Weight Stigma: The Common Denominator in Disordered Eating in Diabetes
By Megrette Fletcher M.Ed., RDN, CDCES
The client seemed to go quite as I summarized a few points from our nutrition. Then, she said, “Well, I’m binging after the kids are in bed.” The comment was offered casually, as an item on a ‘to-do’ list while she continued to talk. After a bit, I was able to circle back and I ask, “What is it about the binge eating that concerns you?” The client explained she was doing it to cope with the many changes in her life since COVID-19, including working full time while homeschooling her two children and assisting her older parents.
The impact that Disordered Eating Behaviors (DEB) have on diabetes care is challenging to quantify because disordered eating isn’t a static occurrence. Inconsistent blood sugars result from erratic eating, limited consistency with medication, fear and guilt from adverse reactions to medication, eroded provider/client trust, and a decreased desire to seek medical care due to shame, self-blame, and guilt. These things obscure the issue, complicate the scope, and contribute to clinical inertia.
Which Came First?
Many people think that coping with food is a choice, and therefore a simple thing to change. This oversimplification of how to cope can lead to something called weight stigma. Weight stigma is prejudice and discrimination towards higher weight individuals. This vanilla definition can include repeated weight-related teasing, bullying, harassment, violence, hostility, pressures to lose weight/be thin, negative appearance commentary, and weight-related micro-aggressions in general. Looking at examples of weight stigma in a medical session can include an unwillingness to wait for a patient who ambles, failure to have adequate-sized gowns, chairs, or blood pressure cuffs for higher weight individuals. Another example might be to suggest weight loss for a client who came in for a concern unrelated to weight. While these examples of weight stigma may appear insignificant, the negative impact of weight stigma is more significant in a medical setting, due to the implicit trust between provider and patient.
Eroding Trust
Weight biased interactions erode confidence and damage the provider-client relationship because they reinforce the weight-centered stereotype. This places the higher weight individual on alert, creating, or reinforcing a stress response. Being “on alert” means that these individuals are more likely to be aware of the possibility of rejection or derogation, which creates a cycle of harm.
The higher weight individuals who have experienced weight stigma want to avoid this shaming experience and may become fearful it will happen again. This preoccupation increases sensitivity and reaction to common weight-centered approaches associated with diabetes care. Being ‘touchy’ is especially true if the patient-perceived their body weight will be a source of embarrassment in that setting.
Looking at the Long-Term Impact of Weight-Centered Care
The long‐term result of this conflict is avoidance and postponement of care, which has a significant impact on health outcomes. Research confirms that because higher weight individuals avoid stigmatizing situations, including seeking medical care, they, thus, present with more advanced and more difficult to treat conditions. In fact, individuals who experience more obesity stigma report less health utility or they place a lower value on health. This is a suspected cause of the low utilization of DSMES services, which are less than 10% for insured clients.
Why Do People Continue to Avoid Care?
“Why don’t they [the patient] come in, don’t they know they have diabetes?” While this question seems benign, there is an invisible bias that may elude many medical professionals. To unpack this, let’s begin with the assumed value of medical care and health.
It makes sense that healthcare professionals value wellness and clients receiving medical care. This is what they do! Yet, our values may not be our doctor’s values. Assuming that we share values is often why appointments fail to create behavioral change.
Susan Dopart, RD, explained, “Research shows our ability to remain neutral and free of judgment pulls clients towards change.” This means that our values get in the way of our clients changing. Why? Our clients may value other things such as work, caring for family, or self-reliance just to name a few. While receiving medical care appears to be beneficial, for many higher-weight individuals who have internalized weight stigma, weight centered medical care is a harming, not a helping, experience. Being told over and over again to lose weight or that being fat is bad reinforces the narrative that a problem is their fault.
The following are two examples to illustrate how weight bias is often associated with diabetes care. “You have diabetes. Your weight is a risk factor.” For someone who has experienced weight stigma and is sensitive to weight-related comments, stating that weight is a risk factor is likely to feel like blame to the client. Emotions can run high and interpret this comment to mean, “You have diabetes because of your weight. You caused diabetes.” Here is another example, “You have diabetes. You should lose 10% of your body weight to improve your blood sugar.” Again, this might be interpreted as “You caused this problem and now you HAVE to go on that XYZ diet [a suggestion that carries its own pain and past experience] and never eat foods you enjoy or you will never be healthy.”
Many healthcare providers have confessed confusion, frustration, and resentment that clients can’t hear them. “What am I supposed to say? I am giving them the facts, which I get isn’t fun, but I don’t have another choice.”
How to Talk to Patients
Counseling clients is imperfect. It is both an art and a science. Approaches, such as Motivational Interviewing (MI), suggest that the emphasis should shift from offering solutions to listening to the client. For example, shifting the initial statement, “You have diabetes. Your weight is a risk factor.” to “You have diabetes.” [Silence] “What thoughts are you willing to share with me?” or “What are you thinking?” stop healthcare providers from telling you what to do and shifts the conversation to listen to your ideas.
Here is another way to rephrase the previous example, which was, “You have diabetes. You should lose 10% of your body weight to improve your blood sugar,” This becomes, “You have diabetes. What ideas do you want to explore to improve this condition?”
Why Include the Patient?
Patients have said to me, “My PCP thinks that I overeat, but I am not overeating. They think that I am not exercising or that I am lazy. They just don’t believe me, and it is frustrating because they stop listening.” Poor communication is often at the heart of unwanted outcomes. Failure to talk about the underlying pathophysiology of diabetes, including that weight gain, often precedes the diagnosis is typically missing. Also, much evidence suggests that insulin resistance is a product of an underlying metabolic disturbance that predisposes the individual to increased fat storage due to compensatory insulin secretion. In other words, obesity may be an early symptom of diabetes as opposed to its primary underlying cause. Weight changes are not limited to disease; they include limited food access, poverty, aging, medication, decreased physical activity, chronic dieting, experiencing weight stigma, increased calorie intake, secondary weight stigma, triggered eating behaviors, and ending restrictive eating.
While weight stigma initially appears to be a social or psychological phenomenon, it is the common denominator in all disordered eating behaviors, including DEB-D which makes it a medical issue. Weight stigma impacts access, trust, communication, and how a patient values health care. Providers who take the time to understand and unpack weight stigma will have improved patient-care interactions and outcomes.
