by Linda Bacon, PhD, and Judith Matz, LCSW
From the Editor: Linda Bacon is a nutrition professor, researcher, and author of Health at Every Size: The Surprising Truth About Your Weight. Her personal website is <www.LindaBacon.org>. Judith Matz is director of the Chicago Center for Overcoming Overeating, Inc., has a private practice in Skokie, Illinois, and is coauthor of The Diet Survivor's Handbook: 60 Lessons in Eating, Acceptance and Self-Care. Her website is <www.dietsurvivors.com>. This article is reprinted with permission from Diabetes Self-Management, November/December 2010. ©2010 R.A. Rapaport Publishing, Inc. For subscription information please call (800) 234-0923. Or for a free trial issue visit us on the web at <http://offer.diabetesselfmanagement.com/>. Here is what these two experts have to say about handling diabetes, food, and balancing the two:
Jenna, a new client, was explaining what she wanted to get out of her counseling sessions. She said, "I want to love food again. I want to pop a juicy strawberry into my mouth and not think about my blood sugar. I want to enjoy a slice of gooey cake at my son's birthday party, guilt-free. I want to go to a dinner party and feel free to eat whatever my friend prepares." And what stopped her from enjoying eating? "I have diabetes," she said.
This was followed by a pause, as if that sentence explained it all—that a diagnosis of diabetes means that food and eating can no longer be enjoyed. Jenna's concerns aren't surprising, given the advice most people with diabetes receive about food choices and meal planning. When you're asked to consider the carbohydrate content, fat content, glycemic load, and potential impact on your weight of everything you eat, it can be extremely difficult to maintain a healthy relationship with food, to truly enjoy eating, and to allow food to nourish you. It doesn't help when doctors, dietitians, friends, and family members all seem to have something to add to the topic of how to eat with diabetes.
If the prospect of choosing foods strikes fear in you or if you've tried several "diabetic diets" and none of them worked for you in the long run, we've got some great news: there's no need to see food as your enemy or to carefully restrict your eating. In fact the opposite is true. The secret to managing your diabetes lies in learning to celebrate food and its amazing ability to nourish you.
Chances are you've been prescribed a food regimen to help control your blood glucose levels. If you're like most people, you find it hard to stick with a rigid plan, and, if your meal plan excludes certain foods that you like, you mourn the loss of those foods. Perhaps you've tried to follow your meal plan, only to find yourself eating the very foods you were told to avoid. Perhaps you were told you needed to lose weight, and, even though you shed some pounds, a few months later they returned. You may wonder why you can't just get your act together and take better care of yourself. In fact, if you have Type 2 diabetes, you may think that if you'd done a better job monitoring your food intake and weight before your diagnosis, you wouldn't be in this predicament now. So here's our first piece of advice: don't blame yourself!
Genes play a large role in the development of diabetes. We're all born with challenges in our genetic code—as well as in our life circumstances—and this is one of the challenges you were dealt. Your body was vulnerable to difficulty with glucose regulation, and some combination of factors triggered that genetic propensity. However, now that a diagnosis of diabetes has made you aware of your body's trouble regulating glucose, you're in the driver's seat. You can learn how to manage your blood glucose and nourish yourself better. To get there, you may need to let go of certain beliefs that harm rather than help you. Intuitive eating means eating what feels right to you, when it feels right.
In the care and treatment of Type 2 diabetes, the value of achieving and maintaining weight loss has long been an unchallenged tenet. So you may be surprised to learn that there is limited evidence to support this emphasis. In fact, evidence suggests that the pursuit of weight loss—which more often results in fluctuating weight than permanent weight loss—can actually be harmful, both physically and emotionally. It also tends to distract a person from the behaviors and attitudes that really can improve one's health, such as eating well, being physically active, and cultivating a positive sense of self.
It's true that the majority of people with Type 2 diabetes fall into the body-mass index (BMI) categories of "overweight" or "obese." But it's also true that insulin resistance, one of the main underlying problems in Type 2 diabetes, encourages weight gain. In fact, weight gain may actually be an early symptom—rather than a primary cause—of the path toward Type 2 diabetes.
A short explanation of the science behind diabetes may help explain how this weight gain happens. Insulin is a hormone responsible for guiding nutrients—both glucose and fat—out of your bloodstream and into your cells. If you have diabetes, your pancreas can't make sufficient insulin and/or your cells are resistant to insulin, meaning they don't respond effectively to insulin's message. In either case you may have difficulty getting glucose into the cells that need it for energy. Instead, the excess glucose remains in your bloodstream, a situation that is believed to contribute to many of the complications associated with diabetes.
In people with Type 1 diabetes prolonged high blood glucose typically leads to weight loss as the glucose exits the body in the urine and the body begins to break down fat tissue for energy. In people with Type 2 diabetes (or prediabetes) whose pancreases still make insulin, the body's response to high blood glucose is to make and release more insulin, resulting in hyperinsulinemia, or higher-than-normal blood insulin levels. Hyperinsulinemia may promote weight gain in three ways: by causing increased storage of glucose as fat; by interfering with the action of the hormone leptin, which normally signals the brain that the body has had enough to eat; and by increasing the pleasure derived from food, even when the body does not need more calories. Given these mechanisms, it's not surprising that many people gain weight when they have Type 2 diabetes.
Without a doubt weight loss is very effective at improving blood glucose control in the short term. But this doesn't mean that your health will be better off in the long run. A review of controlled weight loss studies involving people with Type 2 diabetes showed that initial improvements in glucose control were followed by a return to starting levels of control within six to eighteen months, even in the few cases where weight loss was maintained. What can have lasting positive results, however, is developing sustainable behaviors. A wealth of evidence shows that people of all sizes can substantially improve their blood glucose control and their general health and well-being through healthy behaviors—even in the absence of weight loss.
A new approach to diabetes management that emphasizes wellness rather than weight is called Health at Every Size (HAES). HAES encourages people to trust their body to guide them in making nourishing food choices and attaining a natural weight. The HAES program includes three guiding concepts:
Many people who have diabetes feel betrayed by their body and find it difficult to trust that their body can actually support them in eating well. However, research shows that you can learn to read your body's signals and respond to them in a loving, nourishing way. Intuitive eating means eating what feels right to you, when it feels right. This approach helps you to reclaim the pleasure in eating and at the same time allows your body to help you manage your diabetes.
The first step in becoming an intuitive eater is to shift away from external rules about when you should eat and to learn to listen to your body's internal cues. We were all born with the ability to know when we are physically hungry, and you can reconnect with this natural signal.
To identify your physical hunger, pay attention to signals such as an empty or gnawing feeling in your stomach, a feeling of low energy or lethargy, a headache, difficulty concentrating, irritability, or persistent thoughts of food. Each person experiences hunger a little differently, and your job is to learn what hunger feels like to you. Checking your blood glucose level when you feel these sensations can provide you with valuable information. If it is low, the feeling you are experiencing is indeed physical hunger. If your blood glucose is high, your impulse to eat may be coming from an emotional rather than a physical trigger, but that's not always the case. If for some reason your body doesn't have enough insulin available to move the glucose in your bloodstream into the cells that need it, you may be experiencing real hunger. Insufficient insulin can result from not enough being injected (in those who inject insulin) or from a pancreas that simply can't put out enough to handle the level of glucose in the blood. And while food is the best known contributor to glucose in the bloodstream, high blood glucose can also occur after intense exercise, as a consequence of an infection (even one that you're not aware of having), and as a side effect of certain drugs. Having high blood glucose when you're feeling hungry, therefore, is an opportunity to think about what's going on for you at that moment and to ask yourself whether your urge to eat is coming from a physical trigger or an emotional one.
As you become an intuitive eater, you can experiment with different amounts and combinations of foods and get feedback through assessing how you feel and checking your blood glucose level. If you take insulin, you can also experiment with the dose and timing. You'll find that responding to true hunger is one way to put the pleasure back in eating; food actually tastes better when you are hungry. To ensure that you can eat what you want when you are hungry, it's a good strategy to always carry a bag of food with you that includes a wide range of options.
If you find that you are frequently turning to food before you are physically hungry, ask yourself, "Can I wait?" Remind yourself that as soon as you are hungry, you will eat. The more you practice listening to your body's signals and responding to them, the less you will feel the drive to eat when you're not really hungry. However, if you continue to turn to food for emotional reasons in spite of this work, consider doing some further reading or seeking counseling to learn how to manage your feelings without reaching for food.
Just as it's important to move away from external rules about when to eat, it's also important to let go of the rules about what you "should" or "shouldn't" eat. Instead, think about what food(s) would feel truly nourishing in your body. By choosing foods you like that will also keep your body feeling well, you can end the feelings of deprivation you may have surrounding food. When you eat, pay attention to how various foods affect you. Note how you feel physically and mentally before and after eating. Check your blood glucose level before and two hours after eating for additional feedback on the foods you chose. The more you do this, the more you will feel in charge of your eating and your diabetes care, rather than feeling controlled by them.
Here are some examples of how people with diabetes are using intuitive eating in their everyday lives:
Kara experimented with different types of food as she moved toward intuitive eating. For lunch one day she made a burrito filled with beans, vegetables, brown rice, and cheese. She felt nourished by this meal, and her energy level felt great. Her blood glucose check two hours after the start of this meal confirmed that she was in an acceptable range. Kara's positive eating experience resulted, in part, from the fact that her meal was high in fiber from the beans, vegetables, and brown rice. The fiber both filled her up and slowed the rate of glucose entering her bloodstream, keeping it at a healthy level. Kara was careful to concentrate on how foods felt in her body, which guided her to make choices that supported her wellness.
Jesse loved to eat fried chicken. However, when he checked his blood glucose level two hours after eating a fried chicken meal, it was over 300 mg/dl—well above the preferred range of less than 180 mg/dl two hours after a meal. Jesse recognized that he had also eaten mashed potatoes, gravy, and creamed corn because they were included with the meal, not because he really wanted them. He decided that in the future he would tune in to what he really wanted, not just eat what was offered. The next time he ate fried chicken, he chose green beans and a baked potato as side dishes. His blood glucose level following this meal was 164 mg/dl. Through this process Jesse learned how his body reacts to various foods. He was able to continue eating the foods he loves while successfully managing his diabetes. In the future, if Jesse wanted to eat the mashed potatoes, gravy, and corn with his fried chicken, he could experiment with eating a smaller quantity of each to keep his blood glucose level down.
Chris loved to eat bread. When she checked her blood glucose level a couple of hours after eating several slices from a freshly baked loaf, it was too high. She started to pair the bread with some peanut butter, which helped keep her blood glucose below 180 mg/dl, since fat helps slow the rate at which glucose gets into the blood. Knowing that a high-fat snack or meal can cause a delayed rise in blood glucose after eating, Chris also checked her blood glucose level three to four hours after her snack to receive additional feedback.
Remember the gooey cake that Jenna wished she could eat without guilt at her son's birthday party? After several months of practicing intuitive eating, Jenna realized that on days when she sat around the house, eating a piece of cake would send her blood glucose level too high, leaving her feeling tired. But when she was physically active, she felt better, and her blood glucose level tended to stay in a healthy range. So after a wonderful celebration of her son's fifth birthday, she took her dog for a long walk. Her goal is to walk more regularly. For now, though, she is glad to know that walking helps get glucose out of her blood and into her cells without requiring more insulin. This motivates her to be more active and also enables her to enjoy her cake.
Becoming an intuitive eater and learning how to feed yourself in a way that gives you pleasure takes some experimentation. The payoff is the feeling of sustained energy that comes from matching your hunger with pleasurable, nourishing food choices.
When you are hungry and eat exactly what you are hungry for, it feels very satisfying. As you eat, there's a point when you've had enough, and the food no longer tastes as good. By paying attention to this internal cue, you can stop eating when you are full so that your body feels satisfied and comfortable. But keep in mind that, if there is no physical hunger signal to start eating, there will be no internal signal to stop. One thought that may make it easier for you to put down your fork or spoon when you've had enough is that, when you are hungry again, you will eat again—the same food as you are eating now, or something else if you prefer.
There may be times when you suddenly feel hungry again even though you recently finished eating. This may be because your insulin-resistant cells have not yet received the energy from the meal. Try making your meals smaller in this case and eating more frequently. Smaller meals will require your pancreas to release less insulin, so you may have a better match between the amount of glucose from the meal and the amount of available insulin. You will learn in time, based on the way your body feels, how much food is right for you at a particular moment.
Craving food after a filling meal may also mean that your food choices didn't entirely satisfy your needs. Hillary found that when she ate salmon, a plain baked potato, and vegetables for dinner, she would over-eat cookies later in the evening even though she wasn't hungry. Upon reflection she realized that while she loved the foods she chose, something was missing. In her effort to reduce her fat intake so that she might lose weight, she never felt completely satisfied after a meal. She tried having some cheese and crackers before dinner and found that at the end of the meal she felt comfortably full— eliminating the nighttime overeating of cookies that she didn't really want. On the evenings when she did want something sweet after dinner, she had some cookies or fruit—depending on what she felt like eating at the time—and stopped when she felt satisfied. Hillary recently saw her doctor for a checkup and was pleased by her test results, which are a measure of blood glucose control over the past two to four months.
As you become an intuitive eater, honoring your internal cues and reclaiming the pleasure in eating, you will be in a much stronger position to make decisions about your health. The transition from a focus on dietary control and weight loss to the HAES mindset, with an emphasis on wellness, will put you in charge of managing your diabetes and altering your choices as necessary.
After six months of learning to become an intuitive eater, Jenna reported: "The best part is that the internal guidance of my body's cues is reliable. I don't feel bad about 'cheating' anymore because there's no such thing—it's just eating! I've loved getting back in touch with my real stomach hunger and enjoying what I eat, instead of rushing through and eating as much as I can since, as a large person, I'm 'not supposed' to eat. I find that I feel better and have more energy when I eat healthful foods. I certainly don't deprive myself, but I do try to pay attention to enjoying really good food, prepared with love and eaten slowly. My blood sugar readings have improved significantly, and I'm nicer, too!"
As mentioned earlier, it takes time and practice to develop the skills of intuitive eating. Fortunately, there is a large HAES community and an abundance of resources that can support and inform your journey. For more information about the Health at Every Size philosophy and about resources that can help you reshape your relationships to food, weight, and body image, here are two resources:
We wish you well on the journey to a healthy, positive, and pleasurable relationship with food!