The Role of Spousal Support For Dietary Adherence Among Type 2 Diabetes Patients: A Narrative Review
The Role of Spousal Support For Dietary Adherence Among Type 2 Diabetes Patients: A Narrative Review
The Role of Spousal Support For Dietary Adherence Among Type 2 Diabetes Patients: A Narrative Review
To cite this article: Ariana M. Albanese, Jeff C. Huffman, Christopher M. Celano, Laura M. Malloy,
Deborah J. Wexler, Melanie E. Freedman & Rachel A. Millstein (2019) The role of spousal support
for dietary adherence among type 2 diabetes patients: a narrative review, Social Work in Health
Care, 58:3, 304-323, DOI: 10.1080/00981389.2018.1563846
Article views: 24
Introduction
Type 2 diabetes mellitus (T2D) is a highly prevalent chronic disease that is
projected to become even more widespread. Diabetes affects 9.3% of Americans
(Centers for Disease Control and Prevention, 2015), and the prevalence in the
US is expected to continue to increase, with projections that it will rise to 13.9%
in 2030, and 17.9% in 2060 (Lin et al., 2018). Pre-diabetes is also increasingly
prevalent, with estimates of 84.1 million adult cases in the US in 2015 (Centers
for Disease Control and Prevention, 2017). Globally, the prevalence of diabetes is
estimated to increase from 425 million to 629 million affected individuals by
and ethnicity on the connection between spousal support and dietary adher-
ence. And third, we review the efficacy of existing interventions targeting
spousal support for improved dietary adherence in T2D. We conclude with
suggestions for future work in this area.
Methods
A literature search was conducted primarily using the databases Google Scholar
and PubMed. Key terms used in the databases searched included the following:
spousal, spouse, support, diabetes, diet, gender, and marriage. These terms were
searched in combination utilizing the Boolean logic term “AND.” These
searches were conducted between July 2016 and October 2016. As the present
review is the first to undertake this particular question, the timeframe for
publication years reviewed was not limited. Additionally, given the heteroge-
neity of study designs adding to the knowledge base in this arena, all study types
were included. The sample of articles reviewed was limited to those published
in English. The availability of all studies was confirmed between July-October
2016. The complete list of studies reviewed is presented in Table 1.
A narrative review was utilized, as many of the studies collected were of
a qualitative design, thus better suiting the body of research to a review style
which allows for more description of the studies (Collins & Fauser, 2005; Mays,
Pope, & Popay, 2005; Posthuma, Morgeson, & Campion, 2002). Further, the
heterogeneity of: study designs (e.g., 50% of studies were qualitative in nature),
outcome measures, and analytic techniques precluded the possibility of per-
forming a meta-analysis.
Results
Ultimately, we narratively reviewed 28 studies. Thirteen were qualitative, twelve
employed an observational survey design, two were intervention studies, and
one was a combination of survey and qualitative. Results from relevant studies
were categorized into three major emergent themes: the function of gender
roles and spousal dynamics in spousal support for dietary adherence, the role of
race and ethnicity in the influence of spousal support on dietary adherence, and
interventions specifically targeting spousal support for T2D.
Cornelius et al. Survey 41, 378 Race/Ethnicity: ● Being unmarried, and particularly
(2014) 94% white becoming a widower, is associated with
Gender: 100% an increased risk of developing T2D in
male men, perhaps due to the loss of support
Mean Age: for dietary adherence.
54 years old
Franks et al. Qualitative 230 Race/Ethnicity: ● All spouses report providing some sort of
(2012) (Interviews) 79% white dietary support to their spouse with
Gender: 50% diabetes in the past month
male
Mean Age:
66 years old
Henry et al. Combination 258 Race/Ethnicity: ● Spouses represent a potential threat to
(2013) of Survey and 76% white the healthy eating of their partner with
Qualitative Gender: 50% diabetes through behaviors which sub-
(Interviews) male vert dietary adherence
Mean Age:
66 years old
Koch et al. (2000) Qualitative 6 Race/Ethnicity: ● Men report: they are not responsible for
(Focus Not reported cooking, spousal support is key in their
Groups) Gender: 100% disease management, and their wives
male are involved in their care through edu-
Mean Age: Not cation and dietary monitoring
reported
Mathew et al. Qualitative 35 Race/Ethnicity: ● Women report perceiving less social
(2012) (Combination Not reported support overall
of Focus Gender: 49% ● Men cite their spouse as a primary source
Groups and male of social support for their T2D manage-
Interviews) Mean Age: ment (including dietary adherence),
57 years old women cite a more diverse mix of family
and friends as their primary source of
support
(Continued )
308 A. M. ALBANESE ET AL.
Table 1. (Continued).
Key Social Support Findings Related to
Authors Study Type N Demographics Dietary Adherence
Nagelkerk et al. Qualitative 24 Race/Ethnicity: ● Spouses can be instrumental in diet
(2006) (Focus white adherence as they can provide encour-
Groups) Gender: 50% agement and facilitate good self-
male management
Mean Age:
62 years old
Paisley et al. Qualitative 84 Race/Ethnicity: ● Spouses and long-term partners report
(2008) (Interviews) Not reported playing a positive role in their partners’
Gender: 50% dietary regimen
male
Mean Range*:
23–79 years
old
*Mean age not
reported
Piette et al. Survey 439 Race/Ethnicity: ● Women report less support from family
(2010) Not reported (including spouses) in their care and
Gender: 50% report more family-related barriers to
male their disease management, such as
Mean Range*: managing their diets
25–75
*Mean age not
reported
Rook et al. (2011) Survey 191 Race/Ethnicity: ● Women appear more able to manage
94% white their diabetes independently compared
Gender: 63% to men
male ● Women react negatively to their spouse’s
Mean Age: attempts to exert control over their dia-
67 years old betes management particularly when
their husband’s action is unexpected
Savoca and Miller Qualitative 45 Race/Ethnicity: ● Over half of the men sampled had food
(2001) (Interviews) 64% white prepared by their wives and considered
Gender: 42% their wives integral to their diabetes
male management
Mean Age: ● Half of the women sampled reported that
53 years old they either prepared two meals (one T2D-
friendly one for themselves and one non-
T2D friendly one for their spouse) or
continued to accommodate their spouse
preferentially in food preparation
Seidel et al. Survey 278 Race/Ethnicity: ● Men expect their spouse to be involved
(2012) 95% white in their diabetes diet management
Gender: 50%
male
Mean Age:
66 years old
Stephens et al. Survey 218 Race/Ethnicity: ● Spousal issuing of warnings related to
(2010) 94% white food consumption is associated with
Gender: Not poorer dietary adherence
reported ● Spousal encouragement to eat well and
Mean Age: exercise are associated with increased
67 years old dietary adherence
(Continued )
SOCIAL WORK IN HEALTH CARE 309
Table 1. (Continued).
Key Social Support Findings Related to
Authors Study Type N Demographics Dietary Adherence
Stephens et al. Survey 252 Race/Ethnicity: ● Spousal utilization of the tactics of per-
(2013) 77% white suasion and applying pressure in an
Gender: 50% attempt to improve diet adherence are
male linked to poorer adherence
Mean Age: ● When the responsibility for diabetes
66 years old management is viewed as shared there is
a higher level of dietary adherence on
average
Stodberg, Qualitative 15 Race/Ethnicity: ● Significant others (e.g., spouses or long-
Sunvisson, and (Interviews) Not reported term partners) wanted to be involved in
Ahlström Gender: Not their partner’s diabetes management
(2007) reported and are concerned for them
Mean Age: Not
reported
Trief et al. (2003) Qualitative 74 Race/Ethnicity: ● Spousal reminders to eat well appear
(Interviews) 96% white effective and helpful in encouraging
Gender: 42% adherence
male
Mean Age:
49 years old
Weaver et al. Qualitative 45 Race/Ethnicity: ● Most men sampled relied on the support
(2014) (Interviews) Not reported of others, such as their spouse, to man-
Gender: 42% age their diet
male ● For women, as meal providers to their
Mean Age: families, in low family support scenarios
60 years old the food preferences of other family
members can gain preference over their
dietary needs
● Social influence for health behaviors can
vary by amount of access to economic
wealth
(Continued )
310 A. M. ALBANESE ET AL.
Table 1. (Continued).
Key Social Support Findings Related to
Authors Study Type N Demographics Dietary Adherence
Choi (2009) Survey 143 Race/Ethnicity: ● The positive effect of family support for
Korean diabetes management, including dietary
Gender: 48% adherence, is stronger for men than
male women
Mean Age:
62 years old ● Women mentioned not getting support
even when it was requested
Choi et al. (2014) Qualitative 33 Race/Ethnicity: ● Diet was found to be the primary area of
(Focus Korean diabetes management for which spousal
Groups) Gender: 50% support was relevant, and women
male reported not getting support even when
Mean Age: they asked for it.
68 years old ● Diet changes (such as reducing white rice
intake) were cited as a source of spousal
tension when recommendations con-
flicted with cultural eating habits.
Fisher et al. Survey 158 Race/Ethnicity: ● For Chinese Americans, the perception of
(2004) Chinese- emotional impact in couples is signifi-
American cant in the context of the performance
Gender: 59% of key health behaviors (such as adher-
male ing to a diet)
Age Range*:
25–70 years
old
*Mean not
reported
Liburd, Qualitative 16 Race/Ethnicity: ● For African American men, gender iden-
Namageyo- (Interview) African- tity has been found to be of key impor-
Funa, and Jack, American tance, as cultural expectations regarding
(2007) Gender: 100% masculinity could cause African-
male American men to behave in ways that
Mean Age: may not result in effective management
50 years old of their T2D (e.g. Alcohol consumption).
Samuel-Hodge Survey 345 Race/Ethnicity: ● African American women found that fill-
et al., 2005 African- ing multiple caregiving roles in
American a household was associated with putting
Gender: 0% the family’s needs first and having diffi-
male culty saying ‘no’ to family members,
Mean Age: which can be detrimental to self-care.
60 years old ● It may not be accurate to simply assume
that taking on more caregiving roles
impedes self-care, as elements such as the
quality of the relationship between the
woman and the receivers of care, as well
as the satisfaction and social interaction
that caretaking provides, can influence
the degree to which caretaking serves as
a self-care barrier.
(Continued )
SOCIAL WORK IN HEALTH CARE 311
Table 1. (Continued).
Key Social Support Findings Related to
Authors Study Type N Demographics Dietary Adherence
Song et al. (2012) Survey 83 Race/Ethnicity: ● 83% of men sampled sought support
Korean from their wives for their diabetes, while
American only 60% of women sought support
Gender: 58% from their husbands
male ● Women tended to endorse a greater
Mean Age: unmet need for support, this is under-
57 years old standable given that women are the pri-
mary caretakers in a Korean American
family model
Tang et al. (2008) Survey 89 Race/Ethnicity: ● One’s spouse was the most-frequently
African reported source of social support
American ● Married participants reported more posi-
Gender: 33% tive support and more satisfaction with
male their support
Mean Age: ● Spousal support is a predictor of healthy
60 years old eating
● Women endorsed a greater responsibility
for caretaking and a perception of less
support compared to men
Wen, Shepard, Survey 138 Race/Ethnicity: ● Greater perceived family support and
and Parchman, Mexican living with family members (including
(2004) Americans a spouse) are associated with higher
Gender: 33% reported levels of dietary adherence
male
Mean Age: Not
reported
* unless otherwise stated, the social support examined is that of married cohabitating spouses or unmarried
longterm partners
312 A. M. ALBANESE ET AL.
interviews, women report feeling less social support overall compared to men,
yet endorse utilizing more socially oriented resources outside of their family
such as support groups and educational classes (Mathew et al., 2012). Also, as
also expressed in focus groups and individual interviews, men specifically cite
their spouse as a primary source of social support for their diabetes manage-
ment, while women cite a more diverse mix of other family members and
friends as their sources of social support (Mathew et al., 2012). While, as
supported by survey data, women appear more able to manage their diabetes
independently compared to men (Rook, August, Stephens, & Franks, 2011),
their attempts to seek support outside the home through external relationships
and groups, combined with persistent survey reports of dissatisfaction and
distress (Undén et al., 2008), seem to indicate that the spousal relationship is
not providing support for women with T2D the way that it does for men.
Encapsulating this, one 22-year-long prospective study among men found that
being unmarried, and particularly becoming a widower, was associated with an
increased risk of developing T2D, perhaps due to unhealthy lifestyle changes,
such as poor diet, after losing one’s wife (Cornelis et al., 2014).
A substantial body of previous work indicates that traditional gender
roles afford men with T2D an advantage in their dietary adherence speci-
fically. In traditional marital roles, wives are expected to be responsible for
procuring and preparing meals, and typically provide men with the healthy
food they require (Wong, Gucciardi, Li, & Grace, 2005). Indicative of this,
in one large ethnically diverse sample capturing survey data, married men
were the demographic group most likely to be the recipient of attempts to
regulate their health behaviors by members of their social network (August
& Sorkin, 2010). Additionally, one recent study conducted interviews with
diabetes patients and found that most of the men sampled relied on the
support of others such as their spouse to manage their diet (Weaver,
Lemonde, Payman, & Goodman, 2014). Another study featuring in-depth
semi-structured interviews with T2D patients found that over half of the
men had their food prepared by their wives and considered their wife
integral to their diabetes management via preparation of healthy meals
(Savoca & Miller, 2001). A focus group found similar results, with men
endorsing a feeling of dependence on their female spouses to prepare their
meals (Beverly, Miller, & Wray, 2008a). Not only are men’s spouses a key
source of support in eating, but also, data from focus groups and individual
interviews support the notion that men’s entire families frequently adjust
their eating to match the new dietary needs of the men (Mathew et al.,
2012). Consistent with this, other focus group data found that men with
diabetes reported that their wives involved themselves in their care through
dietary education and monitoring the men’s eating (Koch, Kralik, & Taylor,
2000). Thus, traditional gender roles within a family seem to allow for
increased support, and subsequent improved dietary adherence, for male
SOCIAL WORK IN HEALTH CARE 313
diabetes patients from their wives. These findings reaffirm the literature
stating that wives are a potentially high impact target for dietary interven-
tions in men with T2D (Whittemore, Chase, Mandle, & Roy, 2002).
Conversely, prior work suggests that traditional gender roles do not
promote dietary adherence for women with T2D, and in fact sometimes
overtly undermine adherence. One focus group-based study found that
women perceived a lack of support from their husbands (Beverly et al.,
2008a). Furthermore, as uncovered through interview data, women are
much more likely to be passively supported by their husbands with respect
to diet, compared to husbands being more actively supported by their wives
in general (Wong et al., 2005). Indeed, findings from focus groups and
interviews in T2D patients have further asserted that women report less
support with meal preparation and that women do not cite their spouses as
sources of social support for their diabetes management in their lives with
the same frequency that men do (Mathew et al., 2012).
For women with T2D, their role as meal provider to their family can also
impede their own dietary management. For example, interview data revealed
that in families with low spousal support, the food preferences of other family
members can gain preference over the dietary needs of a woman with T2D
(Weaver et al., 2014). Similarly, survey data has found that women with T2D
report less support from their family in their self-care, and more family-related
barriers to their disease management (Piette et al., 2010). A study of semi-
structured in-depth interviews with T2D patients found that over half of the
women reported that they either prepared two meals (a meal for themselves
and one for their spouse) or continued to accommodate their spouse prefer-
entially in their food preparation (Savoca & Miller, 2001). Rather than families
adjusting in support of the new dietary needs of a husband with diabetes, as
men report, women often experience their spouse’s diet preferences as a stable
entity that can stand in the way of their own diabetes self-management.
Of note, expectations of support from one’s spouse appear to vary by gender.
These differences in expectations may play a major role in how attempts at
spousal support can impact dietary adherence in T2D. For example, survey data
has found that men often expect their spouse to be involved in their dietary
management, and a shared expectation of involvement within a dyadic pair is
associated with better dietary adherence for men (Seidel, Franks, Stephens, &
Rook, 2012). In contrast, additional survey data has found that women often
react negatively to their spouse’s attempts to exert influence over their diabetes
management particularly when their husband’s action is unexpected (Rook
et al., 2011). Simply put, what may be intended as support by the male partner
may be perceived as unwanted attempts at control by the female partner.
Therefore, in some cases, husbands may not purposely withhold support from
their wives, but negative reactions to their unexpected attempts at support may
function to reduce support extended from a husband to his wife over time.
314 A. M. ALBANESE ET AL.
Spousal dynamics
The spouse of a patient with T2D occupies a unique role in disease manage-
ment. A recent systematic review of the interrelation between adults with T2D
and their family found that one’s partner had a significant effect on health
behavior adherence (Rintala, Jaatinen, Paavilainen, & Astedt-Kurki, 2013).
Similarly, in a large diverse sample of patients with T2D who were surveyed
concerning health-related social control, married individuals most frequently
reported their spouse as a source of social influence relevant to their health
behaviors (August & Sorkin, 2010). As uncovered through focus groups, it
seems that in positive scenarios, spouses can be instrumental to patient
adherence to providers’ recommendations, particularly given the opportunity
a spouse has to provide encouragement and facilitate good diabetes self-
management (Nagelkerk, Reick, & Meengs, 2006). Additionally, a study
employing both interview and survey data found that while a positive or
neutral impact seems to be most frequent, spouses also represent a potential
threat to healthy eating, even sometimes undermining the dietary regimen of
their spouse with T2D (Henry, Rook, Stephens, & Franks, 2013).
On the positive end of the scale, many spouses report motivation to help with
diet management, and, in many cases, success in doing so. For example, one study
employing qualitative interviews to examine significant others (e.g. spouses or
long-term partners) of patients with diabetes found that significant others report
concern for their partners’ health and wanted to be involved in their diabetes
management and care (Stodberg, Sunvisson, & Ahlstrom, 2007). Additionally,
another studying employing interviews found that spouses and long-term part-
ners report playing a positive role in their partners’ dietary regimen (Paisley,
Beanlands, Goldman, Evers, & Chappell, 2008), and one final interview-based
study found that all spouses sampled reported providing some sort of dietary
support to their spouse with diabetes in the last month (Franks et al., 2012).
Both interview and survey-based literature suggests that spousal relationships
promoting dietary adherence are those in which 1) the member of the couple with
diabetes feels supported by their partner in disease management but retains self-
efficacy over his or her own care (Beverly et al., 2008a), and, 2) healthy diet
maintenance is viewed as a shared responsibility between the members of the
couple (Stephens et al., 2013). The distinction between encouragement and con-
trol is a critical one. Encouragement, marked by a gentle, positive approach in
which the patient maintains self-efficacy over his or her disease management,
appears to be well-received and effective, as positive spousal encouragement to
exercise and eat healthy foods has been linked through survey data with increased
dietary adherence (Stephens, Rook, Franks, Khan, & Iida, 2010). Additionally,
positive actions like well-timed reminders to eat well appear to be effective for
encouraging adherence. Also, in couples for whom the responsibility for T2D
management is shared, there is a higher level of reported dietary adherence as
SOCIAL WORK IN HEALTH CARE 315
gleaned from survey data (Stephens et al., 2013). Indeed, couples in which the
patient with T2D feels cared for and understood by their partner are more likely to
practice good diabetes self-management. One focus group-based study concep-
tualized the goal of spousal support for diet in T2D as working towards: 1) high
self-efficacy of the patient in his or her dietary regimen, and 2) high spousal
support (rather than control) (Beverly et al., 2008a). The evidence suggests that
a high degree of knowledge of healthy dietary behaviors (Beverly et al., 2008a)
combined with a team-oriented approach between the members of the couple
offers the best chance for success (Beverly, Wray, & Miller, 2008b).
However, even with the best motivations and intentions, not all spousal inter-
action patterns function to promote dietary adherence. For example, controlling
and negative spousal behaviors such as nagging, which remove self-efficacy from
disease management, are viewed as non-helpful and non-supportive by diabetes
patients as expressed in focus groups (Trief et al., 2003). Indeed, as gleaned from
survey data, spousal utilization of the tactics of persuasion and applying pressure
(Stephens et al., 2013), as well as issuing warnings related to food consumption
(Stephens et al., 2010), have both been linked to poorer dietary adherence. T2D
patients have reported in focus groups feeling resentful when their spouses
attempt to control their diet, and this can even result in counterproductive
reactions from patients such as hiding food out of sight from the spouse
(Beverly et al., 2008a).
The impact of race and ethnicity in spousal support for dietary adherence
One key set of demographic factors affecting the role of spousal support in
T2D dietary adherence is race and ethnicity, particularly as they are impacted
by gender roles. These factors are especially important, as the prevalence of
T2D in the US is higher in some racial and ethnic groups, such as non-
Hispanic black (21.8%), Asian (20.6%), and Hispanic populations (22.6%)
(Menke, Casagrande, Geiss, & Cowie, 2015). Additionally, a recent systematic
review of the role of families in diabetes care found that familial traditions and
cultural norms and preferences influence eating behavior (Rintala et al., 2013).
dynamics, report an unmet need for support. Illustrative of this, one survey
study found that the positive effect of self-reported family support for diabetes
management (as indexed by hemoglobin A1c [A1C]) was substantially stron-
ger for men (independent effect of self-reported strong support on
A1C = 0.52 mg/dl) compared to women (0.038 mg/dl) (Choi, 2009). Also,
one survey-driven report found that 83% of Korean American men sampled
sought support from their wives for their diabetes, while only 60% of women
sought support from their husbands, and women endorsed a greater unmet
need for support (Song et al., 2012). This spousal relationship is particularly
relevant for diet in this population. In one focus group study of Korean
Americans, diet was found to be the primary area of diabetes management
for which spousal support was relevant, and women reported not getting
support even when they asked for it (Choi, Lee, Park, & Sarkisian, 2014).
Additionally, diet changes (such as reducing white rice intake) were cited as
a source of spousal tension when recommendations conflicted with cultural
eating habits (Choi et al., 2014).
For Chinese Americans as well, familial and spousal concerns appear to be of
high relevance to health behaviors. It has been found through survey data that
the quality of the emotional relationship between spouses in this population has
an effect on T2D self-management (Fisher et al., 2004). Similarly, two studies
involving interviews with T2D patients and their spouses found that the effect of
the disease on family dynamics was particularly important in the management of
diabetes in the context of a Chinese American family (Chun & Chesla, 2004). An
important response to the diagnosis of T2D for this group involved accommo-
dation of disease management (particularly as it relates to eating) on the part of
all nuclear family members (Chesla & Chun, 2005). Given the influence of
familial emotional well-being on health, the spousal relationship appears parti-
cularly important for successful management of T2D in this population.
African Americans
Gender role expectations in African American populations have an important
effect on spousal support for dietary adherence in some unique ways that can
affect dietary management. In one survey-based study, African American
patients who are married reported more positive support and more satisfaction
with their support compared to unmarried peers, and crucially, this support is
a predictor of healthy eating (Tang, Brown, Funnell, & Anderson, 2008). Also in
line with a traditional family model, in this study women endorsed a greater
responsibility for caretaking and a perception of less support compared to men
(Tang et al., 2008).
One survey-based study of African American women found that filling
multiple caregiving roles in a household was associated with putting the
family’s needs first and having difficulty saying ‘no’ to family members,
which can be detrimental to self-care (Samuel-Hodge, Skelly, Headen, &
SOCIAL WORK IN HEALTH CARE 317
Carter-Edwards, 2005). The authors of this work did note that it may not be
accurate to simply assume that taking on more caregiving roles impedes self-
care, as elements such as the quality of the relationship between the woman
and the receivers of care, as well as the satisfaction and social interaction that
caretaking provides, can influence the degree to which caretaking serves as
a self-care barrier (Samuel-Hodge et al., 2005). In essence, strong caretaking
connections can have the potential to motivate self-care, rather than always
serving as a barrier. Conversely, for African American men, gender identity
has been found through interview-based study to be of key importance, as
cultural expectations regarding masculinity could cause African-American
men to behave in ways that may not result in effective management of their
T2D (Liburd, Namageyo-Funa, & Jack Jr, 2007). For example, cultural beliefs
that it is “feminine” to eat healthy foods and reduce alcohol intake may
function to discourage these practices in men with T2D.
Discussion
Overall, in this narrative review, we found that: 1) there are distinct interaction
patterns among spouses that can promote or hinder dietary adherence for
T2D, 2) demographic factors such as race and ethnicity impact the relationship
between spousal social support and T2D, with gender role performance play-
ing a major role, and 3) interventions to date targeting spousal support for
dietary adherence have been limited and have not consistently yielded the
outcomes that would be expected based on relevant qualitative and survey
data. In observational studies, women have reported not receiving spousal
support, and, indeed, fared better in a couples intervention which functioned
to strengthen support received. Conversely, men, who receive more spousal
support (based on reports from both men and women), benefited from
individual intervention which inculcates a stronger ability to manage diet
independently. Given that eating is a fundamental component of diabetes self-
management which is frequently mismanaged, understanding the ways in
which spousal support can most effectively promote or undermine attempts
at behavior change is a crucial, underexplored area of potential intervention.
As aforementioned, a recent systematic review and meta-analysis by Song and
colleagues examined the relationship between social support and diabetes man-
agement and how various factors impact this relationship (Song et al., 2017).
However, this review further adds to the knowledge base of spousal support for
dietary adherence by: first, narrowing down the examination of social support on
diabetes management to the specific role of spousal support for dietary adherence,
and second, by including qualitative studies in our narrative synthesis. As a result,
this review presents a more focused view of the dynamics occurring between
spouses and how this impacts dietary adherence specifically, and it provides
SOCIAL WORK IN HEALTH CARE 319
Funding
This work was supported by the American Diabetes Association (grant number: 1-17-ICTS-099)
the National Institute of Diabetes and Digestive and Kidney Diseases (grant number:
R21DK109313), and the National Heart, Lung, and Blood Institute (grant number:
K23HL123607 and K23HL135277).
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