Please stop telling patients with Type 2 Diabetes to “Just eat less sweets and carbs”
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I have permission to share the story of a patient I advocate for. She is fat and has Type 2 Diabetes (T2D). Her latest A1C test was 7.1%. This is .1% over her goal and up from her previous test. Her doctor told her that she didn’t need to adjust meds but should “do her best to eat less sweets and carbohydrates.”
This is incredibly common advice (perhaps especially with fat patients for whom many healthcare practitioners seem to always be trying to find a reason to prescribe food restriction, but I hear it from thin patients as well.)
Unfortunately, it is also problematic advice on a number of levels. First of all, it’s imprecise and does not invite confidence in the practitioner’s understanding of nutrition since “sweets” and “carbohydrates” are not two separate categories of food. Worse, as was the case for this patient, the practitioner often has absolutely no idea how many “sweets and carbohydrates” a patient is eating. Many practitioners seem to believe, or at least give patients advice as if, carbohydrate intake is the end all and be all of what could create an increase or decrease in a patient’s A1C and that’s simply inaccurate. Again, given that the practitioner doesn’t typically have information about things like the actual amount of “sweets and carbohydrates” eaten, activity level, etc. it can actually be bad advice from a health perspective, driving harmful restriction. T2D is a complicated condition and grossly oversimplifying it doesn’t help patients. Let’s look at this specific patient (and, again, I have permission to share this.)
What this patient’s doctor doesn’t know (because he didn’t ask) is that she doesn’t really eat sweets (she’s just never been a big fan) and her carbohydrate intake is something that she monitors and that hasn’t changed. What did change was that she had an incredibly stressful three months and her sleep was dramatically reduced and erratic, both of which can contribute to high blood sugar. She tests her blood sugar in the morning, two hours after starting each meal, and at night and her 90-day average on her glucometer was 126, with corresponds with an A1C of about 5.7. Finger stick tests can be off by 15% in either direction and still meet accuracy regulations, so even if we assume the entire number is actually 15% higher than her meter showed, that would be a 90-day average of 145 which corresponds with an A1C of about 6.7, so that still leaves a gap. One possibility is that her liver is overactive at night, causing her blood sugar to rise during sleep, when she is not testing it. This makes sense in her case since her morning glucose is typically the highest of the day.
After discussing options with her weight-neutral dietitian, the patient chose an initial response of focusing on getting more sleep and stress management, and going on continuous glucose monitoring so that she can get a better idea of what’s going on at night with the idea that she will try a high protein/fat snack before bed to help regulate her overnight blood sugar and if that doesn’t work she’ll consider other options, including a medication change.
It's ok if understanding the complexity of T2D isn’t within a particular practitioner’s wheelhouse, but if that’s the case then the best move is to refer the patient to someone for whom it is (preferably a non-diet practitioner since weight loss is also not appropriate advice since it almost never works and the subsequent weight cycling can disrupt blood sugar management.)
Regardless, managing blood sugar is complicated and “eat less sweets than carbs” is not nearly adequate advice.
There are many options for non-restrictive, weight-neutral blood sugar management. I’ve written about it here and on August 23rd at 5:30pm Pacific I will be giving a workshop about this (including a Q&A with weight-neutral endocrinologist Dr. Gregory Dodell.) There’s a pay-what-you-can option and all registrants get a video of the talk and Q&A. Details and registration are here.
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More research and resources:
https://haeshealthsheets.com/resources/
*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.
My husband's blood glucose goes up in response to fatty meat, which every expert says is impossible. I want to tell them to come to my house and watch it happen.
Also, that .1 nonsense for the A1C is so annoying. I go back and forth between 5.6 ("Everything's fine!") and 5.7 ("BWEEEP! BWEEEP! RED ALERT!! PRE-DIABETIC!!"). Given the amount that physicians like to bloviate about how important their extensive education is, they could maybe apply a split-second of rational thought to the situation and see that there is no dramatic metaphysical discontinuity between 5.6 and 5.7. "Oh, but it's evidence-based." Yeah, bite me.
Thank you!
I told my provider recently to please not give any restrictive eating advice, but instead to tell me what she would like me to eat more of, because any restriction advice can make it harder for someone with disordered eating to eat anything, and thus is a set-up for a binge, especially of sweets and fats.
She acted annoyed to that, responding as if this was something particular for me.
Next appointment, I'm going to tell her this is advice from the eating disorder recovery community to providers, not just for people with EDs, but for all patients, as ED prevention. I will explain to her, or write up, a two-column list about the differences between what I call a restrictive approach to eating vs an abundance approach to eating, a la Ellyn Satter: the many benefits of scheduled eating of meals and snacks, with each of the major food groups represented, in quantities one's body asks for, and always providing enough food at each meal and snack, such that there are leftovers, as that is the only way, Satter wisely points out, to ensure that everyone has gotten enough to eat.
Thanks again.