Approximately 193,000 children and adolescents in the United States younger than age 20 have type 1 or type 2 diabetes (Centers for Disease Control and Prevention [CDC], 2017a). The transition from home to college typically occurs during adolescence, a time of substantial life change; yet, how well adolescents with diabetes in the United States manage their health when they transition from home to college is not well understood (Fredette, Mawn, Hood, & Fain, 2016; Lemly, Lawlor, Scherer, Kelemen, & Weitzman, 2014). The transition from home to college often includes a change in residential, social, and learning environments. These changes along with stressors associated with academic achievement may affect daily management of diabetes. Adjusting from dependency on parents/guardians to more independent self-care management of diabetes during this transition presents challenges in metabolic control and increased risk for physical and mental health problems (Meyer, Fish, & Lou, 2017; Morrison, Dashiff, Abdullatif, & Moreland, 2012; Saylor & Calamaro, 2016).
As health practices established throughout adolescence may affect health behaviors and outcomes in adulthood, it is important to better understand the behaviors of adolescents with diabetes transitioning to college through an exploration of their self-care practices associated with nutrition, exercise, sleep, alcohol consumption, and tobacco use. The purpose of the current study was to assess the health behaviors, including those related to harm prevention, of college students with diabetes to reveal which self-care behaviors are practiced or neglected and to compare their health behaviors to college students without diabetes.
The research questions were: (1) What are the health behaviors of college students with diabetes? and (2) Are there differences in health behaviors between college students with diabetes and those without diabetes?
Design and Sample
The current study is a report of the dissertation work of the first author (Cockroft, 2013). This descriptive study involved secondary analysis of data from the Spring 2009 American College Health Association-National College Health Assessment II (ACHA-NCHA II) (ACHA, 2009). The ACHA-NCHA II survey included questions related to health history, nutrition, exercise, physical health, mental health, risk behaviors (e.g., tobacco and alcohol related behaviors), and academic performance and was completed by 87,105 students at 117 schools, representing a sample of different geographic regions and campus sizes. These data are collected annually; however, public use of the data is often 3 to 4 years later than original data collection. As adolescent health behaviors from 2009 remain relevant in 2019, and for the purposes of future studies to compare changes in these behaviors over time, the findings presented here are important. (For more information on these data, access https://www.acha.org/documents/ncha/ACHA-NCHA_Reference_Group_ExecutiveSummary_Spring2009.pdf.)
For the current study, inclusion criteria were students between ages 18 and 24 who reported being diagnosed or treated for diabetes by a health care provider within the past 12 months. These criteria were met by 528 students. A comparison group was selected using a random number generator in SPSS version 21.0 from the 68,798 students who reported they were between ages 18 and 24 and had not been diagnosed or treated for diabetes. Students in the comparison group (n = 688) represent approximately 1% of students meeting the inclusion criteria, a similar proportion to that of students with diabetes. Thus, survey data of 1,216 students were examined.
Select survey questions from the ACHA-NCHA II that addressed sleep, nutrition, disordered eating, problematic tobacco and alcohol use, and exercise were used to assess self-care behaviors. Several Likert responses were converted into dichotomous variables, and other variables were combined or recoded to reflect national health guidelines on these domains of self-care.
Sleep. Sleep was measured using five items assessing adequate rest and sleep difficulties. The focus of items was consistent with the National Sleep Foundation (2015) guidelines to measure sleep. A positive response was feeling rested every day, no problems with daytime sleepiness, zero days of difficulty falling asleep, sleep difficulties not being difficult to handle, and academics not being affected by sleep difficulties.
Nutrition. Nutrition was measured using one item (e.g., daily consumption of fruits and vegetables). Healthy Campus 2020 guidelines promote consuming five or more servings of fruits and vegetables per day (ACHA, 2012). Thus, nutrition was assessed through a dichotomous variable created to reflect whether the national recommendations for consuming fruit and vegetable intake were met.
Disordered Eating. Disordered eating was measured using four items. One item was weight loss strategies. Vomiting, taking laxatives, or using diet pills were combined to form a dichotomous variable indicating unsafe weight loss strategies. Additional comparisons were conducted by looking at perceptions of being about the right weight and responding yes to questions related to eating disorder presence and outcome.
Tobacco Use. Combining the use of four tobacco products into one item was used to assess tobacco usage. For comparison analysis, a response was considered positive if the student reported never used or not within the last 30 days to each of the tobacco products.
Alcohol Use. Alcohol consumption was evaluated with seven items related to quantity of alcohol, protective drinking strategies, impact on academic performance, addiction to alcohol or other drugs, and whether students drove after drinking. Daily consumption of no more than one drink for women and no more than two drinks for men was considered moderate intake for adults, both with and without diabetes (American Diabetes Association [ADA], 2014). To determine moderate drinking patterns, a dichotomous variable representing gender guidelines for consuming one drink for women and two drinks for men considering legal age requirements was created. Protective drinking strategies (e.g., eating before or during drinking, avoiding drinking games) were measured by responses of N/A, don't drink, most of the time, or always. To determine if any protective strategies were practiced, a dichotomous variable was created. A response of no or N/A to all other alcohol questions was used for the comparison analysis.
Exercise. Participation in physical activity by type and frequency was used for exercise measurement. Exercise was assessed through a dichotomous variable to represent whether the national recommendations for exercise were met. The recommendation at the time of the study for moderate-intensity aerobic exercise for at least 30 minutes on at least 5 days weekly, or vigorous-intensity aerobic exercise for at least 20 minutes on at least 4 days weekly, or a comparable mix of moderate/vigorous aerobic activity; and muscle-strengthening exercises at least twice per week are similar to current guidelines (U.S. Department of Health and Human Services, 2018).
Data were extracted from the survey for the 1,216 student records, coded, checked for accuracy and analyzed using IBM SPSS Statistics version 21.0. Descriptive statistics, including measures of central tendency, frequency, variability, and percentages, were used to describe the responses to the survey questions measuring self-care behaviors. Chi-square testing was used to compare the study groups on the selected outcomes because most were categorical.
Average age of students was 20.33 (SD = 1.6 years), 37% were male, 62.7% were female, and four (0.3%) students identified as transgender. Minorities comprised 22.3% of the sample, including non-Hispanic Black, Hispanic/Latino, Asian/Pacific Islander, American Indian/Alaskan, and Native Hawaiian individuals. Full-time (95.4%) and undergraduate (90%) students comprised most of the sample. Many students lived in campus residence halls (41.6%) and more than one half were not in a relationship (53.8%). Students with and without diabetes reported similar perceived stress, place of residence, relationship status, marital status, membership in Greek social organizations, and participation in organized athletics. Statistically significant differences between groups were found in grade point average (GPA) and perceived health status. Students with diabetes reported a lower GPA and a more negatively perceived health status (Table 1).
Characteristics of Students with and Without Diabetes
Research Question 1 revealed important findings about the health behaviors of students with diabetes. Most students with diabetes reported they did not get enough sleep to feel rested and had problematic daytime sleepiness. Only a small portion of students met the nutrition recommendations for daily fruits and vegetables and only one quarter met the recommended physical activity levels. Furthermore, they engaged in harmful behaviors related to drinking, tobacco use, and risky driving.
The findings from research Question 2 indicated significant differences between students with diabetes and those without diabetes in sleep, nutrition, disordered eating, problematic alcohol and tobacco use, and exercise (Table 2). Fewer students with diabetes reported no extreme difficulty falling asleep, no difficulty handling sleep problems, and no academic problems resulting from sleep difficulties. A statistically significant difference was noted between groups for nutrition-related behaviors, except fruit and vegetable intake. Fewer students with diabetes (than those without diabetes) perceived that they were at their “right” weight, fewer reported no history of anorexia or bulimia, fewer reported no academic problems related to an eating disorder, and fewer reported they did not use unsafe weight loss strategies. Fewer students with diabetes consistently used at least one protective drinking strategy, reported no academic problems due to alcohol, reported no history of substance addiction, or did not drink and drive. In addition, fewer students with diabetes reported no use of tobacco products. A higher percentage of students with diabetes reported meeting exercise recommendations than students without diabetes.
Comparison of Health Behaviors of Students with and Without Diabetes (N = 1,216)
The current study revealed the need for improvement of health behaviors of college students with and without diabetes, especially related to sleep, nutrition, disordered eating, problematic tobacco and alcohol use, and exercise. There were statistically significant differences between groups in several categories, revealing students without diabetes reported better health behaviors than students with diabetes.
Of the health behaviors assessed, aspects of sleep were the most problematic for both student groups. Poor sleep is known to have detrimental effects in the general population, especially in terms of health promotion and chronic disease prevention (CDC, 2017b), and poor sleep has adverse effects on college students' academic performance and participation in risk behaviors (Gaultney, 2010; Kenney, LaBrie, Hummer, & Pham, 2012; Lund, Reider, Whiting, & Prichard, 2010; Orzech, Salafsky, & Hamilton, 2011; Phillips et al., 2017). Additional health consequences of inadequate sleep for persons with diabetes include depressed mood, reduced quality of life, decreased motivation, lower grades, and alterations in metabolic control (Barone & Menna-Barreto, 2011; Donga et al., 2010; Perez et al., 2018; Perfect et al., 2012).
The current authors' findings reveal the prevalence of sleep deficiencies among college students with diabetes. Long-term control of blood sugar may be an additional complication of inadequate sleep among college students with diabetes. Saylor, Ji, Calamaro, and Davey's (2019) study of predicted hemoglobin A1c levels related to sleep behaviors among students with type 1 diabetes living on a college campus reported hemoglobin A1c levels increased with decreased weekday sleep duration and increased napping behaviors, suggesting that sleep is a major contributor to glycemic control. These students may not be sufficiently aware of the consequences of poor sleep to their health and well-being and could benefit from further information on this topic.
The recommendations for daily intake of fruits and vegetables were met by few students in either group in the current study. These findings may reflect normative behaviors, as Santos, Hurtado-Ortiz, Amerndariz, van Twist, and Castillo (2017) found similar results among the general college population and college students at risk for diabetes. Given the importance of good nutrition to proper diabetes management, it was surprising that more students with diabetes did not incorporate healthy food choices into their regular nutritional practices.
Although most students did not report an eating disorder, approximately 12% of students with diabetes had weight-loss strategies considered to be unsafe. This finding was contradictory to a similar study of young adults with diabetes compared to a control group of college students without diabetes, where the diabetic group had significantly lower scores on the Eating Disorder Examination Questionnaire when compared to the control group (Keane et al., 2018).
Approximately 30% of students with diabetes in the current study reported using tobacco products. Although this percentage is lower than the 41.6% found in a national sample of 18 to 25 year old adults (Substance Abuse and Mental Health Services Administration, 2017), these findings are nonetheless concerning given the increased risks associated with smoking in persons with diabetes (Pan, Wang, Talaei, & Hu, 2015) and the association of smoking among all college students with high-risk alcohol use, risky driving, depression, abusive relationships, less exercise, and use of emergency and mental health services (Halperin, Smith, Heiligenstein, Brown, & Fleming, 2010).
Approximately all students used at least one protective drinking strategy, which was a positive finding. As unsafe alcohol use can be a health concern for persons with diabetes, additional encouragement to consistently use multiple protective drinking strategies should be given to these students along with information of how hyperglycemia can occur with intake of sweetened beverages and those high in carbohydrates, and alcohol-induced hypoglycemia can occur shortly after drinking and many hours after ingestion (Ansel, 2019).
Students with diabetes acknowledged more difficulty with their academics resulting from problems related to poor sleep, eating disorders, and use of alcohol, which may account for the greater percentage of students with diabetes earning poor grades. Other studies have found a negative effect on cognitive function in adolescents with diabetes related to obesity (Brady et al., 2017) and glycemic control (Abo-El-Asrar et al., 2018), which can impact academic success.
Despite the many benefits to conducting an analysis of ACHA-NCHA II data, including a national representation of college students and large sample, there were some limitations. Specific questions about diabetes were not available, such as type of diabetes, age of onset, or state of diabetes control (e.g., hemoglobin A1c level). In addition, the survey provided self-report data at one time point and possible respondent bias. History of other acute or chronic health conditions, such as fractures or asthma, was not considered in this study; therefore, students in both groups may have had other comorbidities. Finally, generalizability is limited, as universities self-selected to participate in the survey.
The current study helps identify areas where nurses, diabetes educators, campus health personnel, counselors, and primary care providers can positively impact the health of prospective, new, and continuing college students with diabetes. Opportunities for interventions are numerous at the individual, family, and community level, prior to students entering college and after entrance. Although all students can benefit from improved health-promoting behaviors, college students with diabetes are particularly vulnerable and require differential interventions to help them maintain their health and avoid negative outcomes and mental health concerns associated with their behaviors (Clarke et al., 2018; Helgeson et al., 2018).
At the individual level, nurses in community, psychiatric and mental health, and primary care settings can assist older adolescents with diabetes as they prepare for the transition from high school to college (Ashworth, Ward, & Bingley, 2012; Helgeson et al.; 2018; Peters, Laffel, & ADA, 2011; Saylor & Calamaro, 2016). The ADA recommends that providers begin preparing patients for the transfer from pediatric to adult health care practices 1 year prior to the move (Peters et al., 2011) to ensure self-management and mental well-being (Saylor & Calamaro, 2016). Beyond providing guidance related to diabetes self-management skills that optimize metabolic control, including blood glucose monitoring, diet, and exercise, important conversations related to sleep and alcohol and tobacco use should be focused in this preparation. Attention should be given to screening adolescents for mental health problems and disordered eating and include education on risk behaviors associated with sex and substance use (Helgeson et al., 2018; Saylor & Calamaro, 2016; Simms & Monaghan, 2016). Providing a tool kit for adolescents with diabetes prior to leaving for college that includes resources for adjusting to greater independence and a new living environment, such as ADA guidelines for fruit and vegetable consumption, exercise recommendations, and safe alcohol use, could improve health behaviors. In addition, telemedicine may be useful to facilitate communication with students and provide needed support to reduce stress during the transition (Edwards, Noyes, Lowes, Haf Spencer, & Gregory, 2014; Pal et al., 2014).
At the family level, nurses and other health care providers can educate and encourage families to prepare their adolescents with diabetes for the transition to college life. Doing so may reduce maternal stress and enhance the successful transition to college for students with diabetes (Ness, Saylor, & Selekman, 2018). Parents and students should be aware of stress management strategies and mental health resources related to the new independence and academic and social pressures. Parents should be reminded of the developmental phase their child is navigating and to offer anticipatory guidance in the challenges to be faced. Moving from adolescence to adulthood includes many emotional and mental health challenges. Students should be made aware of how to identify in themselves, ways to manage stress, and avenues for assistance with mental health. College counseling and student health services may provide acute and long-term support.
Although families may have had conversations with their adolescent about the importance of nutrition and exercise in diabetes self-management, nurses can provide resources to equip parents to have discussions about the harmful effects of smoking, alcohol use, and risky driving that are unique to a person with diabetes. Nurses can empower parents to have conversations with their student about the use of a designated driver or finding other modes of transportation to avoid driving after drinking alcohol. In addition, parents, nurses, and nurse practitioners can assess and provide strategies for mental health well-being. These strategies may include seeking counseling, stress management activities, and building support systems such as recreation or study groups. Nurses can guide parents to send their student regular positive support messages and care packages containing fruits and healthy snacks and encourage them to participate in organized campus sports and other activities.
The current study also has implications at the individual and community level for college health services, as many goals of Healthy Campus 2020 apply (ACHA, 2012). In addition to encouraging students to use the college health services for their medical health care needs, campus nurses could inform students of locations of after-hours food purchases, recreational facilities, opportunities for activities such as intramural sports teams, eligibility for disability services, and resources such as smoking cessation programs to assist students in healthy nutrition, exercise, and prevention of harm. Providing this anticipatory guidance may lessen stress for incoming students and their families.
The desire for normalcy and to fit in with peers without diabetes is demonstrated in the current study. Because the perceived intrusiveness of the chronic illness upon the young adult's life may be directly and indirectly related to psychosocial outcomes, such as depressive and anxious symptoms (Bakula et al., 2019), interventions to increase awareness of chronic disease among young adults may prove beneficial. Many college students, with or without diabetes, do not see chronic disease as life-threatening and may continue to engage in behaviors that may cause harm (Amuta, Jacobs, Barry, Popoola, & Crosslin, 2016). It is important for campuses to provide an environment that promotes positive behaviors to improve health and well-being for all students, such as campus wellness centers that include facilities for physical activities and peer mentors to promote healthy behaviors. Likewise, community-level interventions designed to alter the campus drinking environment and institute smoke-free policies have been successful in decreasing alcohol-related injuries and interpersonal effects of alcohol use along with positive changes to smoking behaviors (Seo, Macy, Torabi, & Middlestadt, 2011; Wolfson et al., 2012).
College students with diabetes value connecting with peers with their same condition and such connections are shown to have positive health benefits (Fredette et al., 2016; Saylor et al., 2018). Colleges could develop more residential housing where students live in a community designed to promote overall good health (e.g., focuses on nutrition, exercise, sleep, and risk-free behaviors). This type of healthy living environment could have a positive impact on academic achievement and improve all students' self-care behaviors (Ruthig, Marrone, Hladkyj, & Robinson-Epp, 2011). Living in such a space could help students with diabetes find support for maintaining healthy behaviors through mutual interests in healthy living. Alternatively, students with diabetes could be pointed toward positive, age-appropriate online patient communities or social networks for emotional support, condition-specific information, and self-management tools to provide an additional source of community and belonging (Cantrell & Boles, 2015). Campus health services, including mental health services, can establish advocacy groups or chapters of national diabetes organizations to provide opportunities for students to connect with peer mentors and develop a network of individuals with shared health concerns and goals. Establishing connectedness to the college has been associated with educational attainment and graduation among students with childhood onset chronic illness, such as diabetes (Maslow, Haydon, McRee, & Halpern, 2012).
Previous studies of college students with diabetes have addressed alcohol use (Ravert, 2009) and self-management (Balfe, 2009; Ravert, Boren, & Wiebke, 2015; Wilson, 2010) and are primarily designed as qualitative studies that are limited in scope and the number of participants. The current descriptive study represented a large, diverse sample and filled a gap in the literature by examining health behaviors of college students with diabetes. Harmful behaviors related to tobacco use and driving practices have not been previously studied in this population. The health protective behaviors as well as self-care deficits and problem behaviors of students with diabetes were compared to students without diabetes. This study lays a foundation for future work that can determine trends in self-care behaviors of college students with and without diabetes.
Findings from the current study can be used by health care providers, especially nurses, to implement interventions in a variety of settings. All college students with diabetes, regardless of age of onset or type of diabetes, will benefit from additional support from families and health care providers as they move from family caregivers to independence, transfer from pediatric to adult health providers, and adjust to college life all while managing a complex chronic illness in a new academic, social, emotional, and living environment. By developing programs that address all levels of prevention for this at-risk population and empowering these individuals to leave home with more confidence to manage their health, they may achieve greater academic success in college fulfilling their goals of degree attainment, employment, and a future of good health.
- Abo-El-Asrar, M., Andrawes, N. G., Rabie, M. A., El-Gabry, D. A., Khalifa, A. G., El-Sherif, M. & Abdel Aziz, K. (2018). Cognitive functions in children and adolescents with early-onset diabetes mellitus in Egypt. Applied Neuropsychology. Child, 7(1), 21–30. https://doi.org/10.1080/21622965.2016.1224186 PMID: doi:10.1080/21622965.2016.1224186 [CrossRef]
- American College Health Association. (2009). American College Health Association-National College Health Assessment II: Reference group executive summary, Spring 2009. Retrieved from https://www.acha.org/documents/ncha/ACHA-NCHA_Reference_Group_ExecutiveSummary_Spring2009.pdf
- American College Health Association. (2012). Healthy campus 2020: Student objectives. Retrieved from http://www.acha.org/Healthy-Campus/Objectives/Student_Objectives/HealthyCampus/Student_Objectives.aspx?hkey=a9f191de-243b-41c6-b913-c012961ecab9
- American Diabetes Association. (2014). Alcohol. Retrieved from https://myhealthonsite.com/wp-content/uploads/2016/11/Alcohol-ADA.pdf
- Amuta, A., Jacobs, W., Barry, A., Popoola, O. & Crosslin, K. (2016). Gender differences in type 2 diabetes risk perception, attitude, and protective health behaviors: A study of overweight and obese college students. American Journal of Health Education, 47(5), 315–323. https://doi.org/10.1080/19325037.2016.1203836 doi:10.1080/19325037.2016.1203836 [CrossRef]
- Ansel, K. (2019). Drinking with diabetes: Avoiding alcohol? The latest research says you might not have to. Diabetes Forecast, 72(2), 98–101.
- Ashworth, E., Ward, A. & Bingley, P. (2012). The development of an information booklet for students with type 1 diabetes. Journal of Diabetes Nursing, 16(9), 348–354.
- Bakula, D. M., Sharkey, C. M., Perez, M. N., Espeleta, H. C., Hawkins, M., Chaney, J. M. & Mullins, L. L. (2019). The role of stigma in the relationship between illness intrusiveness and adjustment in adolescents and young adults: A path model. Journal of Pediatric Psychology, 44(5), 611–619. https://doi.org/10.1093/jpepsy/jsz004 PMID: doi:10.1093/jpepsy/jsz004 [CrossRef]30802911
- Balfe, M. (2009). Healthcare routines of university students with type 1 diabetes. Journal of Advanced Nursing, 65(11), 2367–2375. https://doi.org/10.1111/j.1365-2648.2009.05098.x PMID: doi:10.1111/j.1365-2648.2009.05098.x [CrossRef]19747295
- Barone, M. T. & Menna-Barreto, L. (2011). Diabetes and sleep: A complex cause-and-effect relationship. Diabetes Research and Clinical Practice, 91(2), 129–137. https://doi.org/10.1016/j.diabres.2010.07.011 PMID: doi:10.1016/j.diabres.2010.07.011 [CrossRef]
- Brady, C. C., Vannest, J. J., Dolan, L. M., Kadis, D. S., Lee, G. R., Holland, S. K. & Shah, A. S. (2017). Obese adolescents with type 2 diabetes perform worse than controls on cognitive and behavioral assessments. Pediatric Diabetes, 18(4), 297–303. doi:10.1111/pedi.12383 [CrossRef]
- Cantrell, K. A. & Boles, J. (2015). The children's corner: Perspectives on supportive care. Bridging isolation for youth with chronic conditions: Are we thinking virtually?Pediatric Nursing, 41(5), 254–256.26665426
- Centers for Disease Control and Prevention. (2017a). National diabetes statistics report. Retrieved from https://www.cdc.gov/diabetes/data/index.html
- Centers for Disease Control and Prevention. (2017b). Sleep and sleep disorders. Retrieved from http://www.cdc.gov/sleep/index.htm
- Clarke, J., Proudfoot, J., Vatiliotis, V., Verge, C., Holmes-Walker, D. J., Campbell, L. & Bridgett, M. (2018). Attitudes towards mental health, mental health research and digital interventions by young adults with type 1 diabetes: A qualitative analysis. Health Expectations, 21(3), 668–677. https://doi.org/10.1111/hex.12662 PMID: doi:10.1111/hex.12662 [CrossRef]29319923
- Cockroft, M. C. (2013). Self-care behaviors of college students with diabetes [Doctoral dissertation]. University of North Carolina at Greensboro. Retrieved from http://search.ebscohost.com.libproxy.lib.unc.edu/login.aspx?direct=true&db=rzh&AN=109863303&site=ehost-live&scope=site
- Donga, E., van Dijk, M., van Dijk, J. G., Biermasz, N. R., Lammers, G. J., van Kralingen, K. & Romijn, J. A. (2010). Partial sleep restriction decreases insulin sensitivity in type 1 diabetes. Diabetes Care, 33(7), 1573–1577. https://doi.org/10.2337/dc09-2317 PMID: doi:10.2337/dc09-2317 [CrossRef]20357381
- Edwards, D., Noyes, J., Lowes, L., Haf Spencer, L. & Gregory, J. W. (2014). An ongoing struggle: A mixed-method systematic review of interventions, barriers and facilitators to achieving optimal self-care by children and young people with type 1 diabetes in educational settings. BMC Pediatrics, 14, 228. doi:10.1186/1471-2431-14-228 [CrossRef]25213220
- Fredette, J., Mawn, B., Hood, K. & Fain, J. (2016). Quality of life of college students living with type 1 diabetes: A qualitative review. Western Journal of Nursing Research, 38(12), 1595–1610. https://doi.org/10.1177/0193945916651265 PMID: doi:10.1177/0193945916651265 [CrossRef]27230752
- Gaultney, J. F. (2010). The prevalence of sleep disorders in college students: Impact on academic performance. Journal of American College Health, 59(2), 91–97. https://doi.org/10.1080/07448481.2010.483708 PMID: doi:10.1080/07448481.2010.483708 [CrossRef]20864434
- Halperin, A. C., Smith, S. S., Heiligenstein, E., Brown, D. & Fleming, M. F. (2010). Cigarette smoking and associated health risks among students at five universities. Nicotine & Tobacco Research, 12(2), 96–104. https://doi.org/10.1093/ntr/ntp182 PMID: doi:10.1093/ntr/ntp182 [CrossRef]
- Helgeson, V. S., Vaughn, A. K., Seltman, H., Orchard, T., Libman, I. & Becker, D. (2018). Trajectories of glycemic control over adolescence and emerging adulthood: An 11-year longitudinal study of youth with type I diabetes. Journal of Pediatric Psychology, 43(1), 8–18. https://doi.org/10.1093/jpepsy/jsx083 PMID: doi:10.1093/jpepsy/jsx083 [CrossRef]
- Keane, S., Clarke, M., Murphy, M., McGrath, D., Smith, D., Farrelly, N. & MacHale, S. (2018). Disordered eating behaviour in young adults with type 1 diabetes mellitus. Journal of Eating Disorders, 6, 9. https://doi.org/10.1186/s40337-018-0194-2 PMID: doi:10.1186/s40337-018-0194-2 [CrossRef]29744106
- Kenney, S. R., LaBrie, J. W., Hummer, J. F. & Pham, A. T. (2012). Global sleep quality as a moderator of alcohol consumption and consequences in college students. Addictive Behaviors, 37(4), 507–512. https://doi.org/10.1016/j.addbeh.2012.01.006 PMID: doi:10.1016/j.addbeh.2012.01.006 [CrossRef]22285119
- Lemly, D. C., Lawlor, K., Scherer, E. A., Kelemen, S. & Weitzman, E. R. (2014). College health service capacity to support youth with chronic medical conditions. Pediatrics, 134(5), 885–891. https://doi.org/10.1542/peds.2014-1304 PMID: doi:10.1542/peds.2014-1304 [CrossRef]25349315
- Lund, H. G., Reider, B. D., Whiting, A. B. & Prichard, J. R. (2010). Sleep patterns and predictors of disturbed sleep in a large population of college students. The Journal of Adolescent Health, 46(2), 124–132. https://doi.org/10.1016/j.jadohealth.2009.06.016 PMID: doi:10.1016/j.jadohealth.2009.06.016 [CrossRef]20113918
- Maslow, G., Haydon, A. A., McRee, A. L. & Halpern, C. T. (2012). Protective connections and educational attainment among young adults with childhood-onset chronic illness. The Journal of School Health, 82(8), 364–370. https://doi.org/10.1111/j.1746-1561.2012.00710.x PMID: doi:10.1111/j.1746-1561.2012.00710.x [CrossRef]22712673
- Meyer, R. A., Fish, A. F. & Lou, Q. (2017). Use of the Hage framework for theory construction: Factors affecting glucose control in the college-aged student with type 1 diabetes. Applied Nursing Research, 37, 61–66. https://doi.org/10.1016/j.apnr.2017.08.001 PMID: doi:10.1016/j.apnr.2017.08.001 [CrossRef]28985923
- Morrison, S., Dashiff, C., Abdullatif, H. & Moreland, E. (2012). Parental separation anxiety and diabetes self-management of older adolescents: A pilot study. Pediatric Nursing, 38(2), 88–95 PMID:22685868
- National Sleep Foundation. (2015, February2). National Sleep Foundation recommends new sleep times. Retrieved from https://sleep-foundation.org/press-release/national-sleep-foundation-recommends-new-sleep-times/page/0/1
- Ness, M. M., Saylor, J. & Selekman, J. (2018). Maternal experiences of transitioning their emerging adult with type 1 diabetes to college. The Diabetes Educator, 44(2), 178–187. https://doi.org/10.1177/0145721718759980 PMID: doi:10.1177/0145721718759980 [CrossRef]29482437
- Orzech, K. M., Salafsky, D. B. & Hamilton, L. A. (2011). The state of sleep among college students at a large public university. Journal of American College Health, 59(7), 612–619. https://doi.org/10.1080/07448481.2010.520051 PMID: doi:10.1080/07448481.2010.520051 [CrossRef]21823956
- Pal, K., Eastwood, S. V., Michie, S., Farmer, A., Barnard, M. L., Peacock, R. & Murray, E. (2014). Computer-based interventions to improve self-management in adults with type 2 diabetes: A systematic review and meta-analysis. Diabetes Care, 37(6), 1759–1766. https://doi.org/10.2337/dc13-1386 PMID: doi:10.2337/dc13-1386 [CrossRef]24855158
- Pan, A., Wang, Y., Talaei, M. & Hu, F. B. (2015). Relation of smoking with total mortality and cardiovascular events among patients with diabetes mellitus: A meta-analysis and systematic review. Circulation, 132(19), 1795–1804. https://doi.org/10.1161/CIRCULATIONAHA.115.017926 PMID: doi:10.1161/CIRCULATIONAHA.115.017926 [CrossRef]26311724
- Perez, K. M., Hamburger, E. R., Lyttle, M., Williams, R., Bergner, E., Kahanda, S. & Jaser, S. S. (2018). Sleep in type 1 diabetes: Implications for glycemic control and diabetes management. Current Diabetes Reports, 18(2), 5. doi:10.1007/s11892-018-0974-8 [CrossRef]29399719
- Perfect, M. M., Patel, P. G., Scott, R. E., Wheeler, M. D., Patel, C., Griffin, K. & Quan, S. F. (2012). Sleep, glucose, and daytime functioning in youth with type 1 diabetes. Sleep: Journal of Sleep and Sleep Disorders Research, 35(1), 81–88. https://doi.org/10.5665/sleep.1590 PMID: doi:10.5665/sleep.1590 [CrossRef]
- Peters, A. & Laffel, L.American Diabetes Association Transitions Working Group. (2011). Diabetes care for emerging adults: Recommendations for transition from pediatric to adult diabetes care systems: A position statement of the American Diabetes Association. Diabetes Care, 34(11), 2477–2485. https://doi.org/10.2337/dc11-1723 PMID: doi:10.2337/dc11-1723 [CrossRef]22025785
- Phillips, A. J. K., Clerx, W. M., O'Brien, C. S., Sano, A., Barger, L. K., Picard, R. W. & Czeisler, C. A. (2017). Irregular sleep/wake patterns are associated with poorer academic performance and delayed circadian and sleep/wake timing. Scientific Reports, 7(1), 3216. https://doi.org/10.1038/s41598-017-03171-4 PMID: doi:10.1038/s41598-017-03171-4 [CrossRef]28607474
- Ravert, R. D. (2009). Alcohol management strategies of college students with diabetes. Patient Education and Counseling, 77(1), 97–102. https://doi.org/10.1016/j.pec.2009.02.004 PMID: doi:10.1016/j.pec.2009.02.004 [CrossRef]19303733
- Ravert, R. D., Boren, S. A. & Wiebke, E. (2015). Transitioning through college with diabetes: Themes found in online forums. Journal of American College Health, 63(4), 258–267. https://doi.org/10.1080/07448481.2015.1015026 PMID: doi:10.1080/07448481.2015.1015026 [CrossRef]25693002
- Ruthig, J. C., Marrone, S., Hladkyj, S. & Robinson-Epp, N. (2011). Changes in college student health: Implications for academic performance. Journal of College Student Development, 52(3), 307–320. https://doi.org/10.1353/csd.2011.0038 doi:10.1353/csd.2011.0038 [CrossRef]
- Santos, S. J., Hurtado-Ortiz, M. T., Amerndariz, M., van Twist, V. & Castillo, Y. (2017). Obesity related dietary patterns and health status of diabetes among at risk Latino college students. Journal of Hispanic Higher Education, 16(4), 291–313. https://doi.org/10.1177/1538192716653504 doi:10.1177/1538192716653504 [CrossRef]
- Saylor, J. & Calamaro, C. (2016). Transitioning young adults with type 1 diabetes to campus life. The Journal for Nurse Practitioners, 12(1), 41–46. https://doi.org/10.1016/j.nurpra.2015.09.010 doi:10.1016/j.nurpra.2015.09.010 [CrossRef]
- Saylor, J., Ji, X., Calamaro, C. J. & Davey, A. (2019). Does sleep duration, napping, and social jetlag predict hemoglobin A1c among college students with type 1 diabetes mellitus?Diabetes Research and Clinical Practice, 148, 102–109. https://doi.org/10.1016/j.diabres.2019.01.007 PMID: doi:10.1016/j.diabres.2019.01.007 [CrossRef]30641174
- Saylor, J., Lee, S., Ness, M., Ambrosino, J. M., Ike, E., Ziegler, M. & Calamaro, C. (2018). Positive health benefits of peer support and connections for college students with type 1 diabetes mellitus. The Diabetes Educator, 44(4), 340–347. https://doi.org/10.1177/0145721718765947 PMID: doi:10.1177/0145721718765947 [CrossRef]29949457
- Seo, D. C., Macy, J. T., Torabi, M. R. & Middlestadt, S. E. (2011). The effect of a smoke-free campus policy on college students' smoking behaviors and attitudes. Preventive Medicine, 53(4–5), 347–352. doi:10.1016/j.ypmed.2011.07.015 [CrossRef]21851836
- Simms, M. & Monaghan, M. (2016). The initial impact of a diabetes diagnosis on mental health in young people and families. Journal of Diabetes Nursing, 20, 291–296.
- Substance Abuse and Mental Health Services Administration. (2017). Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health. Retrieved from https://www.samhsa.gov/data/sites/default/files/NSDUHFFR1-2016/NSDUH-FFR1-2016.htm
- U.S. Department of Health and Human Services. (2018). Physical activity basics. Retrieved from https://www.cdc.gov/physicalactivity/basics/index.htm
- Wilson, V. (2010). Students' experiences of managing type 1 diabetes. Paediatric Nursing, 22(10), 25–28. https://doi.org/10.7748/paed.22.10.25.s26 PMID: doi:10.7748/paed.22.10.25.s26 [CrossRef]
- Wolfson, M., Champion, H., McCoy, T. P., Rhodes, S. D., Ip, E. H., Blocker, J. N. & Durant, R. H. (2012). Impact of a randomized campus/community trial to prevent high-risk drinking among college students. Alcoholism, Clinical and Experimental Research, 36(10), 1767–1778. https://doi.org/10.1111/j.1530-0277.2012.01786.x PMID: doi:10.1111/j.1530-0277.2012.01786.x [CrossRef]22823091
Characteristics of Students with and Without Diabetes
|Students With Diabetes (n = 528)||Students Without Diabetes (n = 688)|
| Female||324 (62)||433 (63.2)|
| Male||195 (37.3)||252 (36.8)|
| Transgender||4 (0.8)||0 (0)|
| White, Non-Hispanic||413 (78.2)||532 (77.3)|
| Black, Non-Hispanic||41 (7.8)||41 (6)|
| Hispanic/Latino||26 (4.9)||53 (7.7)|
| Asian/Pacific Islander||49 (9.3)||70 (10.2)|
| American Indian/Alaskan, Native Hawaiian||11 (2.1)||9 (1.3)|
| Biracial/multiracial||22 (4.2)||20 (2.9)|
|Year in school|
| 1st year undergraduate||150 (28.7)||188 (27.5)|
| 2nd year undergraduate||113 (21.6)||141 (20.6)|
| 3rd year undergraduate||110 (21.1)||159 (23.3)|
| 4th year undergraduate||99 (19)||122 (17.9)|
| 5th year undergraduate or more||23 (4.4)||20 (2.9)|
| Graduate/professional||24 (4.6)||48 (7)|
| 18||70 (13.3)||87 (12.6)|
| 19||120 (22.7)||166 (24.1)|
| 20||106 (20.1)||137 (19.9)|
| 21||105 (19.9)||137 (19.9)|
| 22||67 (12.7)||89 (12.9)|
| 23||35 (6.6)||51 (7.4)|
| 24||25 (4.7)||22 (3.2)|
| Full-time||498 (95.2)||653 (95.6)|
| Part-time||19 (3.6)||23 (3.4)|
| A||151 (29)||244 (35.7)|
| B||275 (52.8)||330 (48.3)|
| C||76 (14.6)||96 (14.1)|
| D/F||11 (2.1)||2 (0.3)|
| Average or less||245 (46.6)||342 (50)|
| More than average or tremendous||281 (53.4)||342 (50)|
|Perceived health statusb|
| Excellent/very good/good||416 (81.6)||618 (91.5)|
| Fair/poor||93 (18.2)||55 (8.2)|
| Not in a relationship||295 (56.3)||356 (52)|
| In relationship, not living together||188 (35.9)||276 (40.3)|
| In relationship, living together||41 (7.8)||53 (7.7)|
| Single||482 (91.8)||637 (93.5)|
| Married/partnered||26 (5)||28 (4.1)|
| Separated||1 (0.2)||0 (0)|
| Divorced||1 (0.2)||1 (0.1)|
| Other||15 (2.9)||15 (2.2)|
|Social Greek organizations|
| Not a member||457 (87.5)||601 (88.8)|
| Member||65 (12.5)||76 (11.2)|
| Campus residence hall||206 (39.4)||297 (43.4)|
| Fraternity/sorority house||16 (3.1)||12 (1.8)|
| Other campus housing||32 (6.1)||59 (8.6)|
| Parent/guardian's home||79 (15.1)||75 (10.9)|
| Other off-campus housing||179 (34.2)||224 (32.7)|
| Other||11 (2.1)||18 (2.6)|
| Varsity athlete|
| No||460 (88.8)||619 (91.4)|
| Yes||58 (11.2)||58 (8.6)|
| Club sports|
| No||451 (87.2)||598 (89.3)|
| Yes||66 (12.8)||72 (10.7)|
| Intramural sports|
| No||393 (76)||525 (78.1)|
| Yes||124 (240||147 (21.9)|
Comparison of Health Behaviors of Students with and Without Diabetes (N = 1,216)
|Health Behavior||n (%)||p Valuea|
|Students With Diabetes (n = 528)||Students Without Diabetes (n = 688)|
| Felt rested every morning in past 7 days||25 (4.8)||30 (4.4)||0.747|
| No problem with daytime sleepiness in past 7 days||49 (9.3)||61 (8.9)||0.791|
| No extreme difficulty falling asleep in past 7 days||188 (36)||302 (44)||0.005*|
| No difficulty handling sleep problems within last 12 months||338 (64.3)||502 (73.3)||<0.001**|
| No academic problems due to sleep difficulties within last 12 months||381 (73.3)||542 (79.6)||0.010*|
| Met fruit and vegetable recommendations||41 (7.8)||36 (5.2)||0.073|
| Perceived to be the right weight||237 (44.9)||389 (56.5)||<0.001**|
| No history of anorexia or bulimia in last 12 months||488 (93.3)||673 (98.5)||<0.001**|
| No academic problems due to eating disorder in last 12 months||486 (93.5)||670 (98.7)||<0.001**|
| Did not use unsafe weight loss strategies in last 30 days||458 (87.4)||642 (94.1)||<0.001**|
| No use of cigarettes or other tobacco products last 30 days||365 (69.8)||513 (75.6)||0.026*|
| Met age and gender criteria for legal and moderate alcohol use||153 (29.8)||203 (29.8)||0.987|
| No binge drinking in last 2 weeks||304 (57.7)||416 (60.6)||0.299|
| Consistently used at least one protective drinking strategy in last 12 months||504 (95.6)||673 (98.5)||0.002*|
| No academic problems due to alcohol within last 12 months||464 (88.9)||646 (94.4)||<0.001**|
| No diagnosis or treatment of substance use or addiction in last 12 months||488 (93.5)||677 (99)||<0.001**|
| No drinking and driving in last 30 days||423 (80.4)||581 (84.9)||0.038*|
| No driving after five or more drinks in last 30 days||498 (95)||662 (96.9)||0.093|
| Met exercise recommendations for past 7 days||143 (27.6)||151 (22.2)||0.034*|