How weight-centric appointments impact clients in a 12-month period of time
What are clients really hearing when you offer weight-centric care? This article will explore how it can lead to clinical inertia, and poorer outcomes.
Many professionals wonder, is suggesting dieting really “THAT” bad? It takes time to unpack how weight-centric care drives clinical inertia. This post explores this scenario and whether weight-inclusive care is a better option.
Imagine your client, B, is coming to see you. They make some changes that result in an eight-pound weight loss. You praise B, saying, "Great job." This praise isn't tied to a specific behavior and is interpreted as "I have to keep losing weight to manage my diabetes."
At the next visit, B hasn't lost any weight. You explain, "Don't worry. You will do better on the next visit."
At their third visit, B regained eight pounds, and their A1C increased. B feels bad, explaining, "I must have fallen off the wagon. I will try harder." You agree and sign off on the plan.
At the fourth visit, B comes in; their weight is up four pounds from their initial diagnosis. They explain they are following a diet, exercising, and trying to manage their blood sugar. Their A1C hasn't improved. You say, "I think it is time to start you on medication." B is silent. Why?
How this lands for the client.
It is possible that B feels weight loss is how diabetes is managed. They haven't been told diabetes care is managed by engaging in specific behaviors (Specifically the ADCES Self-care 7), not by weight loss.
It is also very likely that B believes diabetes can be managed by diet and exercise alone. They have not been told that 100% of people with type 1 diabetes need medication and 88 percent of all people with diabetes need medication. Their belief may be because they have never been offered diabetes education and don't understand the underlying pathophysiology of type 2 diabetes but have only had the desire to lose weight reinforced. When they could not keep their weight off, they were encouraged to 'try harder.'
It is also very possible that B believes there is evidence that sustained weight loss is possible and that this possibility has been studied for people with diabetes.
How can weight loss be a variable in clinical inertia?
At B's second visit, their limited weight loss was acknowledged and used to justify not taking additional action, leading to clinical inertia. As noted above, sustained weight loss has not been clinically effective for many people; therefore, asking your client to have sustained weight loss before starting or adjusting medication is likely to delay treatment.
Yo-yo dieting can make many providers feel trapped because the client explains, 'They will be better.' However, if medications are added and the client restricts their diet, they may have low blood sugar when on a diet, and a few days or weeks later, high blood sugar results after the medication has been taken away.
Extreme diets contribute to erratic blood sugar, erratic eating, low energy, and hypoglycemia. What many providers may have heard is how clients initially 'feel better' when making a change to their diet. This sense can be both physical and psychological. It feels good to take charge and make a decision, that sense of control and insight into a problem shifts a person’s view, and increases motivation. With a complex condition like diabetes, the emotional burst of energy from insight is powerful! However, it is typically short-lived because diabetes is a chronic condition, and your clients' energy when they start a diet is unsustainable. After a few days, weeks, or months, most people feel a drop in physical energy, lower levels of motivation, time pressure, and a desire to return to familiar coping mechanisms, which may be eating.
Current estimates are about 26 percent of young women with type 1 diabetes will develop an eating disorder. Disordered eating in Type 2 diabetes is estimated at two to eight percent by the ADA. Still, it is likely higher in specific populations, including chronic dieters, higher-weight individuals, and people with a history of eating disorders. It is noted that disorders such as binge eating potentially contribute to the development of diabetes. Understanding how EDO impacts diabetes care is helpful for all providers to explore.
The failure to lose weight has been depicted in society as laziness, lack of motivation, or personal failure. To overcome this, a client may seek more and more extreme changes such as cutting out all carbs from the diet, 'going keto,' eating only one meal a day, or engaging in high amounts of exercise.
Extreme diets that eliminate carbs may initially improve blood sugar and increase energy, but over time, it leads to unbalanced restrictive eating, which is the primary driver of disordered eating. The rate of disordered eating in diabetes ranges because Type 1 diabetes is a risk factor for eating disorders (EDO) due to the preoccupation with food and the limiting nature of the diet. Current estimates are about 26 percent of young women with type 1 diabetes will develop an eating disorder. Disordered eating in Type 2 diabetes is estimated at two to eight percent by the ADA. Still, it is likely higher in specific populations, including chronic dieters, higher-weight individuals, and people with a history of eating disorders. It is noted that disorders such as binge eating potentially contribute to the development of diabetes. Understanding how EDO impacts diabetes care is helpful for all providers to explore.
Explore Other Inclusive Education Models
Learning new ways of teaching diabetes care is needed. Many professionals are unaware of the following three models:
Focusing on weight-neutral behaviors helps people with diabetes understand the key areas to address to prevent complications and more effectively manage blood sugars. These self-care behaviors are weight-neutral. They are often missing from weight-centered research, program design, and training. Many healthcare professionals are unaware of whether these programs exist or how weight-neutral models can improve blood sugar management.
As healthcare professionals I’m curious what have you witnessed? How is it similar and different than this observation? “After a few days, weeks, or months, most people feel a drop in physical energy, lower levels of motivation, time pressure, and a desire to return to familiar coping mechanisms, which may be eating.”