Connections Among Daily Occupational Participation,Diabetes Self-Management,and Quality of Life

Method

Results

The sample included 99 participants. Table 1 shows the sample’s demographic, clinical, and HRQoL characteristics, DSM performance, and participation (ASAP). Most (78.8%) participants lived with partners, children, or caregivers. On average, the clinical indicators of T2DM management were above recommended levels for HbA1c (M = 7.98, SD = 1.89), fasting glucose (M = 141.79, SD = 54.13), and BMI (M = 29.69, SD = 5.45).

Discussion

This study aimed to identify relationships between performing various daily occupations, DSM activities, HRQoL, and blood glucose levels of people living with T2DM, most of whom had unbalanced blood glucose levels. The results suggest that engaging in physical activity through daily activities (e.g., caring for a pet, garden, or potted plants) and sports is associated with performing more DSM tasks, and engaging in quiet activities (e.g., reading, watching TV/computer) is associated with fewer DSM tasks. The regression model explained only a small proportion of the variance in DSM, suggesting that additional factors not tested in this study might influence DSM task performance. Thus, it is necessary to investigate other factors that could potentially explain DSM. Interestingly, however, our results demonstrate that some daily occupations have a positive or negative relationship with DSM and HRQoL, and others have ambivalent relationships.

Our regression analyses showed that of the nine ASAP occupation categories, only engaging in physical activity or sport showed a significant positive relationship with DSM tasks overall. Most other occupation categories (e.g., self-care, work, and even social recreation) may be considered obligatory, constituting activities one is required or expected to do. However, engaging in regular physical activity, especially through exercise and sport, stems from a commitment to oneself and calls for discipline and effort. Likely, participants in this study who had found a way to engage regularly in physical activity could transfer that commitment and discipline to completing other DSM activities. This could explain the positive relationship between the physical activity occupation category and the total DSMQ score.

The implications of this finding are aligned with previous research and current recommendations for T2DM management. Earlier studies showed that among people living with T2DM, physical activity—even in small amounts, such as light-intensity walking—can significantly attenuate acute postprandial glucose, insulin, C-peptide, and triglyceride responses compared with prolonged sitting (Dempsey et al., 2016). The ADA recommends moderate-intensity leisure-time physical activity of at least 150 min/wk to manage diabetes because it can help improve blood glucose levels and weight management (AADE, 2017; Colberg et al., 2016). Thus, helping people living with T2DM integrate physical activity into their daily routines could be an important initial goal for occupational therapy intervention.

Our correlation analyses provide further nuances for understanding which occupations might be most helpful in achieving desired physical activity levels. For example, engaging in recreational or leisure occupations was positively correlated with higher DSMQ Physical Activity subscale scores and better mental and physical HRQoL—likely because recreation and leisure occupations indirectly contribute to physical activity. Consistent with this study’s results, the AADE (2017) expanded its description of physical activity to include any daily physical movement, unstructured or structured (e.g., exercise class), to decrease time spent sitting. Qualitative research has suggested that engaging in physical activity with others fosters a sense of mutual commitment, enjoyment, and social interaction, supporting people with T2DM to maintain overall activity levels (Lidegaard et al., 2016). Thus, considering previous research, an important implication of our study is for clinicians to cultivate meaningful active recreation among people with T2DM as a DSM strategy.

This study also found that occupations such as domestic activities, caring for others, and employment had ambivalent relationships with DSM and HRQoL. Domestic activities and caring for others were positively correlated with greater physical HRQoL but also with obesity. A possible explanation might be that although these occupations may be personally fulfilling (explaining the positive correlation with HRQoL), they leave limited time and motivation to engage in DSM activities. Thus, they may contribute to obesity, a known risk factor for the development and progression of diabetes. Furthermore, domestic activities and caring for others involve more intermittent physical effort than sustained exercise. Studies (Hamasaki, 2016; Oh, 2020) showed that moderate- or high-intensity physical activity while doing domestic chores is less efficient for diabetes outcomes than leisure-time physical activity of the same intensity.

In addition, the demands of caregiving can lead to increased stress and, thereby, emotional eating and less time for regular exercise, factors contributing to weight gain (Koumoutzis & Cichy, 2021). The ambivalent relationships in our study align with a previous study showing that, after accounting for nutrition management, physical activity, number of chronic health conditions, and sociodemographic factors associated caregiving with higher odds of obesity and physical activity with lower odds (Ellis et al., 2024). Our findings and those from previous studies underscore the importance of maintaining an occupational balance between obligatory occupations (tending to external needs, such as housework, job tasks, and caring for others) and DSM occupations (tending to one’s own health needs).

Similarly, we found that work-related activities were positively correlated with physical HRQoL but negatively correlated with glucose monitoring. Böheim et al.’s (2023) study showed that being in good physical health was often a prerequisite for workforce participation, which might explain why work was positively associated with physical HRQoL in our study. Conversely, work was also linked with low glucose monitoring, suggesting that it is challenging to integrate glucose monitoring into the workplace routine.

Previous studies also found that work negatively affected diabetes-related outcomes. In one study, adults with Type 1 diabetes and HbA1c above recommended levels (7.3–7.6) who stopped working during the COVID-19 lockdown had better outcomes than those who continued to work (Bonora et al., 2020). Another qualitative study cited psychosocial workplace factors, such as heavy workloads, working environments affording little privacy and hygiene, and workplace norms prioritizing work-related tasks, as detrimentally affecting DSM performance (Loerbroks et al., 2018). An in-depth investigation of the types of glucose monitoring revealed that people with diabetes preferred real-time, intermittent-scan continuous glucose monitoring devices over traditional monitoring because of the equipment, time, and discomfort associated with traditional methods at work (Scharf et al., 2019). Thus, occupational therapists must explore each client’s work role and environment and strategize continuous, convenient, and discreet options for glucose monitoring for those in the labor force. Additional studies are needed to investigate in depth how workforce involvement affects DSM performance and further inform occupational therapy practice with working-age people with T2DM.

Collectively, our findings point to possible competing priorities between self-care plans and other life roles and obligations. Qama et al.’s (2022) scoping review of qualitative evidence on chronic disease management reported a similar finding. It concluded with a call for health professionals to build personalized profiles of patients with chronic health conditions and help them create sustainable routines that balance self-management with other life roles. Although the call was intended for all health professions, occupational therapy practitioners have the well-suited skill set and expertise to fill this gap in chronic care.

People living with diabetes have reported their primary problem as difficulty following a strict treatment plan for the rest of their lives. In addition, the disease-centered health care model lacks dialog and participation in decision-making, hampering the integration of the condition into people’s social and occupational lives (Pera, 2011). Managing a chronic illness requires prioritizing self-care as a primary responsibility, similar to a “job” (Kleman et al., 2023). This concept suggests that people living with diabetes need adjustments and support to make informed decisions about balancing different priorities and performing DSM while maintaining meaningful occupational choices (Fritz, 2014; Pyatak, 2011).

Therefore, it seems reasonable that occupational therapy practitioners and people living with diabetes can benefit from knowing which occupations within people’s routines facilitate or hinder DSM, which is critical for enhancing their persistence with DSM. Qualitative research has consistently emphasized the importance of understanding the typical and atypical life routines among people with diabetes (Chen, 2010). For example, they may change their DSM over time, modifying it in response to factors such as holidays (Coyle et al., 2013). Furthermore, as demonstrated in Luciani et al.’s (2021) study, people with T2DM perceive DSM as a complex and demanding endeavor that includes renouncement (of activities, food, or social relationships), establishment of a routine (making illness visible and helping to negotiate their identity regarding diabetes), and maintenance (by checking health parameters).

Occupational therapy providers are experts in evaluating ADL and routines while examining interactions between an individual’s health, activity, and context, including personal and environmental factors. The occupational therapy profession is concerned with how daily occupations affect health conditions and how chronic health conditions affect a person’s daily life participation and HRQoL (AOTA, 2020). Hence, occupational therapists can respond to the needs of people with T2DM by using a holistic person-centered approach and occupation-focused interventions. This approach comprises strategies such as educating people on the role of activity engagement, providing technological support, and integrating self-management into daily routines while preserving meaningful engagement and enjoyment of other activities (Nielsen & Christensen, 2018). A holistic person-centered approach to achieving glycemic targets is recommended over a glucose-centered model as an integral part of self-care for people with T2DM (Ahmad et al., 2022).

An example of an occupational therapy intervention in this area is the Occupational Therapy Diabetes Self-Management intervention to promote DSM participation, which improved HbA1C and fasting blood glucose levels among study participants with T2DM (Binesh et al., 2023). Another occupation-focused intervention, Integrated Primary Care and Occupational Therapy for Aging and Chronic Disease Treatment to Preserve Independence and Functioning (iPROACTIF), focuses on preserving functional independence through person-centered goal-setting and support for self-managing chronic health conditions. An iPROACTIF feasibility study found high acceptability and satisfaction among its eight participants (Mirza et al., 2020). Another occupational therapy intervention with a bigger sample size and randomized controlled trial, the Resilient, Empowered, Active Living with Diabetes (REAL Diabetes), improves glycemic control and quality of life among young adults with Type 1 or Type 2 diabetes (Pyatak et al., 2018). In sum, self-management interventions with both person-centered and occupation-focused approaches are recommended in occupational therapy for people with chronic conditions. The goal is to help clients establish self-management habits and routines with three main components—education, functional or occupational goal-setting, and problem-solving (Fields & Smallfield, 2022).

Limitations and Future Research

This study’s cross-sectional design precluded examining cause-and-effect relationships between engagement in daily occupations, DSM performance, and T2DM outcomes. In addition, the self-reported nature of the questionnaires might not have captured accurate, objective observations of the study variables. In addition, the ASAP questionnaire has limitations. For example, it does not include questions regarding the type of work individuals perform or capture their satisfaction with daily life activities. Another limitation is that the study included participants with T2DM, most of whom had unbalanced glucose blood levels and came from narrow geographic locations in Israel; therefore, its generalizability to all people with T2DM is limited.

One strength of this study is the accuracy of clinical data from medical charts and the use of standard, valid, and comprehensive questionnaires. Another strength is that the sample included people struggling to balance their blood glucose levels. A more comprehensive sample of people with T2DM and balanced blood glucose levels would increase the generalizability of the study results. Future research would benefit from longitudinal studies examining how clinical variables change with changes in DSM and participation in daily activities. Studies that investigate the moderating effect of occupational contexts on the relationship between DSM and diabetes-related health outcomes (i.e., investigating which occupations strengthen the positive effects of DSM and for which subgroups) are also recommended.

Further qualitative research is necessary to understand better the positive, negative, and ambivalent relationships between specific occupations and DSM. This knowledge can inform future clinical trials of occupation-focused interventions for diabetes management. A few recent studies on occupation-focused interventions have shown promising results for diabetes outcomes such as HbA1c (e.g., Binesh et al., 2023; Rovner et al., 2020), DSM performance, and self-efficacy (e.g., Binesh et al., 2023). These interventions can be further optimized by qualitatively exploring the mechanism by which engaging in specific occupations supports DSM behaviors.

Implications for Occupational Therapy

This study has the following implications for occupational therapy practice:

▪ Occupational therapy interventions should be person-centered, establishing a routine to support each client’s DSM while maximizing their HRQoL. Occupational therapy practitioners should perform a comprehensive occupational profile discerning specific elements within daily occupations, such as paid work, domestic chores, and caregiving, with their ambivalent or divergent effects on DSM engagement and HRQoL. They should identify with clients the most important and valued occupations, and then perform task analyses to determine how to introduce DSM activities into the client’s life context without disrupting valued occupations.

Conclusion

Helping people with T2DM maintain healthy lifestyle choices is part of their treatment and can reduce complications of diabetes and obesity (AADE, 2017; Colberg et al., 2016; Schmitt et al., 2013). Their lifestyles and behaviors constitute ADL. This study provides an exploratory understanding of the occupations that limit and enhance DSM and shows that daily activities play a significant role. A few occupations demonstrate ambivalent associations with HRQoL and DSM, such as domestic activities, caring for others, quiet activities, and work. The findings can broaden occupational therapists’ understanding of which activities and occupations could improve outcomes for people with diabetes. On the basis of these findings, we especially recommend engaging in fewer quiet activities and higher levels of daily physical activities across occupations to promote DSM. These findings reinforce the suggestion that treatment of higher DSM engagement should be personalized and address the person’s daily activities and cognitive, social, and psychological aspects of individualized condition management.