HEATHER M. MACLEAN

Sm. Sri. Med. Vol. 32. No. 6. pp, 689496. 1991 Printed in Great Britain. All rights reserved

0277.9536’91 $3.00 + 0.04 Copyright c 1991 Pergamon Press plc

PATTERNS OF DIET RELATED SELF-CARE 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

INTRODUCTION

Self-care 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 today’s 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 self- care 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

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].

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 non- volunteers. Nevertheless, findings from qualitative studies can be useful in generating hypotheses for survey research, for assessing the relevance of pre- vious 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 adver- tisements on the radio, in a local newsletter of the Canadian Diabetes Association and from diabetes clinics and diabetes education programs of two teach- ing 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 inter- viewee was encouraged to discuss issues that were

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690 HUTHER M. MACLEAN

personally significant. All interviews were tape- recorded 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 percep- tions of their conformity to the recommended dietary regimen, and their general philosophy of diabetes management. References to food and diet were wo- ven 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 or- derly, 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

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 con- siderably 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. Suc- cumbing 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 691

I factors I

Severity

Duration

EXpWlenCe

Threat of comptacottons

Famky support

Peer support

ProfessIonal support

SOClOl norms

Self-monitormq

occupat lo”

Fig. 1. Factors influencing response to diet.

FACTORS INFLUENCING RESPONSE TO 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 person’s 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, dispo- sitions, 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 self- discipline 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

diabetes diet was a personal preference for approach- ing 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. Be- cause 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 HEATHER M. MACLEAN

specific medical condition, i.e. diabetes. These factors included the severity and duration of diabetes, one’s unique history of living with the condition, and the perceived impact of diabetes on the person’s 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 comply- ing 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 wasn’t 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 attribu- table 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


described how gestures from friends that signified caring reinforced the importance of caring for one- self. 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 well- intentioned. 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 inspi- ration. 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 self- monitoring 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

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 meet- ing 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 one’s 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 one’s susceptibility to it, the perceived benefits of changing behaviour and attitudes toward


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 self- care 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 one’s 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 indi- cated 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. How- ever, 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 conven- tional 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) distin- guished 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 synony- mous 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


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 women’s 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 surpris- ing 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 deal- ing with the diabetes diet offer yet another rationale for initiatives in other policy arenas that address gender issues.

Self-care actions occur within a social context. They are part of a pattern of overall behaviour and the meanings attached to the behaviour [2]. Findings presented in this article show how responses to the diabetes diet are not independent actions but reflect individuals’ 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 Wel- fare 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.

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HEATHER M. MACLEAN

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