1. Baldwin, Danielle
  2. Parsh, Bridget EdD, RN

Article Content

TYPE 1 DIABETES mellitus (T1DM) is an autoimmune disease that destroys the insulin-producing beta cells of the pancreas.1 Often affecting but not limited to younger individuals, T1DM requires patients to administer exogenous insulin for the rest of their lives.1,2 In the US, approximately 1.25 million adults and children are diagnosed with T1DM annually.2 This article discusses the emotional challenges associated with T1DM and the importance of self-image for these patients, especially in adolescent populations.


Healthy self-image

Self-image is characterized as the feelings, perceptions, and image that individuals have of themselves.3 A positive attitude can lead to positive self-image, in which patients recognize control over their body, focus on their uniqueness, and put their energy into happiness.4,5


Life experiences such as puberty, social media use, weight issues, and family and school life all affect self-image, which in turn impacts mental health, behavior, and diabetes management.3,4 Along with detailed patient education on diabetes management, including insulin administration, blood glucose monitoring, and maintaining a healthy diet, the assessment of self-image has been identified as integral to promoting patient control over the disease. Positive self-image can provide motivation, hope, and support as patients with T1DM battle many lifetime challenges.3


A common challenge for adolescents, anxiety has also been associated with higher levels of A1C, poor self-management and coping behaviors, depressive symptoms, fear of hypoglycemia, and a lower frequency of blood glucose monitoring.6 In studies from 2017 and 2018, patients with diabetes who reported distress also experienced increased A1C values and poorer psychological health.7,8 A high level of "grit," or the passion to continue forward toward long-term goals, has been associated with improved healthcare management and quality of life.5,9


Self-compassion is associated with improved health outcomes and critical in the management of T1DM.7,10 A part of self-image, it refers to treating oneself with kindness when going through personal challenges.7,10 For example, patients with T1DM may be critical of themselves due to high blood glucose levels and subsequently develop negative emotions such as anger, shame, sadness, or guilt.7 As a result, these patients may avoid monitoring their blood glucose levels and administering correction doses of insulin as an escape from the negative feelings associated with the disease.7 Patients who practice self-compassion experience less distress, increased empowerment, and lower A1C levels in the management of T1DM.7,8


Nursing considerations

When caring for patients with T1DM, consider their self-image as part of the nursing assessment.3,5,7,11 Utilize therapeutic communication such as active listening and avoid judgmental comments and negative facial expressions.4 Similarly, use words framed in empathy. For example, note that a patient "checks blood glucose levels a few times a week" rather than using a negative label such as "poorly controlled."12 Similarly, set realistic expectations regarding diabetes management.13


By using therapeutic communication and asking open-ended questions, nurses can assess a patient's feelings toward the diagnosis; success in managing and living with T1DM; and levels of self-compassion, self-criticism, and emotional balance.10 Additionally, open communication can help nurses determine patient support systems, as well as patterns of disclosure, sharing, acceptance, and coping mechanisms.7 For example, how do patients disclose their disease to others, and how would they like others to respond? These patient-centered questions help healthcare professionals assess a patient's emotional state and T1DM management.3,7


Diabetes distress questionnaires can also help to identify those who need additional screening, education, support, and treatment.8 For example, tools such as the Problem Areas in Diabetes (PAID) Questionnaire and the Diabetes Distress Scale for Adults with Type 1 Diabetes (T1-DDS) offer an effective means of opening lines of communication with patients (see Screening tools).14-17 In some cases, referrals to professional counselors may be indicated for further support. Similarly, summer camps for children and adolescents with diabetes can support patient autonomy and empowerment in social settings.18 Remind patients that they are in control of their self-image. Encourage them to work through emotions related to negative self-image and move toward self-compassion and a more positive outlook.3 Patients with a positive self-image are more likely to manage their blood glucose levels effectively.3



American Diabetes Association:


Beyond Type 1:


Beyond Type 1: Body image and type 1 diabetes


Centers for Disease Control and Prevention:Diabetes


Diabetes Attitudes, Wishes, and Needs:Problem Areas in Diabetes Questionnaire (PAID)


Diabetes Distress Screening Scale:


Diabetes UK:


Juvenile Diabetes Research Foundation:


Screening tools15,17

The follow assessment tools can serve to open lines of communication between healthcare providers and patients with diabetes.


PAID measures emotional distress in patients with diabetes:


* 20-item scale consisting of commonly reported emotional problems


* Each item scored on a Likert Scale of 0 to 4, with 0 representing no problem and 4 representing a serious problem


* Higher scores indicate greater emotional distress


* Valid and reliable in western populations


* Responsive assessment, meaning it can detect change when utilized in intervention studies



T1-DDS assesses feelings and emotions expressed by patients with diabetes:


* Powerlessness: extensive feelings of discouragement


* Negative social perceptions: concerns about negative judgments from others


* Physician distress: disheartenment with current care


* Friend/family distress: too much focus on diabetes from loved ones


* Hypoglycemic distress: concern about severe hypoglycemia


* Management distress: disappointment with self-care


* Eating distress: concerns that eating is not controlled





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