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prioritizing problems

In health care, chronic diseases tend to travel in packs. Those with non-insulin dependent diabetes mellitus (commonly known as type 2 diabetes) are generally, without a doubt, overweight…if not obese. I could and would provide you with statistics, but it’s pointless. Even in my infantile career…this fact is clear as day. So I’m talking with my co-worker today, discussing the role of each of our clinic’s classes — diabetes, lipids, prenatal, weight loss, DASH, etc. While we deal most with diabetes patients, overwhelmingly…patient’s labs are not reflective of dietary and/or lifestyle modifications. Even with unlimited access to dietitians. Hmm.

Now, I’m not arguing the precedence of diabetes treatment, however, patient’s just don’t get it. Blindness, loss of limbs, and dialysis are just not realities to diabetic patients until it’s too late. It’s sad…and what’s a dietitian to do? It is my job to prevent chronic disease complications and educate patients on prevention. Moving along. When I suggested an increase in the number of group weight loss classes, my co-worker disagreed. “Diabetes Self-Management must take priority ahead of weight loss.” Hmm. Sure, I agree…but it’s not working. I can ramble about carbohydrate counting and bedtime snacks day-in and day-out, but again…it’s just not working. I propose weight loss classes but more specifically, lifestyle change classes. These people want to lose weight and may not have the support system or tools in which to get started. A mere 5% drop in body weight will help insulin resistance in our type 2 patients. Futher, patients view weight loss as 1) appealing, 2) comprehensible, and 3) tangible. One can see numbers on a scale drop and feel the self-satisfaction and pride in purchasing a smaller size pant. And while carb-counting may be intended to aid in weight-loss, health care providers typically get wrapped up in the “eat this, not that”.

Granted, there are patients who strongly benefit from a good 90-minute crash course in carb-counting and diabetic meal planning, who walk out of my office feeling empowered, motivated, and prepared to fight the progression of their disease head-on. But sadly, those individuals are far and few between with the majority falling through the cracks.

The American Dietetic Association published a new research study looking at body size acceptance. The study was a 6-month randomized clinical trial with a 2-year follow-up period. The subjects were obese, Caucasian females aged 30 to 45 who were noted chronic dieters. A model used to address health at any size was used, versus a traditional weight-loss program. Variables such as satiety, hunger, and internal cues of hunger were addressed [1].

At the 2-year check-up, the health at every size approach produced long-term behavior change and improvement in all variable outcomes. The dieting group did not. Weight was maintained in the health at every size group while the dieting group had sustained weight loss for only a year before the weight was regained [1].

It is known that age, ethnicity, sex, and lifestyle make drawing absolute conclusions between health and weight nearly impossible, states Morgan Downey, policy director for the Stop Obesity Alliance [2]. While there is no denying obesity as a compounding factor of chronic disease, if American’s could alter their thinking and “eat to live, not live to eat” (as my mother always says) and move more, one’s weight would lose such emphasis in the health world.
As a dietitian, I obviously support the maintenance of a healthy weight. And if you’re overweight/obese, you should lose weight…I should lose those fifteen dang pounds I harp about, darn it! However, dieting shows that sustained weight-loss is atypical. What can we do to permanently change our perception of how we eat and live in order to benefit our health? What I know is that I’m okay with my +15 so long as I live healthfully — continue my healthy diet, continue my healthy lifestyle (drug-free, happy-go-lucky me), and regular moderate-to-vigorous activity. I am hitting the treadmill here at work today during my lunch hour. How ’bout that?

[1]. Bacon, L., Stern, J., Van Loan, M., and Keim, N. Size Acceptance and Intuitive Eating Improve Health for Obese, Chronic Dieters. American Dietetic Association. June 2005.

[2]. LaRue Huget, Jennifer. Eat, Drink and Be Healthy. The Washington Post. July 7, 2009.
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  1. Linda Bacon
    July 9, 2009 / 3:46 pm

    Thanks for this post. I conducted the research study you cited, and as you note it really challenges some basic assumptions about weight that get in the way of successfully working with type 2 diabetes. Sure, it's true that most people with type 2 diabetes are heavier, but insulin resistance causes weight gain. It's the insulin resistance that's the problem, and the role of weight in causing disease is highly exaggerated. Most people don't sustain weight loss – and there's little evidence that those that do sustain improvements in their type 2 diabetes. For these and other reasons, I don't think its effective to encourage attempts at weight loss. Our research suggests transforming the paradigm: encouraging healthy behaviors instead. To learn more, check out the free Health at Every Size Community Resources (www.HAESCommunity.org) or the book I've written which describes the research in much more detail (www.HAESbook.com). Thanks for raising the issue.

  2. Allison
    October 31, 2012 / 7:37 pm

    Thank you for being sure to include “type 2 diabetes” and not just lumping it as diabetes or diabetics as a whole are overweight. As a type 1 diabetic (since age 5) I really appreciate the fact that you took the time to distinguish which form of diabetes you were speaking about.

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