A Diabetes Care and Education Specialist Take On Weight
Explores the six tenants of weight-centric ideas and the questions they raise in diabetes care.
Your thoughts about weight change throughout your life. Understanding why you have these beliefs takes time to sort out. While there are infinite diets and eating styles, there are three fundamental beliefs about weight: Weight-centric and Weight-inclusive, and in between these two is a weight-neutral approach. This article explores the six tenants of weight-centric ideas and the questions they raise in diabetes care.
What is a Weight-centric Approach?
This approach has six tenants. Instead of asking if you believe these tenants to be true or false, let’s consider what percent of the time you think these are true.
1. Weight is under individual control. What percent of the time this is true? Before you answer, think of James, who is ten years old. What percent of the time is this true for James? This may not be true for James. How about Yin, who has just given birth to twins? What percent of the time is this true for Yin? Imagine Marcia, who is sitting before you. Marcia has severe arthritis and is in a wheelchair. She takes medication for her arthritis which is linked to weight gain. Is it true for Marcia? How about Tom, who works the 3rd shift and has poor sleep patterns because of his demanding work schedule? What percent of the time is this tenant true, and who is it true for?
2. An imbalance in caloric intake and energy usage causes weight gain. What percent of the time is this true? Is it always calories in vs. calories out? Does the body regulate calories differently during famine or after weight loss? Is there another approach to nutrition? This tenant believes nothing can change our metabolism or make our cells store calories. What about Yin, who had twins? Or Marcia, that takes medication? Or Tom, who has some sleep disturbances. How could these variables change or shift this equation? In diabetes care, some medications promote weight gain, and others can cause low blood sugar, which is associated with weight gain. When I dig deeper, I wonder how stress or environmental factors impact health. In the book Weathering by Dr. Arline T. Geronimus, Does our food supply, chemicals, pollutants, and additives impact weight?
3. Health status can be predicted by weight. What percent of the time is this true? If it is always true, does that mean people with a BMI under 25 no longer need medical care? Preventive screening? Does that mean people with a BMI under 25 are at no risk for cancer, heart disease, or diabetes? Of course not! Anyone at any age or weight can be diagnosed with diabetes, cancer, or heart disease. While these conditions can be correlated to weight, it is essential to remember that correlation is not causation.
4. Excess body weight causes disease and early death. What percent of the time is this true? Some interesting research completed in 2012 by Matheson looks at this exact question. This study examined healthy lifestyle habits and mortality in 11,761 men and women from the National Health and Nutrition Examination Survey III. The results looked at individuals who adhered to all four healthy habits. This research looked at weight and found that healthy lifestyle habits are associated with a significant decrease in mortality regardless of baseline body mass index1. For people with diabetes, Marmot et al., identified that the Social Determinants of Health contribute to 50-60% of all outcomes2. This again points to other factors outside of weight.
5. Successful long-term weight loss methods involve modifying eating and exercise patterns. What percent of the time is this belief true? It feels like a trick question because I always try to understand what 'successful long-term weight loss’ looks like. As we have seen in the DPP, Look Ahead, and other studies, what 'success' is and what defines long-term are moving targets. When I started as a dietitian, it was believed that people could lose 30, 20, or 10% of their weight and keep this off. The research shows that this isn't true. We do not see an 8% weight loss. Even 5% is tricky. In the 15-year follow-up study of the DPP, reported "Results: After one year, 289 (28.5%) participants in the metformin group, 640 (62.6%) in the ILS group, and 137 (13.4%) in the placebo group had lost at least 5% of their weight. After the masked treatment phase ended, the mean weight loss relative to a baseline that was maintained between years 6 and 15 was 6.2% (95% CI, 5.2% to 7.2%) in the metformin group, 3.7% (CI, 3.1% to 4.4%) in the ILS group, and 2.8% (CI, 1.3% to 4.4%) in the placebo group.3 " These findings point to the question - is it diet and exercise that causes weight change? Maybe not because the Metformin group had the greatest success, with 18 out of 289 who could keep the weight off for at least six years. Does that feel like long-term success to you?
6. Losing weight will result in better health. What percent of the time is this true? Multiple things confuse me about this tenant. The first is when we equate weight loss with improved access to and intake of a nutrient-rich diet. The second is believing that the weight change caused the improvement and not the behaviors (like eating a balanced diet, activity, sleep, medical care, and support) that caused the improvement. The third thing that seems overlooked is that weight loss happens for many reasons, including elevated blood sugar or depression, and both are tied to diabetes. Weight loss occurs in people with other acute and chronic conditions, including gut issues, cancer, and respiratory disease. Our weight and where weight is stored on our body change throughout our lifetime due to age, activity, stress, medications, and exposure to environmental chemicals, like BPA, or so-called 'Obesigens.' Studies show that weight isn't a good proxy for health, yet a weight-centric approach hasn't paid attention to new and conflicting research.
A closer look at the six tenants of a weight-centric approach helps me update my learning. I am open to learning about other views, including a Weight-inclusive Approach, which emphasizes viewing health and well-being as multifaceted.
A weight-inclusive approach is focused on directing efforts toward improving health access and reducing weight stigma. Diet Culture describes a broad anti-diet movement and evaluates the overall effectiveness of dieting, including individuals with and at risk of diabetes. Anti-diet is a phrase that refers to the belief that diet culture is harmful. Intuitive Eating is a 10-step process defined by two Registered dietitians. Mindful Eating is a way to connect with the present moment by eating compassionately. Practicing Intuitive or Mindful Eating can help decrease internalized weight stigma and improve a person’s relationship with food.
Within the size acceptance movement, there is the weight-neutral approach which focuses on removing the moral judgments around food, building awareness of hunger and fullness cues, emphasizing emotional and physical wellness over the pursuit of a lower weight or size, and advocating for the removal of the stigma experienced by people with larger bodies. A Non-Diet approach typically encourages a person to eat in response to physiological cues like hunger and satiety. This middle-of-the-way approach has a lot of appeal for healthcare professionals, especially those unaware of how weight bias, stigma, and shame impact clients, especially clients with diabetes. Puhl's 2022 research published in the ADA journal illuminates the impact of weight stigma in diabetes care.
“There has been little recognition that people with type 2 diabetes are vulnerable to weight stigma and diabetes stigma and almost no research examining the implications of these forms of stigma for their health and well-being. This study examined health behavior correlates of weight stigma and diabetes stigma in 1,227 adults with type 2 diabetes. Results showed that experiencing weight stigma in health care, experiencing differential treatment from others because of their diabetes, and engaging in self-stigma for diabetes and body weight were each significantly associated with increased frequency of binge eating and eating as a coping strategy to deal with negative feelings. Internalizing weight stigma was also significantly associated with lower physical activity levels and worse self-rated health. These findings suggest that initiatives to improve the health and well-being of people with type 2 diabetes must consider the potentially harmful roles of weight stigma and diabetes stigma.4”
Like every healthcare provider trained in a weight-centric model, it has taken me time to understand the research surrounding weight, weight management, and diabetes care. Acknowledging the harm I unintentionally caused by suggesting clients ‘try’ to lose weight was hard. I now understand that a weight-normative approach emphasizes weight and weight loss when defining health and well-being, and this approach doesn’t represent my values. I can’t identify evidence that suggests weight control/weight management is effective. Those 18 people didn’t convince me that sustained weight loss is possible in the follow-up DPP study.
Knowledge isn't static, it is growing, and when I adopt a growth mindset, I am giving myself permission to say, I didn't know, and that is okay. Asking myself, "What approach reflects my values surrounding diabetes, diet, and weight?"
I know hunger hurts, so I must advocate for food access, sovereignty, and dignity. I value food, and I believe food helps us celebrate our culture, history and express our creativity. I believe there is no weight limit on belonging, which is why we need to throw out the scale in diabetes care to return to a place of inclusion. A nourished society benefits everyone, and a weight-centric approach to health is a barrier hurting people with diabetes.
Matheson EM, King DE, Everett CJ. Healthy lifestyle habits and mortality in overweight and obese individuals. J Am Board Fam Med. 2012 Jan-Feb;25(1):9-15. doi: 10.3122/jabfm.2012.01.110164. PMID: 22218619.
Marmot M, Allen JJ. Social determinants of health equity. Am J Public Health 2014;104(Suppl. 4):S517–S519
Apolzan JW, Venditti EM, Edelstein SL, Knowler WC, Dabelea D, Boyko EJ, Pi-Sunyer X, Kalyani RR, Franks PW, Srikanthan P, Gadde KM; Diabetes Prevention Program Research Group. Long-Term Weight Loss With Metformin or Lifestyle Intervention in the Diabetes Prevention Program Outcomes Study. Ann Intern Med. 2019 May 21;170(10):682-690. doi: 10.7326/M18-1605. Epub 2019 Apr 23. Erratum in: Ann Intern Med. 2020 Sep 15;173(6):508. PMID: 31009939; PMCID: PMC6829283.
Rebecca M. Puhl, Mary S. Himmelstein, Jane Speight; Weight Stigma and Diabetes Stigma: Implications for Weight-Related Health Behaviors in Adults With Type 2 Diabetes. Clin Diabetes 1 January 2022; 40 (1): 51–61. https://doi.org/10.2337/cd20-0071