How To Help Clients With Diabetes Who Have Internalized Weight Bias

Four research articles to help you bridge how internalized weight stigma, depression, and diabetes are connected

"Losing weight will make my diabetes better." Explains JJ, a 48-year woman recently diagnosed with type 2 diabetes. "I got my family through COVID, but I gained about 70 pounds."

I remain silent, wondering how I can help JJ understand type 2 diabetes is a complex condition and that there are many reasons why she might have been diagnosed. My mind begins to gauge options. For example, do I mention that her childhood trauma, depression, and change in activity are likely causing her glucose to rise? Maybe it’s better to talk about how her lack of sleep, menopause, or medications might be contributing. Understanding what is the best way to broach the complexity of diabetes, internalized weight stigma, and depression isn’t taught in schools.

Yet, JJ keeps referring to her weight change, how she is unused to having 'this body,' her words accompanied by hand gestures that move up and down her body, like something from a gameshow when the host reveals the grand prize. 

After a few minutes, I offer, "Getting diagnosed with diabetes has reordered your values."

"You could say that." She replies.

"The last few years haven't been focused on you."

"Correct." Her face turns to look directly at me. 

"You want to change this."

Her head nods, "Yes. I think that's necessary."

"There is just one problem. You can see how following a rigid diet and creating unreasonable expectations will make your existing depression worse."

Her eyes blink away the tears that are forming. "Yes. That is my greatest fear."

Understanding how diabetes, depression, and internalized weight bias intersect requires healthcare professionals to create mental bridges between distinct areas of knowledge. This article aims to bridge internalized weight bias and how it relates to healthcare, depression, and diabetes. 

Internalized Weight Bias is when a higher-weight person internalizes negative beliefs about their body. It often causes them to participate in their oppression. For example, Mary comes to her initial appointment stating, "I know I should lose weight." or "Joe states, "I did this to myself." His hand glided up and down his higher-weight body. Tara states, "If I had forced myself to stick with the diet, maybe I wouldn't have gotten diabetes." 

Yet, internalized weight bias doesn't happen in a vacuum. Brown and Batterham found that weight-stigmatizing comments, behavior, or treatment proceeds internalized weight stigma/bias. The specific pathway described in their 2022 research shows weight stigma is followed by internalized weight stigma; next comes implicit weight bias, which is when a person is unaware of their beliefs about weight, and finally, explicit weight bias, where the beliefs are clear. In the above examples, all clients expressed explicit weight bias statements.

Research shows that internalized weight bias and stigma are related to eating disorders, depressive symptoms, anxiety, body image dissatisfaction, and lower self-esteem in adults. The greater the weight stigma, the stronger these connections.

To recap, weight bias and stigma lead to internalized weight bias which is correlated to depression, disordered eating, and low self-esteem. Yet, where does the weight stigma start? Remmert et al. found that over 70% of US adults in weight loss programs report stigmatizing healthcare incidences.  Unpacking this began in 2014 when A. Janet Tomiyama explained The COBWEBS cycle. Many professionals in diabetes care didn’t read this research that shows how internalized weight bias stigma creates stress, which promotes increased eating and cortisol (both impact blood sugar regulation), resulting in weight gain and a repeating cycle that starts a pattern of yo-yo dieting that makes managing blood sugars even more challenging. 

Diabetes and depression are bi-direction conditions that make knowing what to say to a client like JJ even more challenging. Clients with depression are more likely to develop diabetes, and having diabetes is more likely to cause depression. JJ is treating her depression with therapy and medication. Hiroyuki M et al. confirmed that all antidepressant monotherapies and combination therapies, except the combination of tricyclic or tetracyclic antidepressants and trazodone, had a significant association with type 2 diabetes risk. This 2020 research showed antidepressants individually have a chance of causing type 2 diabetes. 

The mental bridge we are building is the link between psychological and physical health. In this case, JJ's mental health is impacted by internalized weight stigma, existing depression, and past trauma. Her mental health is impacting her physical health, resulting in diabetes. Suppose a healthcare professional suggests JJ lose weight. This common and often expected suggestion will likely reinforce the internalized weight stigma, worsening depression, possible coping with food, increased cortisol which will disrupt blood sugar control, and weight gain, which energizes the cycle.

Listening Instead of Suggesting 

Younger me was full of ideas and information, and because of my education, privilege, and position, I assumed I was supposed to make suggestions. However, becoming proficient in Motivational Interviewing has helped me see how the last thing JJ needed was for me to "educate" her. Instead, I asked her, "What do you want to focus on?" JJ shared what she wanted to do and the steps she had already taken. The more she talked about her self-care vision, the clearer she was regarding what would help her.

As the session ended, I asked, "What, if anything do you want to work on between now and our next appointment?"

JJ was quick to offer, "I want to get outside."

"Outside to walk or just getting off the couch and go outside," I asked

"Just getting off the couch. I really can't commit to walking. I can't commit to exercising or trying to lose weight." 

JJ was pushing back and setting clear expectations, which I could affirm. "You know what is going to work for you. Would getting outside twice a week be a reasonable goal?" I asked. "You don't have to walk or ‘do’ anything." Her head nodded in agreement. 

This patient-centered session took a significant detour from reinforcing weight-centric messaging about diabetes care and blood sugar management and instead prioritized the patient's autonomy and mental health. Healthcare professionals need more support and training on nonjudgemental weight-inclusive counseling models for complex clients like JJ.

References

Remmert JE, Convertino AD, Roberts SR, Godfrey KM, Butryn ML. Stigmatizing weight experiences in health care: Associations with BMI and eating behaviors. Obes Sci Pract. 2019;5(6):555‐563. doi: 10.1002/osp4.379 

RL, Kalea AZ. Effective strategies in ending weight stigma in healthcare. Obes Rev. 2022 Oct;23(10):e13494. doi: 10.1111/obr.13494. Epub 2022 Aug 7. PMID: 35934011; PMCID: PMC9540781.

Tomiyama AJ. Weight stigma is stressful. A review of evidence for the Cyclic Obesity/Weight-Based Stigma model. Appetite. 2014 Nov;82:8-15. doi: 10.1016/j.appet.2014.06.108. Epub 2014 Jul 2. PMID: 24997407.

Hiroyuki Miidera, Minori Enomoto, Shingo Kitamura, Hisateru Tachimori, Kazuo Mishima; Association Between the Use of Antidepressants and the Risk of Type 2 Diabetes: A Large, Population-Based Cohort Study in Japan. Diabetes Care 1 April 2020; 43 (4): 885–893. https://doi.org/10.2337/dc19-1175