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Why Weight Loss Is and Isn't Part Of Diabetes Care
A nuanced response to a common question.
Weight-inclusive diabetes care professionals are often asked, "Isn't weight loss part of diabetes care?" My take on this question is complex, and I hope this article will explain why weight loss is and is not part of diabetes care.
Let's start with three reasons why weight loss is part of diabetes care.
When a person's blood sugar is elevated, they will likely lose weight. It is a symptom of diabetes. I have written many times about why this isn't a good omen. Weight loss due to high blood sugar causes muscle wasting and increases the risk of complications, including stroke as well as heart and kidney disease.
People might also lose weight when their blood sugars are better managed because they are less hungry. Hunger is another symptom of high blood sugar. When blood sugars are in the target range, hunger decreases because the cells, deprived of glucose, are now getting nourished and stop sending signals to the brain that they are starving.
Weight loss can happen if someone doesn't have a lot of low blood sugar. Low blood sugar requires us to 'feed' the medication, not the person. When the low blood sugars stop or are reduced, weight loss can result. It is important to note that low blood sugars result from medication, activity, meal skipping, avoiding carbs, and a combination of all four. Low blood sugars are more likely to occur when taking an older class of medications. Newer drugs, including DPP4, SGLT2, and GLP1, may result in weight loss simply because they don't cause hypoglycemia.
Let's discuss four reasons why weight loss is not part of diabetes care.
No one wants to be told they have diabetes. When a person has been diagnosed with diabetes, they typically overcompensate with their diet. There are many reasons, but the most obvious is fear. It is normal to be afraid when you learn you have a chronic illness like diabetes. Our client's initial reaction comes out of fear, not logic. Fear temporarily increases motivation, but fear isn't a sustainable motivator. When clients are told they 'need' to lose weight, they now have two things to fear: diabetes and their success at long-term, non-surgical weight loss.
All humans need and look for autonomy. Food is one of the first ways we express our autonomy. Babies throw, spit out, and play with food to communicate. A person's connection to food and health is complex and changes yearly. Our clients may have difficulty verbalizing their relationship to food, eating, body image, weight, and health. Their relationship can be even more complicated if there are eating, weight, and body image struggles. Other issues that complicate our relationship with food include childhood, racial, environmental, generational trauma, insecurity, intolerances, allergies, and limited access to traditional cuisine.
Our job isn't to minimize, reduce, or ignore our client's complex relationship with food and the privileges it provides some people but rather to unpack them so our clients can manage diabetes while living their best lives. Doing so requires each healthcare professional to challenge the assumption that everyone has the same relationship with food as we do. It is difficult to accomplish, but exposing the privilege and ignorance that keeps us stuck when talking about weight is necessary.
Diabetes Stigma Tangles Our Thinking.
Enter a chronic illness like diabetes. Diabetes and our current treatment obsession with diet and weight complicates our already ineffable relationship with food, eating, health, and body image. Our obsession with size is so loud it drowns out the millions of ways we can effectively manage diabetes without talking about weight.
My stigmatized clients are upset that they have diabetes and are trying to process the assumption of diabetes as a 'lifestyle' disease. As a result, many PWDs can't think straight. They are unaware that activity, sleep, regular medical care, connecting with friends, and reducing stress are just as important. Society's view of health is out of balance, and changing our size won't get our nation back to center. We need to see behind the facade of weight loss.
Balance, not weight loss, is the fountain of health.
A person gets into balance by striving to have a balanced life, not by pursuing weight loss. There are a few unicorns in the world who have lost weight because their life has become more balanced. Hooray! We love them! However, most PWDs attempt an unsustainable dietary change, lose and regain weight, and then internalize this as a personal failure, feeling overwhelmed and assuming it is their fault. They wrongly believe weight loss is the ONLY way to manage diabetes.
At so many levels, this is harmful, but let's focus on the common thought of weight loss as the only way to manage diabetes. It is a clear example of over-identification. Dr. Kristen Neff, author of Self-compassion, states that when we engage in overidentification, our world becomes smaller, and we start to assume this weakness is the cause of our problems. When we engage in over-identification, we are driven by guilt, blame, and shame, creating conditions for isolation, diabetes distress, and depression. It is easy to see how, as a society, we have over-identified weight as the problem with diabetes. A balanced diet is the foundation of health, but a balanced diet isn't the equivalent of a weight loss program when these two things are conflated we 'other' people with diabetes.
The concept of "othering," which Michelle Obama speaks about at length in her book Becoming, is how we often view people with diabetes. Poor people with diabetes. Fat people with diabetes. Black, Latino, Asian, and Native American people with diabetes. They aren't like me. They don't belong to my group. Their needs are not the same as mine. They are different and separate, AKA: 'othered.' This leads to greater levels of oppression. Expecting oppressed people to have a balanced life isn't possible until the Social Determinants of Health are reduced nationally.
We need a new approach to teach diabetes.
It is stressful to feel out of balance. Food is the most common way we cope with stress. Asking clients to engage in an unbalanced approach to diabetes care can drive maladaptive coping. It creates a cycle that results in disordered eating, including binge eating, a condition that disproportionately impacts people with type 2 diabetes.
Healthcare needs a new model to teach diabetes. That is why I created the Four Factors of Diabetes. This model includes the four factors: dietary, lifestyle, medical, and environmental. A flexible model allows us to adjust and shift the focus of diabetes so each client can achieve a sense of autonomy and balance. It can also be used as a public health model by asking about the community's dietary, lifestyle, medical, and environmental barriers. Public health officials know there isn't a one-size-fits-all approach to diabetes, but focusing on a balanced approach to care allows many options and ideas to be considered. It creates the needed space and grace for everyone to contribute.
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