Erin Phillips, MPH, RDN, warned at the start of her lecture that it might cause some discomfort for clinicians attending the American Diabetes Association's 2020 Scientific Sessions, held virtually in June.
That seems only fair, since her goal was to make encounters with the health care system less discomfiting for patients with diabetes. Clinicians can accomplish that by changing their practices to incorporate a weight-neutral approach, according to Ms. Phillips, a registered dietitian nutritionist and certified diabetes educator with the University of Washington in Seattle, and co-speaker Holly Paulsen, RD, an eating disorder specialist based in Iowa.
“Weight-neutral diabetes care recognizes that the pursuit of weight loss is at best unsustainable and, at worst, can cause other health consequences such as weight cycling and eating disorders,” said Ms. Paulsen.
Shortcomings of the current system
As evidence that a focus on weight is not beneficial to diabetes patients, Ms. Phillips reviewed a number of studies.
For example, an analysis of the 2005 to 2012 National Health and Nutrition Examination Survey, published in the International Journal of Obesity in 2016, found that using body mass index (BMI) to judge cardiometabolic health would miss the 30% of people with lower BMIs who are cardiometabolically unhealthy as well as misclassifying the 20% to 50% of obese patients who are cardiometabolically healthy.
“I know a lot of you are thinking, ‘Well, yeah, but still there are a lot of people in the high BMI categories who are unhealthy,’” said Ms. Phillips. Her response was to question how much BMI actually helps clinicians in assessing patients' health.
It's at least not as key as eating healthy, exercising, drinking moderately, and not smoking, according to a study published in the Journal of the American Board of Family Medicine in 2012. “When people were engaging in all four of these healthy habits, the risk of death was essentially the same for people across all BMI categories,” she said.
There's also the issue of how modifiable BMI truly is. Ms. Phillips cited research finding that weight is largely determined by genetic factors and that dieting efforts rarely result in long-term weight loss, including an article published by American Psychologist in 2007. “A review of 31 long-term studies on intentional weight loss found that 85% of dieters regained the weight within five years, and one-third to two-thirds of people regained more weight than they lost,” she reported.
Such weight cycling carries health risks of its own, Ms. Phillips noted, including decreased metabolic rate as well as increased risk for cardiovascular disease and eating disorders. The last of those could be a natural outgrowth of weight loss interventions, she pointed out. “Meticulously tracking calories, getting steps in at any cost, saying no to social events for fear of extra calories—what we prescribe for fat people is what we diagnose as an eating disorder in thin people.”
The health care system may also promote weight stigma, the devaluation and denigration of people perceived to carry excess weight, and that increases patients' risk of both maladaptive eating and chronic stress, she said. “The literature clearly shows that weight bias is rampant in health care.”
Options for change
Making diabetes care less weight-centric will require a number of changes, the experts said.
“Providing health care free of stigma is much more than, ‘I'll be nice to you while I tell you to lose weight,’” said Ms. Phillips. “The weight-neutral approach is an assumption that everyone is capable of pursuing health and well-being, regardless of BMI or weight. … The weight-neutral approach says that higher BMI may be correlated with these poor health outcomes, but people have very little long-term control over their body size, and weight loss is not considered a health-promoting intervention.”
That will likely represent a big shift in thinking for many clinicians and patients, but the process can be started with relatively small changes. “The first thing is to avoid weighing that patient unless it's medically necessary,” said Ms. Paulsen. “Use it of course if you're prescribing medication and need to know the patient's weight in kilograms or assessing fluid status.”
But otherwise, skip the scale and see what happens. “The dynamic that changes for that patient is phenomenal,” she said. “Most patients come in, they see that scale, there's anxiety from the moment they see that. Some patients do not come to their appointments because they don't want to be weighed.”
Clinicians can also improve patient interactions by thinking about their own biases about weight and addressing them, Ms. Phillips suggested. “We know that people with a BMI of 22 [kg/m2] can be diagnosed with diabetes,” she said. “Ask yourself to begin, ‘OK, if this person actually had a BMI of 22 [kg/m2], what advice would I give them?’”
Patients may also need help dealing with their own unproductive thoughts about diabetes and their weight. “What we can do is unpack what they already believe about their diabetes: that it's their fault, that they caused it, that they ate too much sugar,” said Ms. Paulsen.
Many patients will have weight loss as their goal, and clinicians should respect that while also educating them about other ways to improve health, she said. “In that first meeting where we don't weigh them, and they're surprised that they're not being weighed, we can talk about how futile their attempts at weight loss have been,” Ms. Paulsen said.
Ms. Phillips suggested asking patients why they've been trying to lose weight. “Often people will say things like ‘improve my diabetes' or maybe ‘decrease my cholesterol.’ Or maybe they say, ‘I want to be treated better at the doctor's office.’ In that case, what we can do is help people with interventions that will give them the results that they want,” she said.
Empathy, education, and empowerment
A key component of weight-neutral diabetes care is improving nutrition and placing a priority on consuming consistent meals, the experts said. “Up to 40% of our patients with type 2 diabetes experience disordered eating behavior or a diagnosed eating disorder,” said Ms. Paulsen. “This is much higher than the general population. The rules and restriction part of managing diabetes can lead to disordered eating behavior.”
Diabetes patients can fall into diet and guilt cycles, in which food restriction leads to binge eating. Clinicians should screen for these issues with tools like the SCOFF questionnaire or Diabetes Eating Problem Survey, she advised.
Being attentive to signals from one's body, especially in response to carbohydrates, is generally a focus of weight-neutral diabetes care, which encourages mindful eating.
“How do I feel when [I] eat this? How does my blood sugar respond? … We teach them to reconnect to their internal signals of hunger and fullness,” said Ms. Paulsen, offering analogies to other bodily signals. “We know when we're hot or cold. We can perceive that easily, and we don't judge that morally.”
It's also important to avoid judgment of the quality of food patients have available, she said. “We always acknowledge that many of our patients do not have access to what we consider ideal nutrition,” said Ms. Paulsen. “We start where they are and how can they make improvements. … Can we add a can of green beans?”
Weight-neutral diabetes practitioners also try to detach judgment from other aspects of diabetes care, including medication and blood glucose measurement. “Many of our patients don't want to take medication. They look at that as a sign of failure. We can reduce that stigma,” said Ms. Paulsen. She also prefers medications that have less effect on weight and hunger.
With blood glucose, the aim is to make the numbers morally neutral, she said. “Right now, many of our patients look at that as their judgment. ‘Was I good or was I bad? What did my blood sugar say?’” Instead, the goal should be to observe the data with curiosity and use them to make informed decisions.
Exercise is another supported intervention in weight-neutral diabetes care. “We can encourage enjoyable activity. The focus is on how the client feels, how it may affect their numbers when they're testing their blood sugars, but not weight loss,” said Ms. Paulsen.
Optimizing sleep and minimizing stress are also key goals. All of these aspects work toward three main components that make the weight-neutral approach patient-centered, Ms. Paulsen said. These are empathy, education, and empowerment.
Addressing the third aim, Ms. Phillips closed the talk with some humbling insight on nutrition research. “I think it is helpful and empowering for people to hear how little we really know about nutrition in the grand scheme,” she said.
“I give the example of eggs. When I was in undergrad, eggs were very demonized, and now eggs are like the best thing ever. If the person I'm working with has lived long enough to see that transition, or the transition from low-fat, it kind of illustrates how futile it is to find the perfect diet. … Focusing on what's working for you is best.”