Kim came into my office and after a short pause explained that she wanted to lower her A1C because she was going to have fertility treatments to have a baby. It was an exciting decision for Kim and after many years of trying, this 38-year woman explained, it was time to get serious about starting a family.
Kim shared that the fertility clinic required her to lose weight because her BMI was >35 and to improve her A1c, which was now 6.9. As she sat across from me, the tears began to stream down her face, “I feel like a failure.” She explained, verbalizing the shame that she has been experiencing regarding both her weight and her overall diabetes care.
Shame is a funny thing. The moment it is named, it changes. When Kim gathered her courage and made the decision to see ‘one more’ dietitian to talk about diabetes/weight, her shame changed. I sat silent, listening to a very bright, capable member of the community describe how she was angry that she may be denied this treatment because of her weight. Venting her frustration helped her feel heard, and together we were able to establish some weight neutral guidelines to help her meet her goals and have a baby!
We aren’t going to talk about weight
The ground rules were simple, we weren’t going to talk about weight at these meetings. We were going to focus on behaviors, including eating, monitoring, exercise, and sleep. Kim was receptive to getting a device called a Continuous Glucose Monitor, CGM, to better understand her blood sugar readings and spikes. The CGM made a big difference to Kim because it allowed her to understand how different food affected her blood sugar. “Look,” she pointed to the blood sugar of 134 mg/dL, “this is ICE CREAM! I was sure that this would make my blood sugar go sky-high, but it didn’t.” We reviewed the data together and Kim explained that she already had shifted her breakfast away from cereal to yogurt and nuts to lower the carbs and resulting blood sugar spike because of the hormonal effect called Dawn Phenomenon.
“I’m eating,” she explained. “As a teacher, I would skip meals and snacks to help my students. I could see that this caused my blood sugar to become a roller coaster, going up and down.” Working with Kim, I learned that she was able to ‘feel’ her blood sugar more and was able to trust her hunger. “It is telling me to eat, which is something very natural! When I was dieting and trying to lose weight, I didn’t see hunger as a friend. It was more like an enemy!” This is how Kim explained how she had been brainwashed by every diet she had ever been on, a cycle she estimated started when she was 15 and had increased exponentially in the last 5 years as she tried to get pregnant. This told me that Kim was a chronic dieter, and was at risk for having DEB-D, or Disordered Eating Behavior in diabetes. DEB-D is a serious concern and it is estimated to impact up to 40% of clients with type 2 diabetes.
The third meeting.
Kim explained that she needed more support. “I’m doing this, but it is hard.” She was tempted to get support by stepping on the scale and see if she was good. “I was pretty sure it wouldn’t help me. But, I wanted to be reassured I was doing okay.” Together at this meeting, Kim was able to see how hard it is to break free from diet-culture and how using weight change as a way to reassure herself wasn’t effective.
Working with a weight neutral educator required Kim to do some digging – where was she going to get support, how does she encourage herself if she isn’t stepping on a scale? Together we identified her successes, which included an A1c of 5.9, feeling healthy, sleeping better and having more energy. She also identified her support system, which included her family, her friends, online outlets, podcasts, books and diabetes support groups.
At the fourth meeting, Kim was delighted to share that she was pregnant! This happened without fertility treatment, without dieting, without being weighed, and without requiring weight loss. Kim explained “Not stepping on the scale changed everything for me. I wasn’t doing this to ‘lose weight’, I was doing these changes for me, so that I could be healthy.”
Getting pregnant isn’t the end of Kim’s story. Kim understood that her pregnancy would likely make her blood sugars increase and that there would be changes to her overall diabetes care to help her have a healthy baby. Kim explained that these changes in treatment “Didn’t feel like I failed. I understood that diabetes is a condition that is managed.” As I worked with Kim, she was better able to let go of the idea that there is a ‘right’ or ‘wrong’ way to manage diabetes which opened her up to more possibilities.
Disordered eating is a descriptive phrase and not a diagnosis that describes behaviors surrounding weight, body image, and eating. As the term implies, the behaviors are not health-promoting and they have a serious impact on a person’s wellness. Popularized by many fad diets and our society’s fixation on health, weight, and appearance, disordered eating behaviors are normalized in diabetes care.
Providing weight-neutral diabetes care counters this unhealthy trend and focuses on behaviors, which for Kim included monitoring her blood sugar, shifting her diet to prevent blood sugar spikes, eating consistently, and adding in a short walk after dinner. Kim’s counseling session demonstrates how it is possible to shift away from weight-centered counseling. This change allowed Kim to talk about her DEB and to build a support network to help her break free from diet culture and achieve her pregnancy goal.