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Belonging and Ease: Reducing Barriers to Diabetes Care
Learn why belonging and ease are an essential part of any lifestyle change.
Clients with diabetes are looking for lifestyle changes and want to know how to evaluate these approaches without focusing on weight. A person’s diet is a foundational approach to glycemic control. There are many options for an individual to consider, including but not limited to research supporting intermittent fasting, keto, vegetarian dietary approaches to Stop Hypertension, DASH, and the Mediterranean Diet. More and more clients aren’t focused on weight loss but on a complex evaluation of the change process. This is why it is helpful to understand how belonging and ease are part of their analysis.
An avalanche of data supports the notion that nutrition is the foundation of health. A natural response is to wonder what diet is best, regardless of the weight change involved. The habit of defining choices – good or bad, right or wrong – is how people typically sort. This binary method has limitations explored in the article You Have a Superpower and Don't Even Know It! For healthcare professionals new to a weight-inclusive approach, it is easy to miss the key take-home message: binary thinking reinforces systems of oppression.
Understanding systems of oppression, specifically regarding nutrition and dietary change, is challenging. This is why Inclusive Diabetes Care created the basic needs for inclusion model. Learn more about the IDC model.
Initially, dietary changes focus on the individual. The personal responsibility focus blinds us to seeing larger population barriers. Yes, some people (metaphorically the Unicorns) successfully modify and adjust behaviors. However, these people are not the norm. Shifting from an individual to a societal approach requires asking different questions. Let’s use the initial two pyramid questions, belonging and ease, to explore some barriers surrounding implementing these dietary approaches.
When a person starts a diet, the desire to belong is present. Making dietary changes helps someone belong to the group of those who are motivated to manage their blood sugar with diet. Making dietary changes could place a person in a group that views food as medicine. If the dietary change has a large following, like vegetarian, keto, or intermittent fasting, a person’s sense of belonging will overlap; people who want to manage their blood sugar and don’t eat X, Y, or Z and choose to eat A, B, or C instead. This sense of belonging and identity builds cohesion. In turn, cohesion allows groups and subgroups to create products and resources to build additional motivation, reinforcing the sense of belonging and identity. Belonging is helpful both fundamentally and psychologically.
What if you don’t want to lose weight?
Not everyone who seeks nutrition counseling for diabetes is striving for weight loss. Many people, regardless of size, have also come to the realization that dieting doesn’t work for them. When they say, “Restrictive diabetes and or pursuing weight loss isn’t my goal,” can result in feeling judged or excluded by their primary care, which assumes that a person who doesn’t want to lose weight doesn’t care about their diabetes. This assumption has many consequences, including not being offered care that is offered to a straight-sized person. However, focusing on the felt sense of not belonging (because they advocated for care that works best for them) becomes the initial domino. Lost in the conversation is how improving nutrient density and a person’s diary balance, regardless of weight change, improves blood glucose.
As the dominos of othering continue to fall, the struggle intersects with other research, including Dr. Kristen Neff’s work on self-compassion. She explains that belonging is the antidote to isolation. In the book Together, without a felt sense of belonging, Dr. Vivek Murthy explains that isolation physically impacts our health in many ways.
The concept of belonging is important. It is where appearance-based health changes, specifically weight and weight loss, are often used to gauge dietary adherence to a group. Society reinforces the belief that to look healthy, a person must be seen as thin. Appearing thin, along with the power and influence being a straight-size is called thin privilege. If thin privilege isn’t present, an individual must have lost or is actively trying to lose weight.
To unpack this concept more, let’s imagine Sharon weighed 600 pounds, and during the course of her diabetes care, her weight changed. She is now 400 pounds. Despite a 200-pound weight loss, Sharon would likely receive messages from healthcare providers and society saying she is dangerously overweight and should continue to lose weight to belong. Yet, within Sharon's weight-focused group, she may already feel a sense of belonging and even personal power because of her ‘success’ at weight loss. Sharon lives in two worlds. A world where she wants to be seen and heard as a fat person who is actively caring for her diabetes. She also wants acknowledgment for following the recommendations of her medical team. For these reasons, Sharon’s privilege within a weight-centric group is validated because she has been ‘successful’ at weight change. However, Sharon’s sense of belonging outside of this group has been stripped because her BMI is over 30. It traps people like Sharon in a no-man’s land, where they are and aren’t seen as successful. This psychologically damaging situation is often unchallenged and contributes to internalized fat phobia.
Belonging to a group can support a sense of identity.
Groups can decrease isolation, which can increase self-compassion.
Groups can also create resources to increase group identity, support, and loyalty.
Helping clients navigate group dynamics, which can unintentionally reinforce systems of oppression and drive internalized fatphobia, is part of inclusive diabetes care.
The next question answers how easy/hard it is to follow any of these diets to gain entrance to the group of people who follow a specific diet. Many thin-bodied healthcare professionals unknowingly live in a space Christy Harrison, MPH, RDN, calls wellness culture. Wellness culture is based on the fact that every group has a culture and group dynamics, which may be easy for some people to be part of and hard for others. Our privilege blinds us to the challenges others may face within a group.
The ease associated with any group increases or decreases the sense of belonging. It is important to understand how strong the need to be seen as a committed follower of dietary rules is to be part of the group. Overeaters Anonymous used to ask participants to follow the “Gray Sheet” diet, which restricts macro and micro-nutrients to promote weight loss by following an unbalanced diet. This is how many groups become a training ground for disordered eating and eating disorders.
As noted, the above groups are also a source of authority and power used to gain a sense of belonging. It is a complicated topic that takes time to unpack. The following example requires each person to make a personal judgment. Can someone claim to be a ‘vegetarian’ if they eat fish once a month? Can someone say they are following a Keto diet if they eat fruit? There isn’t a ‘correct answer’ to these questions, but a personal choice. Following specific diets is a way people signal that they are part of a group. The need to belong to a group is powerful; many clients will twist themselves into dietary knots just to belong. It is one of the reasons diabetes is a risk factor for developing an eating disorder.
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The Ease of a Binary View
Seeing a diet as good or bad, or the people who eat a specific diet as good or bad, returns us to a binary view. This view of food habits and nutrition is oppressive because it is a form of judgment that reinforces “othering” behavior. As healthcare professionals committed to inclusion, we must remember people and foods are more complex and simply can’t be reduced into an either/or choice.
Focusing specifically on the felt sense of ease requires examining the Social Determinants of Health (SDOH). How easily can a person get the foods needed to follow these diets? Imagine you don’t have a car and must rely on public transportation. How easy is it for you to buy and follow the rules of a diet? What about affordability? How affordable are the ingredients of this diet?
There are many stigmas in diabetes, including the stigma of ignorance. Being ‘smart’ is a virtue. Therefore, it is hard for ANYONE to admit they don’t know. Assessing a client’s learning needs is an essential part of their diabetes plan that is often overlooked, adding difficulty to blood glucose management. Working with a registered dietitian and/or diabetes care and education specialist is helpful.
Evaluate how SDOH barriers can bring ease to your clients with diabetes.
Letting go of the binary view of food and nutrition disrupts the cycles of oppression.
Normalizing the need to learn about diabetes and health becomes an antidote to many stigmas.
Assessing each client’s learning needs to direct them to appropriate resources increases ease.