The Invisible Barrier: Meet Seven Common Stigmas In Diabetes Care

There are many types of stigmas, not only diabetes stigma. Learning about these stigmas reveals a curious paradox regarding how stigma is layered into our felt experiences.

Stigma is the elephant in the room. It is why comedians deliver jokes poking fun at stigma in the numerous ‘fat’ jokes or body image insults woven into most late-night monologues. We are encouraged to laugh at the insult or self-deprecating comment, yet many of us aren’t clear why stigma isn’t always funny, especially for people with or at risk of diabetes. This article will review seven types of stigma and how it impacts healthcare and access. 

Laughing at Stigma

Humor forms a sense of connection only if you understand why you are laughing. It is the reason it is helpful to understand stigma. Stigma refers to the discrediting, devaluing, and shaming of a person because of their characteristics or attributes.¹  When we laugh at jokes that punch down, making fun of those with diabetes or higher-weight individuals, we are agreeing that health and thinness are morally superior.  If you laugh at jokes that punch up, you see illness is an unavoidable part of life as well as the injustice of fatphobia and unrealistic body image standards, and want to highlight them via humor. Stigma generally leads to negative social experiences such as isolation, rejection, marginalization, and discrimination. While humor can connect us, joking about stigma typically disconnects us. If stigma is related to a health condition such as diabetes, mental illness, or poor nutrition due to food insecurity, it may affect a person’s illness and treatment course, including access to appropriate and professional medical treatment. 

Untangling the knot of stigma is hard, and it is made even harder to untangle by the multiple layers of stigma in our lives. Regarding diabetes, there is a direct connection between nutrition and blood sugar. Layers of stigma are tied to diabetes, medical care, medical treatment, body image, diet, and food choices. It is an understatement to say that sigma is complicated. 

Meet The Stigmas

There are many types of stigmas, not only diabetes stigma. Seven common forms of stigma include Diabetes, Financial, Gender, Health, Racial, Weight, and the stigma of not knowing (Ignorance). 

Getting to know these stigmas is a paradox because stigma isn’t a direct experience. Yes, we can know what stigma is intellectually, but research explains we must focus on how stigma is experienced by individuals who live with it in its various forms in order to fully understand it².  Stigma itself is not something experienced directly by an individual. Instead, stigma is experienced indirectly through association with other events or experiences in social or healthcare contexts, such as discrimination, stereotyping or prejudice, being a punchline, and so forth. 

Stigma is the water we swim in, which rhetorically asks, “Does the fish know it is in water if water is all the fish has ever known?” If we have only known a life with stigma, can we imagine a life without stigma?

Stigma and Shame

The connection between the stigma and shame is a straight line. Stigma is the experience and shame is the “felt stigma.” Shame has two parts, the first, “the shame associated with” being reduced to a condition (e.g., “unable to buy food” or “being diabetic”), and the second, “the fear of encountering enacted stigma,” ³which is synonymous with “shaming.” 

Expanding the water analogy further, stigma is the water we swim in, and shame is how we feel when swimming. When a person believes they “are” what they feel when swimming in a stigma-filled pool, the shame has been internalized. The internalized shame leaves a person believing they are profoundly and often irreparably flawed, unworthy, and unlovable.

Pause and feel the meaning of this sentence. Feel how your body reacts to the thought that someone is profoundly and often irreparably flawed, unworthy, and unlovable because of diabetes. Because they are of higher weight? Because they are struggling to buy food or maybe queer or Black? Touch the space in your body where that lands and physically feel the impact of stigma in your body.

Swimming In the Ocean of Societal Stigma 

Seeing how societal stigma is absorbed allows you to see how stigma and shame become directed toward oneself. It can also manifest as self-hatred, self-isolation, shame, and fear of further stigmatization⁴.  It is clear that stigma and shame are not the same thing, but how they are different and connected takes some additional unpacking. 

In the book, My Grandmother’s Hands, Resmaa Menakem explains HIPP theory which is the historical, intergenerational, persistent institutional, and personal trauma a person has experienced. In healthcare, we may not grasp why a client is struggling because we haven’t fully understood the historical, intergenerational, persistent institutional, and personal trauma in any given interaction, including our own lives. We may not see our interaction as “the straw that broke the camel's back.”

This unawareness can help us connect with the seventh stigma, the stigma of unknowing or ignorance. It takes courage to face the inaccurate belief that we are profoundly and often irreparably flawed, unworthy, and unlovable because we are ignorant. Pause and imagine that for generations, your family was accused of being “stupid,” or “incapable,” or “unreachable.” If this is your experience, then the experience of not knowing might land differently for you. If your grandparents didn’t have the opportunity to learn to read or struggled in school, this experience was communicated to your parents, who somehow communicated it to you. This helps us see how emotionally charged life experiences are passed across generations. When limitations, including learning, are codified into our policies, laws, and systems and disadvantage groups of people, it reinforces the barriers between generations. Let’s use food access to imagine the impact of stigma on you and your clients.

Blame the Individual

Seeing everything as the responsibility of the individual has benefits. You can add to the list, but when I am honest with myself, blaming the individual makes me feel safer. When I see food insecurity (which is painful to witness) and blame the hungry person, I reinforce the belief that it is a problem “they” have instead of acknowledging it as a problem. Food insecurity is a global problem. It is a problem in the United States. It is a problem regionally and within each state, county, or town. I FEEL BETTER when I blame the individual instead of seeing how food insecurity is part of the larger food complex.  Separating myself from the pain of food insecurity affords me the emotional distance I crave. I grew up in a family that cycled in and out of poverty. We also cycled in and out of having and not having food. My mother hid it well, but the signs were present - powdered milk, day-old bread, big blocks of cheese, off-cuts of meat, no dessert, and a refusal to accept a free hot lunch. I can separate myself even more if I repeat the stigmas I have heard. These sound like, “They are houseless, addicted, unemployed, lazy, or sick.” This labeling is my attempt not to feel the pain of food insecurity. I am inclined to do this because, as a child, when I asked why we didn’t apply for free hot lunch, I was told, “Oh honey, we aren’t poor like them.” At this moment, the connection between food dignity and generational shame begins to come into focus.  Resmaa Menaken discusses what he calls “dirty pain” in his book, My Grandmother’s Hands, and I suspect it is what I am experiencing – intergeneration shame.  

I FEEL BETTER when I blame the individual instead of seeing how food insecurity is part of the larger food complex.

Dirty pain has a way of making conversations about “me.” This is part of racial stigma and how being White-bodied is afforded more attention during conversations. In a moment, racial stigma is emergent. For example, I might share a story about my grandmother feeding hobos out of the back of the house during the Depression. I think about how these experiences percolated into my family’s food culture and how these beliefs reinforce the stigma (and shame) surrounding food.  My White-body expects to be seen and heard, so I might unintentionally turn the spotlight from increasing food dignity within my community to my thoughts, feelings, and experiences with this topic.

Dignity

 It is not hard to increase a sense of dignity if these three basic beliefs are present:

• Food connects us because having food is a basic need. We all have to eat. When a person doesn’t have access to food, we are alike, connected by our shared humanity and need. This basic need is an invitation to connect to my fear of being hungry as a child, a single mother, a dietitian, and a caregiver for an elderly parent.

• Second, when someone is food insecure, they try to meet this need because everyone needs food. Food isn’t a “nice to have” option. Food is a need. It isn’t a luxury. Hunger hurts, and when I pretend it doesn’t, I am trying to deny the pain I felt when I experienced food insecurity.

• Third, my own suffering isn’t the focus. The focus is on providing food dignity. Any dirty pain I have surrounding stigma and shame can shift the focus or distract the conversation. 

See The Whole Me

These three beliefs allow me to see the person before me, making it easier to come alongside the issues. In Motivational Interviewing, this is called Partnership.  It sounds like interest and curiosity when it lands correctly in a counseling session. 

Unfortunately, I have witnessed a lot of stigma surrounding food, weight, and diabetes. This second-hand trauma can activate dirty pain within me. It can also spotlight the many ways I have unintentionally stigmatized my clients. My world is full of intergenerational and personal trauma, making it hard for me to focus on the client. These complicated and confusing feelings hurt, and I want to offload them badly. The easiest way to do this is by shifting the conversation to my thoughts, feelings, and MY solutions. This is where the pull of teaching feels like a good alternative. It places me in a position of authority. It distances me from my pain and creates a subtle hierarchy where I am the giver of knowledge. This view makes me feel better. Unfortunately, it can reinforce other stigmas, including racial, health, and the stigma of ignorance, but most importantly, it doesn’t increase food dignity. 

When the Past becomes the Future 

If we allow our past to come into focus and see how it touches on the current issue, we can open ourselves up to deeper conversations. Learning more about HIPP theory helps healthcare professionals untangle the trauma of stigma and shame and equips the healthcare industry to stop retraumatizing clients. 

Food dignity must be present in the Food As Medicine Movement because, without it, the conversation will shift away from our common humanity to other issues within the food ecosphere. What results is a cycle that reinforces institutional and systemic oppression. Food isn’t an individual issue – it is a basic human need. Our food-insecure clients with or at risk of diabetes are always trying to meet their food needs, but for most, the invisible barrier of stigma is in the way.

Learn more about the Food Dignity and Food Sovereignty Movements.

1.  Subu, M.A., Wati, D.F., Netrida, N. et al. Types of stigma experienced by patients with mental illness and mental health nurses in Indonesia: a qualitative content analysis. Int J Ment Health Syst 15, 77 (2021). https://doi.org/10.1186/s13033-021-00502-x.

2.  Dolezal L. Shame anxiety, stigma and clinical encounters. J Eval Clin Pract. 2022 Oct;28(5):854-860. doi: 10.1111/jep.13744. Epub 2022 Jul 28. PMID: 35903848; PMCID: PMC7613638.

3.  Dolezal L. Shame anxiety, stigma and clinical encounters. J Eval Clin Pract. 2022 Oct;28(5):854-860. doi: 10.1111/jep.13744. Epub 2022 Jul 28. PMID: 35903848; PMCID: PMC7613638.

4. Li H, Zheng L, Le H, Zhuo L, Wu Q, Ma G, Tao H. The Mediating Role of Internalized Stigma and Shame on the Relationship between COVID-19 Related Discrimination and Mental Health Outcomes among Back-to-School Students in Wuhan. Int J Environ Res Public Health. 2020 Dec 10;17(24):9237. doi: 10.3390/ijerph17249237. PMID: 33321881; PMCID: PMC7764740.