Calibrating logics: How adolescents and young adults calibrate often-competing logics in their daily self-management of type 1 diabetes

Abstract

Adolescents and young adults with type 1 diabetes must manage a demanding chronic condition in their daily lives, but adequate self-management remains a major challenge. In this article, we explore the logics invoked in shaping daily type 1 diabetes self-management among adolescents and young adults and propose an analytical view of self-management as a matter of ‘calibrating logics’. Drawing on Annemarie Mol’s concept of logic, our analysis of in-depth interviews with 21 adolescents and young adults with type 1 diabetes suggested that three main logics collectively shaped their self-management: biomedical, embodied and social. Biomedical logics appeared in the form of routinised insulin therapy, frequent blood glucose testing, and carbohydrate counting, all of which emphasise controlling blood glucose levels. Embodied logics emerged as refined practices such as ‘thinking insulin units’ and ‘listening’ to blood glucose fluctuations. Finally, social logics were at play when discreet or postponed self-management practices were used to adjust to social situations. While these logics may complement each other, study participants invoked how these logics often competed in daily life, generating tensions. We therefore propose viewing self-management as a matter of calibrating logics in which often-competing logics are at play. This can provide nuanced insights into the effort and challenges related to the daily self-management of type 1 diabetes for adolescents and young adults, in contrast to the prevailing dichotomy of adherence versus nonadherence to prescribed treatment regimens.

Keywords

chronic illness and disability ethnography illness behaviour patient-physician relationship

Introduction

Type 1 diabetes is a chronic condition in which the pancreas produces little or no insulin, the hormone that regulates blood glucose levels. Treatment regimens rely on a lifelong array of daily self-management activities to keep fluctuating blood glucose levels as stable as possible. Type 1 diabetes is commonly diagnosed in childhood (Simmons and Michels, 2015) and many people with this condition consequently grapple with self-management during adolescence and young adulthood. During these years, they are encouraged to become independent at managing their condition, not least when transitioning from paediatric to adult healthcare (Peters et al., 2011). However, ensuring adequate self-management and clinic attendance among adolescents and young adults remains challenging (Wolpert and Anderson, 2001; Peters et al., 2011). Most individuals with type 1 diabetes aged 15–24 years struggle to meet clinical targets for glycaemic control, engendering increased risks of developing serious complications (McKnight et al., 2015; Malik et al., 2022).¹ Inadequate management of blood glucose levels is thus a pressing health challenge for young people with type 1 diabetes.

Daily self-management of type 1 diabetes entails testing blood glucose levels and making complex predictions about how they may change due to insulin therapy, food, exercise, sleep and numerous other everyday activities. Various devices facilitate self-management, including insulin pens for injections and finger prickers and glucometers for blood glucose testing. More recently, wearable insulin pumps and continuous glucose monitors (CGMs) have been adopted, particularly by young people (Olsen et al., 2015). These devices deliver insulin and track blood glucose levels. Regardless of which technologies are being used, they provide detailed data that are then reviewed during clinical consultations (Bruni and Rizzi, 2013). Technological advancements may well have enabled fine-tuning of blood glucose levels, but the ‘chronic homework’ of producing adequate and ‘good’ blood glucose data has intensified as a result (Mattingly et al., 2011; Piras and Miele, 2017).

Although self-management of type 1 diabetes is demanding for all people, the life stages of adolescence and young adulthood introduce major changes in education, work, relationships and social identities (Best, 2011; Weissberg-Benchell et al., 2007). Research has explored the challenges of self-managing type 1 diabetes during this phase of life, focussing on the interplay between social identity, autonomy and normality. Studies have highlighted how young people strive to establish autonomy and usually seek to maintain a normal social identity regardless of their chronic condition, which entails participating in social activities on equal terms with peers (Balfe, 2009; Buchbinder, 2009; Rasmussen et al., 2007; Spencer et al., 2021). However, striving for autonomy and normality often clashes with adherence to prescribed treatment regimens (Boman et al., 2015; Commissariat et al., 2016; Ingersgaard et al., 2021; King et al., 2017; Pyatak et al., 2013). For example, due to a fear of missing out on social activities and in an attempt to minimise the disruptive nature of self-management, adolescents and young adults may deviate from their treatment regimens (Commissariat et al., 2016; Ingersgaard et al., 2021). Although findings are inconsistent, several studies have sought to determine how peers and family influence the extent to which adolescents and young adults adhere to treatment regimens (Hains et al., 2006; Lewin et al., 2006; Palladino and Helgeson, 2012; Raymaekers et al., 2017), suggesting that the potential link between (non)adherence and social relationships has received considerable attention.

While research has shed light on the complex challenges of self-managing type 1 diabetes during adolescence and young adulthood, we propose an alternative analytical lens in this article. Rather than viewing self-management as a matter of adherence, we argue for approaching it as a matter of ‘calibrating logics’. More specifically, we explore the logics invoked in shaping daily self-management among 21 adolescents and young adults with type 1 diabetes in Denmark. We describe three main logics that collectively shape self-management, showing how they often compete in daily life. Below, we introduce how Annemarie Mol’s (2008) concept of logic informed our analysis.

Logic framework

Within social sciences, the concept of logic has been applied in explorations of clinical diabetes care (see Ferzacca, 2000; Franklin et al., 2021a; Mol, 2008). In her ethnographic research, Mol attends to various logics in the examination of what ‘good’ clinical diabetes care entails in practical terms (Mol, 2008). Mol draws on resources including philosophy, anthropology, and science and technology studies (STS) in her conceptualisation of logic. She uses the concept of logic to articulate and bring attention to the rationales of practices and to explore what people find appropriate or logical to do in some site or situation (Mol, 2008: 9–10). More specifically, she argues:

(I)t [the concept of logic] seeks a local, fragile and yet pertinent coherence. This coherence is not necessarily obvious for the people involved. It need not even be verbally available to them. It may be implicit: embedded in practices, buildings, habits, and machines. And yet, if we want to talk about it, we need to translate a logic into language (Mol, 2008: 10).

While Mol seeks to identify and articulate logics by exploring clinical care practices, she stresses that practices are not strictly determined by these logics. In real life, practices are creative, and various logics co-exist and may complement each other or clash (Mol, 2008: 1, 9). However, an underlying pattern is inherent in the concept of logic: ‘Events somehow tend to fit together, there are affinities between them. That is what the term “logic” is meant to evoke’ (Mol, 2008: 9). In this sense, logics are not actors themselves, they are patterns in which various elements have been distilled into a ‘pure’ form to articulate them (Mol, 2008: 11–12). Mol examines and translates the logics of clinical care practices into what she characterises as a ‘logic of choice’ that contrasts with a ‘logic of care’. The logic of choice endorses neoliberal ideals of patient autonomy and informed choice, while the logic of care pertains to collaborative, attentive, and subtle ways of adjusting treatment to patients’ unpredictable bodies and daily lives (Mol, 2008). As Mol (2006) argues, ‘good’ clinical care entails creatively calibrating the various elements comprising a situation until they somehow fit and work.

In this study, Mol’s concept of logic inspired us to investigate rationales of practices, technologies, and modes of thinking invoked to shape the daily self-management of adolescents and young adults with type 1 diabetes and identify patterns of logics in interview data. Further, inspired by Mol (2006), we propose the concept of ‘calibrating logics’ to argue that type 1 diabetes self-management entails calibrating the various and often-competing logics comprising a given situation in daily life.

Self-management: Technologies, bodies and social life

A growing body of research has investigated diabetes self-management, exploring how technologies, bodies, and social life are intertwined. In her early work, Mol (2000) argued that people with diabetes are encouraged to live in a calculative mode to predict and counteract blood glucose fluctuations (Mol, 2000), regulating and controlling the body based on numerical values produced by self-management devices. Although people with diabetes are encouraged to think in calculative modes, they must simultaneously accept the fact that bodies do not necessarily act according to calculative rules (Mol, 2000). To deal with an unpredictable chronic disease, self-managing diabetes therefore relies extensively on gaining knowledge-in-practice (Pols, 2014).

Gaining knowledge-in-practice implies adapting devices to fit individual needs and learning to adjust to bodily sensations (Danesi and Pralong, 2018; Danesi et al., 2020; Kingod and Cleal, 2019; Mol, 2008; Mol and Law, 2004). People with diabetes are encouraged to train themselves to sense their blood glucose levels, particularly to avoid severe incidents of low blood glucose levels (Mol and Law, 2004). Although embodied sensations help anticipate blood glucose fluctuations (Danesi and Pralong, 2018; Danesi et al., 2020), they often disrupt everyday activities, resembling a form of ‘noise’ from the body (Kingod and Cleal, 2019). The noise accompanying self-management also includes sudden alarms from devices; for example, some CGMs transmit blood glucose data to insulin pumps that emit alarms for high or low levels. Although alarms may help prompt action on fluctuating blood glucose levels, they can also be triggered by incorrect measures and become disruptive noise rather than helpful tools (Kingod and Cleal, 2019). Regardless of the devices they use, people with diabetes often trust their embodied sensations to anticipate and interpret blood glucose fluctuations (Danesi et al., 2020; Kingod and Cleal, 2019).

This literature is mobilised in the discussion to shed light on how the identified logics can both complement each other and compete.

Methods

Data were collected as part of a more extensive ethnographic study carried out in two diabetes outpatient clinics in the Capital Region of Denmark. That study also included participant observations, but this article focuses solely on data from in-depth interviews.

Data collection and participants

The first (EMK) and third (MDT) authors collected the data from August 2017 to January 2018. Written project information was distributed to potential participants in the clinics during service hours dedicated to adolescents and young adults. We recruited 14 female and 7 male participants from 16 to 27 years of age, with a median age of 20.

Each participant provided verbal and written consent, and written parental consent was also obtained for those aged <18 years. In addition to formal consent procedures, we began all interviews by reiterating our research interest and stating that participants could withdraw from the study without explanation (Fluehr-Lobban, 1994). We conducted in-depth interviews using a reflexive approach that allowed for probing participants’ responses (Kvale, 2007). Interviews lasted 60–120 minutes and were conducted in participants’ family homes or public settings (e.g. cafés), according to their preferences. Six participants also participated in follow-up interviews after clinical consultations. A total of 27 interviews were included in the analysis.

The semi-structured interview guide was based on open-ended questions exploring participants’ background information, diabetes life stories, daily self-management practices and clinical care experiences. As a mind-mapping method (Rees, 2018), participants were asked to illustrate their daily routines (i.e. hours spent on school, work, leisure activities and self-management practices). Using a timeline representing their lifespan, participants were also asked to note diabetes-related events, such as acquiring an insulin pump, to situate them within the context of other life events. These methods supported participants in reflecting but were not directly included in analysed data. Interviews were recorded, transcribed verbatim and anonymised. The study was approved by the Danish Data Protection Agency (Rec. no.: 21024442).

Data analysis

The data analysis centred on exploring the logics invoked by study participants in their reported experiences and practices of self-managing type 1 diabetes. While our attention to logics arose from participant observations and interviews with participants, it also informed our theoretical stance when analysing interview data. In accordance with the principles of a reflexive thematic analysis (Braun and Clarke, 2019), we identified and analysed patterns in the data set using the concept of logic as our ‘core organising concept’ (Braun and Clarke, 2019). To this end, Mol (2008) helped us attend to logics as rationales of practices, technologies, and modes of thinking. First, transcripts were read through as a whole. Data segments, such as quotes in which study participants talked about the importance of daily blood glucose testing, were discussed by the first (EMK), third (MDT) and last (AW) authors to develop initial patterns of logics (e.g. routines of biomedical treatment). Data segments from all interview data were discussed and organised into main logics that could be identified in each interview.

Results

We identified three main logics – biomedical, embodied and social – that shaped daily self-management of type 1 diabetes among study participants. Although the logics are presented sequentially here, they shape self-management collectively and cannot be sharply divided in practice.

Biomedical logics

Biomedical logics emerged as participants stressed the importance of daily routinised insulin therapy, frequent blood glucose testing, and counting carbohydrates, all of which emphasise controlling blood glucose levels. Biomedical logics were invoked as arising from clinicians’ guidance and instructions for technological devices, suggesting ideals of what participants perceived as ‘good’ self-management.

Routinised insulin therapy delivered by any method took the form of a biomedical logic. For example, 17-year-old Julie² stressed the importance of injecting her long-acting insulin every morning:

Whether or not you like routines, it’s just something you need to have – it’s really bad if I forget to take my insulin in the morning because then your long-term blood glucose gets a lot higher – so it’s very important, and it’s one of the first things I do when I wake up because that’s something you’re supposed to do.

When asked how she knew what she was supposed to do in her self-management, Julie referred to clinicians’ guidance. Julie explained that clinicians often ‘praised’ her for being ‘good’ at taking care of her diabetes, but they also encouraged her to remember to inject her rapid-acting insulin before meals, not after. Julie added that she was ‘not good’ at this:

I’m not good at taking my insulin before I eat, so it [the blood glucose] often spikes because it takes about half an hour before the insulin works – it takes some time – so, they [clinicians] always tell me to take it [the insulin] before I eat.

As Julie clarified, her blood glucose levels spiked if she forgot to administer her insulin before eating. By using the phrase ‘not good at taking my insulin’, Julie described forgetting to inject her insulin before meals as being in tension with clinicians’ advice.

Daniel, aged 24, illustrated another biomedical logic by stressing the importance of frequent blood glucose testing. He explained that he was encouraged to calibrate his CGM with a new reference blood glucose value every 10 hours because frequent calibrations enable the CGM to track blood glucose levels as precisely as possible. Daniel elaborated:

If you force yourself to test [the blood glucose] in the morning and the evening to calibrate the CGM, it will do a lot for you and provide flexibility, so I test [the blood glucose] with my finger pricker in the morning – because I must calibrate the [CGM] sensor at least every tenth hour – and I try to test again during the day too, and then again in the evening.

Daniel described forcing himself to routinise daily blood glucose tests because he had to calibrate his CGM. When asked how the CGM could provide flexibility, Daniel responded that it spared him from using the finger pricker every time he needed to test his blood glucose because the CGM kept track of his blood glucose levels. The CGM also communicated blood glucose data to Daniel’s insulin pump, which alarmed when it fluctuated. Daniel explained that this had helped him keep his blood glucose more stable at work, saying ‘I can really feel it in terms of my performance because I work so much better, and I think faster when my blood glucose levels are stable throughout the day’. In this sense, Daniel indicated a biomedical logic of frequent blood glucose testing that helped him improve both his blood glucose levels and work performance, showing how these elements can be intertwined.

Although some self-management practices required routines, others took the form of counting and calculating. For example, as a biomedical logic, counting carbohydrates in meals is encouraged to support the match between food and insulin, especially when using an insulin pump. Insulin pumps automatically deliver small amounts of basal insulin, and extra boluses correct blood glucose spikes. Calculating a bolus insulin dose according to clinicians’ instructions requires entering the current blood glucose value and an estimated amount of carbohydrates into the pump (Tascini et al., 2018).³ Nine participants used insulin pumps, and, as 19-year-old William explained, counting carbohydrates quickly became a part of his routine of managing food and insulin pump therapy: ‘You quickly learn how many carbohydrates each meal has, so you know how many potatoes you eat and need to enter into the pump’.

Although William indicated that counting carbohydrates was easy, he explained that he does not correct his blood glucose spikes often enough. He said, ‘the doctor’s goal is to make me test my blood glucose more often – because more testing leads to more boluses, and more boluses lead to lower blood glucose levels, and that results in a lower long-term blood glucose level’.

As William clarified, the goal of more frequent blood glucose testing was to ultimately improve his long-term blood glucose levels. When asked what he thought about the purpose of this goal, William responded, ‘the goal is to get a good long-term blood glucose – and that’s obvious, that’s the most important thing – but getting there, that’s hard’.

Examples of why this might be challenging are introduced below but, as William indicated here, the biomedical logics of counting carbohydrates and correcting blood glucose spikes can be traced back to clinicians’ insulin pump instructions and guidance during clinical consultations.

Embodied logics

Embodied logics took the form of participants’ refined practices of ‘thinking insulin units’ to match their food with insulin and ‘listening’ to embodied sensations of blood glucose fluctuations. These logics may complement or compete with biomedical logics.

Nine participants described ‘thinking insulin units’ to match food with insulin. For example, 20-year-old Astrid had been using an insulin pump for 9 years but was reluctant to count carbohydrates:

I’ve never counted carbs, and I don’t want to, and I don’t understand it. I know my own body, so it’s much easier for me to look at a plate of food and think that I’ll take 5 or 10 insulin units – so I think insulin units, I don’t think carbs at all.

Astrid’s description of knowing her own body and preferring to ‘think insulin units’ to match food suggested an embodied logic refined through years of practice. Astrid then explained that she had been ‘thinking insulin units’ since childhood when she learned to use an insulin pen. She would therefore ‘feel weird’ if she had to count carbohydrates in every meal because this would change her relationship to food. However, since Astrid began using an insulin pump 9 years ago, clinicians had continually encouraged her to count carbohydrates. She elaborated:

They [clinicians] would never tell you to do something just because they want to be in charge, they tell you to do it [count carbohydrates] because they believe it’s good for you, but I don’t argue against the doctor – only if they tell me to count carbohydrates. [. . .] I simply refuse to look at a plate of food and count [carbohydrates].

Although Astrid indicated that clinicians’ recommendations were well-intended, she refused to count carbohydrates. This caused tension in clinical encounters because she had to ‘argue against’ clinicians but also emphasised that ‘thinking insulin units’ was more logical for her. Other participants who were reluctant to count carbohydrates echoed Astrid’s arguments. As 23-year-old Maja explained, she knew how to count carbohydrates but ‘thinking insulin units’ was more convenient in practice:

I did learn to use all kinds of manuals [to estimate carbohydrates in food], and I was good at counting carbohydrates, but I just stopped doing it. I often eat the same kind of food, so I just learn how much [insulin] I need – it’s basically learning by doing.

‘Thinking insulin units’ stems from ‘learning by doing’ rather than manuals. The accounts of Astrid and Maja both indicated that the embodied logic of ‘thinking insulin units’ competes with the prescribed biomedical logic of counting carbohydrates.

As another embodied logic, participants ‘listened’ to sensations from their bodies. These embodied sensations warned about blood glucose fluctuations and reminded participants to self-manage their diabetes. For example, 20-year-old Sara emphasised the importance of these sensations:

I don’t think about it [diabetes] unless I can sense it – maybe I just don’t put enough energy into it – but if I don’t experience any symptoms, then it’s like you don’t get reminded of it [diabetes], and you can really forget a lot of things if you don’t feel it in your body.

As Sara explained, she might not think about her diabetes until embodied sensations drew her attention to it, suggesting that ‘listening’ to these bodily cues can complement biomedical logics by supporting prompt self-management. However, ‘listening’ to embodied sensations could also be more logical than testing blood glucose levels with technologies. For example, Astrid explained that she usually preferred to eat rather than test when she sensed a low blood glucose level:

I know that I’m supposed to test [blood glucose levels] more often than I do, but I test when I need it, and that’s mainly before or after I eat – I don’t always test before I eat because sometimes I can sense that my blood glucose level is low, and then I’ll just eat – but then I might test my blood glucose level afterwards and realise that it’s a bit too high because I don’t take a dose of insulin and only eat in accordance with that. Sometimes you just weren’t that hungry and at other times you’ve eaten more food than the amount of insulin you’ve taken, so I must admit that I do it on gefühlen and I know that it’s not the best way to do it.

By using the word ‘gefühlen’, Astrid described relying on her intuition and experience in self-management. However, as she indicated, it could be challenging to stabilise her blood glucose without testing and calculating how much food was needed to bring it into the target range. Although Astrid explained that she was supposed to test her blood glucose more frequently, she responded to the sensation of a low blood glucose level as an embodied logic, generating tension between ‘listening’ to sensations of a low blood glucose level and a biomedical logic that prescribes testing blood glucose levels.

Furthermore, some participants described sensing high blood glucose levels as making them hesitant to test with technologies or face the test results. For example, 17-year-old Signe explained that whenever she sensed a high blood glucose level, she concealed the test result: ‘I used to cover up the glucometer’s screen when I knew it [the blood glucose] was high – I just didn’t want to see how high it actually was’.

Later, Signe pointed out that sensing and testing high blood glucose values still made her feel ‘irritated’ with herself. When asked to elaborate, she responded:

I don’t want it [the high blood glucose value] to be there [in blood glucose data] – at least I used to feel that way – but the doctor told me that I have to test it [the blood glucose] even though it’s high because there is no such thing as a bad blood glucose level – there are only bad ways to handle them.

Even though clinicians had encouraged Signe to avoid viewing high values as ‘bad’, sensing high blood glucose levels could still make Signe feel irritated with herself and reluctant to test it. This is a variation of the tension between sensing high blood glucose levels and a biomedical logic that prescribes testing blood glucose levels.

Social logics

Social logics related to adjusting self-management to social situations in daily life. Participants described both discreetly attending to self-management to avoid drawing attention to their diabetes and postponing self-management practices to attend to other priorities such as school, work, or activities with friends. Thus, social logics may both complement and compete with biomedical logics.

Several participants were hesitant to disclose self-management in public spaces such as restaurants, trains, or buses. As 21-year-old Ida explained, she often went to the bathroom to test her blood glucose and inject insulin. She described these practices as ‘kind of private’. When asked why she perceived self-management practices as private, Ida recalled an episode in which a stranger reacted with disgust as she tested her blood glucose: ‘I just think that I have experienced these kinds of incidents that make me want to keep it [self-management] private so that I don’t put myself into a vulnerable position where strangers might make comments about it’.

For Ida, potential vulnerability related to disclosure of her diabetes self-management in public spaces suggests a social logic behind keeping it private that entails discreetly attending to her self-management in bathrooms to avoid drawing attention to her diabetes.

Devices could also be used discreetly to adjust self-management to social activities. For example, Astrid did not mind self-managing her diabetes in the company of her friends, but she preferred to be discreet:

If I’m hanging out with some girlfriends, I don’t want our conversation to end – I can multitask, and I can do this [blood glucose testing] with my eyes closed – but I just think it would be weird to hang out with some girlfriends and talk about something funny, and then I suddenly have to do this [test the blood glucose] right there on the table, then it’s easier to just test under the table and then put it [the finger pricker and glucometer] away. My friends can watch, but I don’t want it to be a big thing – it’s just a part of me and something I have to do.

By using the phrase ‘it’s just a part of me and something I have to do’, Astrid invoked a social logic where discreet use of devices helps avoid drawing attention to diabetes and interrupting the flow of an engaging conversation. This social logic also complements a biomedical logic prescribing frequent blood glucose testing.

Although self-management could be practised discreetly, diabetes could still draw people’s attention. For example, 22-year-old Marie explained that her insulin pump sometimes alarmed during lectures at the university: ‘If the insulin pump is about to run out of insulin, it makes the most horrible beeping sounds – like very loud – and then everyone is looking at you’.

Although Marie did not mind if her fellow students knew about her diabetes, she explained that self-managing diabetes in front of other people might distract them:

It [self-managing diabetes in front of people] draws people’s attention and distracts their focus when they really should be focusing on the lecture – and I don’t like when people ask ‘what is that’ or ‘do you have diabetes’ – it’s not because I don’t want to talk about it – I am open about it – it’s just peoples’ curiosity that can be too much.

As Marie clarified, people’s curious questions could also be overwhelming, invoking a social logic behind keeping her self-management discreet in school.

Other social logics shaped self-management when participants attended to other priorities in daily life, often generating tensions with biomedical logics. Busy days at work with few breaks made diabetes self-management challenging for participants. For example, Julie described difficulties in self-managing her diabetes at her previous employment in a supermarket:

I actually had to talk to my mom about it because if you only have one break, you can only test your blood glucose level once during that shift. I could probably just have done it [tested the blood glucose], but it would be quite difficult to sit there behind the cash register and test, so it didn’t work out so well with blood glucose testing at my job – I mean, if I told them [colleagues] that my blood glucose level was low, then I was allowed to take a break – but you just kind of forget about it.

Although Julie had involved her mother in asking for extra breaks during work shifts, she was still reluctant to bother her colleagues by taking too many breaks, making her postpone her self-management. This exemplified a tension between a social logic of attending to the busy workflow with colleagues and a biomedical logic of frequent self-management. This tension intensified when Julie sensed a low blood glucose and had to promptly attend to her diabetes self-management.

Participants also described postponing diabetes self-management practices during social events. William explained why self-managing diabetes during parties was particularly challenging:

There are really no good excuses for not testing [the blood glucose] to do something about it – it’s just because you’re drunk and don’t feel like it – I’ll admit that, and it’s just a bad excuse. There is no way around it, and if you could micromanage the blood glucose to keep it stable, then you would do that, but when you’re drunk and at a bar or club and you have to get out the finger pricker and glucometer – that’s really not a problem – but you need to put it on a sticky table with alcohol – it’s just really tricky! So, if I test [during parties], I try to get my friends to hold it [the finger pricker and glucometer] and stuff like that, but you can’t do that all the time – then people would get so tired of you.

Postponing self-management during activities with friends exemplified a tension between a social logic of joining a party on equal terms with peers and a biomedical logic of frequent self-management. By using phrases such as ‘it’s just a bad excuse’ and ‘it’s just really tricky’, William exemplified the competing nature of these logics. He stressed the importance of self-managing his diabetes despite sticky tables at nightclubs, but he also worried that this would bother his friends or perhaps make him seem different.

Concluding discussion

Self-management of type 1 diabetes in the daily lives of adolescents and young adults is shaped collectively by three main logics: biomedical, embodied and social. Biomedical logics appear in the forms of routinised insulin therapy, frequent blood glucose testing, and carbohydrate counting, all of which emphasise controlling blood glucose levels. Embodied logics appear as refined practices such as ‘thinking insulin units’ and ‘listening’ to embodied sensations. Social logics are at play when discreet or postponed self-management practices are used to adjust to social situations. These main logics may complement each other or compete.

While previous studies have shed light on the complex challenges of managing type 1 diabetes during adolescence and young adulthood, research has tended to frame the balancing act between self-management and other priorities in daily life as a matter of adherence versus nonadherence (Boman et al., 2015; Commissariat et al., 2016; Ingersgaard et al., 2021; King et al., 2017; Pyatak et al., 2013). This is not altogether surprising, considering that inadequate self-management has been identified as one of the most pressing health challenges for adolescents and young adults with type 1 diabetes (McKnight et al., 2015; Miller et al., 2015). Nonetheless, a focus on adherence leaves little room for interpreting practices, values, and motives that conflict with prescribed treatment regimens as anything other than nonadherence. Inspired by Mol’s (2006; 2008) work and concept of logic, we focussed on the rationales of practices, technologies, and modes of thinking invoked to shape the daily self-management of adolescents and young adults with type 1 diabetes and argue that self-management entails calibrating various and often-competing logics comprising a given situation in daily life.

Calibrating logics inherently involves biomedical logics; as a kind of ‘chronic living’ (Wahlberg et al., 2021), adolescents and young adults with type 1 diabetes must think, act, and live by logics of keeping blood glucose levels as stable as possible. While Mol has examined how logics are intertwined with ideals of what ‘good’ clinical care entails (Mol, 2008), the biomedical logics described in this study suggest specific ideals of what ‘good’ self-management implies. Through a biomedical logics lens, it is oriented towards a specific and measurable goal of controlling blood glucose levels. This, in turn, distinguishes between self-management practices that are aligned with this specific goal and those that are not. When self-management also comprises calibrations of embodied and social logics, tensions emerge if they compete with biomedical logics.

Embodied logics are underpinned by knowledge-in-practice gained from dealing with self-management in everyday life (Pols, 2014). Gaining knowledge-in-practice is crucial for adopting technologies and being able to recognise blood glucose fluctuations (Danesi et al., 2020), stressing that embodied logics must be acknowledged as an important resource in self-management. While calibrations of embodied logics and biomedical logics can perfectly complement each other, they can also be in tension in various ways. For example, ‘thinking insulin units’ to match food intake with insulin is at odds with entering the amount of carbohydrates in meals into the insulin pump to help ensure a proper insulin bolus. Counting carbohydrates, as a calculative mode of thinking about food (Mol, 2000), is embedded within the insulin pump as a biomedical logic and encouraged by clinicians (Tascini et al., 2018). In contrast to simply following device instruction manuals, it is hard to predict what happens when technologies such as insulin pumps are adopted in practice. Technologies are manoeuvred to fit individual needs, values and daily events, giving rise to creative and often unexpected ways of using them (Kingod and Cleal, 2019; Mol, 2008). This becomes apparent when adolescents and young adults refuse to alter their modes of thinking about food because they have refined ‘thinking insulin units’ through years of practice. This also emphasises how ‘thinking insulin units’ can seem to resemble a resistance against a biomedical logic prescribing how devices should be used.

As described in other studies (Danesi et al., 2020; Kingod and Cleal, 2019; Mol and Law, 2004), embodied sensations are often trusted indicators of blood glucose fluctuations. However, our findings suggest that ‘listening’ to these sensations without testing with technologies can represent a calibration in which an embodied logic and biomedical logics are in tension. Training the ability to sense blood glucose levels is considered important in clinical care, but testing blood glucose levels is still encouraged (Mol and Law, 2004). Numerical values produced by devices are therefore perceived as more reliable than embodied sensations (Kingod and Cleal, 2019), not least through a biomedical logics lens. However, for people with diabetes, blood glucose levels are ‘known’ both as numerical values and embodied sensations (Mol and Law, 2004). Knowing how low blood glucose levels feel makes it logical for many adolescents and young adults to respond promptly by eating without testing. Yet, it also compels them to take breaks to self-manage their diabetes, even though this may generate tension with social logics such as helping colleagues during a busy workflow. Thus, embodied logics can be viewed both as causing tension with biomedical and social logics and supporting action on fluctuating blood glucose levels.

Testing blood glucose levels might also result in values that are interpreted as ‘bad’. Although numerical values can enhance a sense of moral responsibility for taking action (Mol, 2000), our analysis identifies a tension in which sensed high blood glucose levels also lead to feelings of guilt. As clinicians gain insights into blood glucose data and can pinpoint values in clinical consultations, the extent to which blood glucose levels are controlled becomes visible (Bruni and Rizzi, 2013; Danesi and Pralong, 2018). Although clinicians may say that no such thing as a ‘bad’ blood glucose level exists, awareness among adolescents and young adults with diabetes that values will be reviewed in clinical consultations may feed into a tension with biomedical logics emphasising blood glucose control.

While the extent to which the blood glucose is controlled becomes visible in clinical consultations, much of the demanding ‘chronic homework’ of self-managing type 1 diabetes in daily life remains invisible (Mattingly et al., 2011). Indeed, when self-management is discreetly practised in bathrooms or under tables, calibrations of social logics and biomedical logics complement each other perfectly. However, the effort of adjusting self-management to social situations receives little appreciation because data on blood glucose levels contain no information about the social conditions in which self-management practices are situated. Consistent with other studies (Commissariat et al., 2016; Ingersgaard et al., 2021), we found that disclosing self-management to others may result in negative reactions or draw perceived negative attention. In addition, sudden alarms from wearable devices may give rise to curious questions. In this sense, self-management devices intervene in social life through disruptive ‘noise’ from sudden alarms and reactions from other people (Kingod and Cleal, 2019; Mol, 2000), instigating calibrations of social logics to adjust self-management.

Although calibrations of social logics and biomedical logics can complement each other perfectly, tensions between them arise when self-management is postponed. As reported in other studies, maintaining the demanding balance between self-management and other priorities in daily life is particularly challenging when adolescents and young adults participate in activities with peers (Balfe, 2009; Buchbinder, 2009; Ingersgaard et al., 2021; Rasmussen et al., 2007; Spencer et al., 2021). However, public spaces, schools, work, and nightclubs do not favour people with chronic conditions such as type 1 diabetes because these environments are often not conducive to self-management practices (Franklin et al., 2021b; Scambler et al., 2014). For example, busy work shifts may not allow for frequent breaks and sticky tables at nightclubs do not invite blood glucose testing. These constraining circumstances and material environments of daily life require ongoing calibrations that often induce moral judgements around actions that are considered ‘good’ and ‘bad’ self-management (Franklin et al., 2021b). For example, this is invoked when adolescents and young adults express a dilemma between prompt self-management and feeling on equal terms with their peers. Through a biomedical logics lens, ‘good’ self-management is oriented towards controlling blood glucose levels, but calibrations of social logics take other priorities into account that may be in tension with biomedical logics, especially if self-management is postponed.

Calibrations of biomedical, embodied and social logics collectively shape self-management in the daily lives of adolescents and young adults with type 1 diabetes. While supporting adequate glycaemic self-management in clinical care is crucial, viewing self-management as a matter of calibrating logics can provide nuanced insights into the effort and challenges related to daily self-management among adolescents and young adults living with type 1 diabetes.

Study limitations

The study was conducted in Denmark where access to healthcare services is universal, and the degree to which our findings can be generalised to other healthcare settings or chronic conditions is unknown. We did not follow young adults in their daily lives to observe their self-management practices, although this could have enriched the study and given rise to additional interview questions. We did not assess age and gender differences in self-management of type 1 diabetes. Challenges for participants in late adolescence may differ from challenges for those who had transitioned to adult healthcare and moved away from their family homes. The experience of self-managing type 1 diabetes could also be influenced by social gender roles (Brooks and Roxburgh, 1999). In particular, young females may face specific self-management struggles (Dickinson and O’Reilly, 2004). Future studies could explore age and gender differences to gain further insights into the logics shaping the daily self-management of adolescents and young adults with type 1 diabetes.

Footnotes

Acknowledgements

We would like to acknowledge and thank all study participants and healthcare professionals at the diabetes outpatient clinics. This work would not have been possible without you.

Ayo Wahlberg would like to acknowledge his European Research Council Starting Grant no. 639275 under the European Union’s Horizon 2020 research and innovation programme.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Emilie Mølholm Kjærulff

Notes

Author biographies

Emilie Mølholm Kjærulff is a medical anthropologist and an Industrial PhD student. Her work focuses on diabetes self-management, digital health, the relationship between people with diabetes and healthcare professionals, and continuing professional development of healthcare professionals.

Natasja Kingod is a postdoctoral researcher. Her research focuses on patients’ use of social media for peer support in daily living with a chronic disease as well as families with children with type 1 diabetes. Her recent research focuses on continuing professional development among healthcare professionals using train-the-trainer models.

Mirjam Due Tiemensma is a medical anthropologist and an Industrial PhD student. Her work is focused on user-experience design and how to develop dementia-friendly communities.

Ayo Wahlberg is Professor with Special Responsibilities at the Department of Anthropology, University of Copenhagen. His research focuses on chronic diseases, quality of life, reproductive technologies, traditional medicine, complementary and alternative medicine, and health metrics.

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