Lifestyle in emerging adults with type 1 diabetes mellitus: a qualitative systematic review

Citation: Núñez-Baila, M.-Á.; Gómez-Aragón, A.; Marques-Silva, A.-M.; González-López, J.R. Lifestyle in Emerging Adults with Type 1 Diabetes Mellitus: A Qualitative Systematic Review. Healthcare 2024,12, 309. https://doi.org/10.3390/ healthcare12030309 Academic Editor: Chrysi Koliaki Received: 27 December 2023 Revised: 22 January 2024 Accepted: 23 January 2024 Published: 25 January 2024 Copyright: © 2024 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). healthcare Systematic Review Lifestyle in Emerging Adults with Type 1 Diabetes Mellitus: A Qualitative Systematic Review María-Ángeles Núñez-Baila 1, Anjhara Gómez-Aragón1,* , Armando-Manuel Marques-Silva 2,3 and JoséRafael González-López 1 1Nursing Department, Faculty of Nursing, Physiotherapy and Podiatry, Universidad de Sevilla, 41009 Seville, Spain; [email protected] (M.-Á.N.-B.); [email protected] (J.R.G.-L.) 2Department of Nursing, Escola Superior de Enfermagem de Coimbra, 3004-011 Coimbra, Portugal; [email protected] 3Unidade de Investigação em Ciências da Saúde: Enfermagem (UICISA: E), 3004-011 Coimbra, Portugal *Correspondence: [email protected] Abstract: Emerging adulthood is a transitional stage with significant lifestyle changes, making it especially challenging for those living with type 1 diabetes mellitus. This systematic review synthesizes qualitative research to explore how emerging adulthood (18–29 years) influences lifestyle behaviors in individuals with type 1 diabetes mellitus. CINAHL, Cochrane Library, Global Health, Nursing & Allied Health Premium, PsycINFO, PubMed, Scopus, and WOS were searched for original qualitative studies addressing the lifestyle of 18–31-year-olds with type 1 diabetes mellitus, published between January 2010 and March 2021 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Thirty-five studies met the inclusion criteria and their findings were categorized into eight topics (emotions and feelings, nutrition, perceptions, risky behaviors, self-care, sleep, social relationships, and stigma) using meta-aggregation, as outlined in the Joanna Briggs Institute Manual for Evidence Synthesis. The spontaneity characteristic of emerging adulthood can undermine self-care. This is because new environments, schedules, and relationships encountered during this life stage often lead to the neglect of diabetes management, owing to the various social, academic, and occupational demands. This review highlights the necessity of creating health promotion strategies tailored to the unique lifestyle aspects of emerging adults with type 1 diabetes mellitus. Keywords: adult; emerging adult; lifestyle; young adult; type 1 diabetes 1. Introduction Throughout emerging adulthood, a stage defined by Arnett [ 1 ] and covering ages 18 to 29, most of the legally adult people do not fully embrace adult identity due to factors such as persistent economic dependence, extended educational engagement, and challenges in accessing or securing stable employment [ 2 ]. This situation results in a delay in achieving traditional adult social milestones and, thereby, conventional adult roles [ 3 , 4 ]. Additionally, this stage was characterized by a great deal of exploration in human spheres and activities such as sexuality, physical exercise, nutrition, socio-occupational relationships, sleep patterns, self-care, and, in many cases, the consumption of alcohol, tobacco, or other drugs [ 5 – 7 ]. While adolescence is also a time of self-discovery and experimentation, it differs primarily in the fact that adolescents are not legally considered adults and they have a lower spending power [8]. For emerging adults, managing chronic diseases like type 1 diabetes mellitus (T1DM) can be particularly disruptive. The required attention often collides with external social demands such as friendships, partnerships, studies, and the overall pace of life [ 9 , 10 ]. According to the International Diabetes Federation the global prevalence of T1DM, which is increasing every year, was 8.75 million [ 11 ]. The onset of T1DM usually occurred in Healthcare 2024,12, 309. https://doi.org/10.3390/healthcare12030309 https://www.mdpi.com/journal/healthcare Healthcare 2024,12, 309 2 of 21 childhood or adolescence, which are the most investigated stages [ 12 ]. However, recent data indicated that 62% of new T1DM diagnoses occurred in individuals over 20, highlighting a shift in research focus to adult life stages [ 11 ]. The multidimensional treatment of T1DM involves medication management, blood glucose monitoring, carbohydrate counting, and physical exercise [ 9 ]. Consequently, the impact of day-to-day diabetes management becomes unavoidable and may lead to lifestyle discordances [10]. Within the context of emerging adulthood and chronic illness management, Meleis’ transition theory offers a pivotal framework [ 13 ]. This theory underscores the significant changes and transitional periods individuals experience, crucial to their development. According to Meleis, these transitions involve shifts not only in health and illness but also in identity, roles, and relationships [ 13 ]. For emerging adults with T1DM, these transitions are particularly profound, requiring navigation through the complexities of their chronic condition alongside the life transitions characteristic of this stage [ 9 ]. Understanding these processes is vital for developing tailored care strategies and support systems, aimed at addressing the specific needs of these individuals [14]. T1DM demands constant self-management and adherence, potentially leading to emotional stress and distress due to the individual’s active role in required self-care [ 15 , 16 ]. For this very reason, it is necessary to know how self-care practices are integrated into the rest of the activities which form their lifestyle, such as nutrition, physical activity, sleep, sexuality, social relationships, and risky behaviors such as alcohol consumption. At the same time, it is also necessary to understand the similitudes of these behaviors with respect to those of their peers without T1DM. A qualitative methodology allows for an in-depth understanding of the reasons for adopting certain behaviors. Several authors [ 12 , 17 , 18 ] claimed that using an exclusively quantitative methodology in the study of lifestyle leads to a lack of knowledge about the motivations behind the behaviors adopted. Therefore, the objective of this systematic review is to comprehensively examine the various lifestyle aspects of emerging adults with T1DM, recognizing that this condition may necessitate unique considerations in different life spheres during a challenging, transitional phase marked by significant changes and demands. By analyzing qualitative studies, this review aims to uncover the underlying motivations for behaviors in emerging adults with T1DM and identify significant gaps, thereby guiding future research directions in this domain. This approach aims to facilitate a deeper understanding of how uniquely T1DM impacts lifestyle choices and challenges during this critical developmental stage. 2. Materials and Methods This systematic review analyzes, through qualitative studies, the influence of emerging adulthood stage on the adoption of lifestyle behaviors in individuals with T1DM. Consequently, the guiding question of this review is as follows: How does emerging adulthood influence the lifestyle choices and challenges of individuals with type 1 diabetes mellitus? This qualitative systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [ 19 ]. In addition, it has a protocol registered in the international prospective register of systematic reviews PROSPERO, with identification CRD42021240637. 2.1. Search Strategy Regarding terminology, the Medical Subject Headings (MeSH) and Health Sciences Descriptors (DeCS) thesauri provided two terms for defining the life stage following adolescence. The term ‘Adult’, introduced in 1996, covered a wide age range, from 19 to 44 years, reflecting a period with varied characteristics. In 2009, the term ‘Young Adult’ was added to specifically refer to individuals aged 19 to 24 years. However, this review, aligning with Arnett’s research [ 1 , 3 , 5 ], established an age range of 18–29 years, and thus used ‘Emerging Adult’ in its title. Moreover, ‘Adult’ and ‘Young Adult’ were included as keywords for the search strategy to collectively cover the group aged 18–29, as previously indicated. Healthcare 2024,12, 309 3 of 21 The systematic search, conducted from March to November 2021, encompassed several databases: CINAHL, Cochrane Library, Global Health, Nursing & Allied Health Premium, PsycINFO, PubMed, Scopus, and WOS. The uniform search strategy applied across these databases included the following terms: (adult OR “young adult”) AND (“type 1 diabetes”) AND (lifestyle OR behavior OR health OR “health risk behavior*”). The search was structured in accordance with the PI(E)CO framework: • Participants: Young adults (18 to 29 years old) with T1DM or insulin-dependent diabetes. •Intervention/Exposure: Behaviors adopted by these young adults in their lifestyle. •Context (instead of Comparison): Age stage of young adults (18 to 29 years old). • Outcomes to be measured: Specific characteristics of the different lifestyle dimensions (nutrition, sleep, physical exercise, social, work and environmental relationships, risky behavior, and self-care). 2.2. Eligibility Criteria The eligibility criteria for study inclusion were as follows: • They were primary qualitative research or mixed methods studies with a significant and explicitly stated qualitative component, focusing on lifestyle aspects and demonstrating consistent methodological quality. Studies had to be available in full text and published between 1 January 2010 and 31 March 2021. • The participant sample needed to consist of emerging adults, defined as individuals aged 18–29 years according to Arnett’s broadest definition [ 1 , 3 , 5 ]. To encompass a wider range of relevant studies, the age criterion was flexibly extended by +2 years through consensus among the authors. Therefore, the final sample of the selected studies included individuals aged 18–31 years. •Studies were considered if written in English, Spanish, or Portuguese. Studies using exclusively quantitative methodology or not related to the object of this review were excluded. In addition, other types of texts were excluded: commentaries, clinical guidelines, dissertations, conference abstracts, editorial letters, PhD theses, books, chapter books, reports, and systematic reviews with or without meta-analyses. 2.3. Quality Appraisal The methodological quality of the selected articles was evaluated using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Qualitative Research [ 20 ]. Inclusion criteria required that studies showed at least 80% of positive aspects in this assessment, indicative of a high methodological quality. This evaluation was primarily conducted by the first reviewer. In instances where scores were marginally close to the minimum threshold and there was uncertainty regarding inclusion, the assessments were further reviewed and corroborated by the second and third reviewers. In short, of the 34 articles assessed, 21 articles (61.76%) achieved a score of 80%, 11 articles (32.35%) scored 90%, and 2 articles (5.88%) attained a score of 100%. The most common factors leading to lower scores were the absence of explicit details regarding the cultural and theoretical position of the researcher, as well as the lack of clarity on the mutual influence between the researcher and the research. 2.4. Bias in the Review Process Several measures were implemented to mitigate biases in the review process. To address publication bias, duplicate studies were identified and removed. Selection bias was minimized by defining inclusion criteria prior to the search and conducting a peer review process in accordance with PRISMA recommendations. To counter study quality and report bias, the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Qualitative Research was employed, as this tool ensures the inclusion of studies that demonstrate high-quality evidence and adhere to correct qualitative methodologies [ 20 ]. The use of the JBI checklist helped to mitigate publication bias by providing a standardized framework for evaluating Healthcare 2024,12, 309 4 of 21 the rigor and credibility of the qualitative research, ensuring that only studies meeting these criteria were included in the review [21]. 2.5. Study Selection and Data Extraction Process In the initial phase of study selection, the first reviewer conducted a systematic screening of titles and abstracts based on predefined inclusion and exclusion criteria. This was followed by an exhaustive full-text review of the articles preliminarily selected to verify their compliance with the established criteria. Subsequently, these full-text reviewed articles underwent an independent evaluation by a second reviewer. The reasons for exclusions, both from the initial discard by the first reviewer and the subsequent exclusions by the second reviewer, were meticulously documented following this comprehensive full-text review. Concurrently, the process of data extraction and synthesis was conducted with scrupulous attention to detail. Key data extracted from the studies—encompassing publication year, geographical location, authorship, study title, sample demographics (age and sex), employed qualitative methodologies, ethics committee approvals, and the nature of participant discourses (categorized as primary or secondary results), as well as lifestyle behaviors addressed—were systematically organized and recorded in a Microsoft Excel®v2016 database. This task of data extraction was independently undertaken by both the first and second reviewers. 2.6. Data Synthesis The synthesis of data in this systematic review was conducted using the metaaggregation approach, which is particularly suited for inclusive reviews of diverse qualitative evidence across various paradigms. This method aligns well with the specific requirements of qualitative research, facilitating a comprehensive understanding of the data. Unlike other qualitative synthesis methods, meta-aggregation allows for the preservation of the unique voices and perspectives within each study while facilitating a cohesive and comprehensive understanding of the data. This method is particularly adept at handling the rich, varied nature of qualitative research, making it an ideal fit for our study’s aim to explore the complex lifestyle dimensions of emerging adults with T1DM [22]. In this review, a ‘finding’ refers to any qualitative insight related to the lifestyle dimensions of emerging adults with T1DM, encompassing behaviors, experiences, and perceptions relevant to nutrition, sleep, physical exercise, social interactions, risky behavior, and self-care. The finding extraction process, guided by the PI(E)CO framework, involved systematically identifying these findings from each study, focusing on the nuanced behaviors and experiences of the target population. This rigorous approach ensures a detailed and comprehensive synthesis of qualitative evidence pertinent to the lifestyle management of emerging adults with T1DM. Following the extraction of relevant findings, the thematic categorization of these data was primarily undertaken by the first author. This stage involved a detailed analysis where the extracted findings were grouped into the aforementioned initial categories as per the PI(E)CO framework. During this process, the second author played a critical role in reviewing and refining the categorization, bringing an additional layer of scrutiny to ensure that the thematic analysis was robust and comprehensive. For the organization of data, our team used a shared document. This approach enabled efficient collaboration and discussion, allowing us to systematically compile, analyze, and refine our findings without specialized software. In instances of disagreement, detailed discussions were held to explore differing perspectives. The collaborative dialogue between all authors facilitated informed consensus, ensuring that each decision made reflected a comprehensive and shared understanding of the data. This consensus approach ensured that the synthesis of findings was coherent, balanced, and representative of all voices in the research team. Healthcare 2024,12, 309 5 of 21 However, a deeper examination of the data by the research team led to the realization that additional categories were necessary to capture the full spectrum of influences on the behaviors of emerging adults with T1DM. Therefore, new categories such as emotions and feelings, perceptions (including self-perception and health perception), and stigma were introduced. These categories, though not strictly behaviors, encapsulate crucial psychosocial traits exerting a significant influence on the lifestyle choices of the target group. The final step of synthesizing the identified thematic categories was a collaborative effort involving all authors. Both the second and third authors played a pivotal role in this phase, facilitating the integration and summarization of both the predefined and emergent themes. This crucial involvement ensured the construction of a cohesive and comprehensive understanding of the key lifestyle aspects and psychosocial influences on emerging adults with T1DM. Meanwhile, the fourth author provided continual support throughout the process, leveraging his extensive experience in systematic reviews as he was trained at the Joanna Briggs Institute. This expertise was instrumental in ensuring that the meta-aggregation process was meticulously conducted and aligned with best practices in qualitative synthesis. The results of the synthesis and meta-aggregation are detailed in the Supplementary Material, Table S1. 2.7. Confidence in the Findings: Application of CONQual This systematic review applied the JBI’s CONQual approach to rigorously assess the confidence in the synthesized findings from qualitative studies [23]. Ranking Levels: In CONQual, findings are classified within a scale of ‘High’, ‘Moderate’, ‘Low’, and ‘Very Low’, reflecting their initial quality level. Qualitative studies typically start at ‘High’ due to their detailed methodology and depth of analysis. Dependability Assessment: The dependability of each finding was thoroughly evaluated. A finding meeting 4–5 criteria for methodological congruence and researcher’s influence retained its ‘High’ rating. Findings with 2–3 criteria met were downgraded by one level, and those with 0–1 criterium were downgraded by two levels. Credibility Assessment: The credibility of each finding was subsequently assessed. Findings were categorized as ‘Unequivocal’, ‘Credible’, or ‘Not Supported’, based on the evidence type and robustness. ‘Unequivocal’ findings maintained their original ranking, while ‘Credible’ findings were downgraded by one level, and mix of ‘Credible/Not Supported’ findings were downgraded by three levels. This structured approach combines initial rankings with thorough dependability and credibility assessments, ensuring a comprehensive evaluation of the synthesized findings. It demonstrates the overall confidence that can be placed in them within our systematic review, clearly reflecting their dependability and credibility. In this systematic review, we classified 2 synthesized findings as ‘Low’, 22 as ‘Moderate’, and 10 as ‘High’. Consequently, we can conclude there is a high degree of confidence in the findings of this review. Further details are provided in Table S2. 3. Results 3.1. Search Outcomes An exhaustive search across eight databases yielded a total of 21,250 records. Following the application of specified inclusion and exclusion criteria and the elimination of duplicate entries, a total of 34 articles were selected for inclusion. This selection comprised 31 studies identified from the initial search and an additional 3 derived from citation tracking. The process of article selection is comprehensively detailed in the PRISMA flow diagram presented in Figure 1. Healthcare 2024,12, 309 6 of 21 Healthcare 2024, 11, x FOR PEER REVIEW 7 of 21 Figure 1. PRISMA flow. *Articles that fall outside the specified age range but which also met at least one other criterion were counted solely under the first reason. Reports excluded: 43 Reason 1 (n = 12): the articles were excluded in the primary review. Reason 2 (n = 10): the articles were included in the primary review. Reason 3 (n = 6): the age range surpasses the established limit. Reason 4 (n = 15): the methodology is not qualitative. Screening Records screened ( n = 20,369 ) Records excluded (n = 20,223) Reports sought for retrieval (n = 146) Reports not retrieved (n = 1) Reports assessed for eligibility (n = 145) Reports excluded*: 114 Reason 1 (n = 91): the age range surpasses the established limit. Reason 2 (n = 5): the quality of the methodology is not enough in relation to the JBI checklist. Reason 3 (n = 4): the article thematic is not in line with our investigation objective. Reason 4 (n = 7): inadequate data. Reason 5 (n = 7): they do not follow a qualitative methodology. Studies included in review (n = 31) Reports of included studies (n = 3) Included Reports assessed for eligibility ( n = 3 ) Records identified from databases (n = 21,250) CINALH (n = 3898) GLOBAL HEALTH (n = 322) COCHRANE LIBRARY (n = 511) NURSING & ALLIED HEALTH PREMIUM (n = 3562) PSYCOINFO (n = 302) PUBMED (n = 5437) SCOPUS (n = 4430) WOS ( n = 2788 ) Records removed before screening: Duplicate records removed (n = 881) Records marked as ineligible by automation tools (n = 0) Records removed for other reasons (n = 0) Identification Records identified from: Citation searching (n = 985) Google Scholar (n = 802) Identification of studies via databases and registers Identification of studies via other methods Reports sought for retrieval Citation searching: (n = 46) Google Scholar (n = 2) Reports not retrieved ( n = 0 ) Figure 1. PRISMA flow. *Articles that fall outside the specified age range but which also met at least one other criterion were counted solely under the first reason. Healthcare 2024,12, 309 7 of 21 Of the articles initially identified, 114 were subsequently excluded from primary research consideration. The reasons for exclusion were as follows: 91 articles were eliminated due to their inclusion of sample populations exceeding the predetermined age range, 7 were excluded on the basis of inadequate data, 7 were ruled out for not adhering to a qualitative research methodology, 5 were dismissed for failing to meet the requisite methodological robustness as per the JBI checklist criteria, and 4 were excluded for lacking relevance to the central theme of this research. 3.2. Study Characteristics The included studies are original qualitative research, employing methods such as in-depth or semi-structured interviews, focus groups, and qualitative surveys. The majority of participants were women, with two studies exclusively involving women [24,25]. Over half of the studies (n = 19) originated from the United States, with the remainder sourced from Australia, Canada, India, Ireland, Portugal, South Africa, Sweden, Turkey, and the United Kingdom. Table 1outlines the characteristics of each study. Healthcare 2024,12, 309 8 of 21 Table 1. Study characteristics. Year Study Location Authorship Research Techniques Sample Total (Women) (Age Range) Categories Addressed 1 2010 Sweden Sparud-Lundin, C. et al. [26] SI and IC N = 13(7); (20–22) EF. P. SR.: (family, peers, and peers with T1DM). 2 2011 United States Pyatak, E. [27] SI N = 8(4); (19–25) EF. P. RB. SC. ST and SR: (health care provider). 3 2012 United Kingdom Snow, R. and Fulop, N. [28] SI N = 17(9); (18–25) EF. SC. and SR.: (work and environmental, social support: health care provider). ST. 4 2013 Ireland Balfe, M. et al. [29] SI N = 35(29); (23–30) P. SC. SR.: (work, family, and health care provider). ST. 5 2013 United States Pyatak, E. et al. [30] SI N = 8(5); (19–25) EF. RB. SC. SR.: (social support: family, friends, and health care provider). 6 2014 Ireland Balfe, M. et al. [31] SI N = 35(29); (23–30) EF. N. P. PA. SC. SR.: (environmental and work colleagues). 7 2014 United States Garvey, K.C. et al. [32] FG N = 26(16); (25–27) EF. SC. RB. SR: (health care provider, peers with T1DM). 8 2014 United States Pyatak, E. et al. [33] SI N = 20(11); (20–22) EF. P. RB. SC. SR.: (environmental, college, and health care provider). 9 2015 Turkey Celik, S. et al. [34] I N = 28(16); (18–25) EF. N. P. PA. RB. SC. ST. SR.: (family, peers, and health care provider). 10 2015 United States Hood, D.G. and Duke, G. [35] SI N = 9(6); (19–24) EF. P. RB. SC. ST. SR.: (environmental, family, peers, and health care provider). 11 2015 Canada Visekruna, S. et al. [24] SI N = 9(9); (22–30) EF. P. SC. SR.: (environmental and health care provider). 12 2016 United States Fredette, J. et al. [36] SI N = 24(21); (18–24) EF. P. SC. SR.: (environmental, peers, peers with T1DM, family, and health care provider). 13 2017 United States Abdoli, S. et al. [37] I N = 9(6); (18–30) EF. P. SC. ST. SR.: (environmental, peers, peers with T1DM, family, health care provider, and God). 14 2017 Canada Clausi, L. and Schneider, M. [25] SI N = 7(7); (18–22) EF. P. SC. ST. SR: (peers). 15 2017 United States Fedor, A. et al. [38] SI N = 13(9); (18–22) SC. SR.: (environmental, peers, peers with T1DM, and health care provider). 16 2017 United States Pierce, J.S. et al. [39] SI N = 10(7); (18–25) P. SC. SR.: (environmental, family, peers, peer with T1DM, and health care provider). 17 2018 United States Calamaro, C.J. et al. [40] QS N = 12(7); (19–26) EF. RB. SC. ST. SR.: (peers with T1DM and health care provider). 18 2018 Sweden Hilli, Y. et al. [41] SI N = 8(4); (20–25) EF. P. SC. SL. ST. SR.: (peers with and without diabetes, associations, family, and health care provider). Healthcare 2024,12, 309 9 of 21 Table 1. Cont. Year Study Location Authorship Research Techniques Sample Total (Women) (Age Range) Categories Addressed 19 2018 South Africa Visagie, E. et al. [42] SI N = 8(5); (18–25) EF. SR.: (family, peers, peers with T1DM, and health care provider). 20 2018 South Africa Willemse, M. et al. [43] I(LS) N = 8(3); (20–25) EF. N. P. PA. SR.: (family, friends, and health provider) 21 2019 United States Addala, A. et al. [44] FG N = 17(11); (18–25) EF. N. P. PA. SC. ST. SR.: (health care provider, work, partner, and environmental). 22 2019 Sweden Carlsund, Å. and Söderberg, S. [45]SI N = 12(8); (19–30) EF. P. RB. SC. SR.: (family, peers, and health care provider). 23 2019 United States Ersig, L. A. [46] QS N = 25(2); (18–24) EF. RB. SL. SR.: (family and peers). 24 2019 Canada Markowitz, B. et al. [47] I N = 33(17); (18–24) EF. P. RB. SC. SR.: (family, peers, and health care provider). 25 2019 Australia Mullan, B. A. et al. [48] SI N = 25(21); (20–30) EF. N. P. SC. ST. 26 2019 United States Ramchandani, N. et al. [49] FG N = 21(15); (18–29) EF. P. RB. SC. ST. SR.: (family, peers, and health care provider). 27 2019 United States Saylor, J. et al. [50] FG N = 12(5); (19–26) EF. N. P. PA. RB. SL. SR.: (family, peers, and professor at university). 28 2020 United States Griggs, S. et al. [51] SI N = 30(20); (19–25) EF. SL. 29 2020 United States Hanna, K. M. and Hansen J. R. [52]SI N = 25(12); (19–26) N. P. PA. SC. SL. ST. SR.: (family, peers, workmates or supervisors, and others). 30 2020 Portugal Santos, A. N. et al. [53] QS N = 59(47); (18–30) SC. SR.: (partner). 31 2021 United States Gray, A. L. et al. [54] SI N = 29(16); (22–24) N. P. SC. ST. SR.: (family, peers, and partner). 32 2021 Canada Habenicht A. E. et al. [55] SI N = 14(7); (18–28) EF. P. SC. ST. SR.: (family, peers, partners, and work/classmates). 33 2021 United States Skedgell, K. K. et al. [56] SI N = 62(29); (18–24) P. SC. SR: (family, peers, peers with T1DM, and health care provider). 34 2021 United States Yorgason, J. B. et al. [57] FG N = 12(7); (22–30) EF. P. SR.: (partner). Abbreviations: Research techniques: Focus Group (FG); In-depth Interviews (I); Internet Chat (IC); Life Story (LS); Qualitative Survey (QS); Semi-structured Interviews (SI). Categories addressed: Emotions and Feelings (EF); Nutrition (N); Perceptions (P); Physical Activity (PA); Risky Behavior (RB); Self-Care (SC); Sleep (SL); Social Relationships (SR); and Stigma (ST). Healthcare 2024,12, 309 16 of 21 Appraisal Checklist for Qualitative Research. This criterion has significantly contributed to the review’s overall quality and validity, aligning with the standards suggested by Creswell and Miller [ 71 ]. In addition, another key strength of our review is the implementation of the JBI’s CONQual approach, ensuring a rigorous assessment of the confidence in qualitative findings [ 23 ]. This methodology allowed for a nuanced evaluation of the findings’ dependability and credibility, contributing significantly to the robustness of our conclusions [23]. Every study encompassed in this review utilized a qualitative methodology, typically involving fewer participants compared to quantitative studies. The optimal sample size for qualitative research is guided by the concept of data saturation [ 72 ], leading to a notable range in sample sizes, from as few as seven (N = 7) to as many as sixty-seven (N = 67). While the sample size in qualitative studies is not inherently a limitation, it is noteworthy that 7 out of the 10 reviewed articles [ 25 , 27 , 30 , 35 , 41 – 43 ]—those involving 10 or fewer participants—do not explicitly address the saturation point. This omission presents a notable gap in the current evidence, warranting consideration in the interpretation of these studies and this systematic review. In systematic qualitative reviews, the diversity of study settings can be seen as a strength, potentially enhancing the transferability of the findings [ 73 ]. However, the variation in countries and cultures necessitates a cautious interpretation of results [ 74 ]. It is important to acknowledge that health services and their offerings differ significantly across countries [ 30 ]. Such variations can notably influence the impact of health education on nutrition, especially regarding recommended diets, whether they are based on planned menus or carbohydrate counting. Additionally, the nature of a health system, be it public or private, along with access to health resources and the affordability of medical devices like continuous subcutaneous insulin infusion pumps, can affect aspects of self-care, social relationships, and perceptions of stigma. While these differences may not be considered strict limitations, they are essential for understanding, interpreting, and applying this review’s findings [30]. Innovative technologies, such as CGM systems and automatic insulin infusion systems, are pivotal in managing T1DM among emerging adults [ 75 , 76 ]. These tools assist in monitoring glycemic levels, recognizing patterns in physical activities and dietary habits, and preventing glycemic imbalances [ 76 ]. They are particularly effective in enhancing selfcare by providing real-time data and facilitating better sleep management through features like alarm programming and insulin delivery suspension, thus contributing to overall better diabetes management and decision making in self-care [ 77 ]. However, it is important to acknowledge the potential stigma from the visible use of these devices, which can lead to feelings of self-consciousness. Healthcare providers should respect individuals’ decisions regarding the adoption of these technologies, ensuring that the benefits are communicated while understanding and addressing any concerns about stigma. This approach fosters a supportive environment, empowering individuals in their diabetes management choices. Moreover, the legal and social definitions of adulthood vary by region, which can influence the results. Lastly, it is worth noting that behavioral particularities are discussed in the reviewed body of literature with minimal mention of lifestyle factors, with the exception of one study [54], which does incorporate ‘lifestyle’ as a key term. The primary limitation of our study arises from the non-inclusion of the term ‘emerging adult’ in our search strategy, as it is absent from the DeCS and MeSH thesauri. This absence presented a challenge in specifically targeting results related to emerging adults with T1DM. Consequently, we employed the descriptors ‘Young Adult’ (encompassing adults up to 24 years old) and ‘Adult’ (including those up to 44 years old). This approach inevitably broadened the age range beyond our initial inclusion criteria, resulting in the exclusion of a substantial number of studies whose samples did not conform to our specified age limits. In addition to these primary search terms, we conducted a thorough examination of secondary literature and performed a citation verification using Google Scholar, adhering to the PRISMA guidelines. Healthcare 2024,12, 309 17 of 21 Although qualitative studies and their corresponding reviews do not permit the generalization of results, they are crucial for comprehending the knowledge, attitudes, and lifestyles of emerging adults with T1DM [ 78 , 79 ]. This review, by focusing on the behaviors that shape the lifestyles of emerging adults with T1DM, offers a holistic framework for health professionals to use [ 80 ]. Proper clinical follow-up, aimed at promoting healthy lifestyle, may enhance their quality of life. This is particularly significant for conditions like T1DM, where improving the quality of life is a key therapeutic goal due to the lack of a cure [ 81 ]. Based on our findings, we recommend further research into diverse coping strategies and improvements in communication and education by healthcare providers to address identified barriers. Additionally, the development of specific interventions to tackle these barriers and enhance facilitators identified in each category is suggested. As a future research avenue, it is imperative to emphasize the importance of longitudinal qualitative and quantitative studies to assess the long-term effects of lifestyle changes and their health outcomes. In developing control programs for emerging adults with T1DM, identifying key behavioral factors is vital for shaping effective interventions. Essential factors include the practice of regular self-monitoring of glucose levels and adjusting insulin based on objective data rather than physical sensations. Proficiency in carbohydrate counting and appropriate insulin dosing in response to dietary intake is also critical. Planning and anticipatory management for scenarios like exercise or alcohol consumption are necessary to maintain glycemic balance. Additionally, fostering a positive attitude towards diabetes and empowering patients to handle social stigma are crucial for enhancing self-management. Focused interventions on these behavioral aspects—self-monitoring, carbohydrate counting, anticipatory management, and positive attitude—can significantly empower emerging adults in managing T1DM effectively. Additionally, such research aligns with Goal Three of the United Nations’ 2030 Agenda for Sustainable Development, which focuses on promoting health and well-being at all ages. By addressing the specific needs of emerging adults with T1DM, this research contributes to the broader objective of enhancing global health, underlining the significance of this often-neglected age group in public health policies and initiatives [82]. 5. Conclusions This systematic review has underscored the importance of qualitative research in deepening our understanding of the unique lifestyle challenges and behavioral motivations faced by emerging adults with T1DM. Our findings reveal a complex interplay between diabetes management and the pursuit of autonomy, highlighting the need for tailored interventions that address specific lifestyle aspects, including diet, sleep, substance use, and sexual health. Key behavioral factors such as self-monitoring, carbohydrate counting, anticipatory management, and a positive attitude towards diabetes management emerged as crucial in facilitating effective self-care among this demographic. Moreover, this review identifies a significant gap in research on the lived experiences of emerging adults with T1DM in areas like sleep, risky behaviors, and sexual relationships, suggesting the need for further qualitative and quantitative studies in these less explored domains. The insights gained from this review point towards the need of developing health promotion strategies that are specifically designed for emerging adults with T1DM. Such strategies should not only focus on clinical aspects of diabetes management but also consider the broader lifestyle and psychosocial factors that influence self-care behaviors. It is imperative that future research continues to explore these areas, contributing to more comprehensive care approaches that support the overall well-being and quality of life for individuals with T1DM during this critical stage of life. Healthcare 2024,12, 309 18 of 21 Supplementary Materials: The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/healthcare12030309/s1 , Table S1: Step-by-step process of the meta-aggregation of qualitative findings. Table S2: Confidence in the findings: Application of CONQual. Author Contributions: Conceptualization, M.-Á.N.-B., A.G.-A. and J.R.G.-L.; methodology, M.-Á.N.-B. and A.-M.M.-S.; software, M.-Á.N.-B. and A.G.-A.; validation, M.-Á.N.-B., A.G.-A. and J.R.G.-L.; formal analysis, M.-Á.N.-B. and A.G.-A.; investigation, M.-Á.N.-B.; resources, M.-Á.N.-B., A.G.-A., A.-M.M.-S. and J.R.G.-L.; data curation, M.-Á.N.-B. and A.G.-A.; writing—original draft preparation, M.-Á.N.-B.; writing—review and editing, M.-Á.N.-B. and A.G.-A.; visualization, A.G.-A., A.-M.M.-S. and J.R.G.-L.; supervision, A.G.-A., A.-M.M.-S. and J.R.G.-L.; project administration, J.R.G.-L.; funding acquisition, M.-Á.N.-B., A.G.-A. and J.R.G.-L. All authors have read and agreed to the published version of the manuscript. Funding: The Predoctoral Research Fellow (M.-Á.N.-B.) in this research was funded by the VI Plan Propio de Investigación y Transferencia of the Universidad de Sevilla. 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