Chevese Turner was 5 years old when she first started showing signs of disordered eating. Ever since she was a small child, her family members (one of whom also had an eating disorder) were concerned about her body — to the point where they would restrict her food intake and monitor her weight.
"I started to hide food and binge," says Turner, who is now the CEO of the Body Equity Alliance. As she got older, she was put on different diets and diet pills, and the binge-and-restriction pattern of eating got even worse. "My eating disorder was in full bloom by the time I was 11 or 12," she says.
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When she was in her 20s, Turner was also diagnosed with polycystic ovary syndrome (PCOS), a hormonal condition that can cause weight gain or difficulty losing weight. Many people who have PCOS are also resistant to insulin — the hormone that helps move glucose (sugar) out of the bloodstream and into the cells of your body, where it can be used for energy later on, per the Cleveland Clinic.
Insulin resistance is also a characteristic of type 2 diabetes — a fact that didn't escape Turner. "I knew in the back of my mind that diabetes was always going to be looming," she says.
Its true: Half of the people diagnosed with PCOS develop type 2 diabetes by age 40, per the Centers for Disease Control and Prevention (CDC).
By the time she was 50, Turner's fasting blood sugar levels indicated she had diabetes. While she wanted to manage her condition, she didn't want to re-trigger her eating disorder in the process. So when she started seeing an endocrinologist, she was upfront about her needs.
"I immediately said that I had a history of eating disorders and PCOS, so in order for me to work with her, I was going to need assurances that I'd never be asked to lose weight," she says.
This is where weight-neutral diabetes care comes into play.
What Is Weight-Neutral Diabetes Care?
Put simply, weight-neutral diabetes care means providing medical care without telling patients they have to lose weight, says Megrette Fletcher, RDN, CDCES, a diabetes educator who coined the term with the Weight Neutral Diabetes Care Symposium (now called Inclusive Diabetes Care), which started in 2019.
The concept is still new, having only gained popularity among the wider diabetes community within the last few years. Fletcher says that, at the heart of the concept, is inclusivity.
"It has to do with how we look at a person," she says. "We're not focused on their weight —weight is not an indicator of success."
New York City endocrinologist Gregory Dodell, MD shares a similar viewpoint. Unless there's a reason to check his patients' weight (for example, if he needs to adjust their medication or suspects they're retaining fluid), Dr. Dodell doesn't even ask them to step on the scale.
"I don't think [checking their weight] is that helpful," he says. Part of the reason, he explains, is that the classifications of "overweight" and "obese" are based off a person's body mass index (BMI), which is a notably flawed measure of a person's body fat.
Why Is BMI a Flawed Measurement?
Not only does BMI fail to distinguish between fat and muscle mass, it may not be applicable to everyone because it was created to apply to white, cisgender men.
In fact, the initial proponent of the index—a scientist named Ancel Keys, who borrowed the formula from mid-19th century mathematician Adolphe Quetelet— never studied BMI in other groups, including children, older adults, cisgender women, people who are trans or people of color, according to a March 2014 article in the International Journal of Epidemiology.
"[Health care] has a very weight-centric model, where, if people lose weight, it supposedly cures all their problems," Dr. Dodell says. But we know this isn't always the case.
Why Weight Isn't Important to Diabetes Care
Fletcher (among other weight-neutral practitioners) has come to understand that weight loss isn't necessarily as important for managing diabetes as people are led to believe. And there's evidence to back that up.
She points to one July 2013 study in The New England Journal of Medicine, which found weight loss did not reduce the rate of heart problems among people with overweight or obesity and type 2 diabetes.
Another January 2016 study in PLOS ONE found people with overweight and type 2 diabetes who lost weight didn't see a reduction in their overall mortality risk or risk of heart trouble over a 13-year period.
On the other hand, lifestyle habits like exercise (without the goal of weight loss) have proven beneficial.
A November 2017 study in BMJ Open Diabetes Research and Care found exercise can reduce A1C levels (a measure of a person's average blood sugar levels over the past three months) even if they don't lose weight. "Exercise should be viewed as beneficial on its own, not merely as an avenue to weight loss," the study authors concluded.
"There's a lot of research emphasizing that the simplistic views we've held around weight and weight loss are not really that accurate," Fletcher adds.
3 Benefits of Weight-Neutral Diabetes Care
For many people, the idea of putting little-to-no-emphasis on weight can be a welcome — and novel — change.
In the past, when someone was diagnosed with prediabetes or type 2 diabetes, "the first recommendation out of many physicians' mouths would be 'lose some weight,'" says Erin Palinski-Wade, RD, CDCES, author of 2-Day Diabetes Diet.
Here are benefits of weight-neutral diabetes care:
1. Emphasis on Overall Wellness
Weight-neutral diabetes care often means improving a person's behaviors to emphasize wellness. This can include healthy eating habits, regular exercise and a good night's sleep. This also doesn't force a result, like weight loss.
"You can't control an outcome," Fletcher says. "You can only control behaviors."
2. Patient Empowerment
A wellness-based approach can be empowering for some people with diabetes, especially those who've struggled to lose weight.
"Having to focus on a number isn't always practical for everyone," Palinski-Wade says. "And for some people, it can be really defeating." (Not to mention that maintaining weight loss is challenging, and weight regain is typical, according to a January 2019 study in Medical Clinics of North America.)
3. Focus on Diabetes Management
A weight-neutral approach to diabetes care also puts the focus back on other diabetes-specific markers of health. Two of these, Palinski-Wade says, are daily fasting blood sugar readings and the A1C level.
That said, people with diabetes can also be at risk for other health conditions, like heart disease, so your doctor will want to keep tabs on your cholesterol and blood pressure levels, too, she says.
Weight-Neutral Diabetes Care and Disordered Eating
Taking weight out of the equation can also help people like Turner, who — along with an estimated 14 to 20 percent of people in the U.S. — struggle with disordered eating, per an October 2019 study in JAMA.
"So many of my patients have histories of eating disorders, and there's a lot of stigma regarding weight," Dr. Dodell says. "I think that [weight] can detract from the visit."
Turner, who also helps coach people through medical issues, says some of her clients, including those with a history of disordered eating, say their physicians remain hyper-focused on weight.
"I've heard some stories of physicians not willing to treat patients because they have overweight or obesity," she says. And this is even after patients have mentioned their past with eating disorders, and their desire to address their diabetes.
Fletcher adds that if people with diabetes lose weight in unhealthy ways — by restricting their calories too much or going too long without eating — it can cause blood sugar levels to fall dangerously low.
You also run the risk of malnourishment, and low levels of vitamins like thiamin (b1), an essential nutrient for people with diabetes, per the National Institutes of Health (NIH).
"We're so weight-focused. Doctors often say, 'Isn't it great they're losing weight?'" Fletcher says. But weight loss is not helpful if you are engaging in disordered eating.
If you struggle with obsessive thoughts around body image, food and weight loss, you are not alone. You may be experiencing disordered eating or an eating disorder. Consider seeking out online support through organizations like the National Eating Disorders Association (NEDA). NEDA's helpline is (800) 931-2237. Texting and online chat options are available.
Weight Stigma at the Doctor
Unfortunately, weight bias isn't uncommon among doctors, according to a November 2012 study in PLOS ONE, which found a high prevalence of what was referred to as "anti-fat attitudes."
Palinski-Wade says some of her clients would actually cancel their regular checkups with their doctor if they felt like they hadn't lost enough weight. They knew they'd feel shamed for it. "This actually holds people back from getting necessary care," she adds.
These views also come with consequences. A November 2016 study in Psychological Science found weight discrimination was associated with a nearly 60 percent increased mortality rate over a 4-year period.
This means weight stigma can pose a serious threat to patients' health.
Concerns About Weight-Neutral Diabetes Care
There are still plenty of medical associations that believe weight loss is the cornerstone of diabetes care.
The American Diabetes Association (ADA), for example, recommends weight loss to people who have overweight or obesity.
Studies also suggest visceral fat (the fat stored deep inside your belly around your organs) is linked to insulin resistance, a precursor to diabetes, according to a May 2014 review in Current Opinion in Endocrinology, Diabetes and Obesity, but researchers aren't exactly sure how or why, or if losing weight would affect insulin resistance.
This is why some organizations like the ADA believe that if weight loss is completely removed from the equation, it might be harmful for people with the condition who also have visceral fat.
While more research is needed, a middle-ground approach may be the safest approach to weight in the context of diabetes care. The thinking goes that weight — or more specifically, body composition and waist circumference — still matter, but that it's better to focus on specific, actionable steps a person can control, like eating more fiber, getting more sleep and reducing stress.
When people take that approach, they also tend to see a reduction in body fat, Palinski-Wade says.
How to Practice Weight-Neutral Diabetes Care
1. Focus on Positive Behaviors
The goal of this type of care, Fletcher says, is for a patient and provider to focus on positive behaviors — eating balanced meals, exercising regularly, managing stress and getting enough sleep — not the outcome of weight loss.
2. Be Upfront About Your Expectations
In order to put weight-neutral care into practice, both the patient and doctor need to be clear on what they expect from each other. When Turner first visited her endocrinologist, she was clear she wanted weight-neutral care.
Doctors should also make sure to explain to patients why they practice weight-neutral care, and other measures of health they use, like blood sugar, A1C levels, blood pressure, etc.
3. Ask to Not Get Weighed
"To this day, my [doctor] never takes my weight when I come into the office," Turner says. "We really focus on what my blood panels look like based on what's going on in my life, my mental health, those kinds of things. We're not focused on weight at all."
Don't be afraid to ask your doctor not to weigh you. If they refuse, they may not be the right doctor for you.
4. Bring a 'Don't Weigh Me' Card
If you are feeling anxious or cannot verbally ask not to get weighed for any reason, there are laminated 'Don't weigh me' cards you can purchase or make yourself to bring to your appointments. Show the card to the doctor or nurse prior to heading to the scale.
5. Ask for a 'Blind Weigh'
If it's medically necessary for you to step on the scale, ask doctors or nurses to be weighed facing away from the scale, so you don't see the number. You can also ask them not to say the number out loud and not to show you any weight-focused paperwork.
Turner calls this a "blind weigh." Because she doesn't want to re-trigger her eating disorder, she asks for blind weighs each visit.
If you feel comfortable, you can ask all practitioners, including your primary care doctor, to implement this practice.
6. Ask About Weight-Neutral Medications
If necessary, Fletcher also encourages diabetes doctors to prescribe weight-neutral medications whenever possible — meaning, medications with less potential to cause weight loss or gain.
"We try to prescribe medications that don't inhibit a person listening and responding to their own internal cues around food and eating," Fletcher says.
How to Find a Weight-Neutral Diabetes Care Team
Ultimately, it's important that patients with diabetes feel seen and heard, Fletcher says.
This means it may take a few attempts to find a practitioner who will provide you with a weight-neutral approach — and you may have to broach the subject first.
The good thing about managing diabetes though, is that, oftentimes, you have a whole team at your disposal: a primary care doctor, an endocrinologist, a dietitian and more.
"Even if you just find one member of the team who is more weight-inclusive, you'll have more support when you go to other appointments to shift that conversation away from just weight," Palinski-Wade says.
"You can say, 'My weight is the same, but look, my blood sugar is improving because I'm improving my sleep or getting a better handle on stress,'" she adds.
Once other practitioners see your improvement, they're likely to become more motivated by those numbers, instead of just your weight.
- BMC Medicine: "How and Why Weight Stigma Drives the Obesity ‘Epidemic’ and Harms Health"
- Psychological Science: "Weight Discrimination and Risk of Mortality"
- PLOS ONE: "Implicit and Explicit Anti-Fat Bias among a Large Sample of Medical Doctors by BMI, Race/Ethnicity and Gender"
- JAMA: "Estimation of Eating Disorders Prevalence by Age and Associations With Mortality in a Simulated Nationally Representative US Cohort"
- The American Journal of Clinical Nutrition: "Long-term Weight Loss Maintenance"
- JAMA: "Effects of Exercise on Glycemic Control and Body Mass in Type 2 Diabetes Mellitus: a Meta-analysis of Controlled Clinical Trials"
- PLOS One: "Intentional Weight Loss and Longevity in Overweight Patients with Type 2 Diabetes: A Population-Based Cohort Study"
- The New England Journal of Medicine: "Cardiovascular Effects of Intensive Lifestyle Intervention in Type 2 Diabetes"
- International Journal of Epidemiology: "Commentary: Origins and Evolution of Body Mass Index (BMI): Continuing Saga"
- Chevese Turner: "Body Equity Alliance"
- BMJ Open Diabetes Research and Care: "Effect of regular exercise training on changes in HbA1c, BMI and VO2max among patients with type 2 diabetes mellitus: an 8-year trial"
- Cleveland Clinic: "Insulin"
- CDC: "PCOS and Diabetes"
- Medical Clinics of North America: "Maintenance of lost weight and long-term management of obesity"
- NEDA: "National Eating Disorders Association"
- NIH: "Thiamin"
- Erin Palinski-Wade, RD, CDCES
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