Research Messaging and Disordered Eating In Diabetes Care

By Megrette Fletcher M.Ed, RDN, CDCES

Evaluating how research messaging may contribute to DEB-D has yet to be fully understood. However, we can begin by considering and evaluating the Joint practice guidelines on language and messaging by The American Diabetes Association and the Association for Diabetes Care and Education Specialists.

The guidelines state four messages are essential to communication, including:

• Diabetes is a complex and challenging disease involving many factors and variables.
• Stigma that has historically been attached to a diagnosis of diabetes can contribute to stress and feelings of shame and judgment.
• Every member of the health care team can serve people with diabetes more effectively through a respectful, inclusive, and person-centered approach.
• Person-first, strengths-based, empowering language can improve communication and enhance the motivation, health, and well-being of people with diabetes.

Reading these guidelines helps professionals like yourself consider how the ‘weight loss cures everything’ messaging could contribute to disordered eating in diabetes. For example,

• How is the complex and challenging nature of diabetes being considered in the research? Specifically, is the research viewing diabetes as a static disease or a dynamic, changing disease involving many factors and variables?
• How does the research consider the chronic nature of diabetes? Specifically, what are the roles and impact of diabetes’ distress in motivation, maintenance of behaviors, and the constant balancing of mental, emotional, and financial resources?
• How has stigma which has historically been attached to a diagnosis of diabetes and can contribute to stress, shame, and judgment been considered in the behavioral burden of this condition?
• How have other types of stigma, [weight, race, sexual orientation, size, physical ability, and gender] which typically precede the diagnosis of diabetes, impacted a person with diabetes coping skills, ability, and identity?
• Have steps been taken within the research to consider the role of weight stigma and weight bias within the intervention team?
• Have steps been taken to validate respectful, use of inclusive [disease, weight, race, sex, gender, physical ability, and age], person-centered approaches, and language by the intervention team?
• What steps have been taken to reduce/eliminate messaging which pathologizes the body, such as ‘diabetic’ or ‘obesity’ in the research?
• To what extent could the layering of stigma be a factor?

Dismantling Fatphobia in Research

Healthcare professionals are positioned to ask more of the research being presented, questioning the evidence supporting weight-centric diabetes care. Evaluate if the research and evidence is oversimplifying diabetes and creating a straw man fallacy or is it suggesting or describing individuals with diabetes in ways that create or suggest blame and shame?

Healthcare messaging starts with research and trickles down to the consumers to reinforce DEB-D behaviors. The messaging surrounding diabetes care and weight need to change. America can take a page from the Royal Australian College of General Practitioners which encourage a “shift to a ‘health gain’ rather than a ‘weight loss’ approach for people with a body mass index (BMI) greater than 30kg/m”

Fatphobic ideas are common and fool many people. It is important to remember that anyone (including fat people) can be Fatphobic. Anyone can produce or consume Fatphobic ideas — in which they THINK there is something wrong with being fat. This belief, which is repeated in overt and subtle ways, is a barrier for people with diabetes.

What can you do?

Try to engage in reflective questions, such as when does my Fatphobia present? Is it when you witnessed suffering? If it came when you wanted to ‘fix’ a person’s suffering, you are not alone. In Motivational Interviewing, this is called The Righting Reflex. The Righting Reflex is a compassionate response to suffering which inhibits change.

Clients want to enjoy eating and have a better relationship with their bodies. The issue is they don’t know how to ask for help, especially when restrictive eating is typically offered as a cure for both diabetes and body image issues. The diabetes industry has also gotten swept up in the ‘lose-weight or else’ cycle and thus engages in Fatphobic thoughts as marketing approaches to drive sales. Marketing methods now layer subtle and overt Fatphobic messaging atop fear which further erodes self-worth. The psychological burden of diabetes combined with Fatphobia fuels diabetes distress and disordered eating cycles in clients.

Disordered Eating Behaviors impact diabetes care in multiple ways. First, disordered eating behaviors aren’t easy to identify. Second, they aren’t a static occurrence. Third, unstable blood sugar levels from erratic eating can prompt clients to engage in compensating behaviors and choices, such as modifying medication frequency or amounts of medication, fearing adverse reactions to medication, or experiencing guilt surrounding blood sugars or food choice, which ultimately erodes their willingness to talk to their provider. The existing shame and guilt associated with disordered eating are often hidden, creating a ‘secret’ which further erodes provider/client trust, prompting a decreased desire to seek medical care due to shame, self-blame, and guilt.

It’s hard to identify how DEB-D began but it is easy to see how the increased emphasis on weight loss as a possible ‘cure’ for diabetes as well as a societal normalization of extreme diets makes disordered eating behaviors seem familiar and DEB-D less noticeable. Adding to the complexity is the biased perception that disordered eating is a ‘young’ issue, and thus there is less emphasis to screen for disordered eating in older adults, or as part of a type 2 diabetes diagnosis. Together, these issues have obscured the frequency and severity of DEB in diabetes until Garcia-Mayer’s recent research concluded up to 40 percent of people with type 2 diabetes have DEB-D. Using these statistics, current estimates suggest DEB-D may affect as many as 11.5 million people.

There is hope and it begins by changing to a weight-neutral approach, which will reduce the stigma and shame surrounding diabetes and body image and help our clients create a positive relationship with food.

García-Mayor R, García-Soidán F. Eating disorders in type 2 diabetic people: Brief review.Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2017;11(3):221–224.doi:10.1016/j.dsx.2016.08.004

Language Guidance for Research, Education and Publication. A joint position paper https://www.diabeteseducator.org/docs/default-source/practice/educator-tools/HCP-diabetes-language-guidance.pdf?sfvrsn=8

Montani J. Dieting and Weight Cycling as Risk Factors for Cardiometabolic Diseases: Who Is Really at Risk? Obesity Review. 2015;22. doi:doi:https://doi.org/10.1111/obr.12251

Willer, Fiona. Health at Every Size (HAES) for People with Diabetes. Australian Diabetes Educator. April 2020. Vol 23:1.