Applying an Anti-Diet Approach in Diabetes Practice
By Grace Ling MS, RD, CD, CDCES
Have you ever wondered if intuitive eating and “therapeutic diets” can live in harmony? During my dietetic internship, I recall we had a special workshop on motivational interviewing and Health at Every Size® (HAES®) led by Ellen Glovsky Ph.D., RD, LDN. Coming from a clinically-focused internship, I believe this was my first exposure to the weight-inclusive healthcare framework. At the time, I recall thinking that HAES® sounded great “in theory”, but I could not see how this approach could ever coexist with the weight-centric interventions for so many of the chronic conditions we learned about in my MNT classes. It seemed like diet restriction and weight loss were advised for everyone—unless, of course, they had an eating disorder. In that case, we should encourage patients to toss their scales, ditch the good/bad food paradigm, and eat the ice cream. Oh, double standards!
Once a tepid fence-straddler, I can say that, over the past several years in professional practice, I have wholeheartedly made the leap and am a proud anti-diet and HAES®-aligned dietitian and am working on my Intuitive Eating Counselor certification. I now work as a diabetes care and education specialist (CDCES, formerly CDE) in an outpatient hospital setting. It has been both challenging and rewarding to bring a weight-inclusive and non-diet lens to this setting.
I am acutely aware that many of the nutrition interventions we recommend in diabetes self-management—like measuring portions, detailed tracking, and counting grams of carbohydrates—feel awfully similar to disordered eating behaviors. Indeed, personal experience and perusal of the literature has taught me that people with diabetes are at a much higher risk of developing eating disorders. Our culture and medical system place an immense amount of pressure on body size and weight, layered with the implied personal culpability, blame, and shame that often accompany a diabetes diagnosis.
On the other hand, I have found that skills like label reading, carb counting, and macronutrient pairing are highly effective in helping clients achieve glycemic targets and can be utilized in an intuitive eating practice. I firmly believe that these are useful skills that can empower people with diabetes, if only we can detangle these skills from the diet culture soup that they tend to simmer in. Here are a few of the interventions I have found to be helpful in my anti-diet diabetes practice:
1. Encourage clients to notice how they may be moralizing food, especially carbs and sugars. Provide education on the function and importance of all macronutrients. Remind them that just as fashion trends repeat themselves, so do diets: in the 90s, fat was “bad”; now, fat rules the keto kingdom and it’s carbohydrates that are shunned.
2. Dietitians know that blood glucose is more erratic with inconsistent meal patterns, prolonged fasting, and restrict/binge cycling, but it can be hard for our clients to recognize this in themselves. Consider a “qualitative” food journal to assist clients in noticing how meal timing and components may impact not only their blood sugars but how they feel throughout the day. Many people enjoy an old school pen-and-paper approach for this, using a printed template, but I’ve also had people use Excel or food photo journals.
3. Carb counting can be useful depending on the individual, particularly for those using insulin:carb ratios via multiple daily injection (MDI) insulin therapy or continuous subcutaneous insulin infusion (CSII), aka insulin pumps. It takes a fair amount of literacy and math skills, but carb counting can provide a lot more flexibility than simply using fixed dose boluses. Rather than trying to make sure their meal fits the amount of insulin prescribed per meal, the individual can eat more intuitively and match their insulin dose accordingly.
4. If your client has the resources (either through insurance coverage or financial ability to pay out of pocket), consider a short-term continuous glucose monitor (CGM) trial. My practice is fortunate enough to be able to provide a limited number of sensors to individuals at no cost and I have training in these technologies. I encourage people with diabetes (PWD) to experiment with many different foods, including those they think are “off limits.” I’ve seen plenty of folks, especially those who are newly diagnosed, breathe a sigh of relief when they see that their blood sugars are not actually as “bad” as they thought! (Pro tip: ice cream and pizza rarely spike blood sugars as much as people think they will.) Rather than trying to live by a set of diet rules that do not serve them, using a CGM can help PWD get to know how their body uniquely responds to various foods.
- Note that CGM is not appropriate for all, and this should be an open discussion with the client. Some may be very anxious about their blood sugar trends, and seeing this amount of data can actually trigger or exacerbate disordered eating and exercise patterns.
5. Diabetes management is a partnership: I like to let the person with diabetes know that they are in the driver’s seat and they are the experts on themselves, and I am but a consultant in their journey. It can be scary for the client to try something outside of the diet culture norm. Try framing things as short-term experiments, rather than a commitment to a paradigm shift. Normalize trial-and-error!
While I can get really excited about this work, a non-diet approach is not for every provider or every client. Both parties on the team must be aligned: not every dietitian is the right match for every client, and not every client is ready to explore non-diet approaches. If something does not feel aligned with your clients’ values or lifestyle, it is important to respect this and adjust accordingly. This could be taking a step back if the work is progressing too quickly or referring out if you do not feel you can meet the client where they are at now.
Thanks for reading! Feel free to connect with me: gracemlingATgmailDOTcom
*Disclaimer: This article is based on my experience and opinion, and is for informational purposes only; it does not necessarily reflect the views of GSDA as a whole and does not serve as professional medical advice.*