. Without the necessary amount of insulin, cells are unable to absorb glucose from the blood⁷. This means that glucose is not converted into energy that the body can use but accumulates in the blood³. As a result, blood glucose levels rise and do not fall without external intervention^5,7. Depending on the reason for the inability of the pancreas to produce the hormone insulin and the extent to which its function is impaired, there are two main types of DM^4,5,7. Depending on the type, treatment may vary: insulin therapy, medication and lifestyle changes may be recommended^1,2,8.

Type 1 diabetes mellitus (T1DM) develops from autoimmune causes at an early age, before the age of 30 ^4,9. In this case, the pancreas’s insulin-producing cells are damaged, i.e., destroyed or inactive, due to immune causes. Consequently, to survive insulin must be injected into the body from an external source⁵. Today exogenous insulin is delivered by PEN injection or insulin pump device⁷.

The development of type 2 diabetes mellitus (T2DM) is mainly due to lifestyle factors such as obesity, a sedentary lifestyle, and an inadequate diet^5,7, although genetic predisposition is also thought to play a role¹⁰. It is often diagnosed after the age of 40 years in people with a genetic predisposition and an inappropriate lifestyle⁵. A comprehensive lifestyle change is essential for its management¹⁰. However, in most of the cases lifestyle changes must be complemented by medication or, in more severe cases, insulin therapy⁴. It may be possible to identify a pre-existing reversible condition of T2DM¹.

This pre-existing prior condition of T2DM is called insulin resistance (IR). In many cases IR can be reversed with a healthy diet and regular exercise^11,12. It can be grouped with DM because it is also a metabolic disorder that is caused by abnormalities in insulin receptors. In fact, IR develops when cells become insensitive to the action of insulin hormone for some reason¹³. It can exist on its own, or it can develop into diabetes or co-exist with other chronic conditions (e.g. PCOS; Ighbariya & Weiss, 2017). IR, like T2DM, is closely associated with certain lifestyle characteristics (e.g. obesity) as well as genetic factors^11,12,14. Obese people, and even children, are at particular risk of metabolic disorders^14,15. The symptoms and possible consequences and complications of IR are like those of diabetes. Although it is a less severe and often reversible condition, it is mostly a chronic, lifelong metabolic problem requiring constant attention and illness management, that can have a significant impact on the quality of life¹⁶.

Living with a chronic illness

IR and DM both worsen the quality of life and have many negative consequences, making them a major public health problem around the world^2,6.The treatment of people with diabetes and DM’s complications (e.g. slow-healing wounds, skin infections, cardiovascular problems, kidney failure, sexual dysfunction, vision problems, neuropathy, limb amputation), functional decline, and high premature mortality rates place a significant disease burden on both the health care system and society^1,4,6,8,17.

The diagnosis of IR or DM is often experienced as a crisis, a grief reaction, and a traumatic event¹⁸. The burden of living with these states is significant, with psychosocial effects impacting self-care, long-term glycemic control, risk of complications, and quality of life^17,19. Diabetic people frequently perceive the daily management of their disease as a significant challenge as it demands a considerable investment of energy and commitment from the person with diabetes^18,20. This is particularly the case when they are striving to achieve a state of optimal metabolic health, a goal that is often unattainable (Silva et al., 2018). Furthermore, the self-care guidelines are often intricate and opaque, which can result in diabetic people experiencing feelings of frustration, anger, being overwhelmed or defeated and lacking motivation to adhere to disease management²¹. Often, illness-related conflicts with loved ones arise and the patient’s relationship with health professionals may become tense as well²².

Diabetes distress

The additional workload associated with the management of DM can contribute to an overall increase in stress levels. This negative emotional or affective experience, arising from the challenge of living with the specific demands of DM, is known as diabetes distress²³. Diabetes distress refers to the worries, doubts, fears, and threats associated with coping with DM, including its management, the risk of complications, possible loss of functions and concerns about access to care^22,23,24. Diabetes distress is an expected response to DM: it doesn’t necessarily represent psychopathology and shouldn’t be considered a co-morbidity, it is simply an emotional aspect of DM²³. It is a multifaceted construct that has implications for various aspects of DM management and self-care, and is common in both T1DM and T2DM diabetic individuals and can also be extended to IR persons. It is associated with lower levels of self-care, general emotional well-being, and with worse metabolic outcomes of illness management^{20,22,23,24,25}.

Health empowerment

Health empowerment is an important indicator of health behavior^26,27,28. It can be interpreted in two different contexts^26,29. In an intrapersonal sense, it expresses the extent to which an individual can make autonomous decisions about maintaining their health. It therefore includes both knowledge and skills related to health maintenance^27,30. In an interpersonal sense, health empowerment expresses the extent to which an individual can cooperate with professionals to maintain their health²⁹. In conclusion, patient empowerment can be defined as the process by which a patient strives to gain comprehensive and effective control over the management of their illness, while developing a close relationship with specialists who can provide professional guidance and information to support the patient’s goals²⁸. In essence, it is the patient’s own control and responsibility over the quality of their own life^28,30.

Enhanced health empowerment is associated with improved health outcomes across a diverse range of individuals with chronic diseases^26,27,28,30 and in individuals who are generally healthy^31,32. However, in patient populations, it is crucial to monitor specific health behaviors to prevent adverse outcomes^26,27,30. In contrast, individuals who are in good health do not feel direct pressure to engage in specific behaviors. Instead, they act in a considered manner, weighing the potential benefits and risks involved³². The provision of appropriate, reliable, and easily accessible sources of information is a crucial element in the enhancement of health empowerment in both groups^31,33.

As early as the 1990s, Anderson and his colleagues highlighted the significance of developing programs centered on patient empowerment within the context of diabetes care. The intervention, which had been tested, led to an increase in patients’ self-efficacy regarding diabetes management and enabled them to control their blood glucose levels more effectively³³. In individuals with type 2 diabetes, diabetes empowerment is associated with enhanced effective self-care behaviors (e.g., dietary habits, physical activity, or foot care), improved medication adherence, and greater knowledge³⁰.

Motivation for healthy eating

Regardless of the reason why someone is trying to regulate their diet (e.g. health, weight loss), as with health empowerment, maintaining a healthy diet requires motivation^34,35. Motivation is essential for an individual to be able to change their behavior³⁴. According to Deci and Ryan (2000) there are 3 different types of motivation in the regulation of behavior: intrinsic motivation, extrinsic motivation and amotivation. In intrinsic motivation, there is a strong internal drive for the individual to feel competent and effective in achieving the goal, without the need for external, material motivators. In the case of extrinsic motivation, the individual acts under the influence of various external motivators (e.g. rewards, expectations of others). An amotivated state is when the individual is unable to control their behavior to achieve the desired goal³⁶. Deci and Ryan have provided a more detailed examination of the various levels of behavioral regulation in their theory of self-determination. 6 levels were defined along a dimension, with intrinsic motivation at one end and amotivation at the other: intrinsic motivation, integrated regulation, identified regulation, introjected regulation, external regulation, and amotivation³⁷. For illustrative examples of the functioning of these motivational levels in relation to healthy eating, see Table 1 on page 369 of the 2021 article by Román and her colleagues³⁵.

In general, previous research has demonstrated that maintaining a healthy diet is more likely to succeed when the motivation to do so is intrinsic^38,39,40,41. External motivators are less effective in maintaining a balanced diet in the long term³⁸. Intrinsic motivation is shaped by external influences as parental example or social expectations^40,42. An excellent example of how intrinsic motivation to eat healthily can be effectively shaped by appropriate information from adolescence is provided in Bryan and his colleagues’ 2016 article. By defining healthy eating as an autonomous action that defies parental control and the manipulative tactics of the food industry, adolescents were able to make healthier food choices³⁹. The individual’s subjective experience of the effectiveness of their own actions in this regard is of critical importance in the consolidation of intrinsic motivation to eat healthily^39,42,43. Individuals who perceive themselves to be efficacious agents in the process are more likely to exhibit stable intrinsic motivation⁴³. According to people living with DM, higher levels of perceived self-efficacy in diabetes management increase the motivation to maintain an appropriate diet and reduce the risk of developing eating disorders^42,44,45. Furthermore, consciousness may serve as a reinforcing factor, with access to appropriate information being a crucial element^38,41,42.

The process of internalizing healthy eating motivation does not differentiate between people with IR and DM and people without these diseases. However, a distinction can be made in that people with IR and DM receive prompt feedback on their dietary choices, as they are required to monitor their body’s condition with greater precision and regularity. Consequently, upon observing incremental outcomes, they may cultivate a robust intrinsic motivation to maintain healthy eating habits in a more expeditious manner than their counterparts in the general population. It should be noted, however, that the development of healthy eating motivation has not yet been the subject of a specific study among people with IR and DM and healthy controls.

Body responsiveness

The incorporation of physical activities, such as yoga and mindfulness meditation, that are specifically designed to enhance body awareness and responsiveness has been demonstrated to have a beneficial influence on the formation of healthy eating habits^46,47,48. Body responsiveness can be defined as ‘the tendency to integrate body sensations into conscious awareness to guide decision making and behavior and not suppress or react impulsively to them’ (Daubenmier et al., 2013, p. 781). Furthermore, body responsiveness mediates the relationship between body objectification and increased risk of developing eating disorders⁴⁶. It has a positive effect in improving eating habits by promoting intuitive eating and preventing emotional eating^48,49. Body responsiveness is positively related to positive indicators of psychological well-being (e.g., satisfaction, positive affect, resilience) and negatively related to maladaptive psychological functioning (e.g., impulsive acting out of negative emotions, mood disorders; Tihanyi et al., 2017).

Higher levels of body responsiveness have been demonstrated to have a positive impact on an individual’s behavior, as evidenced by their efficacy in the management of both diabetes and insulin resistance. The inclusion of body responsiveness in our study was motivated by two factors. Firstly, there is a paucity of research examining its role in the context of living with a chronic metabolic disorder. Secondly, the aforementioned effects of body responsiveness on DM and IR provide a rationale for its inclusion in our study.

Meaning in life

The psychological variables mentioned before collectively encapsulate the degree of activity necessary to sustain a state of optimal well-being. However, beyond action, a sense of belief is also required, namely that the activities undertaken daily are worthwhile and make sense. This is why we believe it is essential to address the construct of meaning in life as well.

The concept of meaning in life can be defined as a mental state that is constituted through a multitude of diverse, subjective experiences⁵⁰. What factors contribute to the meaningfulness of an experience? The process of assigning meaning to an experience involves establishing a network of associations and interpretations that facilitate the comprehension of that experience and inform future actions⁵¹. The concept of meaning provides individuals with the perception that their lives are significant and have a purpose, that they are more than the mere accumulation of seconds, days, and years^50,51. The concept of meaning in life can be conceptualized in two dimensions: that of living and that of seeking. The act of living a meaningful life entail engaging in actions and experiencing situations that one deems to be genuinely worthwhile and fulfilling^51,52. The seeking of meaning in life can function as a kind of motivational base⁵². It encourages the individual to address and rectify the dysfunctional aspects of their life. Nevertheless, excessive searching and an inability to cope with the resulting frustration can precipitate the onset of mental conditions and disorders that pose a threat to physical and psychological well-being^50,51,52. Despite this latter exaggeration, the meaning in life is presented as a positive psychological variable in the studies^51,53.

A new study provides definitive evidence that a clear protective function of meaning in life emerges among people with type 2 diabetes mellitus (T2DM). It is an indisputable conclusion that death anxiety and experiential avoidance have a deleterious effect on quality of life. However, the negative effect of the two variables under investigation was no longer evident when a high level of meaningfulness of life was present⁵³. The process of meaning-making has been shown to result in significant positive changes in the way young people with T1DM live with diabetes. Individuals who view diabetes as an opportunity for personal growth and empowerment, and who therefore invest time and energy in managing their condition, have been found to experience additional distress. However, this approach has also been shown to lead to positive outcomes in terms of disease indicators⁵⁴.

Individuals managing a chronic condition as complex as IR or DM have several options at their disposal. These options can assist individuals in mitigating the adverse consequences associated with the additional distress experienced in relation to the illness. It is evident that empowerment in disease management, intrinsic motivation to adhere to a healthy diet, enhanced bodily responsiveness, and the identification of meaning in life serve as protective factors in this process. Those with IR and DM are more likely to prioritize the aforementioned factors than individuals without IR or DM. This does not imply that individuals without IR or DM are not mindful of these aspects. However, on average, individuals with IR and DM tend to demonstrate a higher level of awareness regarding their bodies and diets compared to individuals without IR or DM.

The aim and hypotheses of the present study

The aim of this research is twofold. First, we want to examine the differences between people with IR and DM along the measured health psychological variables compared to a control group of people without IR or DM. Further, we are interested in how the protective variables are affected by diabetes distress in IR, T1DM and T2DM groups.

In our first hypothesis (H1) we predict that there will be significant differences between people with IR or DM and people without IR or DM according to the followings:

• H1a: There will be no significant difference in the level of subjectively perceived health-empowerment between the individuals with IR and DM and the individuals without IR or DM, because the two groups have completely different dimensions of health. However, T2DM group will report significantly lower empowerment than T1DM and IR group.

• H1b: The T1DM group will differ positively from the other groups in the degree of integrated regulation. The T2DM group is expected to be significantly different from the other groups in that they will have the highest degree of external regulation.

• H1c: People with IR and DM will have higher body responsiveness than people without IR or DM. Among people with IR and DM, T1DM group will stand out in terms of body awareness, while the body-mind disconnection is highest among T2DM individuals.

• H1d: There will be no difference between groups in the presence of meaning in life, but there will be a difference in the level of searching it. The T2DM group will search the meaning in life the less.

Our second hypothesis (H2) is that the groups of IR, T1DM and T2DM individuals would differ significantly from each other in the level of diabetes distress, regardless of the time since diagnosis. According to our assumptions, the level of diabetes distress will be highest among T2DM individuals, and lowest among T1DM individuals, while IR individuals will be between the two diabetic groups.

In our third hypothesis (H3), we are interested in the homogeneity of IR, T1DM and T2DM groups along the measured variables. We hypothesized that the most homogeneous group is the T1DM group, while IR group can be considered a slightly more heterogeneous group, and the T2DM group will emerge as the most heterogeneous group.