Emerging Adults With and Without Type 1 Diabetes
Emerging Adults With and Without Type 1 Diabetes
Objective This longitudinal study compared emerging adults with and without type 1 diabetes on life path decisions, health behaviors, and psychological well-being during the transition out of high school.
Methods Administered questionnaires during the senior year of high school and 1 year later to 117 emerging adults with diabetes and 122 emerging adults without diabetes. Comparisons were conducted with respect to health status, sex, and school status.
Results Those with and without diabetes chose similar life paths and engaged in similar levels of risky behaviors, but disturbed sleep increased for males with diabetes only. Having diabetes was not associated with depressive symptoms, loneliness, or bulimic symptoms, but was associated with lower life satisfaction and lower life purpose over time.
Conclusions Emerging adults with and without diabetes fare similarly on most dimensions studied during the first year out of high school.
The developmental period from ages 18–25 years has been labeled "emerging adulthood" (Arnett, 2000). Emerging adulthood is the period of life during which the possibilities for the future are the most numerous, and identity exploration is at its lifetime peak. Arnett (2000) describes the first phase of emerging adulthood as a time when individuals are both excited about their new freedom but also uncertain because of the unsettled nature of their lives, as they explore the possibilities for their futures with respect to residential status, school status, vocation, romantic relationships, and identity. Adjustment to new responsibilities that arise during the first phase of emerging adulthood occurs rapidly with little structure and supervision, especially for those who move out of the house to live on their own for the first time or to attend college. The heightened freedom and reduced parental monitoring associated with emerging adulthood are coupled with an environment especially conducive to identity and lifestyle exploration, thus creating opportunities for risky behavior (Arnett, 2000; White et al., 2006). These circumstances also result in potential for social isolation and uncertainty about the future, which could diminish psychological well-being. Researchers who have examined risk behavior patterns during emerging adulthood have speculated that poor health behaviors established during emerging adulthood may persist into later stages of adulthood (Laska, Pasch, Lust, Story, & Ehlinger, 2009; Nelson, Story, Larson, Neumark-Sztainer, & Lytle, 2008). Diminished psychological well-being during emerging adulthood is an important concern in and of itself and may predict future declines in psychological well-being. Despite these potential risks, relatively few studies have focused on the health and well-being of emerging adults.
The transition to emerging adulthood may pose a special challenge to those with childhood chronic diseases, such as type 1 diabetes. The demands of managing a complicated illness like diabetes must be integrated into the normative changes in vocation, education, relationships, and living situations that accompany emerging adulthood (Weissberg-Benchell, Wolpert, & Anderson, 2007). In addition to the new responsibilities and freedoms that most emerging adults share, those managing diabetes become increasingly responsible for their self-care, with daily requirements such as blood glucose monitoring and assessment and insulin dose adjustments, and periodic activities such as scheduling physician appointments, ensuring availability of adequate supplies, and caring for themselves when sick. All of these activities are likely to have been monitored at least partially by parents during adolescence. In addition, some of the risky behaviors that occur during emerging adulthood, such as lack of physical activity and smoking, are predictive of long-term health detriments, such as vascular complications, for which those with type 1diabetes are particularly vulnerable (Bishop et al., 2009).
Despite the challenges faced by emerging adults with diabetes, little research has compared the transition experiences of those with and without diabetes. It is possible that those who are coping with diabetes may experience the years of emerging adulthood differently because of potential diabetes-related limitations to their exploration of future possibilities. Thus, the goal of this study was to compare individuals with and without diabetes during the transition out of high school in terms of the following: (1) life path decisions regarding education, vocation, and living situation; (2) health behaviors; and (3) psychological well-being. Below, we briefly review what is known about how individuals with diabetes compare with those without diabetes in each of these three domains during emerging adulthood.
Of the many considerations facing youth during the initial stages of emerging adulthood, those regarding education, vocation, and living situation are likely the most deliberated because of their monumental influence on future outcomes. Research conducted before the Diabetes Control and Complications Trial (DCCT; Diabetes Control and Complications Research Group, 1994) found high school students with diabetes had similar intentions to work or pursue college but were more likely to plan to attend community college and had less career support from parents than control subjects (Myers, 1992). More recent research found that emerging adults with chronic illnesses (cancer, heart disease, epilepsy, type 1 diabetes) had lower college graduation rates, higher unemployment rates, higher probability of receiving public assistance, and lower incomes than those without chronic illness (Maslow, Haydon, McRee, Ford, & Halpern, 2011). However, that study did not examine those with diabetes separately from other chronic illnesses. The effect of health status on the pursuit of higher education is important because a college degree is associated with higher earning potential and job stability and mobility (Montgomery & Côté, 2003). Health status differences in the type of education pursued also is important because retention and degree completion rates are lower among community college students than among those enrolled in 4-year institutions (National Center for Education Statistics, 2008a).
Only a few studies have examined whether having diabetes impacts the decision for an emerging adult to leave home. In 2008, 36% of college students aged 19–23 years lived at home (National Center for Education Statistics, 2008b). One older study found that youth with diabetes (aged 17–22 years) were more likely to live at home (66%) than control subjects (33%), despite no health status differences in the distance of college from home (Myers, 1992). Another older study found a high rate of emerging adults with diabetes (aged 18–22 years) to be living at home (65%), but there was no comparison with emerging adults without diabetes (Wysocki, Hough, Ward, & Green, 1992). Given the drastic diabetes care improvements post-DCCT, it is unclear whether differences in educational and vocational decisions and living situations persist between today's emerging adults with and without diabetes. If those with diabetes are found to choose colleges closer to home, on average, than control subjects, it may be an indication that these individuals are intentionally limiting their options for higher education, which, in turn, could lead to differences in income, quality of life, and life satisfaction both during the college years and beyond. If lifestyle differences are no longer found between the groups, it may indicate that post-DCCT improvements have mitigated some real or perceived lifestyle limitations for those with diabetes that existed in past decades. Encouragingly, one recent study found evidence that diabetes self-management was not associated with whether emerging adults with type 1 diabetes were living independently of their parents (Hanna et al., 2012).
Emerging adulthood is associated with an array of poor health behaviors, including alcohol use, smoking, lack of physical activity, and disturbed sleeping patterns. For example, emerging adults have the highest rate of alcohol use (Substance Abuse and Mental Health Services Administration, 2011), especially for those who attend college (White, Labouvie, & Papadaratsakis, 2005). Drinking poses a more severe risk to individuals with diabetes than to peers without diabetes owing to impaired judgment that could negatively impact self-care (Ahmed, Karter, & Liu, 2006) and increased risk for hypoglycemia (Franz et al., 2002). Smoking is common in early adulthood; 20.1% of adults between the ages of 18–24 years smoked regularly in 2010 (Center for Disease Control and Prevention, 2011). In addition, 90% of smokers begin the habit before the age of 21 years (Mowery, Brick, & Farrelly, 2000), and early initiation of smoking is related to becoming a heavier smoker and to smoking for longer durations (Elders, Perry, Eriksen, & Giovino, 1994). Because individuals with diabetes have heightened risk for heart and kidney disease, and smoking exacerbates the risk for both (Bishop et al., 2009; Muehlhauser, Sawicki, & Berger, 1986), smoking is potentially more detrimental to the health of those with diabetes than those without. Declining physical activity after high school, especially for college students, typically results in freshman year weight gain (Butler, Black, Blue, & Gretebeck, 2004). Physical activity is especially important for those with diabetes because it helps to achieve good glycemic control and may decrease risk for complications (Chimen et al., 2012). Finally, disturbed sleep is common among college students (Lund, Reider, Whiting, & Prichard, 2010), and poor sleep quality is associated with poorer health (Katz & McHorney, 2002). Because poor sleep and poor glycemic control are believed to be reciprocally related (Barone & Menna-Barreto, 2011), disturbed sleep may be more disruptive to college students with diabetes than those without diabetes. In this study, we examined potential differences between emerging adults with and without diabetes in all of these health behaviors. Because youth with diabetes may be more conscious of their health and the increased risk that many of these behaviors pose, we hypothesize lower levels of risk behavior among youth with than without diabetes.
Depressive symptoms increase during adolescence, peak in young adulthood, and then decline throughout the rest of the life span (Arnett, 2004; Kessler, Mickelson, Walters, Zhao, & Hamilton, 2004). A meta-analytic review revealed that youth with diabetes experience more depression than those without diabetes (Reynolds & Helgeson, 2011). The overall effect sizes were small to medium, and smaller in more recent studies. Adults with type 1 diabetes experience more depressive symptoms and are more likely to use antidepressants than peers (Gendelman et al., 2009). Two meta-analytic reviews based largely on cross-sectional studies found that depressive symptoms are an important risk factor for diabetes health because of links to poor glycemic control (Lustman et al., 2000) and diabetes-related complications (de Groot, Anderson, Freedland, Clouse, & Lustman, 2001).
Another index of psychological well-being especially relevant to emerging adulthood is loneliness. Loneliness tends to peak during emerging adulthood (Rokach, 2000). Lonely people experience more disturbed sleep and higher cardiovascular reactivity than those who are not lonely (Cacioppo et al., 2002) and is associated with poor glycemic control (Barone & Menna-Barreto, 2011). Cardiovascular reactivity is linked to long-term cardiovascular complications (Matthews, Zhu, Tucker, & Whooley, 2006). We know of no data comparing the levels of loneliness between emerging adults with and without diabetes.
An aspect of psychological health especially relevant to diabetes is disturbed eating behavior. People with diabetes—especially females—are at greater risk for eating disorders compared with people without diabetes (Jones, Lawson, Daneman, Olmsted, & Rodin, 2000), and disturbed eating behaviors are linked to diabetes-related complications (Rydall, Rodin, Olmsted, Devenyi, & Daneman, 1997). Typically emerging in early adolescence, eating disturbances increase during the transition to college (Vohs, Heatherton, & Herrin, 2001), a trend at least partially attributed to the college environment's high stress, changing roles, and achievement orientation (Striegel-Moore, Silberstein, Grunberg, & Rodin, 1990). Given their strong implications for diabetes-related complications, it is important to examine health status differences in eating behaviors during emerging adulthood.
Finally, one of the primary tasks of emerging adulthood is the exploration and establishment of identity, defined as the extent to which one has explored goal alternatives and committed to life choices (Luyckx et al., 2008). Emerging adults with diabetes with stronger senses of identity experience fewer diabetes-related problems and have lower levels of depressive symptoms than those with weaker senses of identity (Luyckx et al., 2008). Identity exploration is lower in emerging adults with diabetes than in comparison peers (Luyckx et al., 2008). Although we did not include a measure of identity exploration, we examined life purpose and life satisfaction as potential outcomes of the identity exploration process. Emerging adults with diabetes may have more difficulties establishing an independent identity than their peers owing to the greater likelihood of continuing parent involvement and oversight with respect to diabetes self-care that may bleed into other life aspects, resulting in a lower sense of life purpose and/or life satisfaction during early emerging adulthood.
Using Arnett's (2000) theory of emerging adulthood, we examined the life domains that are critical to this stage of development, that are undergoing tremendous change at this time, and that have implications for future well-being—specifically, lifestyle decisions such as going to college and leaving home, health behaviors such as alcohol consumption and smoking, and psychological well-being such as depressive symptoms and loneliness. Few studies have compared these domains among emerging adults with and without type 1 diabetes, and most of the ones that exist are decades old. If emerging adults with type 1diabetes are somehow disadvantaged in comparison with those without diabetes, this sets forth a disadvantage that will influence the course of their futures and suggests intervention efforts may be prudent. Even if those with diabetes are found to engage in the same level of risk behavior as those without diabetes, they may be putting themselves in danger with respect to their health because these health risk behaviors have more severe consequences for those with than those without diabetes.
We compared youth with and without diabetes in their senior year of high school and 1 year later with respect to life path decisions, health behaviors, and psychological well-being. Because of technological advances in the treatment of diabetes, we did not hypothesize health status differences in life path decisions. However, we did hypothesize that those with diabetes would report better health behavior than those without diabetes owing to the stronger health implications of health behaviors. Given past research, we cautiously hypothesized that those with diabetes would report lower psychological well-being than those without diabetes. Because psychological well-being and health behaviors frequently differ by sex, we also compared males and females and explored the interaction between sex and health status (i.e., participants with vs. without diabetes). Because attending college may have implications for risk behavior and psychological well-being (Blanco et al., 2008; O'Malley & Johnston, 2002), we also examined the impact of attending college on health behaviors and psychological well-being.
Abstract and Introduction
Abstract
Objective This longitudinal study compared emerging adults with and without type 1 diabetes on life path decisions, health behaviors, and psychological well-being during the transition out of high school.
Methods Administered questionnaires during the senior year of high school and 1 year later to 117 emerging adults with diabetes and 122 emerging adults without diabetes. Comparisons were conducted with respect to health status, sex, and school status.
Results Those with and without diabetes chose similar life paths and engaged in similar levels of risky behaviors, but disturbed sleep increased for males with diabetes only. Having diabetes was not associated with depressive symptoms, loneliness, or bulimic symptoms, but was associated with lower life satisfaction and lower life purpose over time.
Conclusions Emerging adults with and without diabetes fare similarly on most dimensions studied during the first year out of high school.
Introduction
The developmental period from ages 18–25 years has been labeled "emerging adulthood" (Arnett, 2000). Emerging adulthood is the period of life during which the possibilities for the future are the most numerous, and identity exploration is at its lifetime peak. Arnett (2000) describes the first phase of emerging adulthood as a time when individuals are both excited about their new freedom but also uncertain because of the unsettled nature of their lives, as they explore the possibilities for their futures with respect to residential status, school status, vocation, romantic relationships, and identity. Adjustment to new responsibilities that arise during the first phase of emerging adulthood occurs rapidly with little structure and supervision, especially for those who move out of the house to live on their own for the first time or to attend college. The heightened freedom and reduced parental monitoring associated with emerging adulthood are coupled with an environment especially conducive to identity and lifestyle exploration, thus creating opportunities for risky behavior (Arnett, 2000; White et al., 2006). These circumstances also result in potential for social isolation and uncertainty about the future, which could diminish psychological well-being. Researchers who have examined risk behavior patterns during emerging adulthood have speculated that poor health behaviors established during emerging adulthood may persist into later stages of adulthood (Laska, Pasch, Lust, Story, & Ehlinger, 2009; Nelson, Story, Larson, Neumark-Sztainer, & Lytle, 2008). Diminished psychological well-being during emerging adulthood is an important concern in and of itself and may predict future declines in psychological well-being. Despite these potential risks, relatively few studies have focused on the health and well-being of emerging adults.
The transition to emerging adulthood may pose a special challenge to those with childhood chronic diseases, such as type 1 diabetes. The demands of managing a complicated illness like diabetes must be integrated into the normative changes in vocation, education, relationships, and living situations that accompany emerging adulthood (Weissberg-Benchell, Wolpert, & Anderson, 2007). In addition to the new responsibilities and freedoms that most emerging adults share, those managing diabetes become increasingly responsible for their self-care, with daily requirements such as blood glucose monitoring and assessment and insulin dose adjustments, and periodic activities such as scheduling physician appointments, ensuring availability of adequate supplies, and caring for themselves when sick. All of these activities are likely to have been monitored at least partially by parents during adolescence. In addition, some of the risky behaviors that occur during emerging adulthood, such as lack of physical activity and smoking, are predictive of long-term health detriments, such as vascular complications, for which those with type 1diabetes are particularly vulnerable (Bishop et al., 2009).
Despite the challenges faced by emerging adults with diabetes, little research has compared the transition experiences of those with and without diabetes. It is possible that those who are coping with diabetes may experience the years of emerging adulthood differently because of potential diabetes-related limitations to their exploration of future possibilities. Thus, the goal of this study was to compare individuals with and without diabetes during the transition out of high school in terms of the following: (1) life path decisions regarding education, vocation, and living situation; (2) health behaviors; and (3) psychological well-being. Below, we briefly review what is known about how individuals with diabetes compare with those without diabetes in each of these three domains during emerging adulthood.
Life Path Decisions
Of the many considerations facing youth during the initial stages of emerging adulthood, those regarding education, vocation, and living situation are likely the most deliberated because of their monumental influence on future outcomes. Research conducted before the Diabetes Control and Complications Trial (DCCT; Diabetes Control and Complications Research Group, 1994) found high school students with diabetes had similar intentions to work or pursue college but were more likely to plan to attend community college and had less career support from parents than control subjects (Myers, 1992). More recent research found that emerging adults with chronic illnesses (cancer, heart disease, epilepsy, type 1 diabetes) had lower college graduation rates, higher unemployment rates, higher probability of receiving public assistance, and lower incomes than those without chronic illness (Maslow, Haydon, McRee, Ford, & Halpern, 2011). However, that study did not examine those with diabetes separately from other chronic illnesses. The effect of health status on the pursuit of higher education is important because a college degree is associated with higher earning potential and job stability and mobility (Montgomery & Côté, 2003). Health status differences in the type of education pursued also is important because retention and degree completion rates are lower among community college students than among those enrolled in 4-year institutions (National Center for Education Statistics, 2008a).
Only a few studies have examined whether having diabetes impacts the decision for an emerging adult to leave home. In 2008, 36% of college students aged 19–23 years lived at home (National Center for Education Statistics, 2008b). One older study found that youth with diabetes (aged 17–22 years) were more likely to live at home (66%) than control subjects (33%), despite no health status differences in the distance of college from home (Myers, 1992). Another older study found a high rate of emerging adults with diabetes (aged 18–22 years) to be living at home (65%), but there was no comparison with emerging adults without diabetes (Wysocki, Hough, Ward, & Green, 1992). Given the drastic diabetes care improvements post-DCCT, it is unclear whether differences in educational and vocational decisions and living situations persist between today's emerging adults with and without diabetes. If those with diabetes are found to choose colleges closer to home, on average, than control subjects, it may be an indication that these individuals are intentionally limiting their options for higher education, which, in turn, could lead to differences in income, quality of life, and life satisfaction both during the college years and beyond. If lifestyle differences are no longer found between the groups, it may indicate that post-DCCT improvements have mitigated some real or perceived lifestyle limitations for those with diabetes that existed in past decades. Encouragingly, one recent study found evidence that diabetes self-management was not associated with whether emerging adults with type 1 diabetes were living independently of their parents (Hanna et al., 2012).
Health Behavior
Emerging adulthood is associated with an array of poor health behaviors, including alcohol use, smoking, lack of physical activity, and disturbed sleeping patterns. For example, emerging adults have the highest rate of alcohol use (Substance Abuse and Mental Health Services Administration, 2011), especially for those who attend college (White, Labouvie, & Papadaratsakis, 2005). Drinking poses a more severe risk to individuals with diabetes than to peers without diabetes owing to impaired judgment that could negatively impact self-care (Ahmed, Karter, & Liu, 2006) and increased risk for hypoglycemia (Franz et al., 2002). Smoking is common in early adulthood; 20.1% of adults between the ages of 18–24 years smoked regularly in 2010 (Center for Disease Control and Prevention, 2011). In addition, 90% of smokers begin the habit before the age of 21 years (Mowery, Brick, & Farrelly, 2000), and early initiation of smoking is related to becoming a heavier smoker and to smoking for longer durations (Elders, Perry, Eriksen, & Giovino, 1994). Because individuals with diabetes have heightened risk for heart and kidney disease, and smoking exacerbates the risk for both (Bishop et al., 2009; Muehlhauser, Sawicki, & Berger, 1986), smoking is potentially more detrimental to the health of those with diabetes than those without. Declining physical activity after high school, especially for college students, typically results in freshman year weight gain (Butler, Black, Blue, & Gretebeck, 2004). Physical activity is especially important for those with diabetes because it helps to achieve good glycemic control and may decrease risk for complications (Chimen et al., 2012). Finally, disturbed sleep is common among college students (Lund, Reider, Whiting, & Prichard, 2010), and poor sleep quality is associated with poorer health (Katz & McHorney, 2002). Because poor sleep and poor glycemic control are believed to be reciprocally related (Barone & Menna-Barreto, 2011), disturbed sleep may be more disruptive to college students with diabetes than those without diabetes. In this study, we examined potential differences between emerging adults with and without diabetes in all of these health behaviors. Because youth with diabetes may be more conscious of their health and the increased risk that many of these behaviors pose, we hypothesize lower levels of risk behavior among youth with than without diabetes.
Psychological Well-Being
Depressive symptoms increase during adolescence, peak in young adulthood, and then decline throughout the rest of the life span (Arnett, 2004; Kessler, Mickelson, Walters, Zhao, & Hamilton, 2004). A meta-analytic review revealed that youth with diabetes experience more depression than those without diabetes (Reynolds & Helgeson, 2011). The overall effect sizes were small to medium, and smaller in more recent studies. Adults with type 1 diabetes experience more depressive symptoms and are more likely to use antidepressants than peers (Gendelman et al., 2009). Two meta-analytic reviews based largely on cross-sectional studies found that depressive symptoms are an important risk factor for diabetes health because of links to poor glycemic control (Lustman et al., 2000) and diabetes-related complications (de Groot, Anderson, Freedland, Clouse, & Lustman, 2001).
Another index of psychological well-being especially relevant to emerging adulthood is loneliness. Loneliness tends to peak during emerging adulthood (Rokach, 2000). Lonely people experience more disturbed sleep and higher cardiovascular reactivity than those who are not lonely (Cacioppo et al., 2002) and is associated with poor glycemic control (Barone & Menna-Barreto, 2011). Cardiovascular reactivity is linked to long-term cardiovascular complications (Matthews, Zhu, Tucker, & Whooley, 2006). We know of no data comparing the levels of loneliness between emerging adults with and without diabetes.
An aspect of psychological health especially relevant to diabetes is disturbed eating behavior. People with diabetes—especially females—are at greater risk for eating disorders compared with people without diabetes (Jones, Lawson, Daneman, Olmsted, & Rodin, 2000), and disturbed eating behaviors are linked to diabetes-related complications (Rydall, Rodin, Olmsted, Devenyi, & Daneman, 1997). Typically emerging in early adolescence, eating disturbances increase during the transition to college (Vohs, Heatherton, & Herrin, 2001), a trend at least partially attributed to the college environment's high stress, changing roles, and achievement orientation (Striegel-Moore, Silberstein, Grunberg, & Rodin, 1990). Given their strong implications for diabetes-related complications, it is important to examine health status differences in eating behaviors during emerging adulthood.
Finally, one of the primary tasks of emerging adulthood is the exploration and establishment of identity, defined as the extent to which one has explored goal alternatives and committed to life choices (Luyckx et al., 2008). Emerging adults with diabetes with stronger senses of identity experience fewer diabetes-related problems and have lower levels of depressive symptoms than those with weaker senses of identity (Luyckx et al., 2008). Identity exploration is lower in emerging adults with diabetes than in comparison peers (Luyckx et al., 2008). Although we did not include a measure of identity exploration, we examined life purpose and life satisfaction as potential outcomes of the identity exploration process. Emerging adults with diabetes may have more difficulties establishing an independent identity than their peers owing to the greater likelihood of continuing parent involvement and oversight with respect to diabetes self-care that may bleed into other life aspects, resulting in a lower sense of life purpose and/or life satisfaction during early emerging adulthood.
The Present Study
Using Arnett's (2000) theory of emerging adulthood, we examined the life domains that are critical to this stage of development, that are undergoing tremendous change at this time, and that have implications for future well-being—specifically, lifestyle decisions such as going to college and leaving home, health behaviors such as alcohol consumption and smoking, and psychological well-being such as depressive symptoms and loneliness. Few studies have compared these domains among emerging adults with and without type 1 diabetes, and most of the ones that exist are decades old. If emerging adults with type 1diabetes are somehow disadvantaged in comparison with those without diabetes, this sets forth a disadvantage that will influence the course of their futures and suggests intervention efforts may be prudent. Even if those with diabetes are found to engage in the same level of risk behavior as those without diabetes, they may be putting themselves in danger with respect to their health because these health risk behaviors have more severe consequences for those with than those without diabetes.
We compared youth with and without diabetes in their senior year of high school and 1 year later with respect to life path decisions, health behaviors, and psychological well-being. Because of technological advances in the treatment of diabetes, we did not hypothesize health status differences in life path decisions. However, we did hypothesize that those with diabetes would report better health behavior than those without diabetes owing to the stronger health implications of health behaviors. Given past research, we cautiously hypothesized that those with diabetes would report lower psychological well-being than those without diabetes. Because psychological well-being and health behaviors frequently differ by sex, we also compared males and females and explored the interaction between sex and health status (i.e., participants with vs. without diabetes). Because attending college may have implications for risk behavior and psychological well-being (Blanco et al., 2008; O'Malley & Johnston, 2002), we also examined the impact of attending college on health behaviors and psychological well-being.
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