The Science of Diabetes Self-Management and Care2024, Vol. 50(6) 520–531© The Author(s) 2024Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/26350106241285815journals.sagepub.com/home/tde
Abstract
Purpose: The purpose of the study was to explore factors surrounding management of simultaneous dietary recommendations for heart failure and type 2 diabetes among patient-caregiver dyads.
Methods: Qualitative description was used to explore dyad experiences managing a dual diet. Semi-structured interviews were conducted with patients with a concurrent diagnosis of type 2 diabetes and heart failure and their family caregiver. Each 60-minute interview was conducted virtually. Interviews were audio recorded and transcribed verbatim. Thematic analysis was conducted with coding used for themes at dyadic-and individual levels.
Results: Twelve patient-caregiver dyads (N = 24) were interviewed. The mean age was 57 years (±15 years). Most participants were white (75%); patients were predominantly male, and caregivers were predominantly female (83.3% for both). Dyadic-level themes that emerged included factors that influence simultaneous management of dual diet recommendations. Themes included shared barriers, facilitators, motivators, and strategies for dual diet management. Individual-level themes discussed by patients were barriers and motivators to dual diet management, and caregivers discussed barriers to supporting dual diet management.
Conclusions: Findings from the study highlight that patients and caregivers often work together and share similar barriers, facilitators, motivators, and strategies for adhering to a dual diet. The results provide insight into chronic disease management at the family level and can guide health care providers’ efforts to promote family involvement with dietary recommendations for patients with multiple comorbidities.
Heart failure (HF) is a common complication of type 2 diabetes (T2DM), with the two diagnoses frequently occurring concomitantly since they are pathologically similar and share similar risk factors.1 It is estimated that 35% to 45% of individuals with HF have a concurrent diagnosis of T2DM.2 Moreover, a diagnosis of T2DM alone is associated with a 2- to 4-fold increased risk for the development of HF and increases the risk of mortality among individuals diagnosed with HF.2,3 Furthermore, HF is a main contributor to cardiovascular-related morbidity and mortality among individuals with diabetes.4
Individuals with T2DM and HF who participate in self-care behaviors, such as maintaining a healthy diet, have better health outcomes, improved symptom management, and reduced disease complications compared to those who do not follow self-care recommendations.5,6 However, many individuals with diabetes find following the dietary recommendations the most difficult self-care practice, and only 7% of individuals with T2DM follow all dietary recommendations.7,8 Similarly, a low sodium diet is the cornerstone of HF self-management, yet only 22% to 55% of individuals with HF follow low sodium diet recommendations.9 Family caregiver support has been found to facilitate dietary management among patients with T2DM and among those with HF.9-11 In a study examining management of a low sodium diet among patients with HF and their family caregiver, patients were better able to follow dietary recommendations when the family member also followed the diet.10
Although factors influencing dietary management have been studied among patients with T2DM and patients with HF, less is known about the management of simultaneous dietary recommendations among patients with a concurrent diagnosis of T2DM and HF. Additionally, although family involvement has been shown to influence diet management related to medically prescribed diets in patients with each of these conditions, the specific factors surrounding simultaneous management of dual dietary recommendations as experienced by patient-caregiver dyads is limited. Therefore, the purpose of this qualitative descriptive study was to explore factors surrounding dual diet management as experienced by patients with a concurrent diagnosis of T2DM and HF and their family caregivers at both the dyadic and individual levels.
Qualitative description was used to explore the factors surrounding simultaneous management of a dual low sodium and diabetic diet as experienced by individuals with T2DM and HF and their family caregivers. This method is appropriate for identifying, exploring, and understanding phenomena through the subjective perspectives, meanings, and accounts of those directly involved in or affected by the phenomenon of interest.12-15 The method is characterized by low-inference interpretation using an inductive process that allows the researcher to stay close to the data and develop a comprehensive summary of a phenomenon of interest through the descriptions and meanings that participants have attributed to that phenomenon.12-14,16,17 Qualitative description is especially useful for research conducted to gain insight from study participants about phenomenon that are not well understood.14
For this study, participants were recruited from two randomized controlled trials that assessed the impact of a healthy lifestyle intervention on cardiovascular disease risk among adults diagnosed with a chronic disease and their family caregivers. In both trials, participants were patients who had a chronic health condition and a dedicated family caregiver. For this qualitative study, participants were screened for eligibility, which included having a comorbid diagnosis of T2DM and HF. Participants were recruited by email and mailed invitations. Follow-up phone calls were conducted approximately 2 weeks after invitation letters had been sent to allow prospective participants time to consider involvement. Additional recruitment methods included direct contact by a nurse interventionist familiar with eligible participants enrolled in the two ongoing longitudinal studies. No compensation was provided for participation in the qualitative study. All procedures were approved by the institutional review board of a large Southeastern public university.
Data were collected using semi-structured interviews following an interview guide with additional probes designed to gain deeper insight into responses (Table 1). Data collection began April 2017 and concluded in August 2018. Interviews were conducted once and included both members of the dyad; both individual- and dyadic-level data were collected at the same time during the interviews. Each interview lasted approximately one hour. The interviews were conducted using the video chat programs FaceTime and Zoom via password-protected iPads. Participant dyads joined the interviews from a private area in their home. To maintain participant confidentiality, one of the authors conducted all interviews in a private office. Interviews were recorded using the secure Echo360 software program. Participants were informed of and verbally consented to the recording of the interviews prior to the start of the interview. Interviews were transcribed verbatim by one of the authors and a HIPAA-compliant transcription service (TranscribeMe). All transcripts were reviewed and verified for accuracy by two of the authors. To maintain anonymity, all participants were assigned pseudonyms in interview transcripts; patient participants were assigned names beginning with “P,” and caregiver participants were assigned names beginning with “C.” Extensive field notes were kept during each interview and were used to validate the emerging themes. Audit trails were used to account for trustworthiness of information.
The process of thematic analysis was used to analyze interview transcripts. Through a process of immersion, two of the authors coded the interviews separately, identifying themes that emerged from the data.18,19 Once initial coding of the first three interviews was completed, the generated codes were compared, and a coding guide was developed for the remaining interviews, with additional codes added as they emerged from the data. Initial themes were determined through a review of codes generated through independent analysis conducted by the 2 authors. Through the use of constant comparison, coding and interviewing continued until the two authors determined that data saturation was reached. Coding was used to distinguish dyadic themes and individual themes. Once final themes were determined, a third author reviewed the themes for purposes of verification.
Of 17 patient-caregiver dyads invited, 12 dyads (N = 24) consented to participate. The majority of the patient participants self-identified as white (75.0%) and male (83.3%) and ranged in age from 40 to 83 years with a mean age of 60.6 ± 14.4 years. The majority of caregiver participants self-identified as white (75.0%) and female (83.3%) and ranged in age from 25 to 75 years with a mean age of 57.0 ± 14.9 years. Two caregivers had diagnosed T2DM; no caregivers had diagnosed HF.
Overarching themes were the barriers, facilitators, motivators, and strategies for dual diet management. Barriers were defined as internal and external factors that impacted the ability to simultaneously manage dual diet recommendations. Conversely, facilitators included internal and external factors that more passively aided the ability to follow dual diet recommendations. Motivators were reasons patients and caregivers identified as contributing to the desire to follow dietary recommendations. Strategies were approaches or tactics actively employed by dyads to manage the dual diet.
Dyadic-level themes were identified by both members of the patient-caregiver dyad. Individual-level themes were factors surrounding simultaneous management of dual diet recommendations identified by either the patients or caregivers but were not shared by both. The majority of themes were at the dyadic level, with patients and caregivers identifying shared barriers, facilitators, motivators, and strategies for simultaneous management of dual diet recommendations. Individual-level factors reported by patients addressed barriers and motivators; no individuallevel patient themes related to facilitators or strategies emerged from the data. Caregivers reported specific barriers but no individual-level caregiver themes regarding motivators, facilitators, or strategies emerged.
Dyadic-level barriers. Among the commonly identified dyadic-level barriers to managing dual dietary recommendations were caregiver-permitted lapses. These were defined by dyads as times in which caregivers gave their permission or even encouraged patients to eat foods not in alignment with dietary recommendations to maintain patients’ sense of autonomy. Many caregivers felt lapses should be permitted and that the patients were capable of making their own choices regarding management of the dual diet. However, some caregivers acknowledged permitted lapses occurred because the caregiver was unsure of when it was appropriate to intervene, fearing that they were infringing on the patient’s autonomy.
Both members of the dyad also frequently reported nonsupportive caregiver behaviors as a barrier to simultaneous dual diet management, for example, the caregiver rewarding the patient for successful dual diet management with restricted foods. This is exemplified by the patient of one dyad, who explained:
One of the barriers that is for this diet, honestly, is my husband is too kind in his words. Because it is a problem . . . I don’t have that option with all these diagnoses. And my husband’s very kind and he’s like, well you’ve been good, you can go ahead and try it.
This was compounded by feelings of temptation when the caregiver ate restricted foods in the presence of the patient. Additionally, availability of restricted foods in the home was another frequently reported barrier to dual diet management. Dyads identified this to be a barrier after grocery trips or when restricted food items were stocked for other members of the family (eg, children). This was particularly problematic when hunger levels exceeded interest in following dietary recommendations.
Some dyads reported food taste to be a barrier to management of the dual diet. As stated by one patient, “Food don’t taste as good. I’m hoping I’ll get used to it, so it’ll taste as good when I get used to it. But, I mean, it don’t taste nearly as good as what I’m used to eating.” At the same time, many dyads who reported this barrier stated they were “getting used to” the taste of foods meeting dietary recommendations.
Eating out was identified as a barrier, with dyads feeling their options were limited because many restaurants do not provide foods in alignment with the dual diet recommendations. Eating out was often associated with frequent health care appointments as many of the patients had appointments multiple days a week that required the dyad to drive long distances. Dyads stated that frequent doctor appointments made it difficult to plan meals or prepare food ahead of time. As summed up by a caregiver, “That’s a bad mistake, you know, that when we go to the doctor, we eat out.”
Managing the two diets together required many dyads to focus on one diet over the other. “It’s almost like you put them in a hat and whichever one’s drawn is the one that you’re gonna target that day.” Some dyads reported confusion due to a lack of knowledge about the diets. One dyad reported that despite using various resources to learn more about appropriate foods for the two diets, conflicting information among resources ultimately led to feeling more confused. Underlying the confusion for some was a lack of education about the two diets by their health care providers. Others stated that although they received education about the diets from providers, the education received was often too brief and vague. Common sources of confusion included not knowing which foods qualified as acceptable between the two diets, the amount of carbohydrates that should be consumed per meal, or what the daily sodium intake limit should be. As stated by one patient participant,
It’s confusing to me, very confusing. I don’t know what I’m allowed to eat. I can’t eat canned foods; everything has to be fresh. Can’t have too much carbohydrate because that turns into sugar. I don’t know what I’m allowed to eat . . . I don’t understand. And I’m not dumb.”
Individual-level patient barriers. Strong cravings for foods not aligned with dual diet recommendations were reported as a struggle for most participants; however, many stated they worked hard to overcome these cravings. Some patients reported not being aware they had cravings for certain foods until they were restricted. Some reported feeling overwhelmed and burned-out by the difficulty of managing two diets simultaneously, such as knowing which foods were considered in alignment with the dietary recommendations and balancing the various components of the two diets. Some also reported feeling limited by the two diets because recommendations from both diets limited the variety of foods they could eat. This was exemplified by one patient who commented, “That’s a big barrier, too. There’s only so many different types of food you can eat, which is not good either.”
Overeating and large portion sizes were also reported by participants as a struggle. Similarly, some participants talked about “sneaking” foods and snacking, often without their caregiver’s knowledge, as a barrier. Patients acknowledged that although they had the resources and knowledge to manage the dual diet, they were less likely to follow dietary recommendations when not feeling well. As explained by one patient, “I’ve got the information, the materials. I just need to apply it when I feel, you know . . . it’s just so many times that I don’t feel good that I don’t apply it.”
Individual-level caregiver barriers. Management of the various aspects of the dual diet also contributed to caregivers feeling exhausted and overwhelmed by caregiving responsibilities, such as carrying out household tasks while taking care of their family member’s health-related needs. Some caregivers acknowledged that these feelings often led to unsupportive behaviors, as exemplified by a caregiver’s comment, “Sometimes, me being lazy or me being tired, a frozen pot pie comes out of the freezer, and that’s the worst thing on both accounts.”
Dyadic-level facilitators. All dyads discussed the importance of caregiver support as a facilitator to dual diet management. Caregiver support was reported as having a positive influence on food choices due to the caregiver preparing meals in alignment with dual diet recommendations, providing reminders when food choices are not in alignment with the diets, or providing words of encouragement. Caregivers also discussed ways in which they were able to provide support, such as preparing and eating meals alongside their family member. Having a good external support system was another facilitator to dual diet management reported by dyads. External support systems primarily included members of their health care teams and the dyad’s children. As expressed by one patient participant,
She takes care of me, I mean, totally. Her and, well, my daughter helps her, but probably I look to [caregiver]. She watches my diet, she feeds me, and she knows what I need to eat, and how much I’ve eaten. If I go to eat too much, she’ll tell me.
Juxtaposed to dyads who reported lack of dietary education as a barrier, several reported formal education about the two diets as a facilitator for dual diet management. Education received from specialists, particularly dietitians, was the most frequently identified source of formal education, such as nutrition-based classes; however, most reported that these classes only focused on recommendations for one diet and that the information presented was often repetitive and not as detailed as they hoped.
Most dyads shared that eating at home facilitated management of the dual diet. Cooking at home allowed them to have a better sense of control because they could manage the amount of carbohydrates in each meal and the amount of sodium added to a recipe. One caregiver stated, “We don’t eat out very often, and I think that’s kind of a plus. I can have a little more control over things.” Furthermore, eating meals together promoted family involvement in helping the patient with T2DM and HF manage the dual diet. Better food choices were made when cooking at home, such as opting for fresh fruit rather than cookies for dessert. These sentiments were captured by one caregiver who stated,
We just try to keep things that we can immediately eat. We read labels for the low sodium; we try to buy no salt added products. And try to keep something handy. Like, we always have grapes, we always have blueberries.
Many reported that by making small changes to the way they prepared foods, they became accustomed to the taste of foods in alignment with the dietary recommendations. For example, by slowly reducing their intake of sodium or sugar over time, preferences for foods not in alignment with dietary recommendations had diminished. As explained by one patient,
That made the biggest difference. Because we first started with it, one of the things, you could taste the salt, which we don’t need to be able to do that. And we just kept cutting back until we figured out, “Okay, we need this much less than we used to.” And it’s been working out really well.
Many found that as their preferences changed over time, the foods they previously craved or ate frequently now tasted overly salty or overly sweet or were overly laden with carbohydrates. According to another patient,
It has made a difference; I mean I can tell a difference since I’ve cut down on salt. If I get anything with salt in it, it just don’t taste as good, not nearly as good as it used to.
Dyadic-level motivators. Motivators of dual diet management included improved lab values that led to fewer prescribed medications and an overall sense of enhanced health. Some patients stated that following the dual diet allowed them to stop taking medications and manage their HF and T2DM through diet alone. Similarly, many caregivers reported positive outcomes associated with participating in following the dual diet alongside their family member.
Patient-level motivators. Whereas caregivers contributed to the discussion of motivators for management of the dual diet at the dyadic level, motivators were most frequently discussed at the individual level of the patient. The most commonly reported motivator was fear of dying. Participants reported having family and friends who experienced serious complications or death as a result of not following dietary recommendations. Some participants referenced past critical health crises or having come close to death themselves, which increased their resolve to follow the dual diet recommendations. A desire to live for family (spouses, children, and grandchildren) was another major motivator. As expressed by a participant: “I have two grandchildren, one just born 5 months ago. I want to live, that’s why.”
Many patient participants attributed eating foods not aligned with dietary recommendations to worsening symptoms and complications of the diagnoses. Therefore, avoiding symptoms of uncontrolled HF and T2DM was also a motivator. In addition to reducing the risk for worsening symptoms and complications, avoiding hospitalization was another motivator. As expressed by one patient participant,
I don’t want to go into the hospital, because my sugar’s too high, my salt content’s too high, I’m holding water; you know? All the things in a row, because of bad choices that I’ve made over the past month.
Dyadic-level strategies. Dyads frequently discussed strategies used to better manage the dual diet. Nearly all dyads discussed the importance of adapting to the diet recommendations as a strategy for simultaneous dual diet management. Adapting encompassed forming routines, avoiding foods not in alignment with dietary recommendations, choosing restaurants that offer food options aligned with dietary recommendations, being aware of food choices, and choosing to follow dual diet recommendations despite cravings. All dyads reported using substitution products, such as Mrs. Dash and artificial sweeteners, to gradually reduce intake of salt, sugar, and carbohydrates. Dyads also reported other methods of salt and sugar reduction, such as rinsing canned goods, purchasing low sodium foods, removing the saltshaker from the dinner table, and opting for sugar free foods. Another approach to reduction was consuming smaller portions by using smaller plates, eating single-serving snacks and desserts, and splitting meals at restaurants.
Furthermore, many dyads reported counterbalancing these reduction methods with increased consumption of fruits and vegetables. Some dyads reported increasing fruit and vegetable intake by ensuring at least half their plate was made up of fruits or vegetables, having salads at meals, incorporating shredded vegetables into dishes such as lasagna, and keeping fruits and vegetables in easily accessible locations. In providing support to their family members, caregivers reported incorporating many of these strategies into their own dietary patterns as well.
Meal planning and following specialized diets were also commonly reported strategies for simultaneous management of the dual diet. Dyads reported trying specialized diets, such as the Keto diet, plant-based diets, the glycemic index, the 7-day diet, and the Mediterranean diet. Participants found these diets helpful for managing sodium, sugar, and carbohydrate intake and preventing overindulgence.
Dyads who frequently ate at restaurants also reported developing adaptation strategies to better manage dual diet recommendations while eating out, such as requesting nutrition information for menu items, opting for salads with a light dressing, ordering vegetable plates, and sharing entrees. Some dyads found that familiarizing themselves with the owners and employees of restaurants resulted in a new support system through staff who advised on available food choices in alignment with the dual diet. As described by one dyad, “We eat out enough at these places that they know us, and we know what they cook. We’re friends with the owners at a lot of places.”
Other strategies included using internet-based resources and written materials to better understand dual diet recommendations. Internet-based resources included websites for professional organizations, such as the American Diabetes Association and the American Heart Association, and various recipe sites and social media. Written materials included handbooks, pamphlets, hospital newsletters, and food preparation charts.
Food label reading was also frequently reported as a strategy for management of the dual diet. Most dyads reported reading labels to identify the best options when making food choices. One patient participant shared,
The reading labels has really become an everyday thing. When you go to the store, that’s the first thing you do if you’re going to get canned food. As you turn it around, you read the carbohydrates, the sodium, and all that.
Results of the study indicated the importance of health care providers working with both patients and family caregivers on simultaneous management of dual diet recommendations. Family support was identified as an important facilitator in the present study, which has been found to be positively related to diet management among individuals with T2DM.20,21 A systematic review of qualitative research exploring challenges to dietary modification experienced by patients with diabetes or heart disease highlighted the critical role of family support to diet management for diabetes and heart disease.22 Other studies investigating the effect of family involvement on T2DM outcomes have shown self-management and diabetes control to improve with greater family involvement.11,23,24 Similarly, studies conducted among patients with HF showed reduced sodium intake when spouses also followed low sodium diet recommendations.9,10 Furthermore, a review of evidence identified family involvement as the best strategy for low sodium diet management.25
However, the most identified barrier at the individual level of the caregiver related to supporting patient management of dual diet recommendations. Caregivers frequently reported the sense of feeling overwhelmed and exhausted by caregiving responsibilities. This is unsurprising given the high prevalence of stress and burnout among family caregivers of persons with chronic conditions.26 Caregiver burnout is defined as the negative physical, psychological, and behavioral effects resulting from the chronic stressors associated with caregiving responsibilities, particularly over long periods of time.26,27 Caregivers of individuals diagnosed with T2DM experience high levels of burnout and chronic stress, which can contribute to poor health outcomes for the caregiver.28 Similarly, caregivers of individuals diagnosed with HF experience high levels of caregiver burnout and decreased quality of life.29-32 Furthermore, a recent meta-analysis of studies examining relationships between caregiver health and outcomes among patients with HF found that higher caregiver strain was significantly associated with poorer HF outcomes as measured by the New York Heart Association Class.33
Results from the study also indicated patient-caregiver dyads often feel confused about simultaneous management of 2 prescribed diets. To mitigate confusion surrounding management of multiple dietary recommendations, there is a need for health care providers to not only highlight the similarities and differences between dietary recommendations for multiple comorbidities but also to make management of dietary recommendations more accessible through highlighting the importance of maintaining a generally well-balanced diet to improve health outcomes.34,35 Similarly, to address the finding regarding caregiver-permitted lapses, research has shown that focusing on flexible management of dietary recommendations may be beneficial for managing dietary recommendations.36-38 Compared with rigid management, which is characterized by strict rules surrounding the consumption of foods and an “all-or-nothing” mentality, flexible management is a less stringent approach to dietary management characterized by gradual reduction or occasional consumption of foods that are not in alignment with dietary recommendations in limited amounts.36,38 Whereas rigid management has been associated with a higher likelihood of binge eating behaviors, flexible management has been associated with a lower likelihood of overeating.37,39
Lack of knowledge regarding the dual diet has been supported by research demonstrating that lack of knowledge related to self-management recommendations, including dietary recommendations, is a commonly identified barrier to diabetes self-management.20 Similar studies among patients with HF also found lack of knowledge to be a barrier to following a low sodium diet.40,41 Furthermore, dyadic lack of knowledge about HF self-management is associated with poorer low sodium diet management but is not associated with other aspects of self-management, such as medication management.42
At the same time, having adequate knowledge about the two diets, via formal education or self-driven research, was reported by dyads as a major facilitator. This is supported by other findings that indicate higher nutrition knowledge is associated with better diet quality.43,44 Eating at home, another facilitator commonly reported by dyads, has also been shown in population-based studies to be associated with dietary patterns that meet the higher standards, such as the Dietary Approaches to Stop Hypertension (DASH) recommendations.45
Many other commonly reported barriers in the present study are supported by previous research. For example, eating out at fast food restaurants between frequent medical appointments was a frequently reported barrier to dual diet management. Eating away from home has been associated with a poorer diet quality; an increase in calories, sodium, and saturated fat consumed; and a reduced intake of sources of fiber, such as whole grains, fruits, and vegetables.46,47 The findings from one study further demonstrated that approximately 75% of dietary sodium is sourced from meals eaten outside of the home.48 Dyads in this study also reported time constraints as a major influence for eating out, a finding mirrored in other studies examining barriers to self-management among individuals with T2DM, in which lack of time, perceived control, social support, and knowledge were frequently reported barriers.21,49
Feeling limited by food choices and disliking the taste of foods aligned with dual diet recommendations was a barrier similarly reported in a qualitative study exploring the experiences of patients with HF following a low sodium diet.40 Additionally, feeling limited by food choices was further exacerbated when family members ate foods not in alignment with the dual diet. In a study exploring the experiences among adults with T2DM in Appalachia, participants reported feeling the need to avoid temptations and cravings for high sugar or high calorie foods consumed by their family members and similarly reported sneaking these foods without their family member’s knowledge.50
Compounding this, participants reported management of cravings among the most difficult aspects to following dual diet recommendations. The phenomenon of craving is well documented in individuals with diabetes and is known to commonly lead to difficulty following dietary recommendations.51 Food cravings have been shown to be more prevalent among persons experiencing chronic stress, a common state among persons with diabetes.52 This finding is closely related to reports among patient participants in the present study who indicated that they have higher cravings when not feeling well. Interestingly, strategies identified by dyads to simultaneously manage dual dietary recommendations through consumption of a high protein/low carbohydrate diets or consumption of more fruits and vegetables have similarly been shown to be successful strategies for reducing cravings.53
Many of the strategies reported by dyads for dual dietary management are supported by recommendations from health organizations. Dyads’ reported use of salt and sugar substitutes is in accordance with the 2019 Consensus Report released by the American Diabetes Association, which supports the use of sugar substitutes as a method to reduce daily intake of calories and carbohydrates.54 Additionally, methods for reducing sodium content used by dyads in this study, such as rinsing canned vegetables and using salt substitutes, is in line with current American Heart Association recommendations for reducing sodium intake.55
Being aware of food choices and utilizing food labels were also commonly reported strategies to improve simultaneous management of the dual diet by identifying and avoiding high salt and high carbohydrate foods. Nutritional awareness has been found to have a direct effect on dietary quality, with greater nutritional awareness being associated with better diet quality.44 In a study on food label use and dietary quality, the authors found food label use to be positively associated with diet quality.56 Additionally, in a study examining food label use and nutritional awareness among adults with chronic disease, individuals with diabetes were found to utilize food labels more frequently and have higher nutritional awareness.57
It is imperative going forward that health care providers prioritize the importance of an overall healthy dietary pattern through increased intake of fruits, vegetables, and whole grains and the importance of reducing intake of red meat, refined sugars and starches, and processed foods.58,59 The findings of this study can aid in the development of interventions that provide a toolkit of strategies to address the specific concerns of individuals with T2DM and HF in relation to dietary management by developing approaches that stress the importance of following an overall healthy dietary pattern.
Furthermore, findings of the study inform what is known about the impact of family involvement in dietary management of chronic diseases. Family engagement with healthy dietary patterns has been shown to improve dietary management among patients with chronic diseases.10,11 The findings of this study further add to what is known about the role of family members in dietary management given that the results highlight the notion that patients do not eat in isolation. There is a need for health care providers to engage family members and incorporate their involvement in chronic disease management to better improve patient health outcomes.24,60 The findings of this study can be used to develop interventions that incorporate healthy dietary patterns at the family level to improve health outcomes for not only the patient but also for all members of the family.
Because this study used a qualitative design, generalizability of the findings is limited to those who share similar demographics to the participants in this study. However, as highlighted throughout the discussion section, studies of a similar nature exploring the self-management experiences of patients with T2DM or HF have reported findings similar to those themes identified by participants in the current study. Racial and ethnic diversity was also limited in this study and is not representative of the general population of individuals with T2DM and HF; however, the sample is representative of the samples recruited for the trial studies and the clinic population from which participants were recruited. It is worth noting the interventions for the trial studies were aimed at healthy diet education, which could further bias responses provided by participants in this qualitative study; however, no major diversions in theme content were identified during interview comparison of one dyad recruited from the control group to those of the other interviews.
This study explored the factors surrounding simultaneous management of dual diet recommendations at the dyadic and individual levels as experienced by patients with HF and T2DM and their family caregivers. The findings demonstrate that patients and caregivers often work together and share similar barriers, facilitators, motivators, and strategies in their experiences of managing a dual diet. These results are useful for guiding the development of clinical interventions to support dietary management among patients with HF and diabetes and their family caregivers. Future research should focus on intervening at the family level and providing a comprehensive approach that will support healthy dietary patterns among this population.
We would like to thank Mary Schooler for her assistance with recruitment of participants for this study.
The authors declare no conflicts of interest.
This research was supported through funding provided by the Jonas Nurse Scholars Program and the University of Kentucky College of Nursing.
Leigh Anne DeNotto https://orcid.org/0000-0002-9818-3647
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From Grand Valley State University, Kirkhof College of Nursing, Grand Rapids, Michigan (Dr DeNotto), and University of Kentucky, College of Nursing, Lexington, Kentucky (Dr Chung, Dr Key, Dr Mudd-Martin).
Corresponding Author:Leigh Anne DeNotto, Grand Valley State University, 314 Cook-DeVos Center for Health Sciences, 333 Michigan St NE, Ste. 410, Grand Rapids, MI 49503, USA.Email: deleigh@gvsu.edu
