Marina Payne
Weight-neutral care focuses on establishing self-care behaviours. It does not promote restriction, endorse unsustainable exercise, or encourage disordered eating as a way to “get healthy.”
The benefits of a non-diet, weight-neutral approach to diabetes care aren’t measured on a scale. Instead, they can be seen in improved HbA1c, more balanced meals, consistent movement, and a decrease in the overall burden of diabetes.
Why weight and weight loss should not be the focus of diabetes care?
When we look at weight loss in the management of type two diabetes – there are initial improvements in blood glucose levels following weight loss; followed by deterioration back to starting levels after 6-18 months; even when the weight loss was maintained (Bacon and Aphramor 2011).
The look AHEAD trial was designed to look at the impact of weight loss on those with T2DM and is one of the biggest and longest running studies. The trial was supposed to run for 10 years but stopped at 8 years due to futility. In the first year the dieters lost 8.5% body weight and then started to regain it until they had lost on average 6% at 8 years; which translates to 2.6kg.
A review of 21 long term studies found that on average people were able to maintain an average weight loss of 0.94kg after 2 years (Tomiyama, Ahlstrom and Mann, 2013). Participants who did nothing at all had the same chance of having a heart attack as those who dieted and exercised. (Control group = 1.83 and Intervention group = 1.92 events per 100 person-years; Hazard ratio in the intervention group, 0.95; 95% confidence interval, 0.83 to 1.09; P=0.51) (The Look AHEAD research group, 2013).
People of all body shapes and sizes deserve compassionate, respectful healthcare and supporting overall health for all means reducing weight stigma. Experiencing weight stigma can lead to a host of behaviors that have a negative impact on glucose control, including increased eating and decreased self-regulation, higher cortisol levels, avoidance of exercise, and a greater likelihood of experiencing anxiety disorders.
People who experience weight stigma have also been found to have a 60% increased risk for mortality independent of body mass index. (Sutin, Stephan and Terracciano, 2015)
For more information refer to the article “Focusing on Health Rather than Weight” which was written by my fabulous colleague Josephine.
So, what do we focus on other than weight in diabetes care?
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Medication
Medication plays an integral role in the management of diabetes. Insulin use is more commonly seen in T1DM where an individual is insulin deficient but can also in T2DM as the disease progresses. Oral medications can be used for those with insulin resistance where blood sugar levels are struggling to stay within the target range. This is seen in T2DM to improve the body’s sensitivity to Insulin and allow for increased glucose uptake. Using medication carries some stigma when it comes to diabetes, particularly T2DM or insulin resistance. T2DM has a natural progression and it is important that people are educated about this and about the limits of diet and lifestyle intervention in slowing this progression. Changes in health behaviors, such as diet and exercise (Aphramor 2017). Medication may be necessary in reducing the risk of long-term complications.
Let’s ditch the shame around medication use!
Medication can allow us to be more flexible with food and avoid engaging in disordered eating behaviour that is likely to impact on mental and physical health.
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Experimenting with carbohydrates
Low carbohydrate diets are being recommended to manage blood sugar levels in those with diabetes, in particular T2DM; in an attempt to "reverse” this condition. A reduced intake of carbohydrates means there is naturally less glucose being released into the blood, which may result in lower blood sugar levels. However, this doesn’t change the pathophysiology of the disease. The lack of adequate glucose can lead to headaches, nausea, fatigue, poor concentration, weakness, dizziness, lightheadedness, anxiety and irritability. People with diabetes need carbohydrates just as much as people who don’t have diabetes making a low carbohydrate diet ultimately unsustainable. The bottom line is: carbohydrates are the body’s main source of fuel!
Carbohydrates break down into glucose and glucose is needed for energy. Glucose from carbohydrates is the preferred energy source of the brain. Diets and food restriction, including low carbohydrate diets, will likely lead to chaotic eating and very strong carbohydrate cravings. Chaotic eating patterns can create a blood sugar rollercoaster effect which results in poorer glycemic control. The rigid and strict food and eating advice commonly provided to those with diabetes or insulin resistance to manage blood glucose levels and/or achieve weight loss can lead to the onset of disordered eating or even the development of an eating disorder.
Disordered eating and eating disorders are estimated to affect over 16% of the Australian Population. Eating Disorders do not discriminate and can occur in people of all ages, genders, across all socioeconomic groups and from any cultural background. The overlap of Diabetes and Disordered Eating is shockingly high — up to 40% of patients with type 2 diabetes may have disordered eating behaviors (Garcia-Mayor and Garcia-Soidan, 2017) (Papelbaum et al., 2005). Furthermore, adolescence with diabetes may have a 2.4-fold higher risk of developing an eating disorder (Goebel-Fabbri, 2008).
Carbohydrates are something to experiment with, in a curious and non-judgmental manner, as they naturally do influence our blood sugar. We may look at incorporating more low GI carbohydrates. Low GI carbohydrates have a slower release of glucose into the bloodstream such as wholegrain bread, wholegrain breakfast cereal like oats, multigrain weetbix, and all bran; pasta, long-grain rice, quinoa, barley, starchy vegetables and legumes. Modifying the amount of carbohydrates eaten at one time can also impact the BGL and insulin response.
What we need to keep in mind is that we all respond very differently to different foods and therefore our blood sugar levels are also impacted very differently. There really is no one size fits all approach (Vrolix and Mensink, 2010).
This highlights the benefit of using blood glucose monitoring for some solid information on what works best for you. Blood glucose monitoring should be approached with curiosity, as an experiment to find which combinations and timing of foods work best for the individual.
You might be thinking, thanks to diet culture, “But some carbohydrates are bad for you”!
No food is bad.
You can still have carbohydrates that are higher GI with perhaps some extra thought on what the carbohydrate is being paired with, for example: fibre, fat and protein!
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What is being paired with carbohydrates – most of the time.
Studies have shown that fibre can help reduce HbA1c and fasting blood sugar (Silva et al., 2013). Fibre slows digestion, which allows glucose to enter the blood stream more slowly, making it easier for the body to process. Fibre is found in wholegrains, fruit, vegetables and nuts and seeds. The addition of protein and fat can also help slow the absorption of glucose from your carbohydrates into the blood.
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Establishing a regular eating pattern.
As a guide, try to eat every 3-4 hours to help stabilise blood sugar levels. There is a belief, that is definitely perpetuated by diet culture, that going without eating for long periods is a good thing. Interestingly our body runs generally more efficiently when we eat more regularly as it supports all sorts of metabolic function. When we become more connected with hunger and fullness cues, this 3–4-hour timeframe is when hunger cues are likely to start to pop up. Once more regular eating has been implemented, you may find more predictable cues come up. I use the term “guide” above for a reason. There is no need to get down on yourself if work gets crazy or something has come up with the kids and you end up having a big gap between meals. Life happens. Give yourself some self-compassion for the tough day you’ve had, reflect and move onto the next.
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Looking at stress and sleep
Hormonal changes that occur during acute and chronic stress situations can affect glucose homeostasis. Stress also impacts on blood sugar control (Hilliard et al., 2016). To many people to count have come in to see me and say “I am in constant fear of making the wrong food choice for my diabetes”. We don’t have to feel like this. We can maintain a positive relationship with food EVEN with a diabetes diagnosis. If trying to eat or be active in a certain way to manage blood sugar, impacts on your stress levels, is it actually benefiting your overall health? I would argue, no it’s not.
Ongoing sleep loss has been shown to lead to glucose intolerance (difficulty breaking down glucose) and insulin resistance (insulin not working effectively) – both of which lead to an increase in blood glucose levels. Looking at sleep hygiene may be particularly important in improving blood sugar control.
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Mindfulness
The use of Mindfulness has been such an exciting area of interest. Now, I can tell some of you are rolling your eyes and saying “but meditation is so boring and it’s just not for me”. Meditation is only one form of Mindfulness. Mindfulness encourages attention and focus on the present moment and the development of non-judgmental consciousness; this allows the person to accept the way they are feeling rather than constantly battling to try and change it.
Mindful eating is another way people can return to the present moment as it encourages you to focus your attention on the sensory characteristics of food. Mindfulness based approaches have been found to be particularly effective in supporting diabetes management. It can address the feelings of guilt, that can come with a diabetes diagnosis anger and aid self-acceptance .(Grossman, Niemann, Schmidt and Walach, 2004).
Mindfulness has also been found to have an enhanced clinical effect of glycemic control so not only aids psychological health but could potentially have a positive impact on the management of the physical condition. (Armani Kian et al., 2018). If you would like to have a dabble in some mindfulness practices, the Calm, Headspace and Smiling Mind apps all have mindfulness modules to take for spin.
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Joyful movement
Exercise has been made to be so rigid and just downright HARD. That is why I prefer the term movement. Incidental activity is movement and is associated with everyday activities that is built up over the day. This is a great way to ensure that you’re moving your body without actually having to schedule a structured workout, such as hitting the gym or booking in an exercise class. All movement counts... Let me repeat that.
ALL MOVEMENT COUNTS.
Think taking the stairs instead of the escalator or lift, walking in favour of driving your car to the local shops, taking plenty of ‘walk breaks’ during prolonged hours of sitting or getting off the bus a stop earlier to get in some extra steps.
Once we edge away from the feeling of HAVING to do certain forms of exercise, we can explore the types of movement we WANT to do. Consistent gentle & enjoyable body movement has proven time after time to reduce blood sugar dysregulation regardless of body weight. (Lamarche et al., 1992) (Björntorp, de Jounge, Sjöström and Sullivan, 1970).
So, there you have it, a weight neutral-approach to diabetes care. The permission to be explorative and experimentative with food, eating and movement can feel very foreign for many people. For more support and guidance, I would encourage working with a Non-Diet, Health at Every Size Dietitian.
Armani Kian, A., Vahdani, B., Noorbala, A., Nejatisafa, A., Arbabi, M., Zenoozian, S. and Nakhjavani, M., 2018. The Impact of Mindfulness-Based Stress Reduction on Emotional Wellbeing and Glycemic Control of Patients with Type 2 Diabetes Mellitus. Journal of Diabetes Research, 2018, pp.1-6.
Aphramor, L., 2017. Effecting change in public health. Network Health Digest, 126, pp.57-59.
Bacon, L. and Aphramor, L., 2011. Weight Science: Evaluating the Evidence for a Paradigm Shift. Nutrition Journal, 10(1).
Barnes, V., Davis, H., Murzynowski, J. and Treiber, F., 2004. Impact of Meditation on Resting and Ambulatory Blood Pressure and Heart Rate in Youth. Psychosomatic Medicine, 66(6), pp.909-914.
Björntorp, P., de Jounge, K., Sjöström, L. and Sullivan, L., 1970. The effect of physical training on insulin production in obesity. Metabolism, 19(8), pp.631-638.
García-Mayor RV, García-Soidán FJ. Eating disorders in type 2 diabetic people: brief review. Diabetes Metab Syndr. 2017;11:221–4.
Goebel-Fabbri, A., 2008. Diabetes and Eating Disorders. Journal of Diabetes Science and Technology, 2(3), pp.530-532.
Grossman, P., Niemann, L., Schmidt, S. and Walach, H., 2004. Mindfulness-based stress reduction and health benefits. Journal of Psychosomatic Research, 57(1), pp.35-43.
Hilliard, M., Yi-Frazier, J., Hessler, D., Butler, A., Anderson, B. and Jaser, S., 2016. Stress and A1c Among People with Diabetes Across the Lifespan. Current Diabetes Reports, 16(8).
Journal of Vascular Surgery, 2013. Cardiovascular Effects of Intensive Lifestyle Intervention in Type 2 Diabetes. 58(4), p.1140.
Lamarche, B., Despr??s, J., Pouliol, M., Moorjani, S., Lupien, P., Th??riault, G., Tremblay, A., Nadeau, A. and Bouchard, C., 1992. Is body fat loss a determinant factor in the improvement of carbohydrate and lipid metabolism following aerobic exercise training In obese women?. Medicine & Science in Sports & Exercise, 24(Supplement), p.S18.
Papelbaum, M., Appolinário, J., Moreira, R., Ellinger, V., Kupfer, R. and Coutinho, W., 2005. Prevalence of eating disorders and psychiatric comorbidity in a clinical sample of type 2 diabetes mellitus patients. Revista Brasileira de Psiquiatria, 27(2), pp.135-138.
Silva, F., Kramer, C., de Almeida, J., Steemburgo, T., Gross, J. and Azevedo, M., 2013. Fiber intake and glycemic control in patients with type 2 diabetes mellitus: a systematic review with meta-analysis of randomized controlled trials. Nutrition Reviews, 71(12), pp.790-801.
Sutin, A., Stephan, Y. and Terracciano, A., 2015. Weight Discrimination and Risk of Mortality. Psychological Science, 26(11), pp.1803-1811.
Tomiyama, A., Ahlstrom, B. and Mann, T., 2013. Long-term Effects of Dieting: Is Weight Loss Related to Health?. Social and Personality Psychology Compass, 7(12), pp.861-877.
Vrolix, R. and Mensink, R., 2010. Variability of the glycemic response to single food products in healthy subjects. Contemporary Clinical Trials, 31(1), pp.5-11.