“Excuse me, can you hold on for just a minute, please?” the patient asked.
“Sure, no problem,” I replied.
A pause. Then, “Don’t judge me, Doctor.”
Reflexively, I promised not to. Fears about what I would hear next on the other end of the line began to flood my mind. I then heard her say, “Can I get an iced vanilla latte, an order of everything bagel bites and some hash browns, please?” and I had to laugh.
A young woman approximately my age, this patient had been living with an eating disorder (ED) for at least two years, and I suspect much longer. Her weight had steadily declined until three months ago, when she finally agreed to enter ED treatment. As a rule in ED recovery, one should refrain from using numbers to describe body size, so suffice to say that even after three months of progress, her BMI was still far from normal.
A wave of relief washed over me as she picked up her order at the Dunkin Donuts drive-through during our telehealth visit to discuss her most recent labs. By her own admission, this patient could not have placed this order just a few months ago, and here she was about to eat it — leaps and bounds in improvement by any standard.
As she ate in the parking lot, we continued our conversation about her labs. Her previous electrolyte abnormalities had been corrected, her kidney function had improved, and her blood count was now normal — all good news that I felt grateful to deliver. “What about my sugars?” she asked. The question surprised me. In all honesty, since she was not hypoglycemic, I had not examined her specific blood glucose level or hemoglobin A1c too closely. Scrolling through the extensive list of her lab results, I spotted them and felt a knot form in my stomach. Both elevated: prediabetes.
In my limited clinical experience, many patients fall into this category. Normally, prediabetes is considered more of a wake-up call than a life-altering diagnosis. For this patient, with her history, I was afraid it would be the latter.
If I told her that her sugars were high, would it trigger a relapse? Would she be too afraid to ever eat bagel bites again? Would it be ethical to evade her question and say that she didn’t need to worry about her sugars? These were the questions in my mind as I pretended to search for her lab results. Here was a young woman who had spent years moralizing and eschewing junk food, yet her diet had not saved her from prediabetes. In fact, it may have contributed to it.
Without knowing more of this patient’s story, I cannot identify all the factors that may have conspired to bring her to this point. That said, her concern about her blood sugar during recovery was sobering. So strong was the connection in her mind between weight gain and diabetes that it signaled to me that the health care field is overdue for a reckoning with respect to the discourse surrounding dieting, weight loss and health. Although the connection between excess weight and adverse health outcomes is well established, in our pursuit of better health we may be missing the bigger, more complex picture.
As health care providers, we counsel patients every day about diet and exercise, promising that weight loss will protect them from disease. But what if the way we view food and body size causes more harm than good? Studies have demonstrated that diet-induced weight loss can increase cortisol and decrease insulin — hormonal changes that are associated with increased blood glucose levels.
Data also suggest that cycles of weight gain and loss may promote insulin resistance and the development of diabetes. At the same time, the lifetime prevalence of EDs in adolescents has been estimated at 2.7%, over 200 times higher than that of childhood type 2 diabetes mellitus at 0.01%. Taken in tandem, these findings should prompt us to ask not only whether dieting may be less innocuous than we think, but also whether our approach to mitigating diabetes and weight-related diseases might unintentionally encourage disordered eating behavior.
Every medical intervention, including prescribed weight loss, carries the possibility of harm. We are often quick to recommend weight loss as a panacea. In doing so, we may be inadvertently feeding into the billion-dollar diet industry, whose power comes from our collective belief that health is entirely within one’s control.
This belief obscures the multifactorial etiology of both weight and health; it convinces patients that weight gain and even type 2 diabetes mellitus represent a moral failing, a lack of willpower or self-control. Instead of avoiding discussions about weight loss with our patients, we should remain mindful that their weight and health status impact their self-image and self-worth. Accordingly, we can empower them to make lasting lifestyle changes without encouraging disordered eating behavior.
In the end, I told the patient the truth: Her blood sugar was a bit high, but her body might still be adjusting as she recovers from her ED. I reassured her that, according to the Centers for Disease Control and Prevention, only two percent of patients with prediabetes progress to diabetes in 12 months, and less than 10 percent progress in five years. The patient and I made a plan to continue her ED treatment and recheck her blood sugar in a few months. Importantly, we also agreed not to jump to any conclusions until we had more data. Until then, I hope she continues to enjoy the sweet satisfaction of the occasional donut shop coffee.