Review of Related Literature and Studies

This study was anchored by the theory of Burys (1982) Notion of Chronic
Illness as a biographical disruption, along with Patersons (2001) shifting perspectives
model of chronic illness as the theoretical frameworks in the research study. According to
Bury, chronic illness can be viewed as a critical situation causing disruption in three
distinct areas of the ill persons life; their taken-for-granted assumptions, their biography
and the persons mobilization of resources. How the person experiences his/her illness
and makes meaning of it will depend on the resulting levels of disruption to each of these
three areas. As the affected persons symptoms become more prevalent, the disease
begins to structure his/her everyday life, and then very foundations of the individuals
pre-illness conceptions and beliefs are toppled. The loss of taken-for-granted assumptions
can in turn alter the individuals biography. A new understanding of the illness, the
consequences it has on the person, as well as the effect it has on love ones are all
incorporated into chronically ill persons life stories, changing how they view themselves
as individuals. While struggling to deal with the emotional and psychological
implications of their disease, the affected individuals may simultaneously experience a
disruption in the mobilization of resources (Bury, 1982).
The type of support received by the affected person, his or her social interaction
with others, as well as the cultural, medical and financial resources that are available to
the chronically ill individual all play a role in shaping the affected persons new sense of
identity. In Patersons shifting perspective model of illness, a person with a chronic
illness can assume one of two perspectives; the illness in the foreground perspective, or
the wellness in the foreground perspective (Paterson, 2003). Although individuals may

have a preferred outlook, they are likely to shift between the two several times over the
course of their illness experience. While assuming the illness in the foreground
perspective, the individual focuses on his/her sickness, and the burdens, suffering, and
loss associated with it. They viewed chronic illness as destructive to the self, and to
others in their lives. While the second perspective is assuming a wellness in the
foreground perspective, chronically ill people view their illness as being meaningful, and
as serving purpose in changing their relationship with the environment and with others.
In relation to my study, the theory of Bury and Paterson is the appropriate since
these individuals who suffered diabetes mellitus which is a life-threatening illness, not
only physical aspect is affected but psychologically, emotionally and spiritually.
Being diagnosed with a chronic condition such as type 1 and 2 diabetes mellitus
can be life altering at any age. For children and adolescents in particular, this metabolic
illness can have resounding effects on their psychological well-being (Hood et al, 2006).
From the time they are diagnosed, individuals with diabetes must assume numerous roles,
bouncing among the roles of nurse, physician, mathematician, and dietitian. They must
take over the responsibilities of pancreas, performing tasks that in a healthy human being
occur subconsciously; balancing the level of insulin to carbohydrate in an attempt to
achieve glucose homeostasis. At first, these individuals may receive support from parents
and medical teams in managing the complex everyday tasks of diabetes regimen;
however, as they become more familiar with treatment demands, the responsibility of
maintaining their health falls completely on their own shoulders (Seiffge-Krenke, 1998).
Diet, Lifestyle and the Risk of Type 2 Diabetes Mellitus

According to WHO and IDF (2014), Diabetes is a common condition and its
frequency is dramatically rising all over the world. In developed countries most people
with diabetes are above the age of retirement, whereas in developing countries those most
frequently affected are aged between 35 and 64. The global increase in diabetes will
occur because of population ageing and growth, and because of increasing trends towards
obesity, unhealthy diets and sedentary lifestyles. The prevention of type 1 diabetes is not
yet possible and remains an objective for the future. The prevention of type 2 diabetes has
been shown to be possible and requires action now. Trials have shown that sustained
lifestyle changes in diet and physical activity can reduce the risk of developing type 2
diabetes. For example, the Finnish Diabetes Prevention Study showed that a better diet,
increased physical activity and modest weight loss could substantially reduce the
development of type 2 diabetes in middle-aged adults at high risk. In all studies
conducted so far in people at high risk, lifestyle changes have been substantially more
effective than the use of drugs. The scale of the problem requires population-wide
measures to reduce levels of overweight and obesity, and physical inactivity.
A study from New England Journal of Medicine (2001) showed middle-aged
women with a combination of several life factors affect the incidence of developing type
2 diabetes approximately 90 percent. Obesity and weight gain dramatically increased the
risk, and physical inactivity further elevates the risk, independently of obesity. Cigarette
smoking is associated with a small increase and moderate alcohol consumption with a
decrease in the risk of diabetes, and specific dietary fatty acids may differentially affect
insulin resistance and the risk of diabetes. These results suggest that in this population the

majority of cases of type 2 diabetes could be avoided by behavior modification (Hu et al.,
2001).
Studies have shown that, with good management, many of the complications of
diabetes can be prevented or delayed. Effective management includes lifestyle measures
such as a healthy diet, physical activity, maintain appropriate weight and not smoking.
Medication often has an important role to play, particularly for the control of blood
glucose, blood pressure and blood lipids. Through the provision of optimal heath care
risk of developing diabetic complications can be reduce substantially. Helping people
with diabetes to acquire knowledge and skills to manage their own condition is central to
their leading a full and healthy life.
Management of Diabetes Mellitus
Diabetes is a serious medical condition that requires the use of antidiabetic
medication, or insulin to keep blood sugar levels under control (IDF, 2014). However in
recent years cases of type 2 Diabetes have become more common in young adults, teens
and children. This increase has been connected to climbing levels of obesity. Because of
its higher tendency of debilitating life-threatening complication to arise, therefore a
therapeutic goal for diabetic management is to achieve normal blood sugar (euglycemia)
without hypoglycemia while maintaining a high quality of life. Diabetes has five
components: nutritional therapy, exercise, monitoring, pharmacologic therapy, and
education (American Diabetes Association, 2008).
According to Canadian Diabetes Association (CDA), school personnel should
possess basic knowledge about diabetes and be able to recognize and respond to

hypoglycemia and hyperglycemia (CDA, 2008). To increase the understanding of

diabetes among school staff, the CDA has provided principals and teachers alike with
various informational pamphlets, instructional videos, and interactive CD-ROMs. Despite
the abundance of diabetes education programs in both Canada and the United States,
teachers have not learned significantly more about diabetes (e.g., Gesteland et al., 1989,
Husband et al., 2001).
Emotional Stress cause Type 2 Diabetes Mellitus

Type 2 diabetes mellitus is a serious and common metabolic disorder. The World
Health Organization (WHO) has estimated the number of persons with diabetes
worldwide at more than 220 million (WHO, 2009). These figures are expected to rise to
366 million by 2030 (Wild et al., 2004). Besides, diabetes mellitus is associated with a
two- to four-fold increased risk of coronary heart disease and also an increased risk for
microvascular diseases such as retinopathy, nephropathy, and neuropathy. Patients with
type 2 diabetes also have a doubled risk level for co-morbid depression compared to
healthy controls, hampering the quality of life of patients (Pouwer et al., 2003; Schram et
al., 2009). Moreover, a considerable number of depressed patients suffer from high levels
of diabetes-specific emotional stress (Pouwer et al., 2005; Kokoszka et al., 2009).
Important factors contributing to the increasing prevalence of type 2 diabetes are obesity,
physical inactivity, and an increase in the number of individuals older than 65 years
(Wild et al., 2004).

Interestingly, stress has long been suspected as having important effects on the
development of diabetes. More than 400 years ago, the famous English physician Thomas

Willis (1621-1675) noted that diabetes often appeared among persons who had
experienced significant life stresses, sadness, or long sorrow (Willis, 1675). One of the
first systematic studies testing Williss hypothesis was described in 1935, by the
American psychiatrist Dr. W. Menninger, who postulated the existence of psychogenic
diabetes and described a diabetic personality (Menninger, 1935). Almost thirty years
later, P.F. Slawson et al. described in the Journal of the American Medical Association
that 80% of a group of 25 adult diabetes patients gave a history of antecedent stress
mainly in terms of losses, 1-48 months prior to the onset of diabetes (Slawson et al.,
1963). However, this study had several important limitations, including a very small
sample size, a retrospective, uncontrolled design, and a high risk of selection bias. More
recently, numerous studies have been performed, elucidating the role of emotional stress
as a risk factor for the development of type 2 diabetes. The majority of these studies
focus on depression. However, there is growing evidence that other forms of emotional
stress contribute to the development of type 2 diabetes as well.

In general, the research findings described in this review support the notion that
different forms of emotional stress are associated with an increased risk for the
development of type 2 diabetes, particularly depression, general emotional stress, anxiety,
anger/hostility, and sleeping problems. Conflicting results were found regarding
childhood neglect/abuse, life events, and work stress. In several papers, childhood
traumata and life events have been linked with higher odds of type 2 diabetes, but these
studies were all limited by a cross-sectional design. Moreover, results from longitudinal
studies in that area had conflicting results. A longitudinal study based on data from the
Healthy Women Study showed that persons who had experienced life events were at

increased risk for the metabolic syndrome, including impaired fasting glucose
(Rikknen et al., 2007), while another longitudinal study (Kumari et al. ,2004) found no
significant association between life events and incident diabetes.

An important limitation of the present study is that it is common practice among

researchers to use datasets of longitudinal epidemiological studies for explorative
analyses, so-called fishing expeditions, where the results determine which paper will be
written. As a result, negative outcomes (such as stress is not associated with incident
diabetes) are often not submitted for publication, and are perhaps more often rejected for
publication. In order to avoid publication bias, randomized controlled trials now have to
be registered prospectively in a clinical trial registry. For epidemiological cohort studies,
such a registry is still not available, and as a result we may thus expect that positive
findings are over-present in the scientific literature.

Women exposed to high job demands and low job control (job strain) had a higher
risk of type 2 diabetes compared with those not exposed to this combination of work
stressors. Women also exposed to low work social support (iso-strain) had an even higher
(twofold) risk of developing type 2 diabetes. High job demands, low job control, and low
work social support were not individually associated with type 2 diabetes, supporting the
theory that the combination of the three is toxic to health (Karasek &Theorell, 1990).
Despite the fact that the reliability of the job demands scale is not high ( = 0.67), we are
confident that psychosocial work stress was accurately assessed in our study using the
iso-strain model and that the observed association with incident type 2 diabetes is a valid
one (ADA, 2009).

According to British Medical Journal (2014), prolonged exposure to work stress

may affect the autonomic nervous system and neuroendocrine activity directly,
contributing to the development of the metabolic syndrome. A case-control study showed
that participants in the Whitehall II study with the metabolic syndrome had raised cortisol
and normetanephrine output, and also had reduced variability in heart rate. Decrements in
cardiac autonomic function have been linked to the metabolic syndrome in other
populations and to low job control and social isolation among men in the Whitehall II
study. Psychobiological studies have also shown that heightened stress reactivity and
impaired recovery after stress, assessed by blood pressure and inflammatory markers,
predict the five year progression of the metabolic syndrome. Chronic psychological stress
may reduce biological resilience and thus disturb homoeostasis. Altered adrenocortical
function can influence hepatic lipoprotein metabolism and insulin sensitivity at target
organs. Cortisol is an insulin antagonist, and cortisol output is increased in the metabolic
syndrome. Low concentrations of high density lipoprotein cholesterol and glucose
intolerance have been linked with high basal secretion of cortisol (Phillips et al., 1998).

Age and type 2 Diabetes Mellitus

Similar to metabolic syndrome, the prevalence of impaired fasting glycemia (IFG)

and T2DM increase with rising age. In the US, the estimated percentage of people aged
20 years or older having diagnosed or undiagnosed diabetes in 2005- 2008 was increasing
with age. In the age group of 20-44 years, it was estimated about 3.7% people had
diabetes; while in the age group 45-64 years the number increased to 13.7%; and the
highest percentage 0f 26.9% was found in the age group of 65 years ( Centers for

Disease Control and Prevention, 2011). Similar feature was also observed in England,
where the prevalence of diabetes was increasing with age. The peak prevalence of diabtes
can be found in the age group of 65-74 years with 15.7% in men and 10.4 in women
(Shelton, 2006). the prevalence of glucose intolerance (pre-diabetes and T2DM) increases
with advancing age. Some factors involve in the pathophysiology of glucose intolerance
in the elderly. The main factors are that aging induces decrease insulin sensitivity and
alteration or insufficient compensation of beta cell functional in the face of increasing
insulin resistance ( Chang and Halter, 2003). Decrease in beta cell proliferation capacity
and enhance sensitivity to apoptosis are the states related with aging (Maedler et al.,
2006). Minamino et al. (2009) in their study on mice propose a model in which aging and
inflammation was initiated in adipose tissue and subsequently induced insulin resistance
in adipose tissue, liver and muscle. They also propose that adipose tissue p53 tumor
suppressor mediated the lipid abnormalities and cardiovascular morbidity associated wit
obesity.

Depression and Diabetes Mellitus

Diabetes is considered to be one of the most psychologically and behaviorally
demanding of the chronic illnesses (Cox & Gonder-Frederick, 1992). The stress
associated with managing a chronic illness, the restrictions imposed by the diabetic
regimen, as well as bodily changes resulting from the disease all play a role in
determining how an individual responds to his or her condition. Although many children
and adolescents who have been diagnosed with type 1 and type 2 diabetes are able to
adjust well to life with a chronic illness, others may experience greater difficulty
adjusting to this new way of living. A perceived loss of control, low self-esteem, and

disease complications may lead to feelings of negative affect in the child or adolescent
with diabetes and in some cases may manifest as full-blown depression.
Although there have been several studies examining the co-occurrence of
depression and diabetes, the majority have focused on depression in adults. Studies of
adults with type 1 and type 2 diabetes have shown an increased risk of associated
depression, with 20%-30% of participants with diabetes meeting the criteria for major
depression (e.g., Anderson, Freedland, Clouse, & Lustman, 2001; De Groot, Anderson,
Freedland, Clouse, &Lustman, 2001). Although estimates of depression in youths with
diabetes are thought to be lowering than those seen in adults, they are believed to be
higher than the depression rates seen in the general population (Lustman & Clouse,
2005).
In one of the few studies examining the prevalence of depressive symptoms in
youths with diabetes, Hood and colleagues (2006) administered a series of questionnaires
to 145 participants. Using the Childrens Depression Inventory to assess depression, the
researchers found that 15.2% of the participants scored at or above the clinical cut-off for
depression. The number of individuals with depression in this study was nearly double
that of the highest estimate of depression in youth in general (Anderson & McGee, 1994;
Lewinsohn, Clarke, Seeley, & Rohde, 1994). Other studies that used different tools to
measure depression in diabetes obtained mixed results; showing both higher and lower
incidences of depression (e.g., Egede& Zheng, 2003). Reasons for the mixed results
include differences in methodologies used to assess depression, small sample sizes, and
unrepresentative groups of participants (Ciechanowski, Katon, & Russo, 2000; Korbel,
Wiebe, Berg, & Palmer, 2007).

Similar to trends seen in healthy adolescent populations, females with diabetes

appear to be at a higher risk of developing depression than their male counterparts
(Korbel et al., 2007). This gender difference is thought to emerge between the ages of 1015 years, when the prevalence of depression among girls increases to twice that of boys
(Nolen-Hoeksema, 2001).
Although studies have differed on estimates of the prevalence of depression in
diabetes, one thing remains certain; that the co-occurrence of these diseases is
particularly dangerous for children and adolescents. In youths with diabetes, depression is
associated with a 10-fold increase in suicide and suicidal ideation (Goldston et al., 1997;
Goldston, Kovacs, Ho, Parrone, & Stiffler, 1994). Children and adolescents who take
insulin have a ready method of performing suicide, since an overdose of this hormone
will inevitably lead to severe hypoglycemia and probable death if left untreated.
Depression in children and adolescents with diabetes is also associated with negative
diabetes-related health control outcomes such as poorer glycemic control (Kovacs,
Iyengar, et al., 1990; La Greca, Swales, Klemp, Madigan, & Skyler, 1995), and recurrent
diabetic ketoacidosis (Stewart, Rao, Emslie, Klein, & White, 2005), both of which
increase the likelihood of future diabetes-related complications.
Several researchers have noticed a link between depression and hyperglycemia in
both adults and youths with diabetes (e.g., Engum, Mykletun, Midthjell, Holen, &Dahi,
2005; La Greca et al., 1995). Because of the cross-sectional designs of these studies, it
has not been possible to determine the direction or cause of this relationship. While some
suggest that the resultant high blood glucose levels might be a manifestation of poor
diabetic regimen adherence, others suggest that it may be the physiology of depression

that is to blame. Because 95% of diabetes management is conducted by the patient,

comorbid depression in diabetes may lead to poorer outcomes and increased risks of
complications by lowering adherence to glucose monitoring, exercise, diet, and
medication regimens (Ciechanowski et al., 2000). In a study by Hood and colleagues
(2006) of 145 youths with diabetes, the researchers found that the individuals who scored
higher on the Childrens Depression Inventory reported checking their blood glucose
levels less frequently, had higher HbA1c levels, and a higher level of diabetes-related
stress. Another proposed mechanism for the hyperglycemia that is seen in depressed
diabetic individuals is that cortisol abnormalities that are associated with depression may
have hyperglycemic effects, as might the insulin resistance that accompanies depression
(Lustman& Clouse, 2005).
Medical Complications of Diabetes Mellitus
Throughout their lives, individuals with diabetes will experience numerous
periods of poor metabolic control (Gould, 2002). From short-lived blood glucose
fluctuations caused by imbalances among food intake, exercise, and insulin, to more
long-term instabilities initiated by hormonal changes, numerous aspects of the
individuals biology and environment influence his or her ability to maintain blood
glucose levels within the desired range. While physicians suggest that people with
diabetes should sustain blood glucose levels of between 4-6 mmol/L, many people may
have blood sugars that lie outside of this range. When blood sugars stray out of the ideal
range, a variety of acute and long-term complications may ensue. In the short-term,
fluctuations may cause feelings of anxiety, aggression, or antisocial conduct. In the long-

term, these fluctuations if left unresolved can lead to more serious complications such as
kidney failure, blindness, stroke, and possibly death (Bryden et al., 2001).
In diabetes there are three types of metabolic crises: hyperglycemia,
hypoglycemia, and diabetic ketoacidosis. All three of these conditions can be detrimental
to the health and functioning of the individual with diabetes, and must be recognized and
treated as soon as possible to prevent further complications from arising.
Hyperglycemia is a condition in which levels of glucose in the blood are elevated.
Hyperglycemia occurs as a result of insufficient levels of insulin in the body, which may
be caused by inadequate dosages of injected insulin, increased intake of food, or
decreased levels of exercise. The symptoms of hyperglycemia develop slowly, and
include feelings of malaise, fatigue, and excessive thirst. People who are in a
hyperglycemic state may show signs of deep breathing, rapid heart rate, and, if the
symptoms remain untreated, may go into a coma (DePaepe, Garrison-Kane, &Doelling,
2002).
At the opposite end of the spectrum is the condition known as hypoglycemia, or
low blood glucose. Unlike hyperglycemia, hypoglycemia or insulin shock develops
rapidly in a person with diabetes who is treated with insulin. This glucose deficiency is
caused by excessive insulin, strenuous energy output, insufficient food, or failing to eat
after taking insulin. Individuals in a low may complain of headaches, nausea, and
vomiting, restlessness, fatigue, excessive hunger, sudden changes in behaviour, and,
under serious circumstances, may experience convulsions or coma (DePaepe et al.,
2002). If a person presents with symptoms of hypoglycemia, he or she can prevent further
deterioration by ingesting foods that are rich in sugar such as fruit juice or candy (Gould,

2002). When a person in a low slips into unconsciousness, he or she can be given a
glucagon needle which increases the amount of glucose released by the liver. This needle
is only a short-term solution, and the individual with diabetes must seek medical attention
immediately to properly treat the hypoglycemia.
The final type of metabolic crisis that can occur in individuals with diabetes is
diabetic ketoacidosis. This condition occurs when there is a buildup of ketones in the
body as a result of high levels of blood glucose, and insufficient supplies of insulin. A
person who is experiencing ketoacidosis will exhibit a higher breathing rate, acidification
of the urine, and high levels of potassium in the blood. If ketoacidosis goes untreated for
a prolonged period of time, it can lead to circulatory collapse, and cause coma or even
death (Touchette, 2002). A person experiencing ketoacidosis should be taken
immediately to the hospital for insulin replacement, and fluid and electrolyte therapy
(Gould, 2002).
Physical Limitation
Older adults with diabetes are about 1.5 times more likely to have physical
limitations and alterations in the activities of daily living than those without diabetes.
Disabilities may be directly linked to eye disease, strokes, cardiovascular disease,
neuropathies, and peripheral vascular disease. Older persons with diabetes may also
respond more symptomatically to both hyperglycemia and hypoglycemia. Coupled with
additional comorbidities, the long tenure of diabetes may contribute to frailty. Physical
limitations necessitate adjustment goals and interventions (ADA, 2006)
Finanacial Difficulties among type 2 Diabetes Mellitus

In an older, retired population, financial concerns, insurance issues, and

transportation difficulties can become staggering problems, confounding the delivery of
health care and health maintenance. For the person with type 2 diabetes, expenses can be
a concern- both the expense of medication for diabetes and its comorbidities and the cost
of coverage for multiple medical visits plus podiatric, dental, and eye care. The
healthcare provider must be aware of these issues and seek to ameliorate them whenever
possible. For example, prescribing medications that are preferred and offer maximal
reimbursement or coverage whenever possible reduces the financial burden of the person
with diabetes (ADA, 2006).
Coping Responses to Chronic Illness

According to Carson and Koenig (2004), people with chronic illness use prayer to
present their needs to God, to express their thankfulness, and to confess their dependency
on a God whose strength is infinite. Prayer provides tremendous comfort to someone who
daily experiences the finiteness of personal strength and resources. Prayer reflects an
intimate relationship with a God that is loving and accepting; it can be an expression of
hope that God will be and is reliable. Prayer also provides an outlet for anger and
confusion toward a God who is seen as the source of pain, suffering, and loss.

With all these benefits in mind, it is important to recognize that prayer is not
always easy for someone with a chronic illness. Sometimes the illness saps energy and
mental concentration to such a degree that only the briefest entreaty to God is possible.
At such times the prayers of a supportive person, a prayer network, or shared prayer with
the suffering individual can fill the gap between the individual and God. As healthcare

providers, we cannot prescribe prayer unless we know through our spiritual history that
this is something the patient values. As an educational intervention, however, we might
be able to share research findings about the value of prayer without any hint of coercion
or proselytizing on our part.