Dietary Management in Individuals With Serious Mental Illness and Comorbid Diabetes: A Focused Ethnography Study

ABSTRACT Background Patients with serious mental illness (SMI) are more likely to have Type 2 diabetes mellitus (T2DM). However, studies that discuss the eating habits of patients with both T2DM and SMI are lacking. Purpose This study was designed to explore the beliefs and experiences of Taiwanese patients with SMI who also have T2DM. Methods Fieldwork for this study included 2 years of participant observation and individual interviews with 13 patients with SMI. Data from transcripts of observational field notes and interviews were transcribed verbatim and analyzed. Results The participants described their experiences and concerns regarding dietary management during the period after receiving their T2DM diagnosis. The results of the data analysis were distinguished into three categories, including (a) increased difficulty in life, (b) positive view of dietary control, and (c) inability to abide by dietary restrictions. Conclusions The findings suggest that healthcare professionals should work to better understand the challenges faced by patients with SMI and T2DM in implementing changes and resisting the temptation to eat unhealthy food and provide suggestions tailored to their cultural background, lifestyle, and eating characteristics.


Introduction
Patients with serious mental illnesses (SMIs) such as schizophrenia, schizoaffective disorder, bipolar disorder, and severe major depressive disorder are often influenced by mental, emotional, or cognitive disorders and experience limitations of normal daily function.Studies have shown patients with SMIs contract physical illnesses more easily than the general population (Gandhi et al., 2019), have a 10-to 15-year lower average life expectancy (Schmutte et al., 2018), and increase the global disease burden (Ronne et al., 2020).A comprehensive review of the literature from 1966 to 2010 revealed the likelihood of patients with SMIs developing Type 2 diabetes mellitus (T2DM) to be 2-3 times that of the general population (Ronne et al., 2020).Moreover, the prevalence of T2DM in patients with schizophrenia, bipolar disorder, and major depressive disorder are, respectively, 32.5%, 37.3%, and 30.5% (Tzeng et al., 2020).Taiwan's National Health Insurance Research Database has also revealed that, compared with the general population, patients with SMIs, especially those 60 years old or younger, develop T2DM more easily and receive medication for antihyperglycemia and antihyperlipidemia earlier in life (Bai et al., 2013;Chien et al., 2012;J. H. Hsu et al., 2011).Therefore, a sociocultural perspective was adopted in this study to describe the experience of dietary management in patients with SMIs comorbid with T2DM.
The Importance of Self-Management for Patients With Type 2 Diabetes Mellitus Many international organizations (Aschner, 2017) have suggested that patients with T2DM receive medical treatment; maintain healthy lifestyles; perform self-care; regularly receive tests for their retinas, kidneys, and feet; and control their blood sugar levels to prevent comorbidities from developing.However, international guidelines rarely integrate the needs of patients with both T2DM and SMIs, who often have low cognitive function and negative symptoms (Wykes et al., 2016).One study revealed that, compared with other patients with T2DM, patients with both SMIs and T2DM exhibit significantly inferior self-care behaviors (Cook et al., 2021).Although patients with SMIs are aware of the risks involved with poorly managing their T2DM, they generally fail to follow the recommendations of medical personnel (Mulligan et al., 2018).Some studies have discovered that factors hindering patients with SMIs from self-managing their T2DM include poor health literacy, emotional disturbance, stigmas, psychiatric medicine use, unhealthy lifestyles, lack of social support, and poor relationships with clinicians (Blixen et al., 2016;Cimo & Dewa, 2018;Ronne et al., 2020).Thus, elucidating the self-management experiences of SMI patients with T2DM is crucial.

The Effect of Diet on Diabetes
In diabetes self-management, dietary control has the most immediate and direct effects on blood glucose levels (Uusitupa et al., 2019).However, dietary control is considered by patients with T2DM to be the most challenging self-management task faced.The American Diabetes Association, noting that no particular diet is suitable for all patients with diabetes, recommends that every patient receive personalized dietary guidance (Davies et al., 2018).Previous studies have shown that limiting the daily intake of dietary fiber can improve glycemic control and decrease the risk of developing metabolic syndrome without caloric restriction or weight loss (Magkos et al., 2020).Moreover, the 2018 American Diabetes Association and European Association for the Study of Diabetes consensus report indicated a low-carbohydrate diet can help in managing T2DM and recommended the selection of a diet based on the patient's dietary preferences and metabolic requirements, ensuring feasible, sustainable, and healthy dietary habits (Davies et al., 2018).A systematic review and meta-analysis also reported that following Mediterranean, Dietary Approaches to Stop Hypertension, Portfolio, Nordic, liquid meal replacement, and vegetarian diets can decrease the risk of developing cardiovascular diseases in patients with T2DM (Kahleova et al., 2019).However, Lee et al. (2016) conducted a focus group interview and found that difficulty in changing dietary habits, inability to find healthy food, and poor communication with medical staff are barriers to healthy dietary management in men.Similarly, a research article published in 2021 in New Zealand reported that, although patients with T2DM attempt to find dietary information on the internet, the limited available resources and content frequently do not match their dietary habits (Chepulis et al., 2021).Similar findings were reported in studies on psychiatric disorder for patients with diabetes.A focus group interview in patients with SMI in Canada found dietary habits to be one of the barriers to practicing self-care (Cimo & Dewa, 2018).However, no study has examined the dietary habits of patients with T2DM and SMI.

Dietary Culture
Since the Chou Dynasty (1046 BC to 256 BC), ethnic Chinese populations have considered eating as an essential aspect of life, leading eating to develop into not only a habit but also an aspect of culture (Chen & Xu, 1996).Rong et al. (2017) interviewed Chinese patients with heart failure in China and discovered that it is difficult for them to make alterations in their diet (Rong et al., 2017).Culture is a major factor influencing patient food preferences.Zou (2017) pointed out that the dietary intake of Chinese Canadians, which includes high sodium, low fruit and vegetable, and low dairy consumption, is not in line with hypertension dietary recommendations.These dietary habits negatively affect blood pressure control in Chinese Canadians (Zou, 2017).Rice and noodles are the main sources of carbohydrates and a staple of Chinese meals (Badanta et al., 2021).However, patients with T2DM worry that excessive carbohydrate intake can increase blood glucose levels and thus try to control blood glucose by dieting (Gandhi et al., 2019).Wan et al. (2020) compared the experiences and views on dietary self-management and nutritional requirements of Chinese immigrants in Australia and White Australian women with gestational diabetes mellitus.The study revealed a lack of cultural relevance in the dietary advice received from health professionals by Chinese women with gestational diabetes mellitus and that these women responded by restricting their dietary intake or relying on nutritional supplementation (Wan et al., 2020).In Taiwan, M. T. Hsu et al. (2015) similarly found the illness experiences of women with T2DM to be a shift from being in control of food to being controlled by food.Therefore, understanding dietary control experiences from the perspective of Chinese patients with SMIs after they develop T2DM is critical and may assist nurses to offer patients with SMIs an adequate diabetes-related dietary health education.
The purpose of this study was to explore the beliefs of patients with SMIs and T2DM and their coping experiences in an ethnic Chinese cultural context.

Design
The focused ethnography approach explores a particular problem and its specific context within a discrete group of people during a limited period (Muecke, 1994).The goal is to understand how a particular population lives, how its individuals interact, what they believe, how they behave, and what they do.In this study, we used a focused ethnography approach to look for the social and cultural aspects of the experience of patients with SMI in Taiwan, including how they felt and what they thought in the period after diagnosis.Data were gathered through selected episodes of participant observations and interviews.Data were analyzed using Hammersley and Atkinson's (2019) analytic induction techniques.

Participants
Participants were recruited from a daycare center and an acute psychiatric ward at a medical center in northern Taiwan.Eligibility criteria were as follows: (a) at least 20 years old; (b) diagnosed by an independent psychiatrist with schizophrenia, schizoaffective disorder, bipolar I disorder, or major depressive disorder in accordance with the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) and with T2DM by an endocrinologist; (c) oral hypoglycemic agent use or insulin therapy; (d) able to speak Mandarin; and (e) agreed to participate in the study and be digitally recorded during the individual interview session.Those with severe psychosis, severe cognitive function preventing participation in the interview session, intellectual disability, or organic brain syndrome or who were not able to write or communicate in Chinese were excluded.

Data Collection
Data were collected between January 2016 and April 2018 using participant observations and interviews.Participant observations were carried out over a full year.For 2 days per week, 6 hours per day, researchers observed and communicated with the patients.Field notes were taken and transcriptions were made after every observation session.Although the participant observations were unstructured, they focused on the patients' responses to their T2DM, including how they coped emotionally with changes in blood glucose levels, achieved glycemic control, and faced related challenges during the course of the disease.In addition, their verbal and nonverbal behaviors were observed.Furthermore, the interactions between the medical staff (physicians, nurses, and others) and the patient were studied (Hammersley & Atkinson, 2019).Blood glucose levels and other related blood marker information were collected at enrollment.Each observation period covered a range of relevant features to identify context.Field notes were descriptive and used to document important activities, statements, and observations; a comprehensive record was drafted immediately after each observation period.
Observations and interviews were performed by the first author, who has 10 years of clinical psychiatry experience and nearly 8 years of qualitative research experience.Data were collected using in-depth face-to-face, semistructured interviews, which were conducted in a quiet, private room of the medical center.The focus of the interviews was exploring the dietary practices of the participants, all of whom had SMIs and were receiving hypoglycemic treatment.Data saturation was achieved after no new codes appeared in the analysis.All of the interviews were conducted in Mandarin, lasted from 40 to 70 minutes, and were transcribed verbatim.The guiding questions used in the interview are listed in Table 1.

Ethical Considerations
This study was approved by the institutional review board of the hospital in which it was conducted (reference number: 1-105-05-184).All of the participants were informed that their decision to participate would not affect the medical care they received at the study hospital.They were also assured that they could withdraw at any time.In addition, all were assured their participation would be anonymous and that confidentiality would be maintained throughout the study and in any subsequent publications.Informed consent was obtained from each participant before their interview.

Data Analysis
Data analysis was performed from the start of data collection through to study completion.Observation and interview data were analyzed using Hammersley and Atkinson's (2019) analytic induction technique.Two researchers began by reading the transcripts carefully and then generating an initial list of codes.Next, the codes were analyzed and sorted into themes or subthemes based on the results of discussions among the research team members.Relevant excerpts from the transcripts were referenced to diagram a set of lines and nodes to elucidate the relationships between the codes, themes, and different levels of themes.We then defined and refined the themes to identify the key aspects of each.Accordingly, the themes were integrated into an exhaustive description of participants' experiences after being diagnosed with T2DM.

Methodological Rigor
Methodological rigor was assessed at every phase of the study for duration and depth of fieldwork; participant observation; interviews; and data analysis in terms of credibility, dependability, transferability, and confirmability (Guba & Lincoln, 2005).Credibility was achieved through prolonged engagement.We spent over 2 years with patients in the psychiatric wards to develop rapport.Dependability and confirmability were achieved by sharing emerging themes and the primal text with the participants in this study and with experts in mental healthcare (Guba & Lincoln, 2005).In addition, we provide sufficient detail in the participants' quotes in the Results section to allow readers to judge transferability (Guba & Lincoln, 2005).In addition, all participant views, perspectives, claims, and voices were made apparent in the text, supporting the criterion of authenticity (Guba & Lincoln, 2005).All of the research team members worked together to determine the probing questions, interrogate ourselves, check coding reliability, and evaluate the evidence throughout the data collection process to ensure an ethical relationship with participants was established (Guba & Lincoln, 2005).

Results
Thirteen patients (three men and 10 women) participated in this study.Seven were recruited from a daycare center, and six were recruited from an acute psychiatric ward.With regard to SMIs, 46.2%, 30.8%, and 23% of the participants had respectively received diagnoses of schizophrenia, bipolar disorder, and major depressive disorder.Their mean age was 54.2 (SD = 10.02,range: 38-71) years, and their mean duration of T2DM was 7.2 (SD = 4.8) years.Eleven of the participants were using oral hypoglycemic agents at the time of the study, and two were taking insulin.All were either unemployed or retired.
During the 1-year observation period, the participants described their postdiagnosis experiences and concerns regarding dietary management.Our analysis identified the following categories: (a) increased difficulty in life, (b) positive view of dietary control, and (c) inability to abide by dietary restrictions (Table 2).

Increased Difficulty in Life
In direct comparison with their mental illnesses, nearly all of the participants identified T2DM as an inconvenient and distressing disease.
Life has been very distressing since I got diabetes.When I sit down for less than 50 minutes, I realize I need to urinate.I have to keep going to the bathroom, but I take so many medicines, I have to drink water, or it will become toxic for me.However, it results in me needing to urinate all the time.(Participant 5) To maintain control over their T2DM, participants strove to alter their normal lifestyles.However, despite taking self-management measures, their blood sugar remained high.The participants felt life had become extremely difficult.
I found out I had diabetes.I felt…kind of like I did not want to live.Life is difficult.I have to keep taking medicine for the rest of my life because it cannot be completely cured.(Participant 2) The participants appeared to feel especially distressed regarding their (a) terrible treatment experiences, (b) fear about diabetes comorbidities, and (c) feelings that no one cared that they were sick.

Terrible treatment experiences
The participants regularly visited the diabetes outpatient clinic every 3 months.For each visit, the patients have their blood analyzed to determine their blood sugar before seeing the doctor.However, many participants experienced challenges with having their blood drawn.
Waiting for blood to be drawn is, god…horrible.There are so many people.I leave my house at around 8:00, and I have to wait until noon to get my blood drawn.(Participant 11) Only a few of the participants received guidance from health educators.However, these participants reported feeling uncomfortable during the process.
At first, I thought blood sugar was something I eat every day.Sugar mainly comes from rice, so I started eating germinated brown rice or five-grain rice instead.Then I started keeping track of my starch and sugar intake because I thought those things could be controlled.After the doctor heard about what I was doing, he immediately referred me to the diabetes health educator next door.The woman (raising her voice) scolded me and immediately referred me to the nutrition room.(Participant 7)

Fear about diabetes comorbidities
When participants visited the clinic, they were concerned about their blood test results.When they saw their glycated hemoglobin or blood sugar levels increasing, they started to worry they would develop comorbidities.
Diabetes scares me.Diabetes has many negative effects, such as not being able to feel your feet.If your feet get 4. Taking psychiatric medicines that increase appetite 9 The Journal of Nursing Research injured, such as from clipping your toenails, the injury can get infected.That is why I am concerned.(Participant 4) The participants were afraid they might experience hypoglycemia when they were alone as well as worried they would not be sent to the hospital in time and would die.
I am afraid of fainting.I do not know whether anyone would save me or whether I would wake up if that happened.I have this fear.Therefore, as soon as I feel hungry, I eat.(Participant 5) Feelings that no one cared that they were sick Most participants believed that psychiatrists and endocrinologists treat different problems.Therefore, the participants did not actively discuss controlling their blood sugar with their psychiatrists or nurses.
Dr. Chang is a psychiatrist, which is different from an endocrinologist.He did not know that I have diabetes.I never mentioned it to him.The doctors are from different departments, so I do not need to mention my diabetes.(Participant 5) The participants also stated that, even when psychiatric medical personnel were aware they had T2DM, they provided limited assistance.
The nurses only talked about extremely simple things.Sometimes I receive health education sheets from them.However, those sheets only provide simple information on simple problems that I am already aware of.(Participant 9)

Positive View of Dietary Control
Participants discovered that they developed T2DM because they liked to eat sweet foods and to eat and drink a lot.After being diagnosed with T2DM, they learned about the relationship between food and blood sugar, and they realized that diet control is essential.
In the past, when I wanted to eat supper, I would not just eat one bowl of instant noodles; I would eat two.Now, by 9:00 pm, when people are eating instant noodles, no matter how good they smell, I watch TV and do not have even one bite.If I do, my blood sugar will rise the next day.When I see that my blood sugar has increased, I feel sad.(Participant 10) Dietary control is better than taking medicine After developing T2DM, the participants learned they were required to take antihyperglycemic medication in addition to their original psychiatric medicine.The two types of medicines are taken at different times and frequencies each day.Thus, many of the participants felt they were taking medicine all day.
Dietary control is better than taking medicine!The doctor said that in severe cases of diabetes, people may require amputation.Each day I think about this, and I become worried.That is why I must control what I eat and control my blood sugar.I want to try to control my disease through diet, not through medicine.(Participant 8) One participant saw that his glycated hemoglobin levels had increased in a recent test.Because he had already been dieting to remain healthy, he implemented an even stricter dietary control in response to his results: Last time, the test results were unfavorable, so now, I often make vegetable smoothies to drink.I make a smoothie about once every 2 or 3 days.I try not to eat starch.I try not to eat too much white rice.(Participant 2)

Food choices
Nearly every participant had a method to control their diet.However, because only a few had been educated on diabetes-related health and many had only partially incorporated the information provided by medical personnel into their dietary control measures, their food choices did not necessarily meet the diet requirements for patients with T2DM.
I try to eat salty foods.I add soy sauce to my wheat vermicelli to make the vermicelli salty.I do not eat sweet soups.I do not eat starch.Clear soups and oil are fine to eat.(Participant 5)

Taking health supplements
The participants asked their friends and family about how to use health supplements to control their blood sugar level, believing these health supplements to be effective for this purpose.
When my glycated hemoglobin increases quickly, I take Argin-U to control my blood sugar levels.It is a powder.Another person introduced it to me.He said he took it, and his glycated hemoglobin levels decreased.He suggested I take it.

(Participant 2)
When my body is not doing well, I need to…no, not take medicine, to take Centrum.I regularly take multivitamins.In addition to diet control, I take multivitamins to take care of myself.(Participant 8)

Inability to Abide by Dietary Restrictions
Although many participants want to use diet to control their blood sugar levels, factors such as being unable to find suitable food, a lack of fullness, an inability to resist tempting foods, and taking psychiatric medicine prevented them from controlling their eating as well as they wanted.
Unable to find suitable food Some of the participants were unable to prepare meals for themselves and instead ate at buffets, noodle shops, or 24-hour convenience stores near their homes.Although they were able to eat what they liked at those places, the foods available are not necessarily suitable for patients with T2DM.
When I was at home, I ate whatever, or I sometimes skipped meals.There was a convenience store, an OK Mart, near my house.I often drank coffee there and brought along something to eat.The same was true for lunch.It was also convenience store food such as dumplings, microwavable meals, and boxed lunches.(Participant 3)

Lack of fullness
Because patients with T2DM cannot effectively utilize the sugar in their blood, they feel hungry more easily.
I find that if I control what I eat for dinner…if I overcontrol it, then after a few hours when I am starving, I get up in the middle of night and unconsciously start eating.(Participant 7) Another participant also shared that, although she told herself not to eat sweet foods, because of hunger, she found herself eating even more sweets.
I ate vegetables and fruits, but very soon, after I went to the bathroom, my stomach felt empty.I was still hungry.Because I did not eat rice, I did not feel full.Last night, I ate at 6:00 pm.At 8:00 pm, I was hungry again.I ate two jujubes, but that did not work, so I ate a pack of sandwich crackers.They were very sweet, but I ate another pack.I only felt full after eating the sandwich crackers.(Participant 1)

Inability to resist tempting foods
In their daily meals and when meeting with friends and family to eat, participants enjoyed both meeting with people to eat and the sense of improving their relationships through enjoying food together.However, because families can rarely prepare special meals for members with T2DM or alter their general dietary habits to suit such members' needs, individuals with diabetes must learn to resist tempting foods.
Not every family member has high blood sugar, so they do not need to cook special foods for everyone.Sometimes, family members did not agree with the dietary changes the participants had made.
I need to control my cholesterol, so I eat oatmeal.However, my parents do not eat it and do not agree with my eating it.(Participant 7) When friends and family had get-togethers, the participants struggled to resist eating foods that were unhealthy for them.Furthermore, in such situations, the participants were expected to enjoy the food with their guests to cultivate a cheerful atmosphere.
Taiwanese people's greatest hobby is eating.Sometimes, I am a guest at meals my father hosts.However, as a guest, if I eat nothing, I feel miserable.Also, the table is full of dishes.I think if I was the host of a meal and did not eat but encouraged others to eat, the situation would be awkward.But if I eat, it is bad for my body.(Participant 7)

Taking psychiatric medicines that increase appetite
The participants expressed feeling ambivalent about taking psychiatric medicine.They maintained that when they experienced unfavorable moods, eating sweets could make them feel better.However, doing so would increase their blood sugar level.Furthermore, although taking psychiatric medicine stabilized their mood and symptoms, it increased their desire to eat, and they consequently gained weight.
However, I do not know how to deal with emotional problems.Since I started taking the medicine, I have gained several kilos.Some medicines make me really want to eat.They increase my appetite.I try to control myself and to not eat too much.(Participant 9)

Discussion
This study revealed that the participants were conscious of the risks posed by T2DM and thus wished to control their diets.However, most had problems with high blood sugar levels.Moreover, when the participants sought medical support, they felt anxious and struggled to accept the diabetes-related health information provided by medical personnel.Consequently, the participants adopted inadequate dietary methods to control their T2DM.Some of the participants were unable to control their diets because of factors such as being unable to find suitable food, resist the feelings of hunger, and resist the temptation of food.In addition, because of the side effects of their psychiatric medicine, their blood sugar and glycated hemoglobin levels would increase.The results of this study may assist nurses to better understand the difficulties patients with SMIs face in managing their diabetic diets.The results may serve as a reference for nurses conducting health education programs on diabetic diets for patients with SMIs.
The findings indicate that patients with SMIs and T2DM are conscious of the risk of diabetes with respect to their physical health and quality of life, as the participants recognized that adjusting their diet was critical.Ince et al. (2017) found that patients with both SMIs and T2DM are similar to patients with T2DM only in terms of being generally aware of the risks of T2DM with respect to their life and of feeling anxious and afraid.However, a qualitative interview study in Taiwan revealed that, for patients with T2DM, the lack of obvious symptoms at the onset of their disease may lead them to neglect self-management of their condition.The patients in that study only recognized the potential effects of T2DM after developing renal failure requiring dialysis (Lin & Chu, 2022).This indicates that disease understanding affects patients' willingness to alter their lifestyle and perform self-care.Therefore, when patients with SMIs develop T2DM, nurses must continue to provide them with relevant information and encourage the adoption of effective disease self-management strategies.
This study further revealed that, because the participants had negative experiences in communicating with medical teams specializing in T2DM, they felt anxious about seeking medical support and thus did not receive comprehensive diet-related health information.Schnitzer et al. (2020) evaluated 10 randomized controlled trials and found miscommunication between patients and doctors or doctors' failure to show respect prevented patients from self-managing T2DM.Cook et al. (2021) conducted research in the United States and found similar results as well as found that the key to assisting patients with SMIs self-manage their T2DM is facilitating patient-doctor communication.

The Journal of Nursing Research
Wen-Chii TZENG and Hsin-Pei FENG In this study, although the participants perceived diet control as critical, their personal preferences and the influence of Taiwanese culture prevented them from easily controlling their dietary intake.For example, rice and noodles are staple foods in Taiwan, and these foods are symbolic in holiday dishes.At Chinese New Year, turnip cakes and rice cakes symbolize career success and long life, respectively.However, these foods contain high levels of carbohydrates and should not be consumed in large quantities by patients with T2DM.However, many patients hold misconceptions regarding diet, believing that not eating sweet foods alone should improve their blood sugar levels.These patients also have an inadequate understanding of food exchange, resulting in imbalanced diet and nutrition.Ince et al. (2017) observed similar results, identifying that patients with SMIs and T2DM have less favorable self-care skills, especially with respect to medical treatment and diet compliance.These patients are unwilling to go for walks or exercise, and they struggle to prepare suitable foods for a diabetic diet and to follow this diet.These patients also view their lives after the development of T2DM as restricted.A systematic review revealed that patients with SMIs have unhealthy eating habits, including low levels of fruit and vegetable intake and high intakes of instant foods and sugary beverages (Teasdale et al., 2019).A study conducted in the United Kingdom revealed that patients with SMIs have poor diets because they have fixed eating habits.However, although many patients are aware of their unhealthy lifestyles, they continue to purchase and eat foods not suited to diabetic health (Heald et al., 2017).
In Chinese cultures, eating together as a family or with friends and treating each other to meals are common means of maintaining social relationships (Lim & van Dam, 2020).People from such cultures also often center social activities on dining.People meet with friends and relatives at restaurants to reinforce interpersonal relationships.Moreover, they meet with new friends at restaurants to develop these new interpersonal relationships.Through eating and drinking, they expand their social network.When food is the medium through which individuals with T2DM socialize, their self-control is tested.Lin and Chu (2022) reported that Taiwanese patients struggle to restrain themselves from eating inappropriate foods when offered dishes at family gatherings.Ronne et al. (2020) conducted a systematic review and revealed similar findings, discovering that food plays a central role in Asian cultures, leading people in these cultures to struggle to modify their conventional eating habits to manage diabetes.Therefore, when nurses provide patients with SMIs with recommendations on how to alter their lifestyles or eating habits, they should be cognizant of the challenges patients face in implementing these changes and in resisting unhealthy foods.
Patients with SMIs must take psychiatric medicine daily.However, many patients self-adjust their dosage over time based on their needs.If these patients must also take antihyperglycemics, they may feel they are taking medicine all day long.Participants in this study stated that, although they understood that second-generation antipsychotics may stabilize their psychiatric symptoms, a side effect of this medicine is increased appetite.Consequently, the patients felt forced to choose between stabilizing their mood and controlling their blood sugar level.A qualitative study on taking second-generation antipsychotics also revealed that patients in this situation face extreme difficulties in controlling hunger triggered by medicines, their weight, and related physical and emotional problems (Usher et al., 2013).Similarly, a meta-analysis on medical compliance in patients with both SMIs and T2DM found diabetic medicine prescription compliance to be associated with younger onset of T2DM, regular outpatient clinic treatments, higher medicine prices, a high filled prescription rate, and higher levels of independent medication administration (Gorczynski et al., 2017).Therefore, medical and nursing personnel should emphasize the potential risk of weight gain in addition to the benefits of taking medicines.Medical personnel should proactively assist these patients to plan lifestyle changes and teach them the importance of weight control to help prevent the problems patients experience because of medicine-related weight gain such as altered body image, low self-esteem, withdrawal, and conscious cessation of taking their medicine and to help prevent the development of chronic diseases such as T2DM, hypertension, and heart disease.

Limitations
The minimum age for participating in this study was 20 years.However, the actual age range of participants was 38-71 years.Therefore, the findings represent the dietary control experiences of middle-aged to older patients with SMIs who developed T2DM and are not representative of all age groups.Furthermore, the participants were recruited from a single hospital and were mostly women.Thus, the findings may not be generalizable to all patients with SMIs and T2DM.Moreover, this study excluded patients with severe cognitive disorders and those unable to verbally express their thoughts.Therefore, the dietary control experiences of patients in these excluded categories were not considered.We suggest future studies include psychiatric departments at medical institutions of different levels, increase the number of male patients, and include primary caregivers as research participants.Expanding the research in this way may be expected to facilitate an even deeper understanding of the disease and dietary control concerns and needs of both patients with SMIs and T2DM and their primary caregivers.

Conclusions
The findings of this study indicate that many patients with both SMIs and T2DM consider their diagnosis of T2DM to be more troublesome and distressing than their mental illness.In addition to experiencing diabetic-symptom-related pain, these patients must also alter their lifestyles.However, although many of the participants in this study worked hard to adjust their lifestyles, they felt their blood sugar levels remained outside their control.The participants often struggled with not understanding how they could be consuming appropriate foods and be still unable to curb their appetite.Therefore, we suggest that, before offering patients health information, clinicians should first seek to understand the difficulties faced by their patients with SMIs and T2DM and their challenges in implementing changes and resisting the temptation to eat unhealthy foods.This should better enable clinicians to provide patients with suggestions appropriate to each patient's cultural background, lifestyle, and eating habits.Moreover, clinicians should assist patients with SMIs to improve patient-doctor communications to prevent information misinterpretation and medical noncompliance.
In terms of future research, primary caregivers and nurses in psychiatric departments should be recruited as research participants to elucidate their concerns and needs related to promoting and facilitating disease and dietary control in their patients.In addition, quantitative studies should be designed to explore the factors that affect diabetes self-care behaviors in patients with mental illness to provide a reference for clinical care.
Therefore, I need to choose what I can eat and what I cannot eat.(Participant 9)

Table 1
Interview Guide 3. What changes have occurred in your life since you developed diabetes?4.How do you manage your diabetes?5.How does having both diabetes and a mental illness affect your life?

Table 2
Thematic Analysis