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‘I’m on the train and I can’t stop it’: Western Canadians’ reactions to prediabetes and the role of self-compassion Strachan, Shaelyn; Bean, Corliss; Jung, Mary 2018-07-03

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Running head: REACTIONS TO LEARNING OF T2D RISK  1   1 ‘I’m on the train and I can’t stop it’: Western Canadians’ reactions to prediabetes and the role of 2 self-compassion  3   4 Shaelyn Strachan1, Corliss Bean2 & Mary Jung 2 5 1 Faculty of Kinesiology and Recreation Management  6 311 Max Bell Centre 7 Winnipeg, Manitoba, R3T 2N2 8 2 Faculty of Health and Social Development 9 The University of British Columbia 10 1147 Research Road  11 Kelowna, British Columbia, V1V1V7 12  13  14 Corresponding author: Dr. Corliss Bean 15 Email: corliss.bean@ubc.ca 16 Phone: (613) 240-0358  17  18 Submission date: March 1, 2018 19 Accepted: July 3, 2018  20 RISK REACTIONS TO PREDIABETES   2 Abstract 21 Prediabetes, a condition characterized by impaired glucose regulation, is on the rise worldwide. 22 This condition puts people at risk for cardiovascular disease and 50% of people with prediabetes 23 will develop type 2 diabetes (T2D). People with prediabetes can reduce their risk of developing 24 T2D through lifestyle changes such as regular physical activity and healthy eating. However, the 25 experience of health risks can be associated with negative reactions that can undermine people’s 26 ability to self-regulate the health behaviours that would reduce their health risk. Self-compassion, 27 or treating oneself kindly in the face of challenge, is known to help people manage negative 28 emotions and facilitate self-regulation. Therefore, self-compassion may be helpful for people 29 with prediabetes who have to manage their health behaviours in the context of a health threat. 30 The purpose of this study was to explore how people, from a small Canadian city who learn that 31 they have prediabetes, react emotionally to their prediabetes diagnosis. We also explored 32 participants’ receptivity to applying self-compassion in the context of their prediabetes. Twenty-33 one adults recently notified by their doctors as having HbA1c scores indicative of prediabetes 34 (Mage=57.76, SD=5.43) engaged in a semi-structured interview between June 2017 and January 35 2018. Inductive thematic analysis was used to analyze the data. Four themes emerged. 36 Participants’ reactions to learning that they had prediabetes were characterized by (a) distress 37 and concern, (b) downplay of T2D risks, (c) guilt and shame, and participants were receptive to 38 (d) self-compassion as a beneficial approach to take in relation to their prediabetes. Findings 39 suggest that people experience negative reactions to their prediabetes diagnosis yet are receptive 40 to self-compassion, which could mitigate these reactions. These findings can inform lifestyle 41 behaviour change programs for individuals living with prediabetes by providing a better 42 understanding of the patients’ perspectives of disease diagnosis.   43 RISK REACTIONS TO PREDIABETES   3 Keywords: prediabetes; qualitative research; self-compassion; worry; adults; diagnosis 44 What is known about this topic? 45  A small number of studies demonstrate that people who are living with prediabetes 46 experience confusion about their condition as well as negative emotions. 47  Self-compassion can help people manage negative emotions and has been found to help 48 people self-regulate their health behaviours 49 What does this paper add?  50  Emotional reactions are assessed related to prediabetes among people for whom the 51 knowledge of a prediabetes diagnosis is more recent than that of participants studied 52 in the past.   53  This is the first study, to our knowledge, to explore participants’ receptivity to self-54 compassion, a resource that could help people with prediabetes manage their 55 emotions and self-regulate health behaviours that could improve their health.  56 RISK REACTIONS TO PREDIABETES   4 ‘I’m on the train and I can’t stop it’: Western Canadian’s reactions to prediabetes and the role of 57 self-compassion 58 Prediabetes afflicts millions of people worldwide, with its prevalence estimated to 59 increase to over 470 million people by 2030 (Whiting, Guariguata, Weil, & Shaw, 2011). 60 Prediabetes is characterized by impaired glucose regulation and increased risk of type 2 diabetes 61 (T2D; Buysschaert & Bergman, 2011). Over half of people with prediabetes develop T2D, 62 (Anderson, Freedland, Clouse, & Lustman, 2001). Such a diagnosis often involves physical (e.g., 63 tension, fatigue) and psychological (e.g., anger, denial, depression) consequences to those at risk 64 (National Institute for Health and Care Excellent, 2005). Prediabetes is a reversible condition 65 whereby one’s risk can be reduced through physical activity and healthy eating (Perreault, Pan, 66 Mather, Watson, Hamman, & Kahn, 2012; Tabá, Herder, Rathmann, Brunner, & Kivimäk, 67 2012). However, changing these behaviours requires self-regulation (Terry & Leary, 2011) such 68 as goal-setting, making adjustments, and coping with set-backs (Baumeister & Heatherton, 1996; 69 Terry & Leary, 2011).  70 Adherence to physical activity and healthy eating may be more difficult for people with 71 prediabetes than the general population (e.g., Geiss et al., 2010) as they face the self-regulatory 72 challenges inherent to health behaviour change, while also being at risk for a chronic condition. 73 Facing the risk of developing a chronic condition is associated with negative emotions, which 74 pose added self-regulatory challenges (Baumeister & Heatherton, 1996; Gilbert et al., 2010). 75 Negative emotions can undermine self-regulation, by using up self-regulatory resources 76 (Schmeichel, 2007; Terry & Leary, 2011) which can reduce people’s abilities to make good 77 decisions (Schwarz & Clore, 2003), including those affecting their health. If people with 78 RISK REACTIONS TO PREDIABETES   5 prediabetes experience negative affect, these reactions may interfere with their self-regulation of 79 health behaviours that mitigate their risk.  80 Few researchers have explored individuals’ understanding of T2D risk (Youngs, 81 Gillibrand, & Phillips, 2016), including how people react emotionally (Ritholz, Beverly, & 82 Weinger, 2011). Existing research denotes that people with prediabetes experience guilt about 83 having brought the health risk upon themselves through their past behaviour and for not doing 84 enough in the present to manage their risk (Andersson, Ekman, Lindblad, & Friberg, 2008). 85 People also experience distress, fear and anxiety about their future health (Troughton et al., 86 2008). Alternatively, people living with prediabetes downplay risk factors such as being 87 overweight or question medical test results (Eborall, Davies, Kinmonth, Griffin, & Lawton, 88 2007). These few studies shed preliminary insight into the negative reactions that can accompany 89 prediabetes. The undermining effect of negative reactions to living with T2D has been 90 documented as interfering with self-regulation (Schulman‐Green, Jaser, Park, & Whittemore, 91 2016). 92  Self-compassion may offer people with prediabetes an adaptive way of dealing with 93 health threat and failed efforts towards behavioural changes (Friis, Consedine, & Johnson, 2015). 94 Self-compassion, relating to oneself with care during challenge (Neff, 2003), involves: (a) being 95 kind to oneself (self-kindness), (b) appreciation that one is not alone in suffering (common 96 humanity) and (c) viewing negative thoughts/emotions in a balanced manner (mindfulness). In 97 their narrative review, Sirois and Rowse (2016) outline how each of these components may help 98 those facing chronic conditions (e.g., individuals with prediabetes). Through self-kindness, 99 people with prediabetes can counter self-criticism they may otherwise experience when they 100 struggle to engage in risk-reducing behaviours. Common humanity may help people with 101 RISK REACTIONS TO PREDIABETES   6 prediabetes view personal health threats in the larger context of the challenges that everyone 102 faces in life, which may reduce isolated feelings. Finally, through being mindful, self-103 compassion may help people with prediabetes be aware, in a balanced manner, of the negative 104 emotions they may experience in relation to their health condition rather than ruminating about 105 or ignoring these emotions.  106 Research supports the theoretical position that self-compassion is beneficial for people 107 with chronic conditions. Self-compassion is associated with lower perceived and physiological 108 stress, and adaptive self-regulation of health promoting behaviours (see Sirois & Rowse, 2016 109 for a review). Further, self-compassion is associated with lessened T2D distress (Tanenbaum et 110 al., 2018) and individuals with T2D who underwent a self-compassion intervention reported less 111 distress about their T2D at intervention-end and follow-up than wait-list controls (Friis et al., 112 2016). Self-compassion may also help people with prediabetes manage negative reactions as they 113 try to reduce their risk through lifestyle changes. Though self-compassion may be beneficial for 114 people at risk for T2D (Sirois & Rowse, 2016), some people are fearful of self-compassion 115 because they feel they do not deserve to treat themselves in this way (Kelly, Carter, Zuroff & 116 Borairi, 2013), view it as a weakness, or are unfamiliar with the construct (Gilbert & Procter, 117 2006). To date, we know of no qualitative research aimed at understanding self-compassion for 118 individuals at risk of T2D. 119 Given limited research is available about how individuals react to a prediabetes diagnosis 120 (Youngs et al., 2016), more research is warranted. Therefore, this study’s first purpose was to 121 explore how individuals react upon learning that they have prediabetes. This exploration will add 122 to past research and help identify if the experience of prediabetes is ripe with negative reactions 123 that may undermine self-regulation of health behaviours and, in turn, mitigate further risk. To 124 RISK REACTIONS TO PREDIABETES   7 date, there are few qualitative studies that address peoples’ emotional response to prediabetes 125 diagnosis in comparison to those assessing other experiences, including how people interpret the 126 label (e.g., Hindhede et al., 2015), understand associated causes and risks (e.g., Troughton et al., 127 2008), or outline their likelihood of taking action (e.g., Hindehede et al., 2015). Further, research 128 that does explore emotional responses includes participants who are interviewed more than 1 129 year (e.g., Hindhede et al., 2015) post diagnosis or, time since diagnosis is not reported. 130 Exploring peoples’ reactions to T2D risk as soon as possible after diagnosis should provide 131 valuable information about their reactions. A second purpose was to explore participants’ 132 experiences with and receptivity to being self-compassionate. This exploration can provide 133 information for researchers and healthcare professionals considering whether incorporating self-134 compassion training for people with prediabetes may be necessary and well-received.  135 Methods 136 Procedure 137  This study was part of a larger project where people with prediabetes participated in a 3-138 week community-based lifestyle intervention in Western Canada. Participants were recruited 139 between May 2017 to January 2018 through a private medical laboratory. A monthly newsletter 140 was sent out to all family physicians to inform them of the larger project, including the aim, 141 scope and procedure of the project and intervention. At the end of each month, physicians 142 received a fax from the laboratory listing potentially eligible participants (having HbA1c scores 143 between 5.7-6.4%). These participants had undergone routine bloodwork as directed by their 144 physician. Physicians, informed about the project, indicated on a check box whether their 145 patients were cleared for exercise and could be contacted for potential participation in the Small 146 RISK REACTIONS TO PREDIABETES   8 Steps for Big Changes program. Mail-outs were then sent to these individuals by the private 147 blood requisition laboratory, inviting them to volunteer for the study.  148 Upon receiving ethical approval from the university institutions’ ethics board, interested 149 and eligible participants were contacted by telephone and/or email by the first and second 150 authors. To be eligible for the present study, participants had to: (a) be between 18-65 years old, 151 (b) be able to read and speak English, and (c) have prediabetes (American Diabetes 152 Association’s [ADA], 2016) HbA1c = 5.7-6.4% [n=20]) or complete the ADA risk questionnaire 153 score indicating increased risk (>5; n=1) within the past year. Individuals diagnosed with T2D 154 were ineligible. Informed consent was obtained from participants prior to study commencement. 155 An exploratory qualitative design was chosen to gain an in-depth understanding of 156 participants’ perspectives (Ritholz et al., 2011). An interview guide was developed based on an 157 extensive literature review (see Table 1; e.g., Andersson et al., 2008; O’Brien et al., 2016; 158 Troughton et al., 2008). Interviews were conducted by the first two authors. The interview guide 159 was piloted with two participants. After piloting, the research team discussed the guide and 160 interview process, which resulted in slight modifications to the guide (e.g., addition/removal of 161 question(s), question order). To maximize participant convenience and minimize burden, in-162 person (n = 2) or telephone (n = 19) interview options were provided. All interviews were audio-163 recorded and lasted 39-79 min (M=56). Interviews were transcribed verbatim, reviewed by the 164 second author, and sent to participants for member checking (Creswell & Miller, 2000). 165 Participants received a $20 gift card honorarium.  166 INSERT TABLE 1 167 Data Analysis  168   An inductive thematic analysis was conducted using Braun and Clarke’s (2006) six-169 RISK REACTIONS TO PREDIABETES   9 phases that allows for identifying, analyzing, and reporting themes within data. To aid in 170 trustworthiness, a collaborative approach to analysis (Creswell, 2013) was conducted whereby 171 three researchers independently coded three transcripts and met to discuss themes and sub-172 themes to ensure data were presented in a comprehensive manner. Once main themes and sub-173 themes were identified, relevant quotations for each theme were selected, indicative of 174 participants’ perceptions and represented the sample. Coding discrepancies were discussed until 175 agreement was reached (e.g., theme labels, quotation placement). Authors’ agreed that data 176 saturation had occurred when core themes were well-established and new constructs no longer 177 emerged (Guest, Bunce, & Johnson, 2006).  178 Findings 179  Twenty-one participants (3 males, 18 females) engaged in a semi-structured interview 180 upon learning they had prediabetes, prior to involvement in the lifestyle intervention. Participants 181 ranged from 47-65 years old and all identified as Caucasian. Knowledge of their prediabetes 182 diagnosis ranged from ≤1 month-1 year, with most participants (n = 15) receiving their diagnosis 183 ≤3 months from interview. Additional demographic information is available in Table 2. 184 In each section, overall findings are described and supported by quotations. Results are 185 organized in four themes: (a) distress and fear, (b) denial and downplay of risks, (c) guilt and 186 self-criticism, and (d) self-compassion. Participants’ names were replaced with pseudonyms. 187 INSERT TABLE 2 188 Distress and Fear 189  Distress and fear were at the forefront of participants’ perceptions surrounding their 190 prediabetes diagnosis. Participants vocalized concern about the general diagnosis including 191 RISK REACTIONS TO PREDIABETES   10 Linda and Janet, respectively: “What concerns do I have? That I’m even here (laughs)…that I’m 192 even in the realm of possibility of developing diabetes” and 193 There’s a big element of worry…like I’m on the train and I can’t stop it. You get that 194 worry of, ‘are you going to be able to stop this from getting worse?’…like ‘whoa, what‘s 195 going on here?’...I don’t want to become diabetic, that would be my main concern, I 196 don’t want what comes with that. 197 Other participants expressed concern underpinned with fear about their future health. James 198 recognized a need to make dietary changes: “The worry is that if I don’t deal with it, then it’ll go 199 into full [diabetes].” Participant also identified specific concerns that emerged in three areas: (a) 200 physical conditions associated with T2D, (b) personal or family experiences, and (c) adaptions to 201 one’s current lifestyle. These subthemes are intertwined within one’s dialogue; some overlap 202 occurs between sub-themes below. 203 Physical conditions associated with T2D. All participants spoke of physical effects 204 should they develop T2D. When asked how she felt about her diagnosis, Janet outlined: “You 205 hear about people with diabetes having amputations all the time, worried about stuff like 206 that…left me puzzled, but fearful.” Maria also discussed her physical concerns: “I know that 207 diabetics can have issues with circulation, there’s issues with blindness or eyesight.” Many of the 208 participants’ physical concerns were due to an increased risk of other health issues because of 209 T2D, as outlined by Donna: “Absolutely [I’m worried] because of how it would affect eyes or 210 lack of feeling in lower limbs…and heart disease and strokes.” Participants also expressed 211 concern related to the combination of existing health problems coupled with T2D. For example, 212 Ted discussed his concern about how making the dietary changes necessary to manage his T2D 213 may conflict with the current diet he follows to manage his diverticulitis:  214 RISK REACTIONS TO PREDIABETES   11 I’m worried because I know what I can eat that doesn’t trigger my diverticulitis…now 215 I’m thinking, if I change my diet—the nutritionist says you have to include more 216 vegetables— I’m a little apprehensive because I don’t want to set that into motion. 217 Personal or family experiences. As evident from the above quotations, concern 218 regarding potential physical complications associated with T2D often emerged based on 219 participants’ interactions with relatives who had T2D, as outlined by Deborah: “My father had 220 diabetes and his mother. So health concerns, yeah I [have] concern; I don’t want to develop 221 diabetes. You’re at higher risk for heart attack or stroke; as I get older, these things weigh on my 222 mind.” Witnessing one’s family live with T2D raised concerned for many, leading to discussions 223 around wanting to make lifestyle changes in hopes of preventing it: “I’ve seen the outcomes of 224 the disease, when you see that within your own family…I don’t want to go down that path, what 225 else can I do here?, whether it’s walking or the nutrition” (Donna). Other participants were 226 emotional related to how T2D could affect their future, as outlined by Helen: “The concern will 227 be if it gets to that stage right? It’s a little bit fearful (pause) because (crying) I want to be around 228 for my family”. 229 Adaptations to one’s current lifestyle. Despite expressing desire to make lifestyle 230 changes based on the physical, personal or family concerns associated with T2D, participants 231 expressed concern about having to adapt their lifestyle. Many individuals identified distress 232 surrounding adjustments required to their eating habits and associated sacrifices. Patricia 233 vocalized her concern: “Yeah, ‘will this ever end?’…What [T2D] actually means, the fear that I 234 can’t eat sweets anymore. Those are my concerns. I don’t know what preventions I can take to 235 offset it and don’t want to give up sweets.” One participant discussed how she has always been 236 able to eat any type of food she wanted without consideration, which led to concern: “I guess I 237 RISK REACTIONS TO PREDIABETES   12 have to pay more attention to and cut my portion sizes down significantly” (Janet). Concerns 238 related to exercise were illustrated by two participants who spoke about their hesitation with 239 engaging in physical activity: “Exercise and I are pretty much enemies, but I’m willing to change 240 my attitude” (Helen) and “The challenge will be making a definite commitment to exercise” 241 (Carolyn).  Similarly, participants discussed outlooks related to distress and deflation, often 242 feeling overwhelmed in making behaviour changes: “The self-doubt, but I’m going through with 243 it and hoping I will have a flash of brilliance” (Helen) and “‘How am I going to do this?’ It 244 seems so overwhelming. I know I should ideally lose a hundred pounds to get back to…my ideal 245 weight, but it seems like such an insurmountable mountain to climb that why even try?” (Eileen). 246 Other participants highlighted concern around how their lifestyle would change should 247 they develop T2D. Shirley noted: “You don’t ever want to go down that path and I don’t like 248 needles. Honestly I’m never going to get there…I’ll do everything I need to do to prevent 249 diabetes from happening.” Ted reflected how his perceived changes needed to manage his 250 prediabetes were at odds with current lifestyle: “All my life, my mantra has been: ‘growing old is 251 mandatory, but growing up is optional’. I think it might be time to grow up a bit and look more at 252 life if I want to live past 60 (laughter).” Finally, participants discussed concerns around whether 253 it was too late to make lifestyle changes: “If I kept ignoring the sounds and ate every piece of 254 sugar I got my hands on and became severely obese, I would assume that I’d get full-blown 255 diabetes. The question is will I get it regardless of what I do? I wonder” (Robert). 256 Denial and Downplay of Risks 257 Despite the concern around having prediabetes, participants often conveyed a sense of 258 denial or downplayed prediabetes risks. Three participants outlined their thoughts upon learning 259 they had prediabetes: “My first thought was ‘I don’t think it’s going to kill me’” (Judy), “I didn’t 260 RISK REACTIONS TO PREDIABETES   13 really know what to think, but I’m not at risk for anything yet so…” (Helen), and “I’m assuming 261 that prediabetic doesn’t mean any more than it’s a warning sign and that I’m not definitely down 262 a road that I can’t change” (Cynthia). 263  Some participants downplayed their diagnosis because of the prevalence of T2D: “At that 264 moment, I didn’t think there’s something seriously wrong because you hear people have diabetes 265 all over the place right? You can’t really see that there’s something physically wrong... I wasn’t 266 totally shocked, but certainly wasn’t expecting it” (Laura). While others compared prediabetes to 267 other health concerns they perceived as more serious: “It’s not like you came home from the 268 doctor saying ‘guess what? I have spots on my lungs’” (Maria) and  269 I don’t know if I’m still in denial that it might not happen. I think I’m still thinking that 270 before I get diabetes, I’ll drop dead of a heart attack or stroke. Of the two beasts, I think 271 cardiovascular will get me first. Maybe I’m not taking it seriously…life as usual other 272 than a shot or a couple of pills and a more drastic change in diet. (Martha) 273 Robert discussed how gender played a role, whereby men tend not to worry about such risks 274 until the severity was unavoidable:  275 I never really started worrying about it yet. The problem is guys don’t worry about it until 276 it hits them in the forehead (laughter). We compartmentalize, go on with life; you still 277 gotta go to work, do your job…until the risk seems to be inevitable, that seems to be 278 when you start worrying about it.  279 Guilt and Self-Criticism  280 Participants were critical of lifestyle choices they felt led them to prediabetes and tended 281 to criticize themselves about health behaviours upon receiving the diagnosis. Nancy and Patricia 282 reflected on their personal attributions for being diagnosed with prediabetes: “At the end of 283 RISK REACTIONS TO PREDIABETES   14 everything I go ‘ahh…I could’ve done more for myself today’” and “There’s an element of 284 ‘okay, I knew I was doing this to myself, so you’ve made the bed, you sleep in it’”. Kathleen 285 placed blame on herself for not maintaining a healthy lifestyle: “You realize you are to 286 blame…you know you are fully capable of getting exercise and maintaining a healthy diet, and 287 when you don’t, you realize you’re the one to blame for that.” When asked about how he reacted 288 to his prediabetes diagnosis, Ted blamed himself for his past behaviour and for putting off 289 change: “I’ve eaten like crap for the last 40-45 years. It’s time to change and better 290 myself…maybe I should have tried to control things earlier”. Similarly, James discussed the 291 internal process that occurred after making perceived poor eating choices: “Internally, you do 292 that thing, ‘what did you do that for?, why did you…? You beat yourself up internally. I don’t 293 know how to explain it…you sort of berate yourself, it’s just a normal reaction.” Similarly, 294 Eileen noted: “It sickens me that I let myself get this out of control but you get into a pattern and 295 it’s hard to break out of…I’m out of motivation to do it myself normally.” Helen discussed the 296 challenges associated with maintaining a healthy lifestyle and stated: “You sort of give up for a 297 day or two until you realize you’re judging yourself.”  298 Self-Compassion 299  Participants’ perceptions of self-compassion (or lack of) relative to risk for T2D emerged 300 in three sub-themes representing self-compassion: (a) common humanity, (b) self-kindness, and 301 (c) mindfulness (Neff, 2003).  302 Common humanity. Many participants discussed being surrounded and united by others 303 in prediabetes-related difficulties. Participants discussed experiences being broad struggles that 304 affect many people: “I see it as worldwide, more so in North America; the food we’re eating, the 305 food that’s put in stores. Our lifestyles are too fast and too furious” (Robert), whereas 306 RISK REACTIONS TO PREDIABETES   15 Katherine’s common humanity perceptions were more proximal related to struggles experienced 307 together in her social circle: “All our friends are about the same age so they’re dealing with the 308 same problems and trying to deal with those too.” Several participants discussed how T2D 309 prevalence helped lessen the struggle: “It seems like a lot more people are going ‘oh yeah I’m 310 prediabetic’; there were a couple guys at work that were prediabetic… you’d hear them talking 311 and realize ‘oh, there’s another one’” (Robert).  312 Finally, some participants compared themselves to others who they considered to be 313 suffering more than what they were personally experiencing with prediabetes. Although this 314 aligns with the previous theme, Downplay of Risks, this extends beyond acknowledging that 315 others are also suffering: “I’m a realist, I go ‘whoa – it could have been way worse, it could have 316 been a Type I could have been I’m at risk for stroke and I have high blood pressure’. I find those 317 to be scarier” (Judy) and “There’s a lot of people in a worse state than I am at, so it’s like ‘suck it 318 up’; get over yourself, it’s not that bad” (Michelle). 319 Self-kindness. Participants outlined an understanding toward themselves in a time of 320 adversity. Linda spoke of her understanding of self-kindness for her lifestyle choices: “I am now 321 [self-kind], I never used to be. After years of counseling and dealing with mental health…we 322 have to be compassionate with yourself and others. Being so critical doesn’t serve people well.” 323 For Helen, this notion emerged when she discussed the realities of making a change in her 324 exercise as challenging: “Being consistent about it. Keeping it up…if I miss one day, to forgive 325 myself…be kind to myself like I’m kind to others.” Katherine discussed the inner challenge she 326 experienced with being both critical and kind to herself about her eating habits: “Part of me says 327 ‘you’re smart enough to know better’—that’s the beat me up part—the other part says ‘you know 328 RISK REACTIONS TO PREDIABETES   16 you can do this’ and ‘you’ve done it before so just go with the flow and do what needs to be 329 done’. I have two sides.” 330 Conversely, some participants reflected on how they put others first, before taking care of 331 themselves and how this needs to change: “I just need to think of myself as worth it, worth the 332 work” (Helen) and 333 I’ve thought about doing something for years and it’s always, ‘I’ll start tomorrow’. My 334 daughter gets in the way… always an ongoing list of things and I put myself last. I 335 always want to get everything taken care of that has to do with anybody else and I’m 336 putting myself last. …I just never put myself first and I guess I have to start doing that. 337 (Eileen) 338 Mindfulness. While participants responded to their T2D risk with concern, others 339 adopted a balanced approach, whereby they acknowledged their negative thoughts related to past 340 behaviours and choices, while recognizing the necessity to make changes with openness and 341 clarity. Brenda noted a shift in reaction to T2D risk that reflects a constructive attitude of 342 acceptance and a commitment to change: “I don’t beat myself up for stuff I did before. I try to 343 think more positive[ly] and fix it…I don’t get that upset, kinda like ‘that’s okay’ type of 344 attitude…it can be fixed, don’t worry about it too much.” When Maria was asked about her 345 initial reactions when receiving her prediabetes diagnosis, she responded in a balanced manner: 346 “It wasn’t much of a reaction, it was more of a realization”. Participants recognized that they 347 were in control to make necessary changes: “It wasn’t like ‘oh no’. There wasn’t a depressed 348 feeling...more of an okay, matter of a fact: ‘I need to be more serious about doing something to 349 address this” (Donna). 350 RISK REACTIONS TO PREDIABETES   17 Finally, participants perceived their diagnosis as an opportunity for immediate lifestyle 351 changes that would reduce the risk T2D, yet regardless of the result, have positive health effects. 352 Maria adopted a common humanity approach, while outlining manageable changes should could 353 adopt to reduce her risk: 354 Part of me, at first, said ‘there are lots of diabetics in the world, but there are lots of 355 complications so if you can prevent it why wouldn’t you?’...Let’s say I do develop 356 diabetes, if I made lifestyle changes in advance whatever changes I need to make will not 357 be as huge as if I’d made none…that’s something you have to change downstream 358 anyway so change it now. 359 Michelle discussed how she framed her diagnosis as a chance to make a change:  360 I’m not ‘woe is me’. I’m ‘okay, let’s tackle this! Let’s look at this as a challenge and try 361 to put a positive spin’. I am going to eat a little healthier and make sure I don’t miss my 362 workouts; do what I can and as much as I can so if I still end up getting it, I’ve done 363 everything I could have and then I’ll deal with the next step. 364 Discussion 365 Changing health behaviour offers avenues by which people with prediabetes can mitigate 366 their T2D risk (Tabá et al., 2012). One factor that influences health behaviour self-regulation is 367 emotion (Terry & Leary, 2011). The purpose of this study was to understand how individuals 368 react emotionally to learning that they have prediabetes, which resulted in three themes: (a) 369 distress and fear reactions, (b) denial or downplay of risk and (c) guilt and self-criticism. A 370 second purpose was to explore experiences with, and receptivity to, applying self-compassion in 371 this context which revealed varied experiences. 372 RISK REACTIONS TO PREDIABETES   18 Aspects of prediabetes led to participants’ distress and concern. Participants were 373 concerned about progressing to T2D, experiencing physical ailments associated with T2D, and 374 exacerbating current health conditions. These findings are consistent with past research where 375 physical concerns (Eborall et al., 2007), uncertainty about seriousness of the diagnosis (O’Brien 376 et al., 2016; Troughton et al., 2008) and implications for current health problems (Peel, Parry, 377 Douglas, & Lawton, 2004) have been documented. These concerns may be fuelled by 378 uncertainty around what a prediabetes diagnosis actually means and poor communication about 379 the diagnosis by health care providers (O’Brien et al., 2016).   380 Participants reported reluctance about making the lifestyle changes to mitigate T2D risk. 381 This reluctance related to the lifestyle sacrifices required and a lack of confidence to make 382 changes are similar to findings by Andersson and colleagues (2008). This hesitation to embark 383 on behaviour change was amplified by some participants’ uncertainty about whether it was 384 possible to avoid getting T2D – a finding documented by other researchers (Hindhede & 385 Aagaard-Hansen, 2015; Troughton et al., 2008). Overall, the prospect of lifestyle change to 386 manage risk added another element of distress and concern when receiving a prediabetes 387 diagnosis.  388 While some participants reported experiencing distress and concern, others reported 389 downplay or denial of risk. This denial was evident in a perspective shared by some that 390 prediabetes is merely a warning sign experienced by many that is less serious than other 391 illnesses. This idea, that prediabetes is an insignificant diagnosis, is consistent across a few 392 studies (e.g., Eborall et al., 2007; Hindhede & Aagaard-Hansen, 2015). Further, some 393 participants downplayed the health implications of T2D, expressing that not much would change 394 about their life should they develop the condition. This view is at odds with research; even in 395 RISK REACTIONS TO PREDIABETES   19 prediabetes, individuals are at increased risk of cardiovascular problems (Buysschaert & 396 Bergman, 2011).  397 This denial of risk may demonstrate participants’ efforts to cope with their health risk. 398 People are motivated to maintain a sense of self-integrity, including the capability of controlling 399 important life outcomes, such as their health (Sherman & Cohen, 2006). People can react to self-400 integrity threats by discrediting or denying threatening information. The denial or downplaying 401 of T2D risk and its implications may reflect participants’ efforts to maintain self-integrity in the 402 face of health risk. Another source for the denial may be a lack of understanding about what it 403 means to have prediabetes (O’Brien et al., 2016; Troughton et al., 2008). Indeed, Troughton et al. 404 (2008) suggest that confusion about prediabetes makes it difficult for people to ascribe meaning 405 to the diagnosis. The polarized reactions that participants in this study exhibited–from distress 406 and concern to minimization and denial–reinforce confusion around prediabetes.  407 Participants also expressed guilt and shame relative to their prediabetes diagnosis. 408 Participants commonly expressed self-blame for their past behaviour and its role in their 409 prediabetes diagnosis. Participants felt further guilt and shame when failing, in the present, to 410 stick to health behaviours. The guilt and shame reactions prevalent within our sample have been 411 documented in the experience of other chronic illnesses (Trindade, Duarte, Ferreira, Coutinho, & 412 Pinto‐Gouveia, 2018), but have been less often mentioned in prediabetes research. One exception 413 to this is Andersson and colleagues (2008) who noted participants’ experience of guilt and shame 414 for health behavioural transgressions.  415 These findings add to and build upon past research to document that the experience of 416 prediabetes is wrought with negative emotions and reactions. These reactions may motivate 417 people with prediabetes to change their health behaviour (Hindhede & Aagaard-Hansen, 2015; 418 RISK REACTIONS TO PREDIABETES   20 Peel, Douglas, & Lawton, 2007). There is reason to question whether these reactions are likely to 419 lead to successful behaviour change. According to self-determination theory, motivation driven 420 by guilt or fear is of low quality and unlikely to lead to sustained change (Ryan & Deci, 2000). 421 Indeed, negative reactions compromise self-regulation (e.g., Gilbert et al., 2010), an effect 422 documented among people living with T2D (Schulman‐Green et al., 2016).  423 Self-compassion may offer people with prediabetes a way to manage negative reactions 424 to a prediabetes diagnosis and their efforts to manage health behaviours. A unique finding of this 425 study is that people appreciated and were receptive to self-compassion in the context of 426 prediabetes. Participants discussed all aspects of self-compassion (common humanity, self-427 kindness, mindfulness) when asked about taking this kind approach to interpreting their 428 prediabetes. This is promising given that self-compassion can reduce experiences of negative 429 emotions, and facilitate self-regulation of health behaviour (Neff, 2003; Terry & Leary, 2011). 430 While people with prediabetes recognize the value of being self-compassionate, the widespread 431 negative reactions – like distress, shame and denial – suggest that people in this population may 432 not be exercising self-compassion.  433 This investigation has several strengths. First, the qualitative investigation adds to the 434 limited research on how people respond to news that they have prediabetes (Youngs et al., 2016). 435 This study explored people’s reactions to recently learning about the diagnosis, representing a 436 critical time when people interpret their situation and decide how to respond. Also unique to this 437 paper is our exploration of participants’ thoughts about and responsiveness to self-compassion as 438 applied to their prediabetes experience. Given the potential self-compassion has as a way to 439 relate to oneself during challenging times (Neff, 2003), exploring how people with prediabetes 440 react is prudent.  441 RISK REACTIONS TO PREDIABETES   21 Study limitations also warrant consideration. The sample represents a relatively 442 homogeneous sample in regards to gender and ethnicity, despite recruitment through doctor 443 referral, as all participants were Caucasian and only three men volunteered. Knowing that being 444 diagnosed with and addressing prediabetes is multifaceted based on peoples’ diverse social class, 445 ethnic and gendered backgrounds (e.g., Kautzky-Willer, Harreiter, & Pachini, 2016; Yip, 446 Sequeira, Plank, & Poppitt, 2017), future research is needed to replicate such work in more 447 diverse samples to further explore these constructs. We speculate that we had few men in our 448 study because men tend to be less likely to seek healthcare (e.g., Mansfield et al., 2003), 449 reducing the likelihood that they would have bloodwork completed which was a necessary step 450 for eligibility. Second, women are more likely than men to participate in research for many 451 psychosocial reasons (e.g., Lobato et al., 2014). Another factor limiting generalizability is that 452 physicians had to clear individuals with HbA1c scores in the prediabetes range for exercise, as 453 recruitment for the larger project. Thus, individuals not cleared for exercise by a physician were 454 excluded from this study. As this study was part of a larger project whereby participants had not 455 yet engaged in the lifestyle intervention at the time of their interview, participants may have had 456 a different perspective if they had been interviewed after completing the intervention. For 457 example, researchers have found that people’s initial expectations for behaviour change can be 458 inflated (Trottier, Polivy & Peter, 2009) so our participants’ may have had a higher sense of 459 optimism around their diagnoses and potential for behaviour change than they may have had post 460 intervention. Therefore, findings should be interpreted with caution.  461 Several practical recommendations and areas for future research should be noted. First, 462 healthcare professionals should be aware of the negative reactions people have upon learning 463 about their prediabetes and take steps to reduce these reactions. Healthcare professionals could 464 RISK REACTIONS TO PREDIABETES   22 offer patients with prediabetes a clear explanation of what prediabetes is, the health implications, 465 the likelihood that they will develop T2D, and the risk-reducing efficacy of lifestyle changes 466 (O’Brien et al., 2016). This clear, unambiguous communication about prediabetes may mitigate 467 distress associated with uncertainty. Findings from this present study suggest that there is value 468 in promoting a self-compassionate approach to relating to one’s prediabetes experience. Self-469 compassion is associated with adaptive emotional reactions (e.g., lower stress, shame and 470 anxiety) to chronic health conditions and is associated with health behaviours (Sirois et al., 471 2015). Efforts to increase self-compassion have been successful among a variety of populations, 472 including people with T2D (Friis et al., 2015). Researchers should explore whether self-473 compassion can help people with prediabetes lessen the negative responses typical upon 474 diagnosis and to self-regulate the health behaviours that will help them mitigate their T2D risk.  475 This study highlights the negative reactions that people often experience in response to a 476 prediabetes diagnosis. Understanding these reactions is important given the role that emotions 477 play in self-regulation of health behaviours (Terry & Leary, 2011). Managing health behaviours 478 is crucial for people with prediabetes who are at a critical juncture where they can mitigate their 479 risk of developing T2D through successful behaviour change. This study also takes preliminary 480 steps in exploring participant receptivity to self-compassion, which holds promise as an 481 important coping strategy that should help people with prediabetes manage the emotions that 482 accompany diagnosis and behaviour change challenges.   483 RISK REACTIONS TO PREDIABETES   23 References 484 American Diabetes Association. (2016). Diagnosing diabetes and learning about prediabetes.  485 Retrieved from http://www.diabetes.org/diabetes-486 basics/diagnosis/?referrer=https://www.google.ca/ 487 Anderson, R. J., Freedland, K. E., Clouse, R. E., & Lustman, P. J. (2001). 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IDF diabetes atlas: Global estimates 591 of the prevalence of diabetes for 2011 and 2030. Diabetes Research and Clinical 592 Practice, 94(3), 311-321.  593 RISK REACTIONS TO PREDIABETES   28 Yip, W. C. Y., Sequeira, I. R., Plank, L. D., & Poppitt, S. D. (2017). Prevalence of pre-diabetes 594 across ethnicities: A review of impaired fasting glucose (IFG) and impaired glucose 595 tolerance (IGT) for classification of dysglycaemia. Nutrients, 9(11), 1273-1290. 596 Youngs, W., Gillibrand, W. P., & Phillips, S. (2016). The impact of pre-diabetes diagnosis on 597 behaviour change: an integrative literature review. Practical Diabetes, 33(5), 171-175.  598 Table 1.  Sample Questions from the Interview Guide Interview Guide Section and Topic Sample Interview Guide Questions Section 1: General introduction, rapport building, demographic information  Review of study purpose, reminder of confidentiality and anonymity  Gender, age, length of prediabetes knowledge, rapport building.  Can you tell me a bit about yourself? Section 2: Understanding the condition and initial perceptions  I understand that you recently found out that you are at risk for T2D. Can you tell me a little about this experience?  Tell me what you know about being prediabetic. Section 3: Perceptions of personal role in having prediabetes and reaction to risk  Why do you think you are at risk for T2D?  What concerns, if any, do you have about being prediabetic? Section 4: Presentation of self-compassionate and self-critical ways people may respond to risk  [Interviewer defines self-compassionate and self-critical reactions]. Can you tell me which of reaction rings most true for you?   Why do you take this approach?  What would it feel like to take the other approach described?  Table 2. Demographic Information of Participants Gender Male 3  Female 18 Age (years) M 57.76 SD 5.43 Range 47-65 Length of Prediabetes Knowledge (months) M 4.16 SD 3.98 Range ≤1 month-1 year Marital Status Married 13  Divorced 1  Single 3  Did not disclose 4 Employment Status Full-time 4  Part-time work 5  Not working 2  Retired 10 Note. M = Mean, SD = standard deviation   

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