Today I want to talk about the approach healthcare takes for helping people manage chronic diseases like diabetes. Recently, I met a healthcare practitioner and we were talking about our prospective fields. I told her that I had worked in Chronic Disease Management for a long time, including diabetes and obesity and that I was currently doing a lot of training in treating eating disorders and Intuitive Eating and now worked from a Health At Every Size® framework. Her reaction was something I wouldn't have given much thought to even a year ago: she said something to the effect of "oh, so pretty much the opposite end of the spectrum, hey?"
I want tell you why I have been thinking about that statement a lot. The more I learn about the eating disorder spectrum and Health At Every Size®, the more I think improving a person's relationship with food, teaching them how to pay attention to their hunger and fullness, and how food affects how they feel should be incorporated into treatment for those with chronic disease instead of focusing on weight.
This includes those with type 2 diabetes, high cholesterol, and other health issues that many individuals perceive to be caused by being at a higher weight, even though we have evidence that higher body weights are only associated with these health issues as opposed to causing these health issues. Factors that affect the risk of developing these conditions include dieting and weight cycling, nutritional intake, stress, physical activity, socioeconomic status, and of course, genetics; all of which can also affect weight.
So why is it that even though we don't have any sustainable methods of helping individuals manage their weight (you can check out a research article on that here), let alone evidence that managing weight is important for health, that many healthcare practitioners approach managing many chronic diseases from the lens of weight? This is an especially important question to ask when you consider that dieting, not just fad diets but restriction in general, increases the risk of eating disorders as well as weight gain. You can check out some of that research here.
So let's talk about focusing on health instead of weight. The Health At Every Size® approach is "associated with statistically and clinically relevant improvements in physiological measures (e.g. blood pressure, blood lipids), health behaviours (e.g. physical activity, eating disorder pathology) and psychosocial outcomes (e.g, mood, self-esteem, body image)." If you want to check out the journal article in Nutrition Journal, you can check it out here.
Dieting breeds disordered eating, which is more common than we think.
When I think back on many of the individuals I saw while working in the area of diabetes management and especially while working in a clinic for managing obesity, I see now what I couldn't see as clearly then: disordered eating. I honestly didn't think that I was really focusing on weight when I was working in those settings. I discussed focusing on healthy behaviours as opposed to weight and non-scale victories like having more energy. I taught about the fact that with weight loss, hunger signals would increase and would make losing a large amount of weight difficult and focusing on health was important.
I wasn't as weight neutral as I thought I was at the time, however; I taught about bariatric surgery being the answer for those in larger bodies to lose weight instead of working with clients to improve their relationship with food and their body image. At the end of the day, I still discussed calorie restriction and weight management with all the clients I saw in the obesity clinic.
Looking back and recognizing that disordered eating, I feel a lot of guilt for failing to recognize the harm that was done teaching individuals to focus on calories over their hunger and fullness. Yes, I taught about mindful eating but I'll never forget a client telling me that she was hungry at her current calorie level so I taught her to up her fibre and protein and keep at the same calorie level instead of truly listening to those cues. I feel a lot of guilt about giving calorie limitations to those who showed disordered eating but didn't fit the clinical criteria for an eating disorder, realizing the harm I likely caused them.
First of all, if any of my old clients read this blog, I want to tell you how sorry I am for that. I'm sorry that I didn't truly recognize your struggle and I'm sorry if I made your relationship with food worse instead of better. I would like to say that the story that I just described was the exception rather than the rule when it comes to the role of dietitians in healthcare but I don't think that's true.
The truth is that I didn't learn much about disordered eating, let alone Health At Every Size® and Intuitive Eating in school. The truth is that I was probably closer to that mentality than we were taught in school because I did a lot of additional training on obesity management, which is focusing more on factors like mental health and the issue of weight stigma and its effects on health, the fact that weight is more complicated that calories in and out, and a focus health outcomes although it still has a major focus on weight.
Dietitians need to start teaching our clients not to fear food but to learn to pay attention to what their bodies are telling them about their hunger and fullness. We need to start working more closely with mental health practitioners to help our clients address any issue that may be underneath a disordered relationship with food. We need to learn to recognize the harm that disordered eating does and we need to be aware of people’s relationship with food even if the don’t meet the clinical criteria for an eating disorder.
The truth is that in eating disorders and diabetes management and other chronic disease management isn't always that different. We need to stop treating them that way. I can't remember where I heard this but it hit me hard: 'the behaviours that are encouraged in dieting are the same ones that are discouraged in eating disorders.' I hope that gives some food for thought.