Navigating the storm: A qualitative research on contributing factors to diabetes burnout in young adults with type 1 diabetes

Abstract

BACKGROUND:

Diabetes burnout is a serious and often overlooked condition marked by emotional exhaustion, detachment, and a sense of helplessness in managing diabetes. This qualitative content analysis study seeks to uncover the underlying factors that contribute to the onset and persistence of diabetes burnout. Understanding these factors is essential for informing targeted interventions and supportive policies to improve the well-being of individuals living with Type 1 diabetes.

MATERIALS AND METHODS:

Eleven adults with T1D in Shahrekord, Iran, were recruited using purposive sampling to ensure diverse perspectives. Fourteen semi-structured interviews (50–60 minutes each) were conducted in Persian, with two participants completing follow-up sessions. Interviews were recorded, transcribed verbatim, and analyzed using Elo and Kyngäs’s three-step process: open coding, categorization, and abstraction. Trustworthiness was ensured through prolonged engagement, peer debriefing, member checking, and application of Lincoln and Guba’s criteria.

RESULTS:

Qualitative analysis revealed four interrelated themes contributing to burnout: (1) disruptions in self-management routines (e.g., sleep, exercise, diet); (2) external stressors and resource limitations (e.g., economic instability, healthcare access, medication shortages); (3) fluctuations in physical and emotional well-being; and (4) the role of interpersonal and social support. Many of these challenges were exacerbated by the COVID-19 pandemic, which disrupted healthcare routines and increased psychosocial stress. Participants likened their experience to navigating a suspension bridge—requiring constant adaptation amid instability. These findings highlight the need for holistic diabetes care that addresses both medical and social dimensions, especially during times of crisis.

CONCLUSION:

This study reveals diabetes burnout as a critical but often overlooked barrier to effective diabetes management. Disruptions in daily routines, compounded by crises, heighten burnout risks. Aligning with global health policy benchmarks, our findings support the need for integrated care that addresses both medical and psychosocial aspects of diabetes. Health systems should prioritize mental health support, routine stability, and access to essential resources to improve long-term outcomes for people with type 1 diabetes.

Introduction

Type 1 diabetes (T1D) is a lifelong autoimmune condition that requires individuals to engage in intensive daily self-management to maintain glycemic control and prevent both acute and long-term complications. This includes frequent blood glucose monitoring, insulin administration, careful dietary planning, regular physical activity, and continuous adaptation to physiological and psychosocial fluctuations.[1,2] While the biomedical management of T1D has advanced considerably, these developments have not mitigated the heavy emotional toll that self-management imposes on individuals living with the disease. Over time, the cumulative burden of these tasks can result in a condition known as diabetes burnout—a complex, multifaceted state characterized by emotional exhaustion, detachment from diabetes self-care, and a sense of hopelessness or futility in managing the disease.[3,4]

Despite its growing recognition, diabetes burnout remains an underexplored phenomenon, especially outside Western contexts. Most empirical studies have examined burnout from a psychological or behavioral lens, often attributing it to individual-level factors such as low self-efficacy, poor coping skills, or comorbid mental health conditions like depression or anxiety.[5,6] However, these frameworks may inadequately capture the structural, cultural, and contextual influences that shape burnout experiences in low- and middle-income countries (LMICs). In settings like Iran, where economic sanctions, healthcare resource constraints, and limited access to specialized diabetes care persist, individuals with T1D face additional challenges that can disrupt routine care and amplify emotional strain.[7,8,9] Moreover, in collectivist cultures, family expectations, intergenerational caregiving roles, and community obligations may influence the psychological burden of chronic illness in ways not accounted for by existing models.[10]

The COVID-19 pandemic has further exacerbated the vulnerabilities of individuals with T1D by disrupting healthcare delivery, isolating individuals from support systems, and worsening financial insecurity. For many, these conditions not only intensified emotional exhaustion but also disrupted daily self-care routines—sleep, exercise, and diet—on which diabetes stability depends.[11,12] These broader systemic stressors underscore the limitations of individual-centred approaches and call for a more nuanced understanding of diabetes burnout that considers environmental, relational, and cultural dimensions.

In response to this gap, the present study employs a qualitative content analysis approach to explore the underlying factors contributing to the onset and persistence of diabetes burnout among adults with T1D in Shahrekord, Iran. This methodological choice enables a deep examination of lived experiences and offers insights into the interwoven personal, familial, and structural forces that shape diabetes-related distress. By amplifying the voices of individuals navigating daily self-management amidst economic hardship, healthcare limitations, and sociocultural expectations, this study aims to inform the design of more responsive and contextually grounded interventions. Understanding these dynamics is critical not only for improving psychosocial outcomes but also for supporting sustained self-care and quality of life among people living with T1D.

To guide this study, the Transactional Model of Stress and Coping was used as the theoretical framework.[13] This model conceptualizes stress as a dynamic process involving the individual’s cognitive appraisal of external demands (stressors) and their perceived resources to cope. Diabetes burnout, as experienced by young adults with Type 1 Diabetes, can be understood as a response to persistent stressors (e.g., disrupted routines, resource limitations, emotional fluctuations) that exceed coping resources [Figure 1]. This framework provides a lens to examine how personal, environmental, and social factors interact to influence the experience of burnout.

Figure 1.

Conceptual framework of diabetes burnout based on the transactional model of stress and coping

Materials and Methods

Study design and setting

This study employed a qualitative research approach, utilizing conventional content analysis to investigate the factors contributing to diabetes burnout. Content analysis is a widely used method in qualitative research for systematically examining human experiences and identifying underlying themes and patterns.[14,15] This approach allowed for an in-depth exploration of the lived experiences of individuals with T1D, providing valuable insights into the psychological, social, and behavioral factors associated with diabetes burnout.

Study participants and sampling

Participants were recruited based on the following inclusion criteria: (1) being 18 years of age or older, to ensure participants were adults capable of providing informed consent; (2) having a confirmed diagnosis of T1D, verified through medical records or relevant documentation; (3) having lived with T1D for at least one year, to ensure adequate experience with diabetes self-management and minimize early-stage adjustment factors; (4) demonstrating proficiency in the Persian language, to enable clear and accurate communication during interviews; (5) being actively involved in diabetes self-care; (6) having experienced no major life crises (e.g., bereavement, divorce, job loss, or relocation) in the past six months, to avoid confounding factors unrelated to diabetes; and (7) providing voluntary and informed consent to participate. The researchers maintained reflexivity through regular memo-writing and peer discussions to identify and mitigate personal bias throughout data collection and analysis.

Participants were excluded if they had cognitive impairments that could hinder informed consent or interview participation. Individuals with severe mental health disorders (e.g., schizophrenia, bipolar disorder, untreated psychosis) were excluded to reduce confounding unrelated psychological variables. Participants with a current diagnosis of major depressive disorder or generalized anxiety disorder were excluded unless their condition had been well-managed for at least six months. Additionally, individuals with other chronic illnesses requiring intensive treatment (e.g., cardiovascular disease or cancer) or those currently engaged in psychological interventions for diabetes burnout were excluded to ensure that the study captured unconfounded lived experiences of diabetes burnout.

A purposeful sampling strategy was used to recruit participants with varied characteristics (e.g., age, gender, diabetes duration, socio-economic status), ensuring an in-depth exploration of diverse lived experiences. Participants were informed of their right to withdraw at any point; however, no one opted to do so. The final sample consisted of 11 participants. Data saturation was reached when additional interviews failed to yield new themes or insights, indicating that the sample size was sufficient for the study’s aims.

Data collection tool and technique

Data collection for this study involved 14 semi-structured, in-depth interviews, each lasting between 50–60 minutes. A total of 11 participants completed the study. Fourteen interviews were conducted in total: two participants requested follow-up sessions to elaborate on their experiences, and one interview was resumed due to an interruption.

The interviews were conducted in person at times and locations convenient for participants, fostering a comfortable and confidential environment. Prior to each interview, participants were thoroughly briefed about the study’s purpose and provided with written informed consent. The consent form outlined the study’s objectives, the voluntary nature of participation, confidentiality of responses, and the right to withdraw at any time.

The semi-structured interview guide was developed by the research team and included a mix of open-ended questions designed to explore participants’ experiences with diabetes burnout. The guide allowed for flexibility, with the interviewer adjusting the flow and specific questions based on individual responses. Example questions included: “What does it mean to live with diabetes burnout?”, “Can you describe moments when you felt most overwhelmed by your diabetes management?”, and “When did you first notice feelings of burnout related to managing your condition?” Probing questions were used to explore emotional, psychological, and physical aspects more deeply.

The interviews were conducted by L.R.V, who was trained in qualitative interview techniques to ensure consistency, sensitivity, and neutrality throughout. A recording device was used—with participants’ consent—to ensure accurate transcription. Field notes were taken during and after the interviews and were integrated into the coding process to enrich contextual understanding and capture non-verbal cues. Interviews were conducted in Persian, the native language of all participants, to ensure comfort and clarity in sharing experiences.

Reflexivity

Given the interpretive nature of qualitative research, reflexivity was integrated throughout the study to ensure transparency and trustworthiness. L. R.V responsible for the interviews is a nurse with extensive experience in qualitative methodologies. This background provided valuable insight into the complexities of diabetes management but also introduced potential biases in data interpretation. To mitigate these biases, L.R.V maintained a reflexive journal to document personal assumptions, emotional responses, and evolving interpretations throughout the research process. Regular peer debriefing sessions were conducted with members of the research team to challenge assumptions and enhance analytical rigor. Additionally, member checking was used to confirm that the participants’ meanings and perspectives were accurately represented. These strategies helped to ensure that the findings reflected the lived experiences of participants rather than the preconceptions of the researcher.

Data analysis

Data were analyzed using a conventional content analysis approach, conducted concurrently with data collection. The analysis followed a three-step process as outlined by Elo and Kyngäs[14]: open coding, category creation, and abstraction. Each recorded file was transcribed verbatim after repeated listening. The transcripts were reviewed to gain an overall understanding, followed by detailed open coding. Notes and headings were added to the text margins to identify content elements. These codes were then grouped into categories, with each category capturing a central theme. Ultimately, the categories facilitated the development of a comprehensive and meaningful interpretation of the data.

To ensure the trustworthiness of the findings, Lincoln and Guba’s criteria of credibility, dependability, transferability, and confirmability were applied[15]:

• Credibility: Prolonged engagement with participants and the research context was maintained over an eight-month period, allowing the researcher to build rapport and obtain rich, authentic data.

• Dependability: An audit trail was maintained throughout the study. Two qualitative research faculty members reviewed the methodology and analysis to provide external validation.

• Transferability: Thick descriptions of participants, the setting, and research procedures were provided to support the relevance of findings to other contexts.

• Confirmability: Themes and interpretations were grounded in participant narratives. Member checks were conducted to verify interpretations and refine themes.

To enhance peer debriefing, two faculty members independently reviewed the codes and subcategories. Their feedback confirmed the coding scheme’s consistency and supported the final data interpretation, enhancing analytic rigor and minimizing researcher bias.

Ethical consideration

This study was approved by the Ethics Committee of Shahrekord University of Medical Sciences (Ethics code: IR.SKUMS.REC.1399.052). All participants provided written informed consent prior to participation, after receiving detailed information about the study’s purpose, procedures, confidentiality protections, and their right to withdraw at any time without penalty. Interviews were audio-recorded with explicit permission. The research team adhered to established ethical standards to ensure participant confidentiality, voluntary participation, and protection of personal data throughout the study.

Results

A total of 11 participants (7 female, 4 male) were recruited for the study. The participants’ ages ranged from 21 to 36 years. Among them, three were single, and eight were married. Participants’ experience with diabetes ranged from 12 to 29 years. Their educational backgrounds varied from high school diplomas to Bachelor of Science degrees.

Participants described diabetes burnout as a complex, draining experience shaped by personal, environmental, and systemic challenges. A powerful metaphor shared by one participant likened the experience to navigating a suspension bridge—unstable, demanding constant adjustment, and requiring inner strength and resilience to avoid collapse. This metaphor captured the continuous tension between maintaining balance and falling into burnout.

Qualitative analysis revealed four interconnected themes: disruptions in self-management routines, external stressors and resource limitations, fluctuations in physical and emotional well-being, and the role of interpersonal and social support.

1- Disruptions in Self-Management Routines

A central theme that emerged from the interviews was the significant impact of disruptions to daily self-management routines, which are crucial for managing T1D. Participants described how external events, such as crises or changes in personal circumstances, disrupted their established routines, contributing to diabetes burnout and making it more difficult to maintain control over their condition. Field notes were integrated into the coding process to enrich contextual understanding and capture non-verbal cues. These routine disruptions—particularly in exercise, diet, and sleep—destabilized participants’ diabetes care efforts and left them feeling emotionally depleted and physically unwell. One of the most prominent disruptions was to exercise routines. Many participants highlighted the positive role exercise played in maintaining both physical health and psychological well-being. As one participant explained:

• “Exercise. Well, I go to the gym. It is mandatory. I’ve paid for it, so I’m obligated to dedicate a specific time, two days a week, exclusively to exercise. It was really good; the environment was cheerful. It was also fun and uplifting for the spirit. For at least an hour, daily worries go away from our minds.” [Male, 22 years old]

However, the onset of the COVID-19 pandemic and other external crises disrupted these routines. The same participant continued:

• “The gym was really good. However, for example, during COVID-19, it was closed. Unfortunately, it was not possible to maintain certain things. I continued to do some exercises at home, but it wasn’t very effective in regulating my blood sugar. Before COVID-19, I used to walk for an hour with my colleague at work, but that was also eliminated. When your circumstances change, it becomes really hard to maintain your balance again, and sometimes you just say forget it. Never mind.”

This disruption in exercise routines created additional challenges in maintaining blood sugar levels and contributed to a sense of exhaustion and frustration. A similar pattern emerged when participants discussed changes in their dietary routines. One participant shared their struggle with maintaining a structured routine after losing their job:

• “Routine is important for us to be able to control diabetes. I stayed at home for several months and didn’t go to work. Initially, I told myself that nothing should change and everything should continue as it was before. Because with great effort and measures, I had managed to get my A1C below 7! But it seems that the force of circumstances was stronger. I started waking up late, disrupting my Lantus injection schedule. Sometimes I would wake up so late that breakfast and lunch would merge into one meal. I got tired. It can’t be done. I try, but it can’t be done. Being at home all the time made me constantly make excuses and indulge myself.” [Female, 25 years old]

Similarly, another participant noted:

• “When I went to work, I was committed to eating two fruits, one before noon and one in the afternoon. I was also committed to bringing a basket of fruits and vegetables with my lunch to the university. Once, I tried to maintain this routine, but it’s very difficult for us to get used to these new conditions again. Now, although I’m at home, I might not be very eager to keep everything in place.” [Female, 30 years old]

Finally, changes in sleep routines also had a significant impact on diabetes management. Participants emphasized how changes in work conditions or staying at home disrupted their sleep patterns, further affecting their ability to manage their condition. As one participant expressed:

• “My sleep schedule has been severely disrupted. Staying at home has caused my blood sugar levels to become irregular because I wake up late in the mornings, which messes up my eating and insulin timing. It’s like a storm has thrown my life into chaos.” [Male, 34 years old]

These disruptions not only affected physical health but also led to emotional exhaustion and helplessness—core components of diabetes burnout. Purposeful sampling ensured an in-depth exploration of diverse lived experiences.

2- External Stressors and Resource Limitations

A significant theme that emerged from the interviews was the impact of external stressors and resource limitations on diabetes management. Participants described how changes in their income, access to healthcare, and medications created additional burdens, making it harder to maintain stability in their diabetes routines. These stressors contributed to a sense of helplessness and exhaustion and were often compounded by crises like the COVID-19 pandemic, which exacerbated existing financial and healthcare access challenges. The interplay between systemic barriers and personal effort revealed how structural inequities directly influenced burnout. One of the most pressing external stressors discussed was the changes in income levels or loss of insurance, which severely impacted participants’ ability to maintain their diabetes care routines. As one participant explained:

• “Monthly, a portion of my salary was spent on buying kits, needles, insulin, and going to the gym. Now, my salary has become very minimal. I can strongly say that wages have decreased significantly, and this can affect life, not only mine but many others’ lives. It’s a bit damaging, and I’m forced to cut back on other things to keep my diabetes supplies intact. Sometimes income changes, and sometimes expenses increase, like during COVID-19 when most expenses went towards sanitizers, gloves, and masks. Both are similar.” [Male, 33 years old]

This disruption in income and the increased costs associated with diabetes management created significant stress, forcing participants to make difficult decisions about what expenses to prioritize. The added pressure to maintain necessary diabetes supplies, such as insulin and testing kits, alongside daily living costs, led to a sense of financial strain and contributed to burnout. Another participant expressed how financial strain, and reduced income impacted their ability to stay engaged in diabetes management:

• “For years, I’ve been making every effort to better control my blood sugar. Some days I leave it. Maybe this indifference is very, very temporary, maybe it lasts just one day when, for example, my fingertips are tired from using the lancet, and I wonder what to do for a whole day, but it has never been long-term. The most significant harm of COVID-19 in my life has been reduced income, decreased physical activity, and unconscious stress from hearing that COVID-19 mostly affects people with underlying health conditions. My routine was disrupted. Control slipped out of my hands.” [Female, 29 years old]

These narratives highlighted how financial instability not only limited access to essential supplies but also eroded psychological resilience over time. Another significant challenge for participants was changes in access to healthcare providers, which became especially critical during events such as accidents, fractures, or the quarantine restrictions imposed during the COVID-19 pandemic. Access to healthcare professionals was frequently cited as a key factor in providing emotional reassurance and guidance. As one participant explained:

• “Access to a doctor is very important. It gives you peace of mind. I really have to thank Ms. …so far. She’s a nurse who really does more for us than our doctor. From morning till night, even midnight, we can contact her 24/7. Any question I had, I would get answers on What’s-App or Telegram... With her presence, we are greatly reassured and less worried. When we go out, I personally send her a photo of my test, she checks it, and if there’s a small issue, she tells me to come so it can be recorded in my health profile. She guides us. She refers us to specialists. When I didn’t know her and couldn’t control my blood sugar, no matter what I did, I would give up. I would think it’s impossible.” Female 36 years old]

The absence of consistent healthcare support during times of crisis, particularly in remote consultations or disruptions in regular medical care, left some participants feeling lost and disempowered. These interruptions in access to medical professionals contributed to an increased sense of vulnerability and stress, further exacerbating feelings of burnout. For some, the lack of immediate feedback from a trusted provider meant losing a vital safety net, reinforcing their sense of isolation. Lastly, changes in access to medication were identified as a critical challenge. Factors such as increased medication costs, sanctions, or shortages of essential diabetes medications caused significant disruption to daily routines. One participant shared:

• “There was a period when sanctions were severe, and I had trouble buying Novo rapid because pharmacies didn’t have it, so I had to search a lot. When medication becomes scarce, your routine gets disrupted; you have to change your diet to require less medication for a while or use less than you need. Waking up every day to a new challenge makes you want to give up everything.” [Female, 25 years old]

This medication scarcity not only created emotional distress but also forced participants to make difficult adjustments to their diabetes management plan, often leading to suboptimal care and increasing the risk of complications. The constant uncertainty and need to adapt to new challenges led to a deep sense of frustration and exhaustion.

Together, these external stressors—financial strain, healthcare access disruptions, and medication shortages—undermined participants’ efforts to maintain stable diabetes routines. The compounded nature of these stressors highlighted how burnout was not only a psychological condition but also a social and structural one, shaped by broader environmental and economic conditions.

3- Fluctuations in Physical and Emotional Well-Being

A key theme identified in the study was the impact of fluctuations in physical and emotional well-being on the management of T1D. Changes in health status, even seemingly minor illnesses, had a significant effect on participants’ ability to maintain their routines and effectively manage their diabetes. These temporary disruptions often destabilized blood glucose control and added to emotional fatigue, contributing to a cycle of frustration and burnout. One participant shared their experience with the difficulty of managing diabetes during illness:

• “Managing diabetes was almost okay, but when I got sick, my condition fluctuated because of the medications and antibiotics I used. Some caused a drop in my levels, others an increase. Everything would get mixed up, and it would take time to return to normal. Even a common cold is harder for us. Since I know that infections significantly affect my blood sugar levels. Thankfully, I haven’t had a cold or any infectious disease in the last two or three years, but I’ve had diabetes for 12 years, and when I get an infection, controlling diabetes becomes extremely difficult, and it feels like insulin doesn’t work at all. It gets out of my hands.” [Female, 21 years Old]

This instability was described as feeling like the routine was no longer under their control, and the emotional toll of these disruptions became apparent, with the participant noting how it often felt like the system was “out of my hands.” This experience underscores the vulnerability individuals with T1D experience when their health is compromised. The biological unpredictability introduced by infections, combined with the psychological strain of trying to regain control over blood sugar levels, results in emotional exhaustion and a deeper sense of burnout.

In addition to physical illness, fluctuations in mental health were a significant barrier to effective diabetes management. Participants described how emotional stress, anxiety, or exhaustion reduced their motivation for self-care, perpetuating a cycle of emotional and physical strain. When physical well-being was unstable, emotional resilience often declined, leading to disengagement from essential diabetes care activities.

These overlapping disruptions, whether from illness, stress, or mood changes, revealed how challenges beyond diabetes itself could destabilize self-management. For many participants, the inability to predict or regulate their health during difficult times contributed to a deep sense of loss of control and, ultimately, diabetes burnout.

4- Role of Interpersonal and Social Support

The role of interpersonal and social support emerged as a critical theme in participants’ experiences with diabetes management. Supportive relationships, particularly from family, were described as stabilizing forces that helped participants stay engaged in their self-care routines. Conversely, the absence or reduction of this support contributed to emotional fatigue, a sense of isolation, and increased difficulty managing daily tasks. Changes in family dynamics, whether due to external pressures or personal circumstances, often disrupted participants’ ability to effectively manage their condition. One participant shared how family support helped them maintain their diabetes management routine, but a lack of support from loved ones would leave them feeling depleted and unable to continue:

• “When you don’t have support, you run out of energy. You get tired. I saw this with my friend. For example, my family, like my father, completely made their car available to me so I wouldn’t have to take the bus in this cold weather and during the flu outbreak. My mom tries to boost my immune system by making nutritious and healthy lunches and dinners. My family has canceled most of the invitations we’ve had with some excuse because of me. And they’ve accompanied me as much as possible to avoid attending gatherings.” [Male, 22 years Old]

The emotional and physical support provided by family members significantly eased the burden of diabetes management. Family cohesion offered both practical assistance and emotional encouragement, reinforcing adherence to care routines and reducing the risk of burnout. The participant’s reflection indicates that supportive relationships can make managing diabetes feel less burdensome, providing a buffer against burnout.

In contrast, when support was lacking or inconsistent, participants reported increased feelings of isolation and emotional strain. The absence of reliable emotional and logistical backing made it harder to maintain self-care, often leading to exhaustion and a sense of losing control. For example, one participant said:

• “I always eat at home and structure my life around this routine, unless something special comes up. My family understands my dietary needs and helps me with meal preparation without questioning the type and amount of food I eat, or why and how much insulin I need. This way, I feel more at peace and secure, knowing the people around me are supportive. When I have to eat out, even though I’ve had diabetes for years and don’t hide it, other people’s judgments and questions make me anxious.”[Male, 33 years Old]

The absence of family support often intensified stress and anxiety, especially when participants were already overwhelmed by diabetes complications or external pressures such as financial hardship or illness. Participants expressed heightened concern about sustaining their routines without help. One mentioned:

• “Family plays a crucial role. When I was single, my parents helped me, and now my wife takes on that responsibility. With the current inflation and medicine shortages, if they didn’t check all the pharmacies and secure my medication, I wouldn’t be able to inject insulin on time. Managing life and children while searching for medicine would be impossible alone. If they fall sick or face any issues, I struggle to handle everything. It’s overwhelming, and it was even more challenging during COVID-19.” [Female, 36 years Old]

Another participant said:

• “I am motivated to keep going because I feel the love and support of my family. Knowing that I matter to them, whether I have diabetes or not, and that my well-being affects theirs, pushes me to take care of myself. It encourages me to do what’s necessary for my health because it’s not just about me anymore—it’s about the responsibility I feel towards them.” [Female, 21 years Old]

Discussion

The aim of this study was to explore the contributing factors to diabetes burnout among individuals with T1D, with a focus on how disruptions in personal routines, structural barriers, emotional strain, and social support interact to influence burnout. Participants in this study consistently described managing T1D as walking on a suspension bridge, a metaphor that encapsulates the precarious balance required to maintain routine management. This metaphor reflects the study’s conceptual model, which highlights the fragility of self-management in the face of chronic stressors. This balance is continuously challenged by external stressors, including changes in routine, financial instability, and disruptions in healthcare access. For individuals with T1D, maintaining this balance is essential to avoid burning out. However, unforeseen crises such as the COVID-19 pandemic, economic hardship, and medication shortages make it harder to maintain stability, much like navigating a stormy bridge. These disruptions exacerbate feelings of vulnerability and emotional exhaustion, aligning with the cumulative burden theory,[16] which posits that chronic stressors increase the risk of burnout.

Our findings underscore the significant impact of disruptions in self-management routines on diabetes burnout. Routine changes—such as shifts in exercise, diet, and sleep patterns—impair diabetes management, as shown by Fisher et al.[17] who found that these disruptions can worsen glycemic control and increase psychological distress. Similarly, Akbari et al.[18] emphasized that maintaining consistency is crucial to prevent frustration and disengagement. This study builds on these findings by contextualizing them within Iran’s unique challenges, where structural instability and limited healthcare infrastructure further threaten consistency in routine. In Iran, however, the limited availability of specialized diabetes care and medication, especially during periods of economic sanctions, can create additional barriers to maintaining consistent routines. Participants’ experiences during the COVID-19 pandemic reflect prior studies by Ghosh et al.,[19] which linked disruptions in physical activity and diet to poor metabolic outcomes and emotional distress. The closure of gyms and altered work environments highlight how external structures support self-management. These disruptions align with the Health Belief Model,[20] which suggests that stable environments foster adherence to health behaviors, while instability decreases motivation. Moreover, Demerouti[21] burnout theory explains how repeated disruptions lead to emotional exhaustion and disengagement.

External stressors such as financial strain, limited healthcare access, and medication shortages were critical challenges for diabetes management. In Iran, financial strain and access to healthcare are compounded by sanctions, which limit the availability of essential medications and healthcare services, further exacerbating stress and burnout for individuals with chronic conditions like T1D. Participants likened disruptions to navigating a stormy suspension bridge, requiring extra focus and support. This finding aligns with Schmitt et al.,[22] who linked financial difficulties to diabetes-related distress, and Doosti et al.,[23] who found that financial hardship during the pandemic worsened burnout and distress. Pike et al.[24] also noted that increased healthcare costs during the pandemic added significant pressure on individuals with chronic conditions. The results of this study further affirm that financial instability directly interferes with participants’ ability to maintain core diabetes care behaviors, validating the study’s hypothesis that systemic stressors increase burnout risk. Our findings resonate with Kalra et al.,[25] who emphasized the importance of consistent healthcare access for emotional support in diabetes management, and Abdoli,[26] who described how external stressors like life changes challenge the balance between diabetes management and other responsibilities. These stressors can overwhelm available resources and contribute to burnout, reinforcing the cumulative burden theory.[16]

Participants also reported that even minor illnesses or mood changes disrupted their diabetes management, leading to blood sugar fluctuations and emotional exhaustion. These experiences align with Demerouti[21] who found that mental health fluctuations, especially depression and anxiety, are linked to diabetes burnout. The unpredictability of diabetes during illness, as noted by Kalra et al.,[25] was echoed by participants, who described the psychological toll of managing diabetes during illness. These findings support the dual-process theory of self-regulation,[27] which suggests that when emotional or physical resources are depleted, individuals are more likely to disengage from self-care. In Iran, the cultural stigma around mental health issues, such as depression and anxiety, may further complicate the ability to seek appropriate support, exacerbating burnout for individuals with T1D. Abdoli et al.[28] similarly found that co-occurring health issues can trigger burnout.

Consistent with the study’s hypothesis, social and interpersonal support functioned as both a buffer and a risk factor in diabetes burnout. Our study reinforces the importance of interpersonal and social support in diabetes management. Family support, both emotional and practical, directly impacted participants’ ability to manage diabetes. Given the central role of family in Iranian culture, this support is particularly crucial in helping individuals navigate the complexities of managing a chronic condition like T1D. This is consistent with findings from Ruisoto et al.,[29] who emphasized the role of social support in improving adherence and reducing burnout. Family members’ assistance, such as meal preparation and transportation, alleviated the burden of diabetes management, aligning with the concept of communal coping,[30] which suggests that shared responsibility in managing chronic illness improves both psychological and physical outcomes.

Contrary to previous studies that emphasize individual coping strategies in diabetes burnout, our participants highlighted the irreplaceable role of family and close-knit community ties. This divergence reveals a culturally specific model of communal coping that may be overlooked in Western-centric literature. For example, participants described their family not merely as support systems, but as co-managers of the illness, sharing emotional and practical responsibilities. This finding underscores the need to re-evaluate existing burnout frameworks when applied to collectivist cultures.

Conversely, the absence of support led to feelings of isolation and burnout, consistent with Misra et al.,[31] who found that limited social support increases diabetes-related distress and disengagement from self-care. In Iranian culture, the absence of family support can exacerbate feelings of isolation, as individuals may feel an additional burden of needing to hide their struggles from their community. Kontoangelos et al.[7] noted that life transitions, such as entering college, exacerbate burnout when support systems are disrupted. These findings can be explained by the stress-buffering hypothesis,[30] which suggests that social support mitigates stress. A supportive network can reduce emotional strain and help individuals maintain routines, while a lack of support leaves individuals more vulnerable to burnout, especially during challenging times.

Taken together, these findings both validate and expand upon the proposed conceptual model. While supporting the idea that diabetes burnout arises from disrupted routines, systemic constraints, and diminished psychosocial support, the results also highlight a unique cultural dimension—where collective responsibility and family roles strongly shape experiences of resilience or vulnerability. Future burnout interventions must consider these sociocultural dynamics rather than rely solely on individual behavior change models.

Strengths and limitations

This study contributes significantly to the limited body of knowledge on diabetes burnout among individuals with T1D in low-resource settings. One major strength is its use of in-depth qualitative data collected through rich, semi-structured interviews, offering nuanced insights into the lived experiences of participants. The diversity in participant backgrounds—regarding age, gender, and duration of diabetes—allowed for a comprehensive exploration of burnout across different life contexts.

However, this study’s findings should be interpreted considering several methodological limitations. First, the sample was limited to Persian-speaking adults residing in Iran, which may restrict the transferability of findings to other linguistic or cultural contexts. Second, all participants were recruited from urban areas, potentially overlooking the unique challenges faced by individuals living with Type 1 Diabetes in rural settings. Third, as the study relied on self-reported experiences during interviews, the findings may be influenced by recall bias or participants’ emotional states at the time of data collection. While efforts were made to build trust and minimize response bias, some experiences may have been under- or over-reported. Last, the qualitative design, though valuable for in-depth exploration, does not permit statistical generalization of the results to broader populations. Despite these limitations, the study offers meaningful insights into the lived experience of diabetes burnout and highlights areas for future research and intervention development.

Despite these limitations, the study offers important implications for healthcare providers, policymakers, and families, highlighting the need for culturally sensitive, resource-informed, and emotionally supportive care strategies. Future studies could use mixed-methods designs or longitudinal approaches to further explore the dynamics of diabetes burnout over time.

Suggestions for future research

Future research should explore the following areas to advance understanding and inform targeted interventions for diabetes burnout:

• Longitudinal studies that track how diabetes burnout evolves over time and across major life transitions—such as initial diagnosis, adolescence, pregnancy, and aging—can illuminate key risk periods and inform tailored prevention strategies.

• Intervention studies are needed to test the effectiveness of specific approaches aimed at reducing diabetes burnout. Examples include mobile health applications that offer self-management prompts and stress-reduction exercises, community-based peer support groups to foster shared understanding, and family-focused education programs that build collective responsibility for care.

• Research should examine the impact of family and community-level interventions that strengthen social support systems. For instance, culturally tailored support networks led by trained peer mentors or family education workshops may buffer emotional exhaustion and improve adherence to self-care.

• Cross-cultural and international comparative studies can shed light on how diverse healthcare systems, cultural beliefs, and economic challenges—including crises such as pandemics or economic sanctions—shape experiences of diabetes burnout.

This growing field of inquiry would benefit from interdisciplinary collaboration and the use of mixed-methods designs to generate nuanced, person-centered insights that can be translated into scalable interventions.

Conclusion

This study highlights the complex interplay between personal, structural, and relational factors that contribute to diabetes burnout among individuals with T1D in Iran. Participants described how disruptions in routine, compounded by financial strain, limited healthcare access, and emotional fatigue, undermined their ability to manage their condition effectively. These challenges were intensified by broader crises like the COVID-19 pandemic and ongoing economic sanctions.

A key finding was the culturally rooted importance of family support. Emotional and practical assistance from loved ones played a protective role, while its absence deepened feelings of isolation and burnout. This communal dimension of coping offers an important contrast to more individual-focused models of diabetes care.

Overall, the results call for holistic, culturally sensitive interventions that integrate family involvement, strengthen access to care, and address the emotional toll of chronic disease management. Such approaches are essential to supporting resilience and reducing burnout in people living with T1D.

Key messages

This study addresses a significant gap in the global literature by exploring diabetes burnout—an under-researched yet critical aspect of diabetes care—from a non-Western cultural perspective. While most existing research has emerged from Western, individualistic settings, this qualitative investigation offers rare insight into the lived experiences of young adults with Type 1 Diabetes in Iran, where collective values, family interdependence, and structural limitations shape health behaviors. Participants described navigating personal and systemic disruptions—including economic hardship, medication shortages, and the COVID-19 pandemic—within a sociocultural context that often places responsibility for chronic illness management within family units. By conceptualizing diabetes burnout as walking a suspension bridge, the study introduces a culturally resonant metaphor for the fragile equilibrium required in daily care. These findings not only expand the global understanding of diabetes burnout but also highlight the urgent need for contextually tailored, culturally grounded support strategies in chronic disease management.

Consent for publication

All authors agree to submit the paper for this journal to be consider for publication.

AI use disclosure

Artificial intelligence (AI) tools, specifically OpenAI’s ChatGPT, were used to assist with language editing and improving the readability of the manuscript. No AI tools were used in data collection, analysis, interpretation, or the generation of original content. The authors remain fully responsible for the accuracy and integrity of the manuscript.

Abbreviations

A1C: glycated hemoglobin test; COVID-19: Coronavirus Disease of 2019; HbA1c: Hemoglobin A1c also called HbA1c; LMICs: Low- and Middle-Income Countries; T1D: Type 1 Diabetes.

Ethics approval

The study was approved by ethics in research committee of Shahrekord University of Medical Sciences (project number: 5397 and ethical code: IR.SKUMS.REC.1399.052) in Iran.

Availability of data and material and code availability

All collected data are available.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

This study was approved and financially supported by Shahrekord University of Medical Sciences (Project Number: 5397; Ethics Code: IR.SKUMS.REC.1399.052).