Can a weight-neutral approach improve care for patients with diabetes?
This article is a continuation of The Case for Weight-Neutral Diabetes Care: Part 1. Part 1 featured interviews with Michelle May, MD, founder of Am I Hungry? mindful eating programs and training 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.
For Part 2, Endocrinology Advisor interviewed Megrette Fletcher, MEd, RD, CDE, diabetes educator, Dr May’s coauthor of the book mentioned above, cofounder of The Center for Mindful Eating, and partner in the Weight Neutral for 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?
Megrette Fletcher, MEd, RD, CDE: The current weight-centered approach to diabetes care pays little attention to an individual’s dieting history or past diagnosis of disordered eating. An estimated 30 million people in the United States suffer from an eating disorder such as anorexia nervosa, bulimia nervosa, or binge eating disorder.1 This number is similar to the 2015 Centers for Disease Control and Prevention finding that 30.3 million Americans have diabetes.2
Like diabetes, much of disordered eating goes unrecognized and untreated, and only 1 of every 10 people with eating disorders will receive treatment.3 Yet the overlap of these 2 conditions is shockingly high — up to 40% of patients with type 2 diabetes may have disordered eating behaviors.4 It is tempting to dismiss this statistic and assume that you can look at your client and diagnose an eating disorder. However, eating disorders affect people of all sizes, and they remain, and are in large part, invisible. At present, there is not a validated English language disordered eating screening tool for people with diabetes. This leads to a lack of diagnosis and treatment in many people with eating disorders who are not “underweight,” in large part due to weight stigma.
Weight stigma or weight-based discrimination is the “social devaluation and denigration of people perceived to carry excess weight, [which] leads to prejudice, negative stereotyping, and discrimination toward those people.”5 It can include a “broad range of experiences from minor, everyday instances of differential treatment, or ‘microaggressions’ (e.g., being treated with less respect than others in subtle ways), to being treated unjustly in specific contexts (e.g., being denied employment).”6 Weight stigma is a significant factor in overall health as research shows it is linked to the avoidance of medical care.7
Experiencing weight stigma can lead to a host of behaviors that have a negative impact on glucose control, including increased eating and decreased self-regulation, higher cortisol levels, avoidance of exercise, and a greater likelihood of experiencing anxiety disorders.8,9 People who experience weight stigma have also been found to have a 60% increased risk for mortality independent of body mass index.10 The cause of this startling statistic is not a single variable but a complex interaction of misdiagnosis and misattribution of symptoms based on weight and a higher likelihood of being prescribed weight management instead of necessary interventions for actual health conditions. These experiences create a lower likelihood of patients following provider recommendations and can foster the desire to delay care or minimize symptoms, which result in worse health outcomes and more advanced disease states.
Endocrinology Advisor: What are the reasons that clinicians should move toward weight-neutral care for these patients?
Ms Fletcher: The typical messaging surrounding diabetes is goal-based or outcome-focused, such as lose weight or lose 10% of your current body weight. Unfortunately, this messaging erroneously associates weight loss with curing or treating diabetes. This unintentional association is popularized in the media and press, with books, websites, and health campaigns to “prevent, beat, defeat diabetes” instead of focusing on the day-to-day support needed to manage diabetes. It is easy to emphasize weight-based outcomes that only reinforce the fallacious notion that weight loss is a behavior. In a fast-paced practice, providers are susceptible to agreeing with the patient that “weight loss” can manage blood sugar.
These conditions create the perfect storm for an individual who has been diagnosed with diabetes to re-trigger or justify the use of disordered eating patterns to treat or manage their diabetes. It is essential to state that disordered eating can’t promote euglycemia and is both physically and mentally harmful. Disordered eating patterns are unsustainable, creating a cycle of failed attempts that prompt an individual to engage in more and more extreme behaviors. This results in the development of chronic dieting, weight cycling, and eating disorders, including binge eating disorder, which is associated with depression, substance abuse, and self-harm.
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?
Ms Fletcher: Shifting the focus from weight-centered to a weight-neutral approach can avoid these negative outcomes. Think of weight-neutral care as a type of universal precaution to stop perpetuating disordered eating and weight cycling while improving overall well-being. Weight-neutral care takes the emphasis off weight loss, which is scientifically highly unlikely to be sustained if it occurs at all, and instead prescribes evidence-based interventions that do promote health and well-being regardless of weight change. A weight-neutral provider avoids triggering language and works to become aware of weight bias and weight stigma. Moving from an approach that pathologizes or degrades larger bodies to a weight-neutral or weight-inclusive approach can be broken down into several steps.
Here are 4 steps to consider for your medical practice.
Step 1: Provide the same treatments and services to higher weight clients as you would to individuals who fall in the lower weight range. For example, if an individual has a body mass index of 22, you might explore the benefits of eating balanced meals, consistent exercise, adequate sleep, less stress, or medication vs weight loss. The same regard and curiosity are needed for higher-weight individuals with diabetes.
Step 2: Be clear that diabetes is a chronic disease that [may not be] cured by weight loss or dieting. This clarity helps a client understand that weight cycling — the chronic gaining and losing of weight — is not a treatment goal of diabetes care. Much research demonstrates that sustained weight loss is not achievable by most people.11 Even the results of the Diabetes Prevention Program follow-up revealed that in the 10 years following the intervention, participants regained much of the weight that they initially lost.12 What is curious is that the benefits of program participation were retained despite this weight regain, suggesting that mechanisms other than weight loss were a contributing factor, and it is more likely that the behaviors surrounding weight change but not the weight change itself that are providing the health improvement.
Step 3: Provide weight-neutral healthcare goals, such as the American Association of Diabetes Educators 7 Self-care behaviors.13 These goals are weight neutral and provide the patient with a choice of where to focus their efforts to provide a sustainable approach to diabetes care.
Step 4: Have the patient, not the provider, establish the goals using a patient-centered approach such as Motivational Interviewing. A patient-centered approach does not assume that the individual is in a place to make a change and therefore asks the patient whether a change is desired. In a counseling setting this might sound like, “What lifestyle changes, if any, would you like to learn about to improve blood sugar control?” or “Describe to me a single change that you think would help your blood sugar.” These open-ended questions place the patient in the driver’s seat of change.
A weight-neutral approach to diabetes care empowers the patient to engage in self-care at a pace that meets their goals and values. It is also the pivotal change necessary to address weight bias and end weight stigma in diabetes care.
- National Association of Anorexia and Associated Disorders. Eating disorder statistics. https://anad.org/education-and-awareness/about-eating-disorders/eating-disorders-statistics/. 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. Accessed May 3, 2019.
- Mirror Mirror.org. Eating disorders statistics. https://www.mirror-mirror.org/eating-disorders-statistics.htm. Accessed May 3, 2019.
- García-Mayor RV, García-Soidán FJ. Eating disoders in type 2 diabetic people: brief review. Diabetes Metab Syndr. 2017;11(3):221-224.
- Tomiyama AJ. Weight stigma is stressful. A review of evidence for the cyclic obesity/weight-based stigma model. Appetite. 2014;82:8-15.
- Pearl RL. Weight bias and stigma: public health implications and structural solutions. Soc Issues Policy Rev. 2018;12(1):146-182.
- Phelan SM, Burgess DJ, Yeazel MW, Hellerstedt WL, Griffin JM, van Ryn M. Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obes Rev. 2015;16(4):319-326.
- Schvey NA, Puhl RM, Brownwell KD. The impact of weight stigma on caloric consumption. Obesity. 2011;19(10):1957-1962.
- Major B, Hunger JM, Bunyan DP, Miller CT. The ironic effects of weight stigma. J Exp Soc Psychol. 2014;51:74-80
- Tomiyama AJ, Carr D, Granberg EM, et al. How and why weight stigma drives the obesity ‘epidemic’ and harms health. BMC Med. 2018;16:123.
- Bacon L, Aphramor L. Weight science: evaluating the evidence for a paradigm shift. Nutr J. 2011;10(1):9.
- Diabetes Prevention Program Research Group. 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet. 2009;374(9702):1677-1686.
- American Association of Diabetes Educators. AADE7 self-care behaviors. www.diabeteseducator.org/living-with-diabetes/aade7-self-care-behaviors. Accessed May 3, 2019.
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