Diabetes in Real Life

Effective weight-management strategies in diabetes must address stigma

Maintaining a healthy weight can be a successful strategy for type 2 diabetes prevention and management. However, anyone who has tried to make and sustain lifestyle changes realizes that long-term behavior change — particularly staying motivated — is difficult. Many people do not find success with long-term weight loss and maintenance, largely due to complex issues that influence weight, including environmental, genetic, biological, cultural and social factors. In this issue, Susan Weiner, MS, RDN, CDE, CDN, FAADE, talks with clinical nutrition manager Lisa Hodgson, RD, CDN, CDE, about how to help people with type 2 diabetes sustain healthy behavior changes through commitment, encouragement and ongoing support.

Susan Weiner

Why is it critical for health care professionals to encourage and support the efforts of people with type 2 diabetes to achieve and maintain a healthy weight?

Hodgson: The 2020 American Diabetes Association Standards of Medical Care in Diabetes cite the role of obesity in the development of long-term diabetes complications, including cardiometabolic conditions, which have been well documented. There is a direct relationship between weight status and glycemic, blood pressure and lipid management.

Outcome data examining long-term weight loss and maintenance success are not impressive, largely due to complex issues that influence weight, including environmental, genetic, biological, cultural and social factors. Addressing and sustaining positive behavior changes requires commitment, encouragement and ongoing support.

What barriers do health care professionals face when counseling people on weight loss and maintenance?

Hodgson: One important barrier to supporting weight-management efforts is pervasive weight stigma among health care professionals. Weight stigma projected onto people with diabetes by clinicians may lead them to avoid seeking medical care. It may also perpetuate binge eating and overeating, limit physical activity, encourage disordered eating and foster physiological stress. Writing in the British Journal of Obesity in 2015, Stuart William Flint, PhD, associate professor of psychology at the University of Leeds, noted that stigmatizing attitudes are prevalent among physicians, nurses and medical students and are often reflected in their interactions with patients.

Lisa Hodgson

In addition, clinicians may not have adequate time to discuss complex health issues. This perception underscores the importance of team-based care with a person-centered approach. Diabetes care and education specialists and registered dietitians/nutritionists have the opportunity to spend more time with a person than physicians and advanced practice providers do. They get to know each individual and establish goals that reflect each situation. Social determinants of health are assessed and people are referred to community resources when needed. Clinicians may then reinforce goals and support individuals’ efforts without feeling the burden of time constraints.

What are some important considerations when working with people who have identified weight management as a priority for them?

Hodgson: The 2019 ADA Nutrition Consensus Report notes the best practice of customizing nutrition interventions to fit each person’s preferences and resources, encouraging regular physical activity and including behavioral strategies in every plan. This approach acknowledges the person with diabetes as the center of the patient-centered team, involved in setting goals and developing interventions. Progress toward individual goals is measured at each visit, and goals are adjusted over time.

Addressing emotional eating is an important component of effective weight-management strategies. Some people turn to food as a response to emotions. Collaborating to identify coping strategies like meditation, yoga and mindful eating techniques supports their efforts to respond to emotions while eating a nutritious diet.

Using nonjudgmental and respectful language with all people is important to establishing supportive relationships. Asking about and addressing experiences involving weight stigma is an important component of assessment. Building a behavior change plan around past strategies and what is important to the individual is a way to set up each person for success.

What is the best type of meal plan for those interested in improving eating habits?

Hodgson: The 2020 ADA Standards of Medical Care in Diabetes holds that a weight loss of 3% to 5% is the “minimum necessary for clinical benefit.” Weight loss of 15% is the optimum amount to realize maximum reduction in HbA1c for people with type 2 diabetes. A 7% to 10% weight loss has been shown to prevent the conversion of prediabetes to type 2 diabetes.

The ADA Nutrition Consensus Report authors extensively studied the research on multiple diets to determine which may be the best approach to achieve and maintain weight loss. A reduction in carbohydrate intake for individuals with diabetes is the approach with the most supporting evidence for improving glycemia. The report concluded that medical nutrition therapy and diabetes self-management education and support (DSMES) services should include an individualized eating plan in a format that results in energy deficit in combination with enhanced physical activity. One size does not fit all.

The following recommendations apply to all healthy meal plans and aim to prevent a wide array of chronic diseases: emphasize nonstarchy vegetables, minimize consumption of added sugars and refined grains, and choose whole foods over highly processed foods as often as possible.

The upshot is that it is important to work with each person to determine the healthy eating plan that is most consistent with the individual’s situation, lifestyle, resources and food preferences.

What are some other helpful weight-management strategies to consider?

Hodgson: The use of oral nutrition supplements has grown in popularity in recent years. For chronic meal skippers who tend to overeat later in the day, the use of nutrition drinks as meal replacements may assist with appetite management and stabilization of blood sugars throughout the day.

Intermittent fasting as a weight-management strategy was reviewed in the 2019 ADA Nutrition Consensus Report. This strategy may support weight loss for some people with diabetes by creating a deficit in daily energy intake. The findings indicated that more research is needed.

Weight-loss medications are an additional tool that may be implemented with appropriate individuals in addition to healthy eating, regular physical activity and behavioral changes. Safe and effective options are available, with close monitoring recommended. These are not for everyone but may be a helpful tool for some.

Bariatric surgery may be considered when someone has been unsuccessful in multiple attempts to lose weight. When the benefits of this life-altering procedure outweigh the inherent risks involved in having the procedure and not losing weight, it may be time to consider this option for qualifying patients.

Disclosures: Hodgson reports no relevant financial disclosures. Weiner reports she is a clinical adviser to Livongo Health.

Maintaining a healthy weight can be a successful strategy for type 2 diabetes prevention and management. However, anyone who has tried to make and sustain lifestyle changes realizes that long-term behavior change — particularly staying motivated — is difficult. Many people do not find success with long-term weight loss and maintenance, largely due to complex issues that influence weight, including environmental, genetic, biological, cultural and social factors. In this issue, Susan Weiner, MS, RDN, CDE, CDN, FAADE, talks with clinical nutrition manager Lisa Hodgson, RD, CDN, CDE, about how to help people with type 2 diabetes sustain healthy behavior changes through commitment, encouragement and ongoing support.

Susan Weiner

Why is it critical for health care professionals to encourage and support the efforts of people with type 2 diabetes to achieve and maintain a healthy weight?

Hodgson: The 2020 American Diabetes Association Standards of Medical Care in Diabetes cite the role of obesity in the development of long-term diabetes complications, including cardiometabolic conditions, which have been well documented. There is a direct relationship between weight status and glycemic, blood pressure and lipid management.

Outcome data examining long-term weight loss and maintenance success are not impressive, largely due to complex issues that influence weight, including environmental, genetic, biological, cultural and social factors. Addressing and sustaining positive behavior changes requires commitment, encouragement and ongoing support.

What barriers do health care professionals face when counseling people on weight loss and maintenance?

Hodgson: One important barrier to supporting weight-management efforts is pervasive weight stigma among health care professionals. Weight stigma projected onto people with diabetes by clinicians may lead them to avoid seeking medical care. It may also perpetuate binge eating and overeating, limit physical activity, encourage disordered eating and foster physiological stress. Writing in the British Journal of Obesity in 2015, Stuart William Flint, PhD, associate professor of psychology at the University of Leeds, noted that stigmatizing attitudes are prevalent among physicians, nurses and medical students and are often reflected in their interactions with patients.

Lisa Hodgson

In addition, clinicians may not have adequate time to discuss complex health issues. This perception underscores the importance of team-based care with a person-centered approach. Diabetes care and education specialists and registered dietitians/nutritionists have the opportunity to spend more time with a person than physicians and advanced practice providers do. They get to know each individual and establish goals that reflect each situation. Social determinants of health are assessed and people are referred to community resources when needed. Clinicians may then reinforce goals and support individuals’ efforts without feeling the burden of time constraints.

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What are some important considerations when working with people who have identified weight management as a priority for them?

Hodgson: The 2019 ADA Nutrition Consensus Report notes the best practice of customizing nutrition interventions to fit each person’s preferences and resources, encouraging regular physical activity and including behavioral strategies in every plan. This approach acknowledges the person with diabetes as the center of the patient-centered team, involved in setting goals and developing interventions. Progress toward individual goals is measured at each visit, and goals are adjusted over time.

Addressing emotional eating is an important component of effective weight-management strategies. Some people turn to food as a response to emotions. Collaborating to identify coping strategies like meditation, yoga and mindful eating techniques supports their efforts to respond to emotions while eating a nutritious diet.

Using nonjudgmental and respectful language with all people is important to establishing supportive relationships. Asking about and addressing experiences involving weight stigma is an important component of assessment. Building a behavior change plan around past strategies and what is important to the individual is a way to set up each person for success.

What is the best type of meal plan for those interested in improving eating habits?

Hodgson: The 2020 ADA Standards of Medical Care in Diabetes holds that a weight loss of 3% to 5% is the “minimum necessary for clinical benefit.” Weight loss of 15% is the optimum amount to realize maximum reduction in HbA1c for people with type 2 diabetes. A 7% to 10% weight loss has been shown to prevent the conversion of prediabetes to type 2 diabetes.

The ADA Nutrition Consensus Report authors extensively studied the research on multiple diets to determine which may be the best approach to achieve and maintain weight loss. A reduction in carbohydrate intake for individuals with diabetes is the approach with the most supporting evidence for improving glycemia. The report concluded that medical nutrition therapy and diabetes self-management education and support (DSMES) services should include an individualized eating plan in a format that results in energy deficit in combination with enhanced physical activity. One size does not fit all.

The following recommendations apply to all healthy meal plans and aim to prevent a wide array of chronic diseases: emphasize nonstarchy vegetables, minimize consumption of added sugars and refined grains, and choose whole foods over highly processed foods as often as possible.

The upshot is that it is important to work with each person to determine the healthy eating plan that is most consistent with the individual’s situation, lifestyle, resources and food preferences.

PAGE BREAK

What are some other helpful weight-management strategies to consider?

Hodgson: The use of oral nutrition supplements has grown in popularity in recent years. For chronic meal skippers who tend to overeat later in the day, the use of nutrition drinks as meal replacements may assist with appetite management and stabilization of blood sugars throughout the day.

Intermittent fasting as a weight-management strategy was reviewed in the 2019 ADA Nutrition Consensus Report. This strategy may support weight loss for some people with diabetes by creating a deficit in daily energy intake. The findings indicated that more research is needed.

Weight-loss medications are an additional tool that may be implemented with appropriate individuals in addition to healthy eating, regular physical activity and behavioral changes. Safe and effective options are available, with close monitoring recommended. These are not for everyone but may be a helpful tool for some.

Bariatric surgery may be considered when someone has been unsuccessful in multiple attempts to lose weight. When the benefits of this life-altering procedure outweigh the inherent risks involved in having the procedure and not losing weight, it may be time to consider this option for qualifying patients.

Disclosures: Hodgson reports no relevant financial disclosures. Weiner reports she is a clinical adviser to Livongo Health.