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Families, Systems, & Health

2007, Vol. 25, No. 1, 36 52

Copyright 2007 by the American Psychological Association


1091-7527/07/$12.00 DOI: 10.1037/1091-7527.25.1.36

Managing Family Support and Dietary Routines:


Type 2 Diabetes in Rural Appalachian Families

This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

SHARON A. DENHAM, DSN, RN


MARGARET M. MANOOGIAN, PHD
LYNDEL SCHUSTER, MS

Keywords: type 2 diabetes, dietary routines, family support, Appalachians, diabetes education

Using the Family Health Model (Denham,


2003), this study aimed to understand the
ways family support processes and routines
influence dietary patterns of individuals
with type 2 diabetes. Interviews were conducted with family dyads, a person with
type 2 diabetes (n 13) and a family support member (n 13). Themes emerged
within three domains: (a) confronting dietary routines, (b) changing dietary routines, and (c) living with new dietary routines. Findings indicated that (a) support
members intentionally provide assistance
to persons with type 2 diabetes (T2DM), (b)
cultural food preferences, family traditions,
and intergenerational dietary patterns influence behavior changes, (c) gender influences the kinds of family support offered,
and (d) awareness about dietary routines
on special days appeared greater than on
typical days. T2DM should be considered a
family rather than an individual disease
with needs for diabetes education to include
family support members.

rom many perspectives, diabetes is a


costly burden for individuals, families,
and the nation. In the past decade, diabetes increased nearly 50% and is expected to
grow 165% by 2050 (American Diabetes Association, 2003a). Type 2 diabetes (T2DM)
accounts for 90 95% of all diagnosed cases
and was the sixth leading cause of death in
2000 (American Diabetes Association,
2004). Even with underestimates of true
economic costs, annual diabetes care expenditures are approximately $132 billion,
double the health care costs for nondiabetic
persons (American Diabetes Association,
2003b).
This study explored how family members influence dietary patterns when a
family member has T2DM. Current research has largely ignored the influence of
family processes on T2DM self-management (Fisher et al., 2000). Because disease
management largely takes place in home
settings (Fisher et al., 1998), family members play critical roles as they influence
chronic disease management (Rolland,
1994). Social support and family context
may facilitate or threaten self-care behaviors in T2DM (Epple, Wright, Joish, &

Sharon A. Denham, DSN, RN, School of Nursing,


Ohio University; Margaret M. Manoogian, PhD, Child
and Family Studies, Ohio University; and Lyndel
Schuster, MS, Nutrition and Dietetics, Ohio University.
Correspondence concerning this article should be
addressed to Sharon A. Denham, DSN, RN, School of
Nursing, Ohio University, Grover Center E370, Athens, OH 45701. E-mail: denham@ohio.edu

36

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MANAGING FAMILY SUPPORT

Bauer, 2003; Ford, Tilley, & McDonald,


1998). Factors such as marital relationships (Trief, Britton, Wade, & Weinstock,
2002), family characteristics and family
context (Chesla et al., 2003), and gender
(Hepworth, 1999; Navuluri, 2000) influence quality of life and disease management. For instance, Trief et al. (2003) illuminated the different types of family support among married couples regarding
diabetes management. Relevant to dietary
routines, married partners supported their
partners nutritional health through food
procurement, meal preparation, and
shared meal plans and undermined dietary
routines through critical comments and ineffective communication.
Family interventions targeting illnesses
such as diabetes require substantial lifestyle changes that need greater support
than is generally given through education
programs covered by most health insurance providers (Martire, 2005). Familyfocused studies on patients with type 1 diabetes have shown that interventions can
be cost-effective, improve A1C results, and
produce positive quality of life (Anderson,
Brackett, Ho, & Laffel, 1999; Hanson,
DeGuire, Schinkel, & Kolterman, 1995).
Investigating family contexts may shed
light on the types of support that influence
positive outcomes for individuals with
T2DM. In Appalachia, the region selected
for this study, family life is valued and
includes close-knit ties with elders often
living near children and grandchildren
(Purnell & Paulanka, 2005).
Managing T2DM requires attention to
healthy eating patterns in families. Dietary behaviors are influenced by knowledge of diabetes management, previous
eating patterns, and mediating factors
such as self-efficacy, level of social support,
and time management skills (Savoka &
Miller, 2001). Dietary change requires new
food habits and modification of lifelong eating behaviors, yet little is known about specific meal planning and eating practices
among families with diabetes (Savoka,

37

Miller, & Ludwig, 2004). Additionally, nutritional activities in families may be tied
to gender and family roles, where women
often have the responsibility for planning
and implementing family meals (DeVault,
1991).
Families use patterned behaviors called
routines to arrange ordinary life to cope
with health and illness events (Fiese &
Wamboldt, 2000). Routine health behaviors shape family health outcomes
(Denham, 1999) and suggest potential
links to risks associated with chronic illness (Denham, 2003). Routines are embedded in the cultural and ecological context of
families and highlight ways to focus on
whole-family processes as well as individual and family dynamics (Fiese et al.,
2002). Differences within families occur as
members support and threaten dietary
routines (Schuster, 2005). More information is needed to understand how routines
motivate health outcomes and place individuals at risk (Denham, 2003).
To understand disease characteristics
and individual processes experienced by
persons with diabetes, scholars have suggested the use of ecological models (Chesla
et al., 2003; Fisher et al., 1998). An ecological model encourages the understanding of
family health from an embedded context
perspective. One such model, the Family
Health Model (Denham, 2003), suggests
that families create and modify their experiences of a disease over time within contextual, functional, and structural domains. In the contextual domain, family
health is influenced by the internal environment (e.g., member, family, and household context) and the external environment
(e.g., neighborhood, community, historical,
and political context). The functional domain addresses unique individual factors
(e.g., values, perceptions, motivation,
roles), family process factors (e.g., cohesiveness, resilience, individuation, boundaries), and member processes (e.g., communication, coordination, caregiving, control)
that influence family health processes and

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38

DENHAM, MANOOGIAN, AND SCHUSTER

outcomes. The structural domain focuses


on family health routines and provides the
framework for this study. Routines pertinent to diabetes management within the
structural domain include such areas as
meal preparation, blood glucose monitoring, exercise, and medication schedules.
Because those activities that support or
constrain diabetes management typically
occur at home within the family system,
the goal of this research was to understand
how individual and family routines support
and threaten health outcomes from two
perspectives, the person with T2DM and
the family member. Recognizing that family members mutually engage in support
behaviors, we posed the following research
questions: (a) how do individuals with
T2DM use health routines to self-manage
prescribed medical care, and (b) how do
family support members influence the routines and health outcomes for individuals
with T2DM?
METHOD
Data for this study come from a larger
pilot project that investigated the influence
of family health routines on diabetes selfmanagement through focus groups, individual interviews, and measures specific to
diabetes, family routines, and health status. Focusing on the individual interviews,
this study sought to understand the specific and intimate experiences of family
support and diabetes self-management
routines. Eligibility criteria for participants were (a) a self-report of a diagnosis of
T2DM for at least one year, (b) identification of a family support member willing to
participate, (c) minimum of 18 years of age,
(d) current resident of an Appalachian
county, and (e) family history of residence
in Appalachia. Family support members
were persons who had sanguineous or legally established relationships with persons with T2DM.
The convenience sample was identified
through (a) flyers in health service areas at
Ohio University, (b) volunteers from com-

munity presentations on diabetes, (c) a list


of potential participants from another diabetes study, and (d) snowball techniques.
Potential participants were contacted by
phone. After the study was explained and
eligibility was determined, separate home
interviews were scheduled with the person
with T2DM and an identified family support member. Semistructured interview
guides (see Table 1) were used to illicit
information and detail regarding family
support and dietary routines. Persons with
T2DM were interviewed first and demographic information was obtained. Family
support members were asked the same
questions from their perspective as a provider of support. For instance, persons with
T2DM and family support persons commented on a time when they felt their family members with T2DM best managed diabetes. Each audiotaped interview lasted
approximately one hour, and interviews
and field notes were transcribed verbatim.
Participants each received a $25 honorarium.
Data were analyzed with MAXqda, a
qualitative software program, by the research team who had complementary expertise in health-related routines, knowledge of diabetes, nutrition, family relationships, and family contexts. Coding of the
data occurred as suggested by Lofland and
Lofland (1995) and Berg (2004). First, interviews and field notes were reviewed repeatedly, focusing on the health routines in
families. From these initial reviews, data
regarding family support and dietary routines were found within three areas that
families experienced after the initial diagnosis of T2DM, involving the activities that
families undertook (a) to address their established dietary routines, (b) to change
their routines in order to manage the disease, and (c) to negotiate and maintain new
routines. Following this initial review, a
more focused coding strategy was implemented by the research team in which
eight themes and 33 subcodes emerged
across the three domains. For this study,

MANAGING FAMILY SUPPORT

Table 1
Semi-Structured Interview Protocol

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Questions for persons with diabetes


1. Tell me a little about yourself and your
family relationships?
2. How long have you had diabetes? What
were your initial reactions?
3. Describe ways your personal routines
changed after you were diagnosed with
diabetes?
4. Tell me about things you do on a typical
day to take care of your diabetes. How are
your family members involved in these
activities?
5. In what ways are your family members
involved with helping you care for your
diabetes? (dietary routines,
activity/exercise, medicines, blood glucose
testing, skin care, medical care)
6. Describe ways your family influences your
activities to help your health?
7. Are there routines that you learned
growing up that influence you either
positively or negatively as you manage
your diabetes?
8. Can you give me some examples of things
you might do differently when taking care
of your diabetes on special occasions/days
(e.g., celebrations, holidays, birthdays)
compared to what you do on typical days?
9. When taking care of your diabetes, what
kinds of activities occur every day versus
those that happen only once in a while?
10. Tell me about a time when your diabetes
was best managed.
11. Do the things you need to do to control
your diabetes ever cause disagreement(s)
within your family?
12. What kinds of things do you do to take
care of your diabetes when something
unusual occurs, for example, if someone
gets ill, a loss is experienced, or a
stressful event happens?
13. In conclusion, can you tell me about ways
others could do a better job in helping you
with the activities needed to keep your
diabetes under control?
Note. Similar topics were addressed with family support persons.

the focus was primarily focused on the


codes linked to dietary routines. Once the
coding strategy was established, two members of the research team coded the data.
To begin the coding process, three re-

39

searchers reviewed three of the interviews


and compared findings to ensure interrater
reliability. After interrater reliability was
established, two researchers then completed data coding and analysis going back
to the conceptual model as needed to assist
in confirming meanings. Finally, dyads
were examined in order to understand how
T2DM occurred within specific family
groups, a form of typologizing elaborated
by Lofland and Lofland (1995).
Subjects
Participants represented 13 families
having a member with T2DM from two Appalachian Ohio counties (see Table 2). All
participants were White. Participants with
T2DM were married (n 8), widowed (n
3), or divorced (n 2) and ranged in age
from 63 to 70 years of age for men (n 3)
and from 48 to 78 years old for women (n
10). Participants who were family support
members ranged in age from 36 to 70 years
for men (n 3) and 23 to 73 years of age for
women (n 10). Most participants with
T2DM had the disease for many years. The
family dyads consisted of spousal pairs
(n 5), as well as intergenerational pairs
including mother-daughter (n 4), mother-son (n 1), sister (n 1), motherdaughter-in-law (n 1), and neighbor/
lifelong friend (n 1). Because the lifelong
friends lived across the street, experienced
daily contact, and described their relationship as family like, they were included in
the sample. Acknowledging the ways that
individuals with diabetes identify family
support when they live alone, family support members could be identified as living
outside of the household.
FINDINGS
Three domains emerged as participants
described family experiences with dietary
management. These domains focused on
the initial and long-term management of
T2DM and included (a) confronting dietary
routines, (b) changing dietary routines,
and (c) living with new dietary routines.

40

DENHAM, MANOOGIAN, AND SCHUSTER

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Table 2
Demographics of Participants With Type 2 Diabetes
Gender
of
PWD

Marriage
status

Current
age

Female

Divorced

78

74 years

Male

Married

67

Not sure

Female

Widow

76

Not sure

Female

Widow

71

69 years

Female

Divorced

65

64 years

Female

Married

71

60 years

Male

Married

70

40 years

Female

Widow

53

45 years

Female

Married

48

40 years

Male

Married

63

43 years

Female

Married

59

54 years

Female
Female

Married
Married

56
51

55 years
36 years

Age at
diagnosis

Routines for
managing
diabetes
Usually
regular
Seldom
regular
Usually
regular
Usually
regular
Seldom
regular
Usually
regular
Seldom
regular
Always
regular
Seldom
regular
Seldom
regular
Usually
regular
No response
Usually
regular

Gender
of FSM

Current
age

Relationship
to PWD

Male

49

Son

Female

64

Wife

Female

46

Female

73

Daughterin-law
Best friend

Female

42

Daughter

Male

70

Husband

Female

62

Wife

Female

48

Sister

Female

23

Daughter

Female

43

Wife

Female

41

Daughter

Male
Female

47
31

Husband
Daughter

Note. PWD person with diabetes; FSM family support member.

Within each domain, themes emerged that


illuminated the ways that family support
and dietary routines are experienced when
a family member has T2DM. As described
by both persons with T2DM and their family support members, these domains were
not static and did not necessarily represent
a temporal order. For instance, participants could describe more than one time
period where new dietary routines were
reintegrated because of a change in family
context or because adherence routines
were not effective. In the findings, participants with T2DM are identified as persons
with diabetes, whereas participants who
support family members with T2DM are
identified as family support members. We
use the identifier participants when referring to the total sample.

Confronting Dietary Routines


The reaction to learning about the
T2DM diagnosis was met with feelings of
shock, fear, shame, and uncertainty by participants. For those with T2DM who had a
family history of diabetes, their own diagnoses were viewed as expected rather than
surprises. All participants understood the
need to adopt new dietary routines in order
to comply with diabetes self-care. As they
described their dietary routines, participants focused on food perceptions, routine
dietary patterns, and nutritional education.
Food Perceptions
Participants held beliefs about appropriate food choices, healthy meals, and cultural food preferences. Food perceptions

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MANAGING FAMILY SUPPORT

appeared to be influenced by family culture


as the type and importance of food within
the family experience were emphasized. Intergenerational dietary patterns that highlighted how families made meal choices
and prepared food were also apparent.
Cultural food patterns within families
motivated eating practices as participants
suggested that healthy dietary standards
often conflicted with typical Appalachian
eating patterns. For example, one person
with T2DM reported: If you cannot put
gravy on it, it aint worth eatin. Participants also voiced the important role of food
in family cultural traditions. As a family
support member explained: We do like to
eat. Its a family that likes to eat. Theres
no doubt about it. Food is a big part of this
whole community. Another family support
member emphasized how her husbands
food preferences were linked to family eating practices: My husbands eating habits
are bad too cause there were 13 in his family. So they ate whatever they had, you
know, lots of bread and butter.
Time and place influenced current eating patterns among families, underscoring
the importance of intergenerational dietary patterns. One person with T2DM noted:
Well, I think some of the things we
learned growing up has probably
helped us become diabetic. Well, we
were a pretty big family, and it was
during the Depression a lot of the years
when I was growing up, and we always
had lots of potatoes, bread, and beans.
And back then, most parents would say
if you take it on your plate, youd have
to eat it.
A woman with T2DM explained how
generational traditions influenced her familys mealtime routines and celebrations.
The way I grew up, makes it hard to
manage it or take care of it [diabetes].
Both grandmothers had it, but on my
fathers side, my grandparents were

41

Hungarian and my grandmother was a


true Hungarian who cooked, cooked,
cooked. There was no mention of the
word diabetes around her. I cook a lot
like my mother did or my grandmother,
which is a little too much.
Another woman with T2DM highlighted
the importance of generational patterns by
explaining how her mother was very strict
about her diet and I saw how much it did
help her. Although information about appropriate food choices learned through diabetes education influenced behaviors, dietary routines were greatly influenced by
memories linked with families of origin.
Routine Dietary Patterns
Participants described routines concerning dietary patterns (e.g., preparing
and eating meals and snacks, shopping for
groceries) and how family behaviors were
influenced by having a member with
T2DM. Some past behaviors supported positive dietary self-management, but others
threatened adherence to prescribed meal
plans. One husband with T2DM shared
how he changed his eating routines to conform to his wifes preferences:
Most of the time you know, she gets up
and fixes breakfast; shell fix me two
eggs and turkey bacon. Used to get up
and eat a bowl of oats, but she kinda
got on that Atkins diet which, which
neither one of us did any good and
stayed on it. Theres lotta protein in
bacon and eggs. So I gave up my oats
and milk and bread.
His wife provided additional insight:
Well, I think his problem is he tries to stay
on two diets. I said you cant, you cant do
that. You cant eat your bacon and eggs and
then for lunch, go eat a lot of breads. Attempting to encourage protein replacement
for starches, she found her husbands preferences interfered.
Misconceptions about foods and dietary
requirements were evident, influencing di-

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42

DENHAM, MANOOGIAN, AND SCHUSTER

etary routines. One family support member


remarked: I think he doesnt get the
starch. He thinks starch stuff isnt sugar.
He doesnt get that it makes sugar, and Ive
never got that across since he has been a
diabetic.
Participants often commented on restricted foods. One family support member
exclaimed, Its not the weight Im concerned about, its what she eats. I mean she
loves milk, and I know milk has a lot of
sugar in it, and bread, its loaded with
sugar. Another family support person
commented on her husbands servings by
explaining: I think maybe he eats too
much of what hes allowed to eat. Food
preferences influenced food consumption in
excess of diabetes standards.
Responsibility for grocery shopping varied based on things such as member roles,
ability or willingness to drive, and physical
mobility. Two women with T2DM had
health conditions that hindered ambulation, and family support members completed the grocery shopping for them. Family support members often described grocery shopping as a role used to support the
person with T2DM. For example, one
daughter said, When I am out and about,
I will call and say, Hey, Im gonna hit the
store; Im gonna get this for supper tonight,
does that sound good? Two women with
T2DM explained that healthier food options were too expensive and three support
members suggested cost was a factor when
selecting foods to purchase. Although grocery shopping was viewed as important,
few reports of planned changes in shopping
or purchasing routines were described post
diagnosis by persons with T2DM or family
support members.
Post diagnosis, most families attempted
to adhere to time schedules, which often
interfered with other activities. One
woman with T2DM said:
See, I try to eat exactly the same time
everyday. Where before, it was like
okay, stop, grab a hotdog or do it this,

do it that, no. Ive tried now to eat


breakfast at the same time, eat lunch
at the same time, and eat the evening
meal.
A family support member explained
how he helps his wife with meals: The one
thing that maybe I do to try to influence or
help with a little bit is meals. She really
needs, well, everybody needs to eat regularly and consistently. We dont always do
that, but thats always my goal. One son, a
family support member, remarked, The
only thing we do is try to eat dinner at the
same time. Thats about the only thing I
really try to do so she [mother] can get her
shot on time. Family support members often were able to influence the timing of
meals but offered less help in adhering to
dietary routines unless they prepared
meals.
Eleven women with T2DM held primary
responsibility for family meals. They experienced tension and conflict when they
needed to adhere to a meal plan that was
not universally shared among family members. One woman with T2DM stated:
Theres some foods that I try to [avoid]. I
really give in to what they like and will eat
rather than stickin to any kind of diet
thats just for me. Her daughter agreed:
Shes probably is the main person who
makes the meals, my mom. She does a lot
of the meal planning and because certain
people dont wanna eat certain things,
shell make what they wanna make instead
of what she should eat. When asked who
she was referring to by certain people, the
daughter responded Oh, my dad and
brother. Those with T2DM often indicated
that they prepared foods and meals less
than optimal for diabetes self-management
in order to satisfy other family members.
In some cases, women with T2DM who
were in charge of family food preparation
were able to establish healthy routines. A
family support member reported that after
diagnosis, family meal patterns changed
positively. She explained: Shes [mother-

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MANAGING FAMILY SUPPORT

in-law] changed how we eat on Sunday,


and nobody disagrees with that. Most of us
were in agreement with the fact that we
dont always need apple pie, although we
love her apple pie. Some families accepted
changes when they saw it as positive. A
family support member explained: We try
to do it [eat] in moderation. She [wife with
T2DM] used to make lots of cookies and all
that kind of stuff. Weve kind of cut that
part of it down so thats not too tempting
for either one of us.
Regardless of outcomes, most participants agreed that some changes in dietary
patterns followed the initial diabetes diagnosis and that often one person motivated
these changes. This person, typically the
family member who assumed responsibilities for food purchase and preparation,
played a role that was critical to health
outcomes. Reflective of the types of responsibilities that women undertake in families
and potentially due to the traditional family patterns observed in Appalachia (Rural
and Appalachian Youth & Families Consortium, 1996), women appeared to have
more control over family dietary routines.
This responsibility, however, did not ensure that effective dietary routines were
implemented because some women failed
to implement healthy meal choices in deference to the food preferences of others.
Inadequate Nutritional Education
As reported by participants, six persons
with T2DM and no family support indicated that they had participated in any
kind of nutritional education regarding the
changes needed in dietary routines to manage diabetes. This lack of knowledge and
training had implications for how well families managed diabetes and how family
members supported one another.
Those persons with T2DM valued the
education they received regarding food
choices and dietary routines, and family
support members were enthusiastic about
the help these programs provided their
family members. Although unable to incor-

43

porate all she had learned about nutrition


into her dietary routines, one woman with
T2DM explained how education helped
her: They are trying to teach me how to
control diabetes through diet and exercise.
Im not quite into the exercise part of it yet.
Try learning to control what I eat, right
now, thats good enough. Her daughter described the benefits of nutritional education for her mother: I know that all she
does is talk about going to the nutritionist,
and they are helping her with her diet and
what she should be eating and how she
should be eating.
The ways that participants received information and education regarding the dietary aspects of diabetes management had
consequences for families. Participants received dietary information from a variety of
sources including physicians and other
medical personnel, pamphlets, the Internet, and TV programs, as well as members
of the community, friends, and other family
members. With a variety of available resources, participants reported that they
typically sought advice from informal information sources, primarily others in their
families or community, or relied on personal experiences. As one man with T2DM
shared, Ive never had any classes, just
experience, knowing that I should have
been more careful. At times, this worked
well for families, yet it was clear in interviews that many families struggled with
inaccurate or partial knowledge about appropriate food choices and dietary routines
needed for diabetes management. For example, a woman with T2DM was talking
about the advice her family support person
provided about the high sugar content in
watermelons, I said, No it dont. She said,
Its full of sugar. I said, Why it grows
outside in the yard, with the rain! How
could it have sugar in it? And she said,
Thats loaded with sugar.
In many cases, family support members, unsure about their own knowledge of
dietary routines for those with T2DM, depended on their family member with T2DM

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44

DENHAM, MANOOGIAN, AND SCHUSTER

to provide them with the information


needed to enact effective dietary routines.
For instance, one daughter-in-law described the importance of the nutritional
education her mother-in-law shared with
her: She comes home and tells me about
things at the center when they come and
bring things. This appeared to work well
in this family, but other families experienced problems when little nutritional education had occurred or when persons with
T2DM were withholding or not understanding the need for dietary changes. A
different woman with T2DM referring to
her daughter exclaimed, Im my own boss.
I do what I wanna do. She says if you
wanna kill yourself, go ahead. Because of
these problems, participants emphasized
the importance of family members receiving help in managing T2DM. One husband
said it would be a big help if he and his
wife could learn meal planning together.
His wife with T2DM agreed and mentioned
that they had little experience with diabetes management.
Changing Dietary Routines
Persons with T2DM shared experiences
regarding actual dietary changes and how
family support members assisted or
thwarted these efforts. Family support
members expressed some of the challenges
and frustrations they experienced when assisting with dietary changes. Generally,
participants described how they altered
routines on ordinary and special days, attempted and made dietary changes, and
kept track of dietary routines.
Altering Routines on Ordinary and
Special Days
Changes in daily family routines were
temporary for some while others appeared
more satisfied with their established diabetes management routines. One family support member reflected on family behaviors
after her mothers diagnosis: I dont think
as a family weve changed very much. I
think we are more cognizant of the fact and

did attempt, especially in the beginning, to


avoid temptations. But then, when there
didnt seem to be adverse reactions, we
kind of just fell back into the old routine.
Others reported major changes. For example, one person with T2DM acknowledged:
I guess it has really affected our lives. It
just takes me longer to get everything
ready.
Family dietary patterns varied on typical versus special days such as family celebrations, holidays, or social events. A
woman with T2DM who reported poor glycemic control and dietary routines on typical days described behaviors on special
days: I eat a little different yes. . .but we
still indulge on those occasions. Her
daughter agreed: She does tend to indulge,
and we knowingly participate in her indulgence I guess or overeating or whatever
you wanna call it. Her self-destructive patterns, whatever you wanna call it.
Over half of those with T2DM described
altering patterns on special days and expressed anxiety over temptations. A
woman with T2DM described the difficulty
of changing deeply rooted family rituals:
Well, the hardest part is that I still
want to cook everything that is traditional. I am just awful for tradition you
know. . .and we had traditional dishes
for holidays like Christmas time and
Thanksgiving. So, it wasnt much fun
to cook for Thanksgiving this year you
know. But I did fix turkey and some
dressing and mashed potatoes and
gravy, and I made candy sweet potatoes, not very many, but just because it
wouldnt be Thanksgiving.
One woman with T2DM worried about
the holidays: Well, actually thats the
worse time of the year with all the sweets
and stuff. I am learning more self-control
about it. A family support member described another common holiday experience:

MANAGING FAMILY SUPPORT

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Our little group here, we always do


something together but nothing special
is fixed for her. Shell just eat whatever
everybody else eats and deal with it
later. Thats pretty much how it is. I
mean, we would if she wanted it that
way or if it had to be that way. You
know, Id be more than happy to make
something special for her to eat.
In contrast, a wife supported her husband with T2DM by fixing alternatives:
The last several holidays weve had, he
has been real good about not eating the
pies. Used to be, hed eat half the pie. Hell
say, Does that got sugar in it? I always try
to make him Jell-O or something.
Persons with T2DM sometimes commented on the barriers and successes of
changing dietary routines for special
events. A woman with T2DM explained: I
mean everything they do is a potluck, and
its really difficult, and you dont want to
hurt somebodys feelings by not eating
their food. Another person with T2DM described her strategies for a special gathering that involved a meal: I eat what I want
to eat, the rest of it, I kind of skipped. They
werent aware that I wasnt eating all the
food. Because Appalachian families value
such gatherings, feelings of guilt when
choosing not to eat may have implications
for diabetes management.
Attempting and Making Dietary Changes
Eight persons with T2DM discussed
ways family influenced adherence to medically prescribed nutritional routines. Failure to consistently adhere to dietary
changes seemed tied to inadequate motivation to change behaviors, long-standing
food preferences that were not easily altered, wavering forms of family support,
valuing family traditions over new dietary
changes, and societal influences that encouraged adherence to old patterns. Twelve
participants discussed difficulties in altering nutritional routines. One woman with
T2DM commented: Im not doin near

45

what I oughta be doin. I eat too much stuff


that I shouldnt. Old habits are hard to
break. One family support member explained difficulties when personal esteem
and reputation were linked with cooking
abilities. She commented, Shes the major
pie baker in the town. So, thats probably
been the hardest thing is the getting away
from the desserts. Although all participants appeared to understand that dietary
changes were needed, attempts to make
needed changes remained challenges for
families.
Persons with T2DM discussed barriers
faced when family members were unwilling to change dietary routines, often because of food preferences. A wife spoke
about her husband and others as unwilling
to change eating habits after she was diagnosed with T2DM. She perceived him as
supportive of some diabetes-related health
routines except for eating, he hasnt
changed his diet. Another woman with
T2DM stated that she and her husband
shared family cooking duties. When asked
if her husband made special considerations
when cooking, she replied: No. He likes
bread and potatoes. Another woman with
T2DM discussed issues regarding grocery
shopping. She said: When I go into the
store, hell say dont forget to get some
cookies. But I dont always eat them. Sometimes I do, but not always.
Some family support members were
concerned that they negatively influenced
the family member with T2DM by eating
normal food in front of them. One family
support member said:
With regards to the things we bring
into the house to eat. You pick up the
nice fruit and the low cal stuff, but the
ice cream still comes in. Shell buy it for
us because she knows we like it. So
thats got to be difficult when shes supposed to be avoiding things.
Evidence existed that family support
members also positively influenced their
family members with T2DM by acting in

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46

DENHAM, MANOOGIAN, AND SCHUSTER

supportive ways to those with T2DM. A


family support member revealed: And I
have to say, there are lots of times, when I
wanted to eat, I always had to eat dessert.
I am very conscious that she cant and so I
dont eat dessert. One person with T2DM
explained: My husband will eat anything,
and since Ive been diabetic, I pretty much
eat what I want to, just smaller amounts.
Her husband expressed his willingness to
alter his eating patterns by eating everything in moderation rather what we used to
make. This form of dietary support, however, appeared to be less often available
when women with T2DM lived alone or
with male household members.
Keeping Track
Family members methods of keeping
track of dietary management included
communication patterns aimed at behavioral control. One husband, a family support member, said, I keep an eye on the
cokes. Thats about the biggest thing that I
question her about. Sometimes she gets a
little testy about it if I mention it. Comparing her tracking methods with her father, one daughter commented, He will
respond if she [mother] says I need this or
I need that. He probably doesnt roll his
eyes and say why didnt you come in and
eat something as much as I do. Within
single households, family support members
often used different methods to keep track
of the patterns used to convey messages of
support.
Nine persons with T2DM and most family support members described how family
support members consistently inquired
about diabetes management. People with
T2DM often viewed these inquiries as wellintentioned and supportive. For example,
one husband with T2DM saw his wifes
verbal prompts as supportive: I guess if
you ask, my wife does help me and shes
constantly after me about what I shouldnt
have or you shouldnt have that. Another
woman with T2DM describing how her
family members track her condition re-

sponded: Theyre supportive that way.


They do ask me a lot, and my son asks me
a lot when he calls and that. Hes always
asking if I been watching my sugar. Another woman with T2DM noted, My son
sometimes he gets particular like, Mom,
you know youre not supposed to have that
or Mom, you know. . . Cause he cares!
When elaborating on support concerning dietary adherence, participants explained how comments were interpreted as
nagging or scolding. For example, a woman
with T2DM talked about eating out with
her adult son: I will have a hamburger or
something. Maybe I eat a little more beef
than I should, but I dont eat it very often!
I am not going to eat something deliberately to kill myself. I know I cheat once in
a while, who doesnt? She reported adequate glycemic control and felt attacked
when questioned by family members. An
older woman with T2DM reported on the
behavior of her adult children, Well, they
say Should you eat that? And I say, Look,
I am 71 not 101!
Other approaches of keeping track of
food intake were evidenced in families,
sometimes leading to family tension. For
instance, one daughter, a family support
member, described an active response to
her mothers food choices:
If I see her eating cookies or something,
I say, No! You are not allowed to have
them. And you know, like take it out of
her hand. And if she says, Well, I am
going to have a piece of cake, I am like,
No! You are not going to have a piece
of cake.
Another husband with T2DM and his
wife reported that they had no conflict over
diabetes management, yet later, the husband shared: She bitches about it if I eat
sugar or something. Voicing her perspective, the wife stated: Thats what I try to
have him eat, but he doesnt cooperate. But
that causes some conflict. Later, she reported using an additional strategy to keep
her husband on track: Then I tell the doc-

MANAGING FAMILY SUPPORT

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tor on him, which doesnt make him


happy.
Living With New Dietary Routines
Participants described daily issues that
arose from diabetes self-management that
pertained to changing, following, or neglecting dietary routines. Those with
T2DM verified that while some prescribed
care regimens were followed, others were
often neglected. Shame, anger, and frustration were experienced as attempts to modify dietary routines failed. Family support
members often minimized the difficulties
associated with T2DM for the member with
T2DM. When no immediate negative physical indicators were observed, family support members were either unaware or ignored the possibility of diabetes complications. Participants described the behaviors
associated with daily dietary routines as
owning the disease, controlling weight factors, and balancing routines.
Owning the Disease
Family support members assisted and
used various approaches to meet the needs
associated with diabetes. Those with
T2DM often discussed independence. For
example, nine persons with T2DM described personal responsibility for diabetes
management with little reliance on family
support. One man with T2DM commented:
I believe that when you get up in the
morning and look in the mirror, youre
looking at the one responsible for the disease. Nobody else can take care of me. He
elaborated: Im my own boss. I do what I
wanna do. She says if you wanna kill yourself, go ahead. If I wanna eat a steak thats
there, Im gonna eat it! This spousal dyad
expressed many disagreements about who
was in charge of decisions and routines.
Some persons with T2DM asserted their
independence and responsibility for diabetes management while accepting support.
A woman with T2DM explained, Im not
that disabled yet. Theyre quite aware that
mom can take care of herself. See, Im very

47

independent. Thats why Ive lived alone


for 20 years. Her daughter agreed: Mom
kind of takes care of herself as far as that
goes. You know if she was really sick or was
in the hospital, I would know that and be
there for her.
Nine family support members discussed
their perspective on providing support to
family members who denied need of help.
One family support member said: I think
the diabetic has to take control and do it
yourself. I mean, were here for supporting. Although she assisted her spouse and
was willing to provide care, she was adamant that daily routines were his responsibility. A similar response came from a
woman discussing her husbands diabetes
care: You gotta take care of your own body.
And if youre not willing to do that, I feel
like youre on your own really. Hes gotta do
for himself. Interestingly, this husband
with T2DM reported that his wife assisted
him with medications, meal planning, groceries shopping, and cooking. She also had
taken the initiative to seek nutritional education related to diabetes. Not uncommon
to this sample, some incongruence about
diabetes management existed. His wife
said caring for the disease was her husbands responsibility, yet she actively provided support.
Glycemic control was a concern for
many. If adequate glycemic control was
achieved, family members were less likely
to offer care. A family support member
spoke about her mother: We all know she
has it and everything, but its not something that we think about all the time. She
deals with it, and its not something were
always worried about I guess cause she
has it [blood sugar] under control. A different daughter stressed: Well, if she
[mother] would get to where she couldnt
take care of it, I would take over and do it
for her cause I know how to take care of her
in that situation. Right now, theres really
no point in me doing anything cause she
got it under control.

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48

DENHAM, MANOOGIAN, AND SCHUSTER

Controlling Weight Factors


Although no anthropometric data were
collected, being overweight or obese was
visually assessed in 13 persons with T2DM
and 6 family support members. Although
not directly questioned about weight issues, participants discussed the desire, attempts, disappointments, and successes in
managing weight. Most participants were
aware that weight loss had the potential to
improve diabetes and support from other
family members was discussed as important in this process.
All persons with T2DM expressed the
need to control their weight. One woman
with T2DM explained: You know I do try
to watch what I eat really, a lot. Im overweight, and I try really hard to decrease
that and take care of that problem, but
thats easy to say and very hard to do.
Family support persons recognized the battle with excessive dietary consumption and
shared similar experiences as household
patterns affected the entire family. The
daughter and support person of another
woman explained what happens in her
family, I just try to get her to lose weight
with me. It aint workin very good.
Another reason weight loss was viewed
as difficult was its links with hypoglycemia. Persons with T2DM explained incidents resulting from calorie restriction and
increased physical activity in attempts to
lose weight. One man who did not take
insulin to control his diabetes explained:
To me, losing weight has always been very
difficult because being a diabetic if I get so
hungry, then I get the shakes, and I cant
stand it when I do that. Usually, then my
sugars low. Family support members often shared fears about hypoglycemia and
made sure that high sugar foods were
available. The husband of one woman with
T2DM described what happens when they
plan to be away from the house, It gets
kind of tricky around mealtime cause she
takes insulin, and if she dont get food in
time, she bogs out. So we just have to work

with it. Working with it often meant that


persons with T2DM consumed additional
unneeded calories.
Weight management was closely linked
to therapeutic diabetes care and was an
obstacle for those with T2DM and family
support persons. Three family members
commented on their personal weight issues
and discussed positive and negative ideas
about weight loss attempts. A family support member who was trying to improve
her personal behaviors described attempts
to encourage her mother to also lose
weight: I just try to get her to lose weight
with me. It aint workin very good.
Balancing the Routines
Balancing daily routines such as exercise, nutrition plans, blood glucose monitoring, medications, and physician visits
with dietary patterns were of great concern. Five persons with T2DM described
ways diabetes self-management influenced
individual and family routines. Evident
among persons with T2DM were statements about the complexity of managing
multiple routines for diabetes care. For example, one person with T2DM described
the ways dietary routines complicated life
for her and her family:
I never was a big breakfast person, but
now if we get up and are going to be on
the road or anything, I have to eat
cause I take the meds and itll go too
low before we stop for lunch or whatever. So, its changed that. I dont much
like eating that early, and we have to
make sure we stop at certain times
whether were ready to or not.
Another woman with T2DM described
how she balanced routines to prevent hypoglycemia. Frustrated with the increased
time needed to manage and plan routines,
she described her life changes: Usually if
its a special occasion like a dance or a
party or something, my whole day is circled
around that you know. Ill just do that one
big thing because if you do a lot you have to

MANAGING FAMILY SUPPORT

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have more insulin and thats hard to regulate you know cause I dont want to get
there and have an insulin reaction. Balancing her diabetes care routines also influenced her nutritional intake:
Its inconvenient as hell. You sweat,
and you get wet, and it happens wherever you are or whatever youre doing.
Or if I do any extra activity like even go
outside and walk in the yard or help
mow the grass or something, it causes
me to take more calories than I need to
take in. I do have a hard time with
that. I get mad.
Those families that had a member with
severe hypoglycemia appeared especially
concerned about balancing diabetes care
routines.
DISCUSSION AND CONCLUSION
Utilized in this study, the Family
Health Model (Denham, 2003) underscored
the multiple ways persons with T2DM and
their family support members influence dietary routines. Participants provided detailed accounts of multiple member roles,
interactions between households, and various contextual settings, and dietary routines. Many instances were described
where support and assistance were offered
to persons with T2DM, yet family support
members often lacked accurate knowledge
about the dietary routines and the care
processes pertinent to therapeutic management of T2DM. Variations in types and
accuracy of T2DM knowledge were observed among participants in a single family as well. Whereas knowledge about
T2DM may account for some variations in
diabetes self-management, education alone
will not address the disparities found in
household routines, values surrounding
eating, or the complex processes linked
with dietary change.
For this Appalachian population, cultural food preferences, family traditions,
and intergenerational dietary patterns influenced behavior changes related to di-

49

etary patterns. Cultural and relational


contexts are critical when addressing disease management within families. Health
professionals generally approach dietary
change as if it is an individual activity
when, in fact, these changes influence the
entire family. Findings suggest that persons with T2DM are likely to experience
varying levels of family support associated
with their cultural heritage, traditional
patterns of family life, and related food experiences. Furthermore, support levels are
not stationary measures, but fluctuate over
time even within single support persons.
Although the efficacy of dyadic educational
interventions has not clearly been shown,
validation of member concerns and increasing knowledge of potential supportive relationships seems a logical approach to dietary behaviors (Martire, 2005).
Because gender of the person with
T2DM influences how family support is
offered and received (Hepworth, 1999;
Navuluri, 2000), women who were family
support members were more likely to be
fully engaged in supportive activities when
compared with men in families. Evidence
exists that women are more likely to construct care based upon the needs of others,
especially those of a spouse or male family
members (Cigoli, Blinda, & Marta, 1994)
and influence how various aspects of dietary routines are experienced in families
(DeVault, 1991). Of particular concern are
women diagnosed with T2DM. Although
the small number of participants in this
study limits the ability to generalize findings about gender and dietary management, data are supportive of other gendered findings and suggest that families
may need specific dietary education to address potential implications of gendered
family practices.
Prior investigation of family health routines has focused on families with children,
little effort has been concentrated on adult
family members with chronic illnesses. The
formation of family routines has been used
as a form of therapeutic intervention with

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50

DENHAM, MANOOGIAN, AND SCHUSTER

family therapists and appears useful in


helping families redefine routines when
members hold disparate views (Fiese &
Wamboldt, 2000). Participants faced obstacles concerning the daily and routine implementation of dietary plans that benefited the health of those diagnosed with
T2DM. For example, emphasis on dietary
routines and needed precautions among
both those with T2DM and family support
members appeared more important on special days, while daily routines were often
mismanaged. Family support members, in
many cases, were either unclear as to how
they could best offer support or were unknowing as to the implications of the daily
routines for their loved ones specifically,
and family life in general. Fiese and
Wamboldt (2000) recommended that the
assessment of another chronic disease,
asthma, include (a) the current degree of
organization and routinization, (b) the degree of disruption caused by the condition,
and (c) the routines developed specific to
the disease. Similarly, families who have
members with T2DM may be better assisted to implement disease management
strategies with these recommendations.
Although family expectations implied
that households should be supportive and
demonstrate care, organization of care
needs was primarily viewed as the responsibility of the individual with T2DM. Treating diabetes as a family disease could influence the ways educational interventions
are planned by including family support
members in assessment, deconstruction,
and reconstruction of dietary routines. Intentional inclusion of family members in
diabetes education would allow for dietary
instruction and planning with multiple
members by incorporating meaningful values and typical dietary consumption patterns. Individuals often have difficulty
transferring knowledge into behaviors
(Savoka & Miller, 2001). Knowledge about
dietary routines is important for those with
T2DM. Instruction, however, needs to occur for multiple member cooperation

among those expected to provide support.


Additional research about how family relationships and specific household factors influence potential therapeutic changes is
also warranted.
Limitations of this study should be considered. First, the use of a small convenience sample restricts generalizabilty of
the findings. The investigators previous
research with Appalachian families suggests that participants are likely to be representative of others in this rural Appalachian region, although recognition of variability among residents of Appalachian
regions is critical. Issues raised by participants do have merit and would be useful in
constructing measures for larger, representative samples that address T2DM dietary
management in families. Because differences exist in member roles and supportive
interactions among various family support
members and family types, the inclusion of
an equal balance of diabetes participants
(i.e., male and female) and particular support members (e.g., spouses, adult children, siblings, etc.) in future studies may
provide clearer indications about types,
forms, and degrees of support. More information is also needed regarding whether
dietary routine patterns are regional in nature or if other populations share similarities.
Many family tensions exist in diabetes
management about the responsibility of
care. Especially for those who may be
stressed by initial diagnoses, have little
prior experience living with the disease, or
are challenged by limited resources and
family support, diabetes education is
bound to be challenging. Dietary routines
are essential and central aspects of daily
lives of interactive households. More needs
to be known about the ways families with a
member diagnosed with T2DM successfully change family routines and the kinds
of educational interventions and professional support that adequately sustain
changes over the life course. Using a family
lens when addressing diabetes manage-

MANAGING FAMILY SUPPORT

ment may contribute to more effective


practices and better outcomes for all involved.

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