Diet modification challenges faced by marginalized and nonmarginalized adults with type 2 diabetes: A systematic review and qualitative meta-synthesis
Abstract
Objectives: Diet modification is an important part of the prevention and treatment of type 2 diabetes, but sustained dietary change remains elusive for many individuals. This paper describes and interprets the barriers to diet modification from the perspective of people with type 2 diabetes, paying particular attention to the experiences of people who experience social marginalization.
Methods: A systematic review of primary, empirical qualitative research was performed, capturing 120 relevant studies published between 2002 and 2015. Qualitative meta-synthesis was used to provide an integrative analysis of this knowledge.
Results: Due to the central role of food in social life, dietary change affects all aspects of a person’s life, and barriers related to self-discipline, emotions, family and social support, social significance of food, and knowledge were identified. These barriers are inter-linked and overlapping. Social marginalization magnifies barriers; people who face social marginalization are trying to make the same changes as other people with diabetes with fewer socio-material resources in the face of greater challenges.
Discussion: A social-ecological model of behavior supports our findings of challenges at all levels, and highlights the need for interventions and counseling strategies that address the social and environmental factors that shape and sustain dietary change.
Keywords : Social marginalization, qualitative meta-synthesis, systematic review, diet modification, type 2 diabetes
Introduction
The rates of diabetes mellitus have increased dramatically in the past decades, with over 2.4 million Canadians and 24 million Americans living with the disease, representing approxi- mately 8% of the general population of each country.1,2 More than 90% of adults with diabetes have type 2 diabetes mellitus (T2DM), which correlates with increased age, body weight, and family history.1 In industrialized countries, the prevalence, mor- bidity, and mortality rates of diabetes are higher among indigenous peoples,3 immi- grants,4 nonimmigrant ethnic minorities,5 and people of low socioeconomic status.6,7
T2DM causes several wide-ranging com- plications, and when blood sugar levels are uncontrolled, diabetic complications can negatively affect all aspects of a person’s quality of life.8,9 People with type 2 diabetes who are unable to control their condition through medication, diet, and exercise often experience multiple, interconnected compli- cations, which affect their physical, emo- tional, practical, and social well-being. Uncontrolled blood sugar levels contribute significantly to both the short- and long- term complications associated with diabetes. The short-term consequences of uncon- trolled diabetes include dizziness, restless- ness, confusion or cognitive dysfunction, headaches, weakness, anxiety, depression, and nausea, among others; these often impair daily functioning.8,9 The long-term effects of uncontrolled T2DM include a greatly increased risk of cardiovascular dis- ease, kidney failure, damage to eyesight and hearing, foot damage, nerve damage, a decline in mental health status, and an increase in overall mortality.8,9
While there is no consensus as to the ideal diet for type 2 diabetes, there is ample evidence that modifying diet by limiting the intake of red meats, balancing macronutri- ents, eating regularly, and controlling caloric intake and weight gain offers one of the most effective ways to maintain glycemic control. Appropriate diet modification, clinically indi- vidualized to each patient’s treatment goals and preferences, correlates with a lower risk of diabetes related morbidity and mortal- ity.8–10 As a result, alongside medication adherence and consistent physical activity, many clinical care guidelines recom- mend diet modification.8,9,11 Despite the known importance of diet modification and the proliferation of self-management inter- ventions to encourage diet modification, many adults with type 2 diabetes struggle to adopt and maintain a clinically recommended diet.12,13 Available country-based data show low adherence and sub-optimal diet quality among people with type 2 diabetes.14–16
This systematic review and qualitative meta-synthesis examines recent published qualitative research to provide evidence that answers the following research ques- tions: What barriers do people with type 2 diabetes experience when trying to modify their diets? How does social marginalization affect the experience of diet modification?
We chose to focus our analysis on the differential challenges faced by people who are socially marginalized and those who are not as marginalized. This analytic decision reflects the differential health outcomes and prevalence of diabetes in marginalized groups3–7 and corresponds to the available literature: nearly two-thirds of qualitative studies regarding diet modification for people with diabetes describe the experi- ences of research participants identified by the author as socially marginalized.
We conducted this study using an inter- sectional theoretical lens17,18 to guide our understanding of the significance of social marginalization. Our interpretive lens views each person with diabetes as living within a specific social context shaped by their unique perspective, situation, and access to (or deprivation from) certain resources. The social, economic, and political environments of people with diabetes, including the effects of race, class, and gender identities, play a critical role in mitigating or magnifying existing challenges to diet modification.17,18 Recognizing the artificiality of categories of social identification, but still requiring a way to categorize included papers for the pur- pose of the systematic review, we use each author’s identification of participants as marginalized. We recognize that individual participants may experience their identities differently, and that participants in studies where the author does not identify margin- alized identities within the sample may still experience social marginalization.
Our analysis reveals that while all people with diabetes experience common challenges when modifying their diets, social marginal- ization can magnify the experience of common challenges and introduce new chal- lenges. While we did identify some chal- lenges characteristic of specific types of marginalization, we caution readers from making a causal link between particular aspects of identity and specific diet modifi- cation challenges, as members of groups do not share all the same experiences. For example, two people with diabetes may both identify as female senior citizens who are first-generation Bangladeshi immi- grants. However, due to their particular social supports, financial resources, educa- tion, and health care experiences they may have very different experiences when trying to adapt their diet to fit diabetes guidelines.
Methods
We conducted a literature search on 1 April 2015 using OVID Medline, EBSCO Cumulative Index to Nursing and Allied Health Literature (CINAHL), ISI Web of Science Social Sciences Citation Index (SSCI) for studies published from 1 January 2002 to 1 April 2015. We chose to limit the search to papers published since 2002 to balance comprehensiveness with manageability. We limited our search to high-income countries where health care and food and diabetes education are available to most of the population, choosing the regions of Canada, United States, Europe, Australia, and New Zealand as a proxy for resource availability. We combined our published filter for qualitative research with a diabetes search filter developed by information scientists.19,20 We searched within the existing results for publications with the following words in the title or abstract: food*, diet*, nutrit*, eat*, meal*, challeng*, modif*, lifestyle. Two authors read titles and abstracts. If consensus was not reached with a title and abstract review, the full text was reviewed for eligibility and discussed by three authors.
Inclusion and exclusion criteria
We included studies that were published between 1 January 2002 and 1 April 2015. They consisted of primary, empirical quali- tative research using any descriptive or inter- pretive methodology. Eligible publications studied an adult patient population (>18 years of age) with T2DM or an unspecified type of diabetes. The studies took place in North America, Europe, Australia, or New Zealand and addressed any aspect of the experience of diet modification, nutrition, food, or meals. The studies were published in English and available either through the McMaster University library system or from the corresponding author.
We excluded studies when the topic of diet (as previously defined) was not suffi- ciently prominent to merit mention in the title or abstract (e.g. general self-manage- ment studies with no specific mention of diet). We excluded studies that primarily addressed the experiences of people with type 1 diabetes, gestational diabetes, or those without a diagnosis of diabetes. We also excluded unpublished studies (e.g. theses) and those that did not use primary empirical data. Finally, we excluded quan- titative research, which we defined as using statistical hypothesis testing, quantitative data and analyses or studies that expressed results in quantitative or statistical terms.
We did not exclude qualitative research on the basis of methodology or independ- ently assessed quality. The decision to include findings from all relevant studies is based on a number of factors: the relative similarity of qualitative data analysis, regardless of methodological orientation; the common occurrence of research reports with no cited methodological orientation; the ongoing debate among qualitative researchers about what constitutes meth- odological adherence and quality.21,22 Consistent with our methodology, we excluded studies for only one reason: when we could not discern data to support the findings.21 This approach evaluates the rigor of qualitative research by looking for empir- ical evidence in support of the reported judgments or inclusions. One cannot easily evaluate ‘‘methodological conformity, con- gruence or sophistication’’ (p. 155)21 in a methodological field where researchers con- ventionally under-report procedural details, and the quality of findings tends to rest less on methodological processes than on the conceptual prowess of the researchers.23
Analytical method
Using the technique of integrative qualita- tive meta-synthesis, we analyzed the findings from all eligible studies.21,22 Qualitative meta-synthesis is an integrative technique that combines findings from multiple studies to produce a synthesis of evidence which both retains the original meaning of the authors and offers a new, integrative inter- pretation of the phenomenon.21,22 Consistent with this methodology, we started with pre-defined research questions and a search strategy that guided data collection, relevance determination, and data extraction. Our research questions are: What barriers do people with type 2 diabetes experience when trying to mod- ify their diets? How does social marginaliza- tion affect the experience of diet modification?
At least two authors extracted the data, with discrepancies resolved by team consen- sus. The data for this synthesis were the researchers’ qualitative findings: the ‘‘data- driven and integrated discoveries, judg- ments, and/or pronouncements researchers offer about the phenomena, events, or cases under investigation’’ (p. 909).24 Through a staged coding process similar to that used in grounded theory,54 we broke the studies’ findings into their component parts (key themes, categories, concepts, etc.), which we then thematically re-grouped across studies. These categories developed based on rele- vance to the research question, prevalence, coherence, and significance, provided the foundation for analysis. We then synthe- sized and further developed the categories using an inductive and constant compara- tive25 approach. Data consist of previously published evi- dence, so research ethics approval was not required.
Results
The database search yielded 16,127 citations published between 1 January 2002 and 1 April 2015 (with duplicates removed). Figure 1 illustrates the bibliographic search process. We synthesized 120 papers. These 120 papers describe the experiences of 3721 participants (3283 patients, 203 family mem- bers, and 235 clinicians). Ninety-two studies (76%) involved marginalized participants, and many included participants experien- cing multiple types of marginalization. Tables 1 to 3 describe the included studies, including geographic location, method- ology, and forms of social marginalization studied, respectively.We discuss five key barriers to diet modification: (1) self-discipline, (2) emo- tions, (3) family and social support, (4) social significance of food, and (5) know- ledge and information. These barriers are overlapping and inter-related, and have a cumulative effect when combined (Table 4). Social marginalization further magnifies the challenges experienced in relation to each barrier.
Self-discipline
Many authors describe self-discipline as a central intrapersonal challenge to diet modi- fication26–32 both for people who identify as socially marginalized26–28,30,31,33–52 and nonmarginalized.29,53–65 Some authors explore the nature and experience of exercis- ing self-control, but most concentrate on the challenges and enablers of self-discipline for those trying to modify their diets.
The central challenge to self-discipline is bring, whether related to the taste, eating circumstances, or the freedom to consume whatever one wishes.64,66 Other challenges to self-discipline included disliking the taste of healthy food, or the taste of food prepared with diabetes-friendly substi- tutes,33,34,40,47,52,53,67 and having a hard time giving up unhealthy favorites26,28,34,36, 41–43,45–48,51,52,55–57,68–70 whether because of taste or because of social or cultural significance.33,35,36,40,42,68,71–84 Self-disci- pline is further challenged when eating away from home, especially during celebra- tions and holiday gatherings.30,32,44,46,52,57,65 Portion control is a frequently discussed self-discipline strategy, acting as both a barrier and facilitator of diet modification. As a barrier, portion control is described as time consuming, associated with feelings of hunger, and resulting in a reduction of pleasure from food. As a facilitator, portion control can encourage diet modification by allowing participants to continue to eat enjoyable foods, albeit in small quantities.26,28,29,33,38,52,57,71 Regardless of whether portion control is described as a barrier or facilitator, it is still labeled as a challenging strategy that is not enjoyable or easy to do.
Participants conceptualize self-discipline as something that can and should be con- trolled by the individual,56,58,60,61,87 and something that exists in limited capacity, eroded by repeated temptations or difficult circumstances. Participants would activate self-discipline by avoiding tempting food and circumstances where unhealthy food is typically consumed.46,51,52,64 Other enablers to self-discipline include awareness and edu- cation of how and why people with diabetes should change their diet.33,45,49,88 Awareness of the consequences of not changing one’s diet can be a powerful motivator of dietary self-discipline. Awareness was typically explained to mean having a fear of the complications of uncontrolled diabetes46,53,64,76,89 whether from personal experience,29, 36,42,54,58,90,91 or witnessing the experiences of others.34,92
There is a gendered divide in the reports of self-discipline and how it affects diet modification, with several authors reporting findings that ‘‘dietary struggles were a much more prominent part of women’s self-care behavior’’ (p. 6).35,46,50–52,63,65 This may be related to the common experience of using food consumption practices to regulate weight, as reported by the female partici- pants in Balfe’s study.54 Gendered roles may also shape spousal interaction around self- discipline; Beverly found that men who relied on their spouses to maintain a healthy diet exhibited lower levels of self-control, and that control over food-related decisions is often a source of conflict between spouses.55
Emotions
Numerous researchers describe negative emotions as one type of intrapersonal bar- rier detrimental to dietary change. Stress is the most frequently mentioned emotion.28, 33,38,40,54,58,60,61,65,68,73,74,80,89,93–101 Stress is described by Jones et al. as particularly detrimental to dietary modification because ‘‘high levels of stress divert priority away from management’’ (p. 446)49 of diabetes.99 Coping with stressful circumstances in one’s everyday life may present barriers to healthy eating.28,33,40,58,60,61,73,74,85,94,96,98,102 The
stress of everyday life may include busy routines as a result of work or family commitments,33,40,58,60 caregiving stress,60, 94,103 or stress from living in poverty or experiencing discrimination and racism.85,96, 99,104 Diabetes itself may be a cause of stress, as patients try to cope with the diagnosis of diabetes and the many self-management activities they are instructed to engage in.49,65,80,85,89,93,98 Participants also describe feelings of stress related to the fear of diabetic side-effects and their conse- quences,28,74,89,105,106 including a fear of hypoglycemic events.54,107
No matter what the cause, stress may challenge self-discipline,58 leading people to feel less motivated,65,73 to manage their diets. Others may seek comfort from stress in food.33,51,52,54,97,108,109 When experien- cing challenges with their self-management regimens, patients may experience guilt or anger,46,51,52,54,58,64,65,76,110–112 which may in turn cause stress and further challenge their self-management efforts, creating a cycle of defeat.
Other negative emotions related to diet modification include depression, loneliness, and isolation,28,34,54,58,63,76,89,111 especially when people with diabetes are not able to freely partake in the social occasions and rituals, which center around food.
Family and social support
The influence of family is an important part of dietary self-management26,28,32,34,35,37, 39–45,54,55,58,59,62,69–71,73,75,76,80,82,89,92–96,113–121and the interpersonal relationships surround- ing a person with diabetes can act as both a barrier or facilitator of dietary change. As the household is the main site of food planning, preparation, and consump- tion, other household members often have a strong influence over diet modification efforts. Many authors suggest that efforts towards dietary change must accommodate the routines, resources, and activities of the household.34,39,40,58,73,120,122 Sometimes this influence can be very helpful: family mem- bers can provide instrumental32,37,50,59,73,75,82, 93,95,119,121–123 and social/emotional support,especially when they have been educated on the needs and requirements of a diabetic diet.39,41,55,62,80,92,93,95,114,117
Family members can also present signifi- cant barriers to dietary change.30,32,37,55,58, 70,124 It is difficult to integrate new eating patterns into established family preferences and habits,26,30,34,35,39,40,43,45,71,75,76,80,92,
115–117,119,123 which may have intergenera- tional and cultural significance.39,113 Family eating habits reflect the preferences of the members, which the diabetic individual may feel reluctant or powerless to change, or guilty about requesting such a ‘‘sacrifice’’.34, 40,42,43,62,75,85,89,115,120 When acting as the main cook for the family, a person with diabetes may feel beholden to the wishes of others in terms of what type of food is served, and when.32,34,39,40,85,120 Those who are not the main cook for the family may have little control over menu planning or portion allocation.34,40,60,75 These issues of control and cooperation are described as a gendered problem; families may be more likely to accommodate the needs of men with diabetes, while women with diabetes are more likely to sacrifice meal plans to accommodate family requirements or desires. 34,39,42,44,59,70,120,122,126
People with diabetes may feel a sense of social isolation when they are not able to fully participate in social occasions because of their dietary needs.28,49,63,75,98 Participants in many papers also empha- sized the enjoyment that food brought to them during these social occasions and the importance of participating in community and family life in this way.28,38,39,42,51,53,75,78, 95,113,116 ‘‘Socialising and enjoying onself may be valued more highly than health, so people sometimes opt for ‘doing the wrong thing’’’(p. 2378),56 which can also be under- stood as prioritizing social well-being, com- munity, and family memberships over diabetes care.
The concept of food as a form of social participation was especially pronounced in studies of people who are members of culturally marginalized communities.35,38, 39,42,44,51,53,56,60,71,75–77,79,113,126–128,130 For these people, food is an important way of participating in traditions and staying in touch with cultural communities, with many specific foods mentioned as integral to cul- tural identity and membership.33,35,38,42,44,51, 71,75,76,78,127 For example, ‘‘rice is viewed as a symbol of strength, sustenance, sacrifice, wealth and togetherness and may be eaten at every meal. Reducing or eliminating rice from one’s diet may be perceived as rejecting Filipino culture and is thus con- sidered a difficult loss for many Filipino Americans’’(p. 847).76 The cultural signifi- cance of food also extended to traditional methods of preparation, making diabetes- friendly substitutes or cooking methods less appealing.33,42,78 Declining, abstaining, or asking for accommodation might be con- sidered offensive in some situations.33,39,42, 51,76,79,127
Knowledge and information
Many studies described the importance of knowledge about nutrition when making dietary changes. Knowledge is treated in very different ways across this body of literature, with some studies focused on describing specific gaps in knowledge. Common knowledge gaps include the con- sequences of uncontrolled diabetes, portion control, the concept of calories, how to count carbohydrates for diabetes manage- ment, the relationship between food and blood glucose level, the difference between sugar and fat, which vegetables should be counted as carbohydrates, and how to plan meals with fruit.28,35,41,50,52,58,61,63–65,68,72,73,76,85,88,89,91,92,106,118,125,131–138
Other authors deeply interrogate the relationship between knowledge, motiv- ation, and behavior change, e.g. Greenhalgh et al.114 One synthesis of find- ings on knowledge identified that there are two types of important knowledge for diet- ary modification. First, a person with dia- betes must have knowledge of the basic information about dietary modification. Second, that person must also have the knowledge that allows them to adapt their diet to the changing circumstances of their lives, accommodating schedules, special events, cravings, slip-ups, etc. ‘‘Participants emphasized the importance of having gen- eral knowledge about T2DM as well as knowing how to manage the disease’’ (p. 902).26 Greenhalgh names this distinc- tion ‘‘knowing that’’ (abstract knowledge) and ‘‘knowing how’’ (practical understand- ing), hypothesizing that when patients are ‘‘noncompliant’’ it may be that they lack practical understanding of knowing what to do.114 This idea is present (explicitly or implicitly) in many papers that emphasize the need for information about specific strategies that can be adapted to the needs and preferences of people with diabetes.26,41, 50,57,62,85,114,139,140 Researchers give many different examples of what these particular strategies might include, such as meal- planning with specific circumstances in mind, which diabetes-friendly foods are affordable, how to read food labels, how to incorporate traditional foods and cooking practices, how to adapt and plan when you have a lack of time for cooking or limited cooking skills, how to accommodate cele- brations, cravings, and slip-ups.26,32,34,41,47,
50,57,62,67,73,78,80,85,114,137,141,142
There is a wide recognition that know- ledge may be a necessary condition for dietary modification, but it is not a suffi- cient condition to make and sustain diet- ary change. Knowledge may be difficult to apply because of the affordability of food, incompatibility between dietary rec- ommendations and personal or trad- itional eating habits, a lack of time for planning, shopping, and preparation, a lack of cooking skills, comorbid condi- tions with conflicting requirements, insuf- ficient numeracy and literacy skills to interpret food labels, and challenges incor- porating recommendations for unfamiliar foods and ingredients. 31,34,40,41,47,50,52,66,73, 78,80,85,96,99,114,118,141,143 Sometimes there are interpersonal barriers, such as when the person with the knowledge about diabetes is not in control of the meal planning, food shopping, and preparation.39,60,128
There are only subtle distinctions between the topic of knowledge across studies of marginalized and nonmargina- lized people, with studies of socially margin- alized people placing more emphasis on the specific circumstances of an individual’s life that require adapted information. For example, diet recommendations may incorp- orate foods that some people are not famil- iar with, or do not typically use.34,47 Other groups may need information on how to adapt traditional ingredients and cooking methods to a diabetes-friendly diet.73,78,80 Literacy and numeracy challenges to gaining knowledge and finding information may be higher in some groups, and in those who do not fluently speak or read the dominant language.118
Magnifying effect of social marginalization
A simple explanation of the challenges faced by people with diabetes as they modify their diets is that food is an important part of life, and diet modification requires changes that ripple through most other aspects of life. Food requires resources, planning, and knowledge; food brings people together, solidifying community, maintaining iden- tity, and conveying love. Changing the way you eat means changing the way you live. Because of the profound change required for diet modification, even the most motivated, highly resourced individuals face challenges. People who face one or more types of social marginalization are trying to make the same changes with fewer socio-material resources and in the face of greater challenges.
As an example of the way social margin- alization magnifies the challenges of diet modification, consider the effect of poverty. All people make dietary changes within their household group or family, and are chal- lenged to balance the needs and preferences of family members with and without dia- betes. For people with diabetes living in poverty, this challenge may be especially acute, as diabetes-friendly food is often more expensive, drawing resources away from other family members.39,47,85,99,106,144 The diversion of resources included not just the cost of the food, but also the time and resources required to buy the food, which may not be readily accessible in all neigh- borhoods.43,47,66,67,85,99,145 Meal planning and preparation was a common challenge across most studies, but people living in poverty may face additional planning and procurement challenges including ‘‘having to choose between lower prices and long commutes by public transportation, taking up several hours at a time and carrying multiple bags, or higher prices at closer-by stores, where often they are also forced to shop due to time constraints (e.g. holding multiple low-paying jobs)’’(p. 152).99
Discussion
Diet modification is an important part of the control and management of T2DM, but continues to challenge many patients. A strong body of literature has demonstrated that self-management interventions, includ- ing diet modification, can be at least as effective as medication in preventing dia- betes and in controlling diabetic side-effects and comorbidities.146–148 Despite a prolifer- ation of programs and interventions to encourage and support dietary change, sus- tained change remains elusive. While studies have shown a wide variety of interventions to have positive effects on diet modification, a meta-analysis by Norris et al.149 revealed that the benefits of many interventions decline after the end of the intervention. The difficulty in sustaining dietary change resonates with our findings, which empha- size the central role food plays in social life, and the influence of a myriad of social factors on food planning and preparation.
This is recognized by international guide- lines that recommend that self-management interventions and counseling should consider the health beliefs, decision-making skills, cultural preferences, and the financial and social resources of the person with diabetes.8,9,11
The discursive and theoretical emphasis on self-management in the diabetes litera- ture emphasizes the control, motivation, and behavior of the individual. Our findings are congruent with a social-ecological model of behavior change, highlighting that ‘‘self-management is dependent on the environmental contexts that surround the individual’’ (p. 1523).150 The barriers identi- fied by people with diabetes as they engage in diet modification correspond to the different levels of influence identified by social-ecologists.150–153 For example, at the intrapersonal individual (biological and psy- chological) level, people with diabetes may struggle with taste preferences or emotional comfort eating. At the interpersonal (family, friends, small group) level, people with diabetes may struggle to accommodate the tastes and preferences of their family mem- bers into meal changes, they may feel sabotaged by friends or family members, and they worry about not wanting to spoil a celebration by declining to eat in the same way as everyone else. At the system, group, or cultural level, people with diabetes may encounter dietary recommendations that conflict with their cultural food preferences or they may feel stigma in disclosing their diabetes. At the community or policy level of influence, they may not be able to afford diabetes-friendly foods, and they may not have access to information that supports adaptive problem solving.
For people with diabetes who experience social marginalization, environmental fac- tors may present larger barriers in the area of culturally inappropriate or incongruent education and information, language diffi- culties, financial or physical obstacles to procuring and preparing healthy food, etc. The particular social location of each person with diabetes will influence the social-ecological environment in which that person is making dietary change, and present a correspondingly individual set of barriers and facilitators.151,153 For instance, a form of social marginalization such as poverty can influence diet modification on many different levels: a lifetime of eating available food may shape an individual’s tastes and food prefer- ences for cheap, high-fat, carbohydrate- heavy food.47 Interpersonal relationships may lead people living in poverty to have to choose how to allocate scarce familial resources. For example, with limited money for food, a person with diabetes living in poverty might have to choose between feed- ing the whole family with less expensive food, or buying a smaller amount of more expen- sive diabetes-friendly food for themselves.39, 43,85 At the system, group, or cultural level, people living in poverty might experience stress at higher levels than others, which people with diabetes have identified as a causal factor for poor eating habits.85 At the community or policy level, the lack of fresh produce and healthy foods in poor neighborhoods might make it inaccessible to many people living in poverty.99 The use of a social-ecological theoretical lens clarifies the multiple, magnifying impacts that social marginalization has on diet modification.
Our findings and socio-ecological per- spectives to health behavior change both suggest that multi-level interventions most effectively change behavior, rather than person-focused approaches which target the individual in isolation from his or her envir- onment.151 Interventions that target the individual’s knowledge, motivation, and behavior often neglect the influence of the social and environmental factors that shape and reinforce health behaviors.150,152,153
Strengths and limitations
This study provides a comprehensive synthe- sis of the perspectives of people with T2DM on barriers to diet modification. There is a significant amount of qualitative research on this topic, and it has not yet been gathered together in this way. Existing systematic reviews of qualitative research focus on dia- betes management more broadly, and in this broader view are not able to address some of the nuances of diet modification. The large number of studies included in this meta- synthesis provides a breadth and depth of information from a wide range of partici- pants and health care contexts, increasing the transferability of our findings across settings. Limitations of this work include a focus on English-language reports, and a focus on resource-rich nations. Caution should be used when considering the relevance of these results to low and middle income jurisdictions.
Conclusion
Analysis of 120 primary, qualitative studies on challenges to diet modification revealed several inter-linked and overlapping barriers to diet modification, including self-disci- pline, emotions, family and social support, the social significance of food, and know- ledge. The analysis also highlighted the magnifying effect of social marginalization on the identified barriers, with different forms of social marginalization compound- ing the barriers experienced by patients. The particular social location and circumstances of a person with diabetes will significantly 3-MA affect the challenges that individual faces.