Is the Food As Medicine Movement another weight loss program for people with diabetes?

This article explores the benefits and barriers of the Food As Medicine movement to improve the nutritional status of people with diabetes.

The ADA scientific sessions have concluded, and for those of us in Diabetes care, there is a lot of research to process. Hot topics include a growing push to think of Food As Medicine. Meaning that changing our diet is as effective as medication. This effort is referred to as lifestyle medicine. As an inclusive Registered Dietitian, nutrition is the foundation of health, so I am curious. 

What existing systems do we have to improve the nation's nutrition status?

Recreating the wheel is a lot of work. Asking, "What existing systems do we have to improve the nation's nutrition status?" brings us to Women's Infants and Children, WIC. WIC is the OG of the Food as Medicine space. Founded in 1972 and made a permanent part of the Food and Nutrition of the US agriculture department, our investment in WIC continues to save dollars because

• WIC targets lower-income families

• It provides them with nutritious foods that follow the US dietary guidelines.

• It costs 56.00 per person, but each dollar invested is estimated to save $8 in health care costs. 

Using a successful program like WIC as a model has some significant advantages of recreating a Food As Medicine program for people with diabetes, including:

• We have an existing system to copy 

• We could offer nutrition education for people with diabetes as part of the program. Since our current use of Diabetes Self-management Education, DSME, is poor, this could be a game-changer! 

• We could track health outcomes to understand better the impact of the social determinants of health on our most vulnerable population - older adults!

• We could offer this program for people at RISK, rolling the diabetes prevention efforts into a Food As Medicine program. 

Barriers

The most significant barrier centers around cost. With our current political climate, is our nation willing to invest $50-100 per person with diabetes to improve their food intake and choices? As an inclusive healthcare professional, I am curious about having this conversation. I did a Google search and a Google Scholar search but didn't read a single headline about offering a WIC-like program to people with diabetes.  

I found a movement to cover weight loss medication. Creating simple financial pros and cons investment-wise, these medications' monthly costs are $800-1,300. Again, I got curious. Why would a more expensive proposal get traction? Where is the pressure to support weight loss efforts coming from? 

Growing up watching detective shows, I know that the first rule on investigation is to follow the money. I suspect pressure comes from Pharmaceutical companies, weight loss companies, and the existing weight-centric healthcare model. The situation becomes a David and Goliath fight; having disproportionate financial resources can reinforce the idea that weight is an individual problem. Dovetailed in this familiar narrative is the belief that weight loss is a viable way to treat and prevent diabetes rather than improving education, food access, and quality. These narratives are part of everyday life, making them hard to recognize and question.

Weight Loss Industry

Like my Healthcare peers, I have been trained in a weight-centric model. It means I was taught to believe the following six tenants—

1. The belief that weight is under individual control. 

2. That an imbalance in caloric intake and energy usage causes weight gain. 

3. That health status can be predicted by weight. 

4. That excess body weight causes disease and early death. 

5. Successful long-term weight loss methods involve modifying eating and exercise patterns, and finally, 

6. Losing weight will result in better health.

I needed to pause and consider if this reflects my current beliefs. It is what Inclusive Diabetes Care is all about. Getting curious helped me consider another way of seeing and interacting with my clients. Learning more about how the weight-loss industry and diabetes can influence my thinking is essential. I would recommend the three-part series by Ragen Chastain.

The Size Acceptance Movement

Within the size acceptance movement, there are several approaches. On one end is a weight-neutral approach which focuses on improving a person's relationship with food and 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. On the other end is an Anti-diet or Weight-Inclusive approach, further showing how diet culture is harmful, reinforcing many forms of oppression. Included in a weight-inclusive model is advocacy for the needs of fat bodies. Research shows weight bias and weight stigma are barriers to medical care for both the client and the provider. 

Food As Medicine

When asked about the FAM movement within the Inclusive Diabetes Care community, individuals expressed concern about food stigma/food dignity. Weight Inclusive Diabetes Care Professionals understand that food costs are an issue because people with diabetes already manage the most expensive chronic illness. Food access is complicated. It is multidimensional and includes physical access to stores (distance and density), affordability and quality of available food, and access to culturally appropriate foods (Rose et al., 2010). It is also more complex than having a store because of many unseen barriers. I read the research outlining the value of community mapping and how collectively, the group could identify key obstacles I would never consider. When addressing food insecurity, it is essential to include the people impacted instead of simply assuming that money can 'fix' the issue.

The Healthy People 2030 found a disproportionate impact of 28.6 percent of low-income households were food insecure, compared to the national average of 10.5 percent. It rings true because when I ask my clients to tell me more about their barriers to eating a 'healthier' diet, they share:

• I can't afford nutrient-rich foods with my current income."

• I need help getting to the store (due to lack of a car or physical limitations.)

• If purchased, I cannot prepare the ingredients because of physical limitations due to illness, the demands of caring for others, or existing physical or mental limitations.

Take Barbara, who came to see me the other day. She is disabled and gets $248 monthly food stamps for herself and her daughter. She explained that this represents 80% of her $300 food budget. 

"When the check comes in, I can buy fresh food and cook. When the money runs out, I rely on the Dollar store and the value menu at the local burger place." Working with Barbara, it was clear she was the expert at stretching her food dollars and talking with me about the issue was loaded with shame.  

Using WIC as a FAM model. 

Does Food As Medicine land as another effort to help those with existing privilege? The people that are most impacted by food insecurity - people with diabetes who are food insecure see food as both the cause of the problem and the barrier to care. This topic has many internalized stigmas, which I would love to get your take on, so please respond to be included in my next issue.

Next issue: What is internalized stigma, and how does it relate to food dignity? 

Who to follow? I am learning a lot about food access from Jasmine Westbrooks, MS CDCES; Ashley Carter, RD, creators of Eat Well Exchange.org; Tambra Raye creator of WANDA: Women Advancing Nutrition, Dietetics, and Agriculture and the work of Clancy Harrington, creator of Food Dignity movement.  Inclusive Diabetes Care Substack is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber.