Diabetes mellitus is a relatively new clinical problem in the pediatric population. For instance, only a few decades ago, the prevalence of diabetes type 2 in children and adolescents was significantly low. Nevertheless, Reinehr (2013) notes that since the mid-1990s, researchers started to observe a growing incidence of diabetes around the globe and especially in such developed countries as the USA, Canada, Germany, Japan, and others.
As Reinehr (2013) continues, this rise in the occurrence rate of diabetes mellitus is correlated with a substantial increase in both the prevalence and the degree of obesity within the pediatric population. Over the years, the problem had evolved to the extent when this adverse metabolic condition in children and adolescents became one of the most serious threats to public health. The risk of life-long morbidity, which children and adolescents with diabetes mellitus face, emphasizes the need for effective nursing interventions and their timely implementation. It is valid to say that in order to develop successful intervention strategies, one should necessarily know all the factors leading to the onset and progression of the disease.
It is possible to say that in the case of diabetes type 2, the risk factors are primarily external/environmental in nature. Considering this, such holistic nursing care theories as Myra Levine’s Conservation Theory and Dorothea E. Orem’s Self-Care Deficit Nursing Theory will be applied to analyze the mechanisms of adolescent diabetes occurrence, as well as plausible intervention methods, because these theoretical models consider person-environment interactions as an essential attribute of human health.
Literature Review: External Risk Factors for Diabetes Development
Pathophysiological mechanisms involved in the development of diabetes mellitus include insulin deficiency (i.e., insufficient production of insulin) and insulin resistance (i.e., impaired use of insulin by cells). As Dendup, Feng, Clingan, and Astell-Burt (2018) state, insulin resistance is associated with both genetic and lifestyle factors, as well as aging. For instance, the lack of physical activity and the intake of energy-dense food predict overweight and obesity which, in turn, trigger the development of insulin resistance and insulin secretion abnormalities (Dendup et al., 2018; Reinehr, 2013).
In their study, Caccavale et al. (2015) emphasized the role of adolescents’ disordered eating in the progression of diabetes type 1. The researchers note that the major factors determining inadequate dietary behaviors include societal pressures, changes that took place within the body during puberty, bodily dissatisfaction, as well as “suboptimal family functioning, including poor cohesion, communication, and support” (Caccavale et al., 2015, p. 9). These findings indicate that family dynamics and relationships with peers are essential risk factors leading to adverse outcomes in relation to the metabolic disorder development in the pediatric population.
Environmental determinants influencing individuals’ exposure to risk factors which then trigger such intermediary health outcomes as increased blood lipid and blood glucose levels, hypertension, and obesity include limited availability of health services, physical activity resources, community safety/violence, urban sprawl and walkability, level of pollution, and some others (Dendup et al., 2018). As Dendup et al. (2018) state, along with unhealthy dieting behaviors and physical inactivity, these environmental factors contribute to the following risks: excess stress, social anxiety and isolation, and disturbed sleep.
Additionally, Jeon, Ha, and Kim (2015) note that the degree of environmental contamination with toxic chemicals and metals, including cadmium, mercury, persistent organic pollutants, and bisphenol A is associated with the occurrence of diabetes in the general population. It is worth mentioning that these findings on environmental chemicals-diabetes links are relatively new, inconsistent, and controversial. Nevertheless, they still may indicate that environmental hazards take part in the progression of diabetes.
Problem Description and Discussion
The occurrence of diabetes in adolescents and children can be explained from the perspectives of the Conservation Theory and the Self-Care Deficit Nursing Theory. Mefford (2018) states that Levine’s Conservation Model is concentrated on the promotion of an individual’s wholeness through adaptation to the environment. In this theoretical model, the term “wholeness” is utilized as a synonym for health.
It implies “a sound, organic, progressive mutuality between diverse functions and parts within an entirety, the boundaries of which are open and fluid” (Mefford, 2018, p. 167). It means that health is defined by the quality of human-environment interactions. Every individual adapts to the environment in which he or she lives, whereas disease mainly occurs when a person’s adaptive energy starts to deplete. For example, when exposed to environmental stressors such as family conflicts and social anxiety, the endocrine system releases epinephrine and cortisol, which make the liver produce more glucose in order to provide the body with sufficient energy to “fight” the external threats.
Along with responding to stressors through this biological process, a person may adapt to it by changing behaviors. For instance, he or she may start to eat more food to cope with psychological distress. As Mefford (2018) observes, “long-term stress can take tall on the individual, sometimes leading to a state of exhaustion” (p. 168). Thus, in the context of enduring exposure to stressors, one may become incapable of maintaining health and safety and can stop seeking wholeness (Mefford, 2018). As a result, the disorder, such as diabetes, occurs.
The individual’s wholeness is disrupted when in case there are threats to energy balance, structural integrity, personal integrity, and social integrity in the environment (Mefford, 2018). These threats can be observed in the process of diabetes development as well. For instance, physical inactivity and an unhealthy diet contribute to the imbalance between energy input and output. As the findings of the literature review show, the impaired energy balance affects the physiological processes in a negative way, causing insulin deficiency and resistance (Dendup et al., 2018).
Additionally, a sedentary lifestyle and disordered eating behaviors threaten one’s structural integrity. According to Mefford (2018), “structure and function are strongly interrelated complementary aspects of the human organism” (p. 169). It means that to preserve the structure of the body, a person must support the physical processes through healthy activities that help conserve the continuity of tissue and the overall functionality of body organs and parts. At the same time, it is apparent from the findings of the literature review that behavioral patterns in adolescents with diabetes do not usually support structural integrity but rather result in overweight and obesity, as well as other adverse conditions.
As for personal and social integrity, it can be substantially threatened by such environmental factors as a family and social relationship dynamics, community safety, and similar socio-cultural and community-linked risks. Mefford (2018) notes that personal integrity refers to self-respect and self-worth, as well as other essential attributes of human dignity. Conflicts and continual intrusion into one’s personal space by others can be detrimental to selfhood and self-determination.
It is possible to say that the negative effects induced by unsound social and community dynamics can be especially pronounced in children and adolescents as their identity, sense of belonging, and selfhood are at the critical stage in the process of formation. As the findings provided by Dendup et al. (2018) indicate, social isolation and stress-mediated through unhealthy diet behaviors foster the pre-diabetic condition, which leads to diabetes type 2 in the long run. At the same time, conservation of personal and social integrity can help the adolescent to adapt and sustain his or her wholeness more efficiently.
Similar to the Conservation Model, the Self-Care Deficit Theory focuses on human-environment interactions yet also emphasized the importance of self-care in the maintenance of health. Self-care is defined as the performance of activities that a person practices “on their own behalf in the interest of maintaining life, healthful functioning, continuing personal development, and well-being” (Berbiglia & Banfield, 2018, p. 201). At the same time, the disease develops in the context of self-care deficit. It may arise in case a person’s self-care agency is underdeveloped, i.e., when one lacks the ability and motivation to perform the self-caring activities and maintain health (Berbiglia & Banfield, 2018).
There are a few environmental and biological/demographic factors that determine individuals’ self-care agency. In the case of adolescent diabetes, they include the pattern of living, availability of resources, family system, and socio-cultural context. The factors of age and the overall developmental state may also be associated with the adolescent’s low value of self-care agency because mature people are often more aware of the need to regulate their behaviors in order to stay healthy.
According to Baus, Wood, Pollard, Summerfield, and White (2013), “diabetes mellitus is the seventh leading cause of death in the United States and is a major contributor to decreased life expectancy, increased rates of heart disease, stroke, kidney failure, lower-limb amputations, retinopathy, and adult-onset blindness” (p. 1f). It is also observed that diabetes is associated with a high risk for the development of mental disorders, and the diagnosed individuals are prone to the occurrence of mental problems two times more often than those without diabetes (Patterson & Moxham, 2016). The findings on the lifelong morbidity in patients make it clear that the holistic approach for the intervention of adolescent diabetes and youth’s health behaviors is required.
The adverse external factors identified in the literature review create some major barriers to the maintenance of health and management of their adverse condition in the youth with diabetes. Among these there are a limited understanding of the disease, misconceptions about it, the lack of necessary equipment and resources to preserve and promote health, poor communication about the disorder-related issues, the lack of social and family support, and some others (Pansier & Schulz, 2015). These limitations prevent the members of the pediatric population group from engaging in self-care. Therefore, the intervention strategy must aim at both the elimination of adverse factors and the obstacles to diabetes management, which they induce.
Remedy Gaps and Proposed Solution
It is possible to say that nowadays, behavioral modifications are by far the most common types of diabetes intervention among all population groups. It means they primarily aim at the conservation of energy and structural integrity in individuals. Also, school-based diabetes interventions that focus on the development of knowledge about the disease, risk behaviors (e.g., lack of exercising, non-adherence to medication treatment, etc.), and health behaviors (e.g., monitoring of carbohydrates consumed, etc.), as well as staff education, and promotion of safe school environment are common (Pansier & Schulz, 2015).
To some degree, these educational strategies include the component of personal and social integrity conservation. Nevertheless, Pansier and Schulz (2015) state that there is no clear evidence about their effectiveness in terms of adolescents’ quality of life. At the same time, it is possible to say that an effective diabetes intervention will primarily focus on the development of self-care agency in adolescents mainly because their level of dependence on parents/caregivers may vary, i.e., they may lack independence and autonomy in relation to the maintenance of own health (Rajkumar et al., 2015).
Therefore, consistently with the Self-Care Deficit Theory, the adolescent’s self-care demand can be addressed by implementing specific helping methods within the supportive-educative system of nursing to provide necessary assistance for the maturing person and guide him or her through the transitory developmental stage towards better and independent self-care. The supportive-educative nursing system overlaps with the four conservation principles suggested by Levine in her theory. Additionally, it targets such an essential element of self-care as motivation. For this reason, its application for the intervention of diabetes in adolescents may be considered promising.
Considering the population-specific action limitations identified in the case summary, the nurse can utilize such helping methods as teaching, provision of physical/psychological support, and provision and maintenance of the environment that supports personal development (Berbiglia & Banfield, 2018). Education of the patient will aim to provide him or her with accurate information about risk and health behaviors and develop the behavioral skills to meet the following self-care requisites: maintenance of sufficient intake of food/water and maintenance of balance between activity and rest (Berbiglia & Banfield, 2018).
However, the assistance in the creation and maintenance of the supportive environment should be the major element in the intervention because it fosters such an important self-care requisite identified by Berbiglia and Banfield (2018) as “the promotion of human functioning and development within social groups in accordance with human potential, known human limitations, and the human desire to be normal” (p. 201). Therefore, this nursing activity focuses on the elimination of environmental determinants of diabetes.
The given helping method requires a collaborative approach. It is important to involve parents in the process of the adolescent’s self-care agency development in order to increase the level of parental support. The nurse can educate caregivers about the importance of family dynamics as well as other environmental factors, including the availability of health-supportive household resources in the maintenance of health and the promotion of positive behavioral changes.
The parents should be trained to implement appropriate communication approaches that can increase the adolescent’s intrinsic motivation for self-care. As Rajkumar et al. (2015) state, “when individuals feel a sense of control over their behavior, their intrinsic motivation for engaging in that behavior is enhanced, whereas limiting personal freedom elicits resistance” (p. 243). Thus, it is important for both the nurse and parents to respect the youth’s opinions while eliciting his or her perspectives, providing relevant information, and encouraging responsibility for their own health. Additionally, in case the nurse identifies adverse parent-child communication patterns, it may be recommended to refer the patient and his caregivers to family counseling.
In order to assess the effectiveness of the proposed intervention, a qualitative research instrument will be applied. The subjective qualitative measures will be as follows: the level of diabetes self-care, autonomy, social and family support. Additionally, the nurse can measure the patient’s perceived improvement/deterioration of health status and management self-efficacy. The objective patient data must be collected as well to support the self-reported information. All types of data will be collected prior to the commencement of the intervention and repeatedly during the regular follow-ups (every four weeks) within the period of six months. The data collection methods will be the personal interview and the routine health assessment.
The expected long-term criteria of the intervention effectiveness will include the reduction of negative psychological symptoms and behavioral patterns as a result of environmental adaptation mediated through lifestyle change and greater social engagement. It is also expected that the adolescent patient will also demonstrate the enhancement of physical health indicators manifested in the normalization of insulin level and weight loss. The ultimate positive result of intervention will be manifested in better health and environmental conditions and improvement of psycho-emotional and social performance of the patient.
Since qualitative data is subjective and exploratory in its nature, it is important to use the right evaluation method for the selected research instrument. As stated by Sousa (2014), “the validation of data from qualitative research is directly related to the trustworthiness of its interpretations and conclusions, and these are considered to be reliable and coherent when they are internally consistent, effective and fecund, in other words, when there is the consistency of meaning” (p. 215).
First of all, the analysis results must be consistent with the research aim, which is the evaluation of the effectiveness of the supportive-educative nursing system in the conservation of adolescents’ wholeness and development of self-care agency in them. Additionally, the research will aim to assess such an intermediary outcome of the intervention implementation as the length of patients’ adaptation. These two aims will serve as the major research criteria and will guide the nurse through the process of data collection and analysis. The research findings will then consequently be analyzed backward based on these criteria to ensure internal coherence and consistency. To ensure trustworthiness, the dependability of data on evidence provided by other researchers will be evaluated.
The case report demonstrates that the onset of diabetes in youth can be largely defined by multiple external factors, including physical activity resources, community situation, family dynamics, and others. The selected theoretical models − the Conservation Model and the Self-Care Deficit Theory − helped to explain the mechanisms through which those adverse factors can trigger the development of metabolic disorders in children and adolescents.
From Levine’s perspective, it happens because environmental hazards threaten individuals’ structural, personal, and social integrity and lead to energy misbalance. Orem’s view suggests that the environment where a person lives, as well as some of the internal factors, may determine his or her ability to take care of herself. These theories supported the choice of the supportive-educative nursing system as the primary framework for the intervention of diabetes in youth as it allows addressing the population-specific care needs and action limitations effectively.
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