What Is A Weight Centric View in Diabetes Care?
This article explains what weight centric view is. When we adopt an inclusive view it makes our jobs in diabetes care easier, and reduces diabetes stigma, distress, and burnout for our clients.
What is a weight-centric view of diabetes?
A weight-centric view holds that weight loss is beneficial and is a primary or secondary goal of diabetes care and education. This view is not in alignment with the 2023 Standards of Care for Diabetes or the ADCES Self-care Seven Behaviors for Diabetes Education, and yet it dominates the conversation surrounding diabetes. "Lose weight, and that will cure your diabetes" is a false statement that continues to fuel the belief that the cause of diabetes is weight; therefore, the solution is weight loss. The causes of diabetes are complex, and in focusing on type 2 diabetes, 11 possible defects have been identified, none of which are related solely to weight.
When these facts are presented, many professionals counter there is research that supports weight loss as an intervention for diabetes care. When asked to review the details of these studies, the necessary critique is missing because diabetes professionals do not have the time to engage in a detailed review of the research. Thus the busy healthcare professional becomes an unintentional pawn for the weight loss industry. How? Healthcare professionals are trained in a weight-centric paradigm, and unless they understand what a weight-centric paradigm is, there will be pulled into it. The following 2022 review article has carefully explained the consequences of a weight-centric approach to healthcare.
What if we didn’t talk about weight in diabetes?
A weight-neutral approach does not see weight loss as the goal of diabetes care and education. It does not identify weight loss as a goal but focuses on healthy eating, activity, and skillful (non-harming) coping as beneficial. This view sees a person's weight status as an outcome of existing conditions and behaviors. A weight-neutral approach does not require weight loss, nor does it encourage or praise weight change as part of diabetes care. A weight-neutral approach does not prescribe medication based on weight loss but evaluates the likely core defects that might increase blood sugar. A weight-neutral approach to diabetes education focuses on nonjudgmental educational models such as ADCES Self-care 7, The Four Factors of Diabetes, and Am I Hungry: Mindful Eating and Diabetes, which are currently available.
For healthcare professionals to offer a weight-neutral approach to diabetes, they must take time to understand their own existing weight bias. You may wonder about the difference between weight bias and weight stigma. Weight bias is how you, as a healthcare professional, feel about a person's weight. Uncovering your bias is challenging, but there are resources, including Harvard’s Implicit Weight Bias Test and the Weight Neutral Self-Assessment, which can help you understand underlying thoughts and beliefs. Unpacking your bias isn't linear but more like a tangle of many oppressions, including gender, sex, economics, trauma, and so much more! Weight bias is often supported or implied when you recognize your thoughts which may sound like, "I think fat people need to try harder to lose weight." Weight stigma, on the other hand, is what your patient experiences from that belief. You may never utter the words, but implicit bias is when your unspoken thoughts become actions. "Do you think you can try harder to lose weight before we start you on medication?" could be one-way weight bias is expressed, resulting in weight stigma.
Consequences of weight bias or weight stigma may include:
Client/patient distrust (Why do they think I am not currently trying?)
Clinical inertia on the part of the provider
Yo-yo dieting
Self-blame
Dealing with our own internalized weight bias.
Understanding the role of weight bias (which comes from society and provider interactions) differs from weight stigma, which is experiencing a weight-biased interaction. The four specific weight biases to consider are defined below.
Extrinsic Weight Bias: This is conscious bias. The professional knows they have negative beliefs about fat people and purposefully act on them.
Intrinsic Weight Bias: This is subconscious weight bias. The professional has bought into stereotypes and negative beliefs about higher-weight people and is operating from them without being conscious it is happening.
Internalized Weight Bias: This occurs when a person (regardless of their size) internalizes negative beliefs about their body. Internalized weight bias can be expressed when a thin or fat person wishes to lose weight. The desire to lose weight (which is an outcome, not a behavior) causes individuals to participate in their oppression.
Structural Weight Bias: This is when the products and services fat people need (including everything from chairs and blood pressure cuffs to research, pharmaceuticals, best practices, et al.) are created based on thin bodies and to the specific exclusion of higher-weight bodies.
Unpacking bias requires the healthcare community to look at inclusion and to see how weight bias is a barrier to diabetes care because a person's weight is determined by many factors, including access to food, community, adequate financial resources, as well as epigenetic and genetic links. The complexity of weight is beginning to be understood, but many healthcare professionals cling to the false belief that weight is simply a result of calories in and out. This weight-centric view is communicated subtly and overtly and is often experienced as weight stigma.
Stigma is the opposite of inclusion. Stigma energizes disconnection. Stigma supports the idea that people with diabetes are the problem or that having diabetes is the patient’s fault. The narrative is that a person with elevated blood sugar did or didn't make some action or choice, and because of this, they have diabetes.
Stigma is a fundamental aspect of diabetes distress and burnout.
While these terms – stigma, distress, and burnout - are familiar, it is helpful to define them to understand how they are connected to larger issues.
Diabetes Stigma: The CDC defines Diabetes Stigma as "negative attitudes, judgment, discrimination, or prejudice against someone because of their diabetes.”
Diabetes Distress: The American Diabetes Association defines Diabetes Distress as "The emotional distress that results from living with diabetes and the burden of relentless daily self-management."
Diabetes Burnout: Beyond Type 1 defines Diabetes Burnout as "a state in which someone with diabetes grows tired of managing their condition, and then simply ignores it for a period of time, or worse, forever.”
The future of diabetes is inclusive.
Shifting to an inclusive view of diabetes requires all healthcare professionals to understand the fat person's needs while recognizing the impact of weight stigma and internalized weight bias. A weight-inclusive view requires additional training in weight science, advocacy, and size inclusion. The following article, How To Untangle Weight-Centered Diabetes Care, can guide a more nuanced understanding. Additional training needs to be provided by Fat Acceptance stakeholders within your diabetes/nutrition organization to ensure stakeholders and information regarding weight inclusivity are free of bias. This acknowledges the conflict of interest when resources are produced by organizations benefiting financially from the weight loss industry. The Obesity Action Coalition, Obesity Society, and Weight Loss Surgery program are weight-centric organizations or efforts with existing bias. The National Association to Advance Fat Acceptance (NAAFA), Council on Size and Weight Discrimination (CSWD), Association for Size Diversity and Health (ASDAH), which holds the trademark for, Health At Every Size (HAES), are weight-inclusive organizations. A few Weight Inclusive Training Organizations include Inclusive Diabetes Care, EDRDPro, Am I Hungry, and the Center for Body Trust. In addition, weight-inclusive training overlaps with identifying, treating, and preventing disordered eating, DEI (Diversity, Equity, and Inclusion), and other anti-racism work. A weight-inclusive approach includes weight-neutral training to provide diabetes care while focusing on acceptance.