Meeting the Psychosocial Needs of Young Adults With Diabetes in the Clinic and Beyond

Young adulthood is a developmental phase occurring between the ages of 18 and 25 years with social, physical, and cognitive characteristics that distinguish it from adolescence and adulthood (1). Often referred to as “emerging adulthood,” this stage, for many individuals, involves transitioning from a parent-directed adolescent experience largely taking place at home and school to independent adult roles and experiences, separate finances, and their own mature relationships (1). As a result, the young adult period is inherently unstable due to multiple developmentally normative transitional events and competing educational, social, and economic demands (1).

The emerging literature base indicates that young adults with type 1 or type 2 diabetes experience developmental challenges similar to those of young adults without diabetes, but with the added challenge of managing a complex chronic medical condition (2–4). Thus, the daily demands of diabetes care, including the need to coordinate daily self-management, find and engage with appropriate health care providers, and obtain access to supplies and medical care, must be incorporated into all of the normative decisions that young adults make related to relationships, occupations, living arrangements, and financial management (3,4).

Recognizing the challenges that young adults with diabetes face, the American Diabetes Association in 2011 published a position statement on diabetes care in young adults (5). Among other things, this position statement called for a framework to guide treatment decisions for, and research with, this population (5). In the past decade, there has been an upsurge in diabetes research focusing on this unique and challenging developmental period. Nonetheless, most young adults with diabetes continue to struggle to meet glycemic targets, and these findings are even more pronounced in young adults from racial and ethnic minority backgrounds (6,7). Retrospective studies show that up to 50% of young adults develop diabetes-related complications (e.g., retinopathy, neuropathy, and hypertension) in their 20s (8,9). People with diabetes are at disproportionately higher risk for mental health issues, including depression, anxiety, and eating disorders (10,11), and many endorse elevated levels of psychological distress and mood concerns (12,13). Thus, despite widespread recognition that young adulthood is a critical period of risk for many people with diabetes, little is known about how to provide clinical care that meets their complex psychosocial needs.

In this Diabetes Spectrum From Research to Practice section, we explore a number of timely and clinically relevant topics and evidence-based strategies for engaging young adults with type 1 or type 2 diabetes in clinical care, through a series of six articles by experts on the topics. In our first article (p. 328), Dr. Persis V. Commissariat and colleagues set the stage for readers with an overview of the unique developmental tasks and challenges that young adults with diabetes experience. Next (p. 336), Dr. Shivani Agarwal and Molly Finnan elaborate on additional competing demands related to social determinants of health and health care disparities that make diabetes self-care even more challenging for young adults from racial and ethnic minority and lower–socioeconomic status (SES) backgrounds. Our third and fourth articles focus on provider and health care system issues related to young adults with diabetes. Dr. Maureen Monaghan, Breana L. Bryant, and colleagues provide an overview of health communication and strategies for engaging in high-quality health communication with young adults with diabetes (p. 345). Then, Dr. Jennifer K. Raymond, Jaquelin Flores Garcia, and colleagues describe the benefits and challenges of implementing telehealth for diabetes-related visits with young adults from racial and ethnic minority and lower SES backgrounds (p. 357). Our fifth and sixth articles focus on individual and social issues related to how young adults navigate the real world. Specifically, Dr. Marisa E. Hilliard, Samantha A. Carreon, and colleagues focus on social support and illustrate the types and sources of social support that young adults with diabetes receive and how social support relates to diabetes outcomes (p. 363). Finally, Dr. Rachel M. Wasserman and colleagues focus on diabetes-specific risk-taking, review existing models of risk-taking behavior, and apply these models to risks that young adults with diabetes may take with their diabetes self-care (p. 371). All six articles provide clinical recommendations based on the available evidence for providers who may work with young adults with diabetes.

I would now like to highlight some important themes that stand out in this special issue.

Young Adult–Centered Care

The Institute of Medicine defines patient-centered care as “providing care that is respectful of, and responsive to, individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions” (14). Although attempts to provide patient-centered care have become largely the norm in the past few years, the articles in this special issue highlight strategies for providing patient-centered care for young adults. This effort is particularly important across the transition from pediatric to adult diabetes care, during which young adults are expected to navigate a new health care system and form collaborative relationships with new providers. Also, because many young adults struggle with diabetes self-care as well as mental health and social issues, it is important for providers to use person-centered language that is not judgmental or overly directive.

Multiple Levels of Influence

The variety of topics covered in this issue highlights the importance of considering a wide range of risk and resilience factors when providing care for young adults with diabetes. Examples we include in this issue span individual (i.e., risk-taking and social support), environmental (i.e., social determinants of health), and health care systems (i.e., care delivery mode and health care communication) levels. Providers must be willing to intervene on these multiple levels of influence to work effectively with young adults with diabetes.

Social Determinants of Health and Health Disparities

Many of the articles describe a dearth of research on young adults with diabetes from historically underserved or marginalized backgrounds. Agarwal and Finnan provide a comprehensive overview of the complexities of navigating these social challenges while also managing diabetes, highlighting the need for comprehensive multidisciplinary care to address systems-level issues. The other articles highlight how normative stressors for young adults with diabetes may be exacerbated in young adults from underrepresented groups and the importance of including young adults from diverse racial/ethnic statuses, sexual and gender orientations, levels of acculturation, and socioeconomic statuses in research.

Nascent Research Base

Several of the articles in this issue highlight the need for well-designed observational research on young adults with diabetes to better understand the risk and resilience factors that impact psychosocial and diabetes outcomes, as well as intervention trials to target these factors. Yet, research on young adults is challenging given the many competing priorities and barriers that may interfere with young adults’ ability or desire to participate in research and for those who do enroll, the competing priorities and barriers that create obstacles for young adults to continue in research studies (15). Novel and innovative methods for recruitment and retention are needed.

Young Adulthood as a Unique Time of Discovery

In his seminal publication on emerging or young adulthood, developmental psychologist J.J. Arnett described young adulthood as “the period of life that offers the most opportunity for identity exploration in the areas of love, work, and worldviews” (1). The articles in this special-topic collection highlight how many young adults with diabetes are also exploring their “diabetes identity” (16). They are learning how to integrate diabetes into their new young-adult roles, figuring out who to obtain diabetes-related support from and how to obtain this support, finding their voice as they navigate many social and health care systems challenges, and making many new health care decisions. Health care providers have a unique opportunity to assist and support young adults as they figure out how to live with diabetes and define their goals for their health, as well as how diabetes fits into their love, work, and world views.

Taken together, these articles show that clinical care for young adults with diabetes is multifaceted and must address multiple levels with a focus on young adults’ unique psychosocial needs and expand beyond the health care setting. Additional research is needed, but I hope these articles may equip providers with strategies for engaging young adults with diabetes in their health care, while also stimulating new ideas for research targeting this complex population.