This study used a purposeful sample of 12 participants consisting of nine female and three male parents aged 37–57 years were included in this study. Table 1 summarizes the sample demographics including age, gender, and ethnicity of each parent.
Insert Table 1
The parents shared their understanding and experiences related to T2D, as well as potential strategies that could support the development of interventions to prevent prediabetes and T2D in adolescents. Two main themes and multiple subthemes were identified, described with quotations below and presented in Table 2.
Insert Table 2
Parental Understanding of T2D
According to parents’ responses, T2D involved having poorly regulated High Blood Sugar levels that contribute to multiple symptoms and complications resulting in Severe Health Impacts. Parents recognized that addressing T2D meant emphasizing behaviour modifications such as Managing Your Diet to reduce the health impacts of T2D. However, parents were unable to explain the body’s regulation of blood sugars and had difficulty differentiating between healthy and unhealthy foods.
High Blood Sugar
Most of the parents defined T2D as being associated with elevated blood sugar levels. Explaining what T2D meant, one parent (P7) stated that “your sugar is high” while another parent said (P10) that “your body doesn’t regulate your sugar levels” and one parent (P6) affirmed that “you don’t want that sugar.” However, some of the parents stated that increased blood sugars were related to elevated cholesterol levels (P8), increased intake of sugar especially through sweets (P3), or the body’s inability to produce insulin (P5). One parent (P12) stated, “insulin in the body has something to do with that.” Overall, parents’ responses focused on a person’s consumption and levels of sugar or sweets while only two spoke of the role of insulin in T2D.
Severe Health Impacts
Parents recognized that T2D impacted overall physical and mental health due to its related symptoms and complications that were experienced personally, or by family members and friends. Parents mentioned various symptoms such as thirst, droopy skin, visible ageing (grey skin), leg/foot pain, weight gain/obesity, hypoglycemia (low blood sugar), and sleep disruption. In addition, parents spoke about the observed impacts of diabetes including feeling overwhelmed (P8), blindness (P2), renal failure that necessitates dialysis three times a week (P4), limb amputation (P3,11), “shark foot” (P2), risk of cardiac arrest and heart problems (P4, 12). One parent (P2) shared her father’s experience with T2D and the subsequent complications:
He had juvenile diabetes and found out when he was 14. And then truckers do not take care of themselves - at all. He was about 27 years old when he became blind completely from diabetes, and then he ended up with a condition called Shark Foot? It’s where your arch support gives way, and your foot turns inwards. So, he had that for several years due to diabetes and not taking care of it.
The observed symptoms and complications exemplified the severe health impacts of T2D on their physical health. The parents understood that the occurrence and severity of health impacts were linked to T2D.
Managing Your Diet
Parents understood that with proper management through behaviour modification, people with T2D diabetes can lead normal lives. Although parents talked about physical activity and stress management, the most-discussed behaviour modification was diet management. Parents stated that diets high in sugar and carbohydrates were a risk factor for the development of T2D.
Parents felt that through diet management, people living with T2D could reduce the need for more aggressive therapies such as oral medication and high insulin dosages. However, for T2D prevention, the parents acknowledged that diet management served as an early intervention. One parent (P2) explained what diet management meant to her, “do not eat so much of the fast food, just eat a little bit more things that are beneficial to your body like fruits and vegetables and healthier food.” Prevention through diet management was especially important to parents that had observed symptoms and complications of T2D in family members. Parents’ understanding of T2D was limited to physical definitions such as severe impact on physical health and behaviour modifications. Parents identified that modifications to diet were necessary to reduce risk factors of T2D; however, they were unable to pinpoint nutrition content of foods and how they affect well-managed blood sugar levels.
It Takes a Village
Based on parents’ responses, prevention of T2D in adolescents involved multiple influences, and they felt that It Takes a Village to motivate changes in adolescent health behavior. Parents identified strategies for T2D at the individual, family, and community levels which involved multiple supports such as teachers, medical professionals, community organizations, and peers.
The Onus is on the Adolescent
This subtheme acknowledges that the decision to engage in interventions for T2D prevention ultimately depends on adolescents’ desire to participate in healthy habits including physical activity, healthy eating, and adequate sleep. Speaking about what adolescents can do to reduce the risk of T2D, one parent (P10) suggested that adolescents with T2D should “refrain from junk food, make [their] own food, and engage in regular and ongoing physical activity.” Despite offering suggestions, parents understood that during adolescence, identity is defined outside the context of family and that adolescents begin to make personal decisions. As one parent (P3) explained, “adolescence is a time where one is old enough to start taking care of [oneself] and [one’s] own health.”
Adolescents’ decision-making about their health can be supported through education. Thus, parents thought that diabetes education should be provided at younger ages to support healthy decision-making in adolescence. As one parent (P10) explained, “kids in kindergarten and Grade 1 have the ability to understand, you know, what a healthy food choice is if you teach them.” This subtheme acknowledges that the effectiveness of preventative interventions is dependent on adolescents’ decision to opt in. This same participant elaborated that even with the availability of resources and support to encourage healthy lifestyle changes, “a person still has to want to do it.” Therefore, adolescents need to be motivated through increased awareness of their risk for T2D and education on how their decisions impact personal health.
Starts at Home with the Parents
Adolescents’ adoption of health habits is nurtured by families through encouragement, active role-modeling, and acting as a deterrent for behaviours that increase risk for T2D. As one parent (P10) explained:
It's up to the parents to monitor and limit what the kids do, like as a far as screen time, and it's also up to the parents to encourage the kids to get exercise and eat properly. So, I just feel so strongly that it starts at home.
Parents spoke about encouraging adolescents to engage in health positive behaviour such as physical activity, healthy nutrition, and yearly health monitoring. Parents also mentioned buying home exercise equipment and enrolling adolescents in recreational sports in order to encourage activity. In addition to encouragement, active role-modeling was utilized and involved parents choosing to eat healthier and participate in physical activity to encourage adolescents to follow their example. Thus, active role-modeling often resulted in changes to family habits. One parent (P8) explained her efforts to incorporate healthy foods into family meals:
Every meal has a vegetable with it. Whether it’s like a protein, like a meat? Whether it’s chicken fingers that are breaded, it will have a salad and not the pasta, right? Everything in our house has to have a vegetable.
Parents expressed that encouraging their families to participate in healthy behaviour increased motivation in themselves and adolescents to adopt lifestyle changes.
When encouragement and active role-modeling were unsuccessful, fear tactics were used to deter adolescents from risky behaviours. Parents told adolescents about experienced or observed negative health impacts of T2D to stress the urgency of T2D prevention and the consequences when T2D risk is not taken seriously. A mother (P3) stated:
Sometimes, because I am telling this with the kids sometimes you know what? That’s not, that’s why mom has that because she always like this, like that. So, if you are in the habit of eating like that, you will be getting like this. At age 20 or 25, sometime like that, you will get high blood sugar or diabetes, like your auntie because [your aunt] is always eating sweets.
From childhood, adolescents spend most of their time at home with their parents and, therefore, parents have more opportunities to implement foundational health habits by providing encouragement and serving as role models. However, parents' guidance does not guarantee an adolescent’s engagement in healthy behavior.
We Need More Support
Parents identified a need for education, resources, and involvement of actors such as teachers, medical professionals, community organizations, and peers that can improve access to education, support, and resources to prevent T2D. Parents acknowledged they did not have sufficient knowledge to effectively engage in healthy decision-making to prevent T2D in their adolescent children and families. As one parent (P11) explained, “when I see, that it’s 13 grams of sugar per this much, well, I don’t know how much sugar I'm supposed to eat in the first place.” In addition, parents expressed gaps in knowledge related to risk factors, pathophysiology related to prediabetes and T2D, symptoms, complications, healthy eating, and available resources about T2D.
Parents thought that adolescent education about T2D should occur at a younger age since the information the parents learned during their school years has been beneficial in their adulthood. From their experiences, parents suggested that education should include how to read labels, knowledge of the food guide and food groups, and how to identify items with added sugar. Additionally, parents agreed that it would be beneficial to integrate similar information into core curriculum in schools to facilitate adolescents’ healthy decision-making. One parent (P5) stated, “We need to get the Canadian Food Guide implanted in the kids’ heads and which foods are actually healthy and which foods are not. And, help them try to make those right decisions.”
From a young age, adolescents spend much of their time in school. Therefore, parents suggested teachers could play a role in health education, advocacy for healthy meals and snacks, and creation of opportunities for adolescents to engage in healthy activity. As one parent (P7) explained, “in the class, maybe teachers should give them, like five minutes to stand up and then go jogging, just to boost them.” Furthermore, parents thought that teachers should ensure inclusivity to address isolation and bullying which reduces the motivation of at-risk adolescents to engage in physical and social activities. In addition, parents felt that teachers could work in partnership with school counsellors to provide mental and emotional support to adolescents. As one mother (P12) explained:
I'd say access to somebody who the adolescents could talk to at the school. Um, maybe a counsellor or somebody. I know there are counsellors there, but you don’t see them very often in the school. But I know some of the kids there, I think they need it and some of the kids that do bully, maybe if they had that attachment to someone else in the school that they could trust and bond with they would not bully other students.
According to the parents, since teachers spend a lot of time with students, they are in an optimal position to build trusting relationships which increases likelihood that students will listen to T2D education provided by teachers and seek support when experiencing mental health concerns.
Together with teachers, medical professionals work within the healthcare system to address T2D prevention. Parents felt that nurses and physicians play a role in T2D awareness, education, and the completion of annual screening and testing. In addition to nurses and physicians, parents suggested that psychologists provide mental and emotional support and dieticians provide nutritional education. A participant (P2) spoke about the need for input from medical professionals:
We need health care supports to increase and regularize screening, increase staffing (diabetes specialists) in order to shorten wait times, and ensure students are given individual and holistic attention to help catch any particular health problems they might need help with.
Parents also thought that the vigilance of medical professionals was needed to ensure early identification of T2D risk and subsequent assessments. As one parent (P9) explained:
For type 2, I think if they got tested sooner, they can even break it sooner. So, then there won’t be so many people that have it. Then they might make those healthier life choices because they know about it early and took care of it sooner. It is no different than cancer or anything else. If you know about it and you catch it soon enough, you can take care of it.
For parents, the increased availability and involvement of medical professionals was important to ensure early intervention and improve accessibility to education and resources for preventing T2D in adolescents.
Alongside medical professionals, community organizations participate in T2D prevention by implementing free programs and raising awareness of available resources for adolescents and parents. Parents suggested that community programs address education, food preparation, cooking, and physical activity. For example, one parent (P9) suggested a community program that could “get teenagers out at the grocery store and have somebody there to really show them how to shop. They don’t know how to read the ingredients or the weight in grams.” Community programs can be utilized to reinforce education provided in schools and by medical professionals. In addition to community organizations, peer mentorship can provide social and emotional support and motivate adolescents to engage in healthy behaviors. Explaining a peer mentorship program, a parent (P10) stated, “it could be someone their age. Or it could be someone older, and they would be helping them to become more physically active. Or eat healthier.” A participant (P9) said:
A Boys and Girls’ type program where someone aged 27 or 28 would pair up with their child. They could participate in snow shoeing, Ski-Doo-ing, exercises, fishing, and hiking, to name a few activities. But this program would allow parents to join and would require financial backing.
Acknowledging the influence that peers have on adolescents, peer relationships can be utilized to spread awareness and reinforce education about T2D. Overall, parents wanted more free resources, education, and support to address T2D prevention in adolescents. Additionally, parents thought that efforts coming from multiple resources simultaneously would act as reinforcement for healthy habits in adolescents and decrease their risk of developing T2D.
Getting the Message in Their Face
The prevention of T2D worldwide requires distributing education in ways that target larger audiences. Therefore, dispensing T2D education through social media would enable easy access to more adolescents. One participant (P10) stated:
If it’s not coming from home, then we’ve got to get the message in their face, and again I've seen ads on TV that do talk about limiting screen time, and you know they’re just kind of stark messages, but to me they are effective. Because they’re educational. They're trying to reach a mass group.
Similarly, another mother (P9) said, “look at the stupid challenges that they have on Facebook and YouTube. They’re slapping people with cheese. How about slapping people with nutrition?” In addition to a wider reach, parents suggested using ads showing worst-case scenarios, which could involve showing people with negative impacts of diabetes to ensure ads are memorable and make adolescents consider behaviour modifications. One parent (P2) said:
You know how they have the stupid pictures on cigarette packages that make it look disgusting? Why can’t diabetes be the same kind of thing, and we post it on social media to show that if you developed diabetes, well this can happen to you? It would be like giving them, I hate to say it, but the worst-case scenario.
Overall, parents thought that ads should capture the potential severity of T2D while being informative. In addition, parents viewed technology and social media as barriers for adolescent engagement in physical activity; however, they acknowledged that adolescents use of social media could be used to widely distribute T2D education and resources. Digital information can be accessed anytime, can be viewed multiple times, and easily shared with peers.