The number of people in the United States who are considered to be overweight or obese has increased along with the prevalence of diabetes. According to the Centers for Disease Control and Prevention, the prevalence of obesity in 2015 to 2016 was 18.5% in children and adolescents and 39.8% in adults, and the prevalence of diabetes in 2015 was 9.4% for the total US population.1-3
While these parallel trends are often viewed as being closely linked, there is no definitive evidence that a high body mass index (BMI) causes type 2 diabetes (T2D) or that weight loss is an effective strategy for long-term diabetes management in all patients. In addition, studies have shown that weight stigma — which has been found to be highly prevalent among physicians4 — is associated with a greater risk for negative health outcomes and mortality than a high BMI, and a focus on weight can reinforce and promote this stigma (see “Is Weight Stigma Worse Than Obesity? How to Provide More Compassionate Care”). Nonetheless, the goal of weight loss is a key component of treatment plans for many patients with T2D.
Some experts propose that an emphasis on healthy behaviors rather than on weight loss may be a more effective approach in helping people with diabetes limit disease progression and manage symptoms, while also supporting their mental health and reducing weight stigma. To learn more about this view and related research findings, Endocrinology Advisor checked in with several proponents of weight-neutral diabetes care.
Below are interviews with Michelle May, MD, founder of Am I Hungry? mindful eating programs and coauthor of Eat What You Love, Love What You Eat with Diabetes: A Mindful Eating Program for Thriving with Prediabetes or Diabetes, and Holly Paulsen, RD, LD, CEDRD-S, a certified eating disorders registered dietitian at Jones Regional Medical Center in Anamosa, Iowa. Part 2 of this article will feature an interview with Megrette Fletcher, MEd, RD, CDE, diabetes educator, and Dr May’s coauthor of the book mentioned above. Ms Fletcher is also cofounder of The Center for Mindful Eating and a partner in the Weight Neutral 4 Diabetes Care Symposium, an online conference for healthcare professionals.
Endocrinology Advisor: What are some of the problems associated with the current weight-focused approach to diabetes care?
Michelle May, MD: The association between higher weight and diabetes is just that — an association. While BMI is correlated with certain conditions, available data cannot confirm that BMI causes these diseases. Causality can only be inferred by experimental design.5 There are many other factors that may explain or partially explain the link, including insulin resistance, social determinants of health, weight stigma, exercise, and nutrition, to name just a few.
Diabetes is a chronic condition that requires a sustainable approach to self-management, and weight loss is not a sustainable intervention. A review of 31 long-term studies on dieting found that the majority of individuals are unable to maintain weight loss over the long term and one-third to two-thirds of dieters regain more weight than they lost. The authors concluded that “…there is little support for the notion that diets lead to lasting weight loss or health benefits.”6
Another review of weight loss studies concluded that no weight loss initiatives to date have generated long-term results for the majority of participants. At best, only 20% of participants maintain weight loss at 1 year after completing a weight-based lifestyle intervention, and the percentage of those maintaining weight loss decreases further by the second year.5
In addition, the most common outcomes of a weight-focused approach are yo-yo dieting and weight cycling, disordered eating, and weight stigma:
- Yo-yo dieting: Patients with diabetes who yo-yo diet may vacillate between hyperglycemia and hypoglycemia, making diabetes more difficult to manage and contributing to diabetes distress.
- Disordered eating: Obsessively measuring and logging food intake, preoccupation with body size, and/or a hyperfocus on exercise distracts individuals from self-care and living their lives fully.
- Weight stigma: In a survey of nearly 2500 patients, 53% reported inappropriate comments from doctors about their weight. They also reported experiencing stigma from nurses (46%), dietitians (37%), and mental health professionals (21%).7
Holly Paulsen, RD, LD, CEDRD-S: Research supports a strong correlation between diabetes and disordered eating. Some studies indicate that up to 40% of patients with T2D meet criteria for an eating disorder.8 The promotion of intentional weight loss and restrictive eating plans (ie, diets) as treatment for diabetes may actually increase the occurrence of eating disorders in this population.
Disordered eating is incompatible with optimal blood glucose control. Continued attempts at dieting and weight loss often lead to weight cycling, or periods of weight loss followed by weight gain. Weight cycling in itself can have metabolic consequences, with some studies finding increases in mortality and morbidity correlated with such practices.9
Endocrinology Advisor: What are the reasons that clinicians should move toward weight-neutral care for these patients?
Dr May: A weight-neutral or weight-inclusive approach aligns the clinician and patient toward effective and sustainable behavior changes. A systematic review and meta-analysis published in 2015 concluded that “weight loss for many overweight or obese individuals with type 2 diabetes might not be a realistic primary treatment strategy for improved glycemic control. Instead, nutrition therapy for individuals with T2D should encourage a healthful eating pattern, a reduced energy intake, regular physical activity, education, and support as primary treatment strategies.”10
Ms Paulsen: When we continue to characterize weight loss as a ‘behavior’ and use this as our focus for treatment, we are failing to acknowledge that there are only a very small percentage of individuals who can maintain weight loss in the long term.
Shifting the focus from weight-centered care to encouraging behaviors the individual can control such as regular eating, balanced meals, enjoyable exercise, and attention to overall emotional well-being has been shown to improve glucose levels.
We can promote good health and management of diabetes without focusing on restrictive eating and weight loss. Patients can benefit from realizing that their health is more than just a number on a bathroom scale. This approach is freeing for the patient, as it reduces their disease burden and the shame and hopelessness that often follow unsuccessful attempts at weight loss.
Endocrinology Advisor: What does this approach look like in practice, and what are your recommendations for those who are interested in offering or learning more about weight-neutral diabetes care?
Dr May: Weight is not a behavior! Rather than recommending futile and repeated weight loss attempts for diabetes self-management, the clinician who is weight inclusive will choose to focus on implementing evidence-based interventions such as physical activity, balanced eating, glucose monitoring, medication adherence, preventive care, problem solving, developing support, and other skills and behaviors for diabetes self-management. Whether the patient loses weight or not, these behaviors improve glycemic control.
Ms Paulsen: A weight-neutral approach in diabetes education and counseling encourages patients to engage in specific behaviors that promote health, independent of weight changes. The focus would be on scheduling regular medical appointments, taking medication as prescribed, monitoring blood sugars if appropriate, employing strategies for managing stress, eating balanced meals, and engaging in regular physical activity.
The nutrition piece of weight-neutral care strives to empower the patient to eat regularly and balancing macronutrients when possible. With mindful eating or intuitive eating approaches to diabetes management, the individual is ultimately following internal signals of hunger, fullness, and satisfaction with food choices to guide eating.11 These methods reduce restrictive eating that often fuels disordered eating and binge eating in particular.
Endocrinology Advisor: What are additional takeaways for clinicians, remaining research needs in this area, or any other points you would like to mention about the topic?
Dr May: Unfortunately, the current weight-focused paradigm makes it difficult for clinicians to see beyond weight loss as a treatment. Given that weight loss is not a sustainable intervention and did not reduce cardiovascular complications in the Look AHEAD trial,12 shifting the focus to other behaviors proven to improve diabetes management and decrease complications is a better use of time and resources. In a 2017 paper regarding the Look AHEAD trial, the author stated that it is “important to avoid prioritizing weight loss as a primary goal of treatment and instead to shift attention to improving blood glucose levels and reducing diabetes-related complications.”13
Ms Paulsen: Providing diabetes care in a weight-neutral manner is about treating patients as partners in the management of their health. So many patients feel the stigma of having a larger body and may avoid medical care because of this. We as clinicians can be that “soft place to land” for our patients, where they can feel empowered to manage their disease instead of fighting their weight. The change in the patient’s perspective can often been seen immediately when they are cared for in a weight-neutral manner. Patients often become more engaged in their health care as a result.
- Centers for Disease Control and Prevention. Childhood Obesity Facts. Prevalence of Childhood Obesity in the United States. https://www.cdc.gov/obesity/data/childhood.html. Updated August 13, 2018. Accessed May 3, 2019.
- Centers for Disease Control and Prevention. Adult Obesity Facts. Obesity is common, serious, and costly. https://www.cdc.gov/obesity/data/adult.html. Updated August 13, 2018. Accessed May 3, 2019.
- Centers for Disease Control and Prevention. Prevalence of Both Diagnosed and Undiagnosed Diabetes. https://www.cdc.gov/diabetes/data/statistics-report/diagnosed-undiagnosed.html. Updated February 2, 2018. Accessed May 3, 2019.
- Sabin JA, Marini M, Nosek BA. Implicit and explicit anti-fat bias among a large sample of medical doctors by BMI, race/ethnicity and gender. PLoS One. 2012;7(11):e48448.
- Tylka TL, Annunziato RA, Burgard D, et al. The weight-inclusive versus weight-normative approach to health: evaluating the evidence for prioritizing well-being over weight loss. J Obes. 2014;2014:983495.
- Mann T, Tomiyama AJ, Westling E, Lew AM, Samuels B, Chatman J. Medicare’s search for effective obesity treatments: diets are not the answer. Am Psychol. 2007;62(3):220-233.
- Puhl RM, Brownell KD. Confronting and coping with weight stigma: an investigation of overweight and obese adults. Obesity. 2006;14(10):1802-1815.
- García-Mayor RV, García-Soidán FJ. Eating disorders in type 2 diabetic people: brief review. Diabetes Metab Syndr. 2017;11(3):221-224.
- Bacon L, Aphramor L. Weight science: evaluating the evidence for a paradigm shift. Nutr J. 2011;10(1):9.
- Franz MJ, Boucher JL, Rutten-Ramos S, VanWormer JJ. Lifestyle weight-loss intervention outcomes in overweight and obese adults with type 2 diabetes: a systematic review and meta-analysis of randomized clinical trials. J Acad Nutr Diet. 2015;115(9):1447-1463.
- Miller CK, Kristeller JL, Headings A, Nagaraja H. Comparison of a mindful eating intervention to a diabetes self-management intervention among adults with type 2 diabetes: a randomized controlled trial. Health Educ Behav. 2014;41(2):145-154.
- Wing RR, Bolin P, Brancati FL, et al; the Look AHEAD Research Group. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med. 2013;369(2):145-154.
- Salvia MG. The Look AHEAD trial: translating lessons learned into clinical practice and further study. Diabetes Spectr. 2017;30(3):166-170.
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