Introduction
Methods
Participants
Methods and materials
Timeline and food box
Protocol and measures
Timeline | Food-box | |
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Key questions | Could you talk me through your timeline? In what way did this specific moment change eating practices/behaviour/diet? What were the things you were eating during this specific period? | Could you explain why you have chosen these specific objects? |
Sample follow-up questions | How was your childhood? Could you describe how things used to be at the dinner table when you were a child? What kind of foods did you eat as a child? How did you learn how to cook? When did you leave parental house? What kind of foods are liked by your partner? When did you become a parent? What is it like being a parent? How did you experienced breakfast/lunch/dinner when your children lived at home? What foods did/do your children like? How did T2DM diagnosis affect you? How has T2DM diagnosis influenced your eating behaviour? | When did you start eating this specific product? Do you eat/use this at specific occasions or with specific persons? Are you satisfied with your current eating practices? And why (not)? What things make it easier for you to eat healthily? Why? What things make it difficult for you to eat healthily? Why? How do you deal with these? What would be your ideal eating pattern? What would help you to reach this ideal eating pattern? If you compare your eating practices in the past to now, what has changed? |
Analysis
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Explanations of why this specific participant identified these specific events as turning points, and of how the social-, historical- and/or physical context influenced eating behaviour in turning points.
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Individual challenges to, coping strategies with, and resources for healthy eating
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The researcher’s impression of the participant’s character, and if (s)he seemed to be in charge of eating behaviour (i.e. eating in line with intentions, not necessarily with dietary guidelines) and life in general (i.e. is this person living his/her ideal life? Is (s)he happy with his/her life?).
Results
Participants’ characteristics
Personal characteristics | Socioeconomic position | T2DM | Self-management | SoC | |||||||||
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Pseudonym | Age (years) | Living situation | Children (n) | Education1 | Income2 | Occupation status3 | Disease duration (years) | HbA1c4(mmol/L) | FGL5(mmol/L) | Physical activity6(days/week) | Self-monitoring blood glucose7(days/week) | Smoking | SoC7(0–52) |
Diane ♀ | 49 | Children | 2 | Medium | Low | Lowc | 5 | 69 | 6.4 | 0 | 0 | Noh | 21 |
Ria ♀ | 75 | Partner | 2 | Medium | Mediuma | Lowd, e | 10 | – | 7.0 | 7 | 0 | No | 30.5 |
Annie ♀ | 60 | Alone | 0 | Medium | Low | Lowc | 11 | 52 | 6.8 | 3.5 | 0 | Noh | 42 |
Mieke ♀ | 56 | Partner + children | 2 | Medium | Medium | Medium | 16 | – | 7.0 | 7 | 0 | No | 35.5 |
Saskia ♀ | 67 | Alone | 2 | Low | Low | Lowd, e | 20 | 92 | 11.1 | 1.5 | 1–2 | No | 24 |
Karin ♀ | 65 | Alone | 2 | Medium | Low | Lowd, e | 0.5 | 69 | 11.0 | 1.5 | 0 | No | 35 |
Jan ♂ | 73 | Partner | 1 | Low | Medium | Lowd | 0.5 | – | – | 0.5 | 0 | No | 41 |
Carla ♀ | 71 | Partner | 1 | Medium | Mediumb | Lowd | 10 | – | 9.4g | 1.5 | 1 | Yes | 49 |
Freek ♂ | 72 | Partner + children | 3 | Medium | Low | Lowd | 19 | 62 | – | 3.5 | 0 | No5 | 41 |
Marja ♀ | 69 | Partner | 1 | Medium | – | Lowd | 10 | 43 | 8.5 | 3.5 | 0 | No | 21.5 |
Henk ♂ | 66 | Partner | 3 | Medium | Low | Lowf | 10 | 60 | – | 7 | 0 | No | 26.5 |
Mark ♂ | 66 | Partner + children | 3 | Medium | Low | Mediumd | 21 | 66 | – | 7 | 7 | No | 43 |
Dennis ♂ | 69 | Partner + children | 3 | Medium | Medium | Lowd | 10 | – | 5.5 | 3.5 | 0–1 | No | 36 |
Claudia ♀ | 77 | Alone | 2 | Low | Low | Lowd | 15 | – | 6.4 | 1 | 0–1 | No | 22 |
Tygo ♂ | 71 | Partner | 2 | Low | Low | Lowd | 10 | – | – | 5 | 0 | Noh | 44 |
Theo ♂ | 62 | Partner + children | 4 | High | High | Lowf | 10–12 | – | 7.2 | 0 | 0 | No | 43 |
Robert ♂ | 64 | Partner | 2 | Medium | Low | Lowf | 23 | 61 | – | 3.5 | 1 | No | 40 |
Turning points
Turning points for unhealthy eating
Saskia: It’s just that worries about my daughter [who was receiving care from a psychiatric institute] were a priority [above healthy eating]. And those worries just dominated my life- the anxiety and everything [...] Stress had a big influence on me at that time. […] If I am tense.. well, if I am tense and realise that, I really don’t have to check my glucose, then I know that I am on a level of 13, 14 and sometimes 15 [blood glucose level]. When I am more rested, I can think more clearly, and when I can accept my situation, then I know that just go back again to a level of 8.
Carla: [Who talks about her partner leaving her and cheating her financially] With that experience, I had such an emotional knock, I was like this [pointing her index fingers together]. I lost so much weight then. And I really couldn’t eat or drink. Nothing. [...] My boys went to my mother [...], because I didn’t cook. I didn’t feel like it at all.
Tygo: I am an emotional eater, if I feel bad, I eat everything I can get my hands on.
Karin: I actually think that after my husband died, I started eating a lot due to grief. I would describe this as, responding through snacking. Then the weight piled on. Now that I think about it. Before that, it was different. When you have a partner, you don’t sneakily snack. At least, I didn’t.. but when you are alone [...] and you experience grief, you don’t know what you have to do to cope with it. He always came home at 3 o’clock [in the afternoon; a typical time for tea/coffee in the Netherlands] [...] Well, now, I do have a cookie or something with may tea, but I used to have a nice chat with him. Now I have to drink my tea or coffee alone, you know. It is actually that I started to eat to cope with the grief.
Saskia: That’s when I started injections, after he [husband] died. The anxiety, the stress, are cooped up inside me.
Turning points for healthy eating
Diane: Yes. I have recouped after hitting ‘rock bottom’. I do notice that I manage my life more than before. That being healthy, and that quitting smoking also came up as an issue. I just succeeded with that in one go.
Henk: Not being entirely in control. Your body always craved food. And then it ended and now, I have it reasonably under control.
Interviewer: Yes, and how did you succeed?
Henk: Through shock. At 83 k, I realised that it was going wrong. And then other things came to light.
Diane: That first year, before I had children [I didn’t cook]. That time I associate with really living for fun. I was drunk almost every day [laughing]. Yes, that was quite something.. yes, wild! [...] I also sometimes used to say that she [my daughter] saved my life.
Interviewer: How did you go about [Eating more healthily]?
Diane: Oh I just did. I knew clearly how it shouldn’t be, but I didn’t know exactly how it should be. And yes. Making the most of it […], but that is with everything. Also, with raising the children. I was not raised properly. That’s way I needed assistance with raising them.. that’s also how it is with cooking. However, I enjoyed having breakfast together in the morning [...] I thought that was always very important.
Annie: I have experienced it as a very wonderful experience. Due to the fact that you are sitting with a group of people, around 10, 12 people, who actually know very well what you are going through, because you are almost all going through the same thing, and that makes it easier to live with. You don’t have to explain anything. [...] I still have contact with a few people from there. [...] You are, of course, receiving therapy at that time, and at some point, you start to see things differently. And then you have slowly elevated your perspective [...] this comes from how they support you in looking at things differently. You realise that the outlook is simply different. [...] And I have to say, I have benefitted a lot from it.
Saskia: Before getting married [...] I had also lost a lot of weight. [...] I wanted to fit into my wedding dress [...], but that motivation maybe lasted a week after that. After getting married, it was gone again [...] That now seems simply unwise: [...] to make sure you were slim as possible just to fit into your wedding dress.
Personal meaning of turning points
Annie: I was born in 1957 and until 1995 everything went smoothly. I never actually once thought that there was anything that could have an influence my eating. Well in 1995, I lost my job after 20 years and my relationship with my partner also fell apart. In response, I started to eat a lot [...] My partner and I also worked together. We used to see each other every day at work. And when that stopped, there were a lot of things that we didn’t talk about anymore. Most of it was connected with work and then at some point.. [...] I stopped seeing him every day, you know? Then it just becomes very different, yes.
Freek: A dietitian could tell me how much weight I would need to lose and this and that, but kind of authoritarian pressure doesn’t work for me.
Dennis: They [health professionals] don’t think along with you, but more in the line of: “Let me tell you what’s going to happen”, and that does not work for me; I’d just tell them to piss off.
Freek: [My mother made] all the old-fashioned traditional Dutch dishes; stamppot, kale with sausage, carrots, sauces, etc. We also slaughtered our own pigs and cattle ourselves, so there was plenty of everything. We had the potatoes ourselves, you had the fruit ourselves; all year round. [...] We only had to buy butter, a pack of sugar, and some flour. [...] In winter, apples were picked and peeled, and they were sent to the stone factory. There, they were dried and you could eat them on a winter’s day. [...] Everything was used. [...] And then you also knew what you ate. Do you remember what you eat now? It’s all stuff from abroad. People now don’t know anything about half the food they eat.
Coping styles
Active coping
Annie: [While describing the items of her food box; pictures of all sorts of healthy foods] That is what I eat. And people who really know me will recognize me in this because I eat healthy nowadays.
Dennis: The thing with food is, as I have already mentioned, that if you have good food, you don’t need any sauce, so there won’t be any excess sugars.
Dennis: For now, my values are okay, my weight is going down, so I am satisfied. Then I will not continue to hurt myself with the thought of having to do this or that, or worry about what’s allowed or not. [...] If I do that, it becomes an obsession and I don’t want that.
Saskia: I want something that is entirely tailored to my needs – identify what makes me fat, like meat, so I can leave that out. I figured that out a bit and implemented it myself.
Tygo: Well, I’ve been to a dietitian before [...], but they switched jobs a lot.. I have had three or four different ones there. And then the next one left and so on... That didn’t work. And then I started exercising here, and there was Fleur [dietician]. Then Adam [fitness trainer] said: “Do you want to go to a dietician?” I wanted to, so then I went two or three times and then she [Fleur] quit, then she went to Loenen [another city]! I said: [...] “I would like to continue working with you!”. And then we went to Loenen [...] That click that was there. If I have a good feeling with someone...
Dennis: Josien, [practice nurse] she talked about it and then she said she could also send me to a dietician. “Would you like that?” she asked. It wasn’t that I had to, but she really asked for my consent. “If you want, she can call you to make an appointment.” Well, I thought it wouldn’t hurt to try. And that whole conversation with the dietitian then also came back to Josien [...] You are not rushed along or anything. Because you get that a lot, those professionals who just become snappy if you don’t do as they ask.
Mark: We eat a lot of vegetables, lots of fresh vegetables if possible. And in the evening I do eat eggs or nuts for 2 or 3 days a week instead of a sandwich. So, no bread on those days, that’s how I started this diet. And I feel very comfortable with that [...] She [practice nurse] always pushed for those medicines. But then those shows about diabetes were on television [shows on national TV in which people improved their T2DM by making dietary changes]. Then I thought: if it works that way with food, why wouldn’t it work me? I will just go for it and see what the results will be.
Diane: And then I stopped smoking last year and then I was at 109–110 [kilos]. And now I am a year further and I am around 105 [whispering]. So, I lost five kilograms in a year’s time .. even though my life [style] [...] this is very small, don’t you think? Five kilos in 1 year [...], I really don’t understand how that is possible. And if I were to have a bad week, I’d easily gain 3–4 k again.
Ria: It is not important to me, eating. I mean, let me put it this way: I care very little at all for food.
Freek: Just do what you have to do and what makes you feel best. And that’s it in a nutshell [...] It’s the little things, but if you do it that way every day, you can do a lot.
Ria: No, I thought that I was [eating healthily], I’m satisfied with it [...] I will keep it up, if nothing else comes into my body. And that I get the answers of ‘yes you are doing good’ when I go to the GP check-ups.
Passive coping
Interviewer: Has anything changed [in how you view the disease] compared to 10 years ago?
Mieke: No, no. I still think ‘oh, that one is sick’ [points to empty seat on couch]. Not me, you know.
Marja: In terms of food and drink, we just ate the same things as always, nothing special. You can cook nasi once, but then you bear in mind what you put into it. And that you would eat that once. We also never eat at a Chinese restaurant or anything.
Mieke: but it is often his job, [...], which always causes problems. So, now I’ve told him [her husband] if you have some event again, then I’ll stay home. [...] especially when it involves food, you know? If I have to hand over control to someone else. That I no longer have control of it myself. Yes, that, that’s difficult for me [...] Regularity is actually best for me. Just go to bed on time, eat on time, and get up on time.
Claudia: I lost a lot of weight years ago, at that time, I went to the dietitian and everything. [...] But when I stopped, it immediately came back again, so I said to myself that I wouldn’t do that anymore.
Karin: So ... yes. That’s why I just do it. I also have no idea if my sugar gets too high, what I have to do then.. how I can notice it or something. I don’t know that either [...] So.. I do actually find it a bit tricky. [...] And why you do it or not; I don’t think that my doctor would be concerned.
Mieke: I’m really getting sick of it. [...] And then I also said to Marijke [practice nurse] “I’ll just give up”. I’d say, take me as I am, even if that means I’m overweight. I don’t care anymore. [...] Do you understand? I mean, ... then you have peace with yourself. And maybe that’s when you will lose weight.
Interviewer: And what are things that make it easier for you to eat healthily?
Karin: Well.. I don’t really know that. I don’t find it easy at all. But it just has to happen. I have to be careful. If my sugar is too high then you will also have problems and I also think about being a mother where the father is no longer there for the children. I then think, yes, this mother should of course continue to live a little longer. Yes, it sounds a bit strange but that is of course how it is. That can make me a little bit emotional [crying].