Diabetes and Diet: A Patient and Dietitian’s Perspective

I was first diagnosed with type 2 diabetes in 1998 at age 42 years.

Ill health, both physical and emotional, had plagued me for many years following the birth of my children. I was diagnosed with both postnatal depression and a mystery virus after the birth of my first child in 1981. However, I personally feel that the depression may have had a lot to do with the fact that my husband missed the birth as the baby came early and he was away working abroad and could not return home until our baby was 1 week old. I had been “comfort eating” and “eating for two” throughout my pregnancy and this continued afterwards. We then received good news of an office-based job for my husband, and although this involved moving quite a distance away, leaving family and friends behind, things did settle down at our new home and all was well for awhile. I made friends who encouraged me to join them at Weight Watchers. However, when my husband’s job changed again and he returned to working abroad, life took a retrograde turn and I reverted to old food habits. We lost a child to an ectopic pregnancy. We gave up hope of another baby until I had succeeded in losing weight again. I lost 3 stone and was suddenly pregnant! The pregnancy was difficult, but all was well this time after the birth and I picked up good eating habits for a while.

Emotional eating from stress has always been my problem, I do well for a while, then something happens to upset me and I slip back into old eating habits. Spending a lot of time alone with the children while my husband worked abroad contributed to my emotional stress; my coping mechanism was “comfort eating” interspersed with many yo–yo diets. My lack of self-confidence was carefully masked by an outward bright, jolly persona.

However, I never felt really well. I received some help from a clinical psychologist in Oxford (and later from a cognitive behavioral therapy [CBT] therapist) through my general practitioner, but diabetes was never suggested as a possible cause of my physical symptoms, even though I was in the morbidly obese category! However, in 1998 a nursing friend suggested I ask for a diabetes test following recurring infections which did not respond to treatment; and yes, I was a type 2 diabetic with a fasting glucose average of 17. This explained many of the symptoms I had been having, maybe even for the past 20 years since my children were born.

At first, I learnt to deal with medications and advice, but then my father died, and things went downhill for a while again until I pulled myself together with help from a CBT therapist and support from a new slimming group who did not know the “old me”. I could make a fresh start.

I also joined the gym and lost 4 stone for a special family occasion, discovering the benefits of exercise on both mind and body. However, none of these steps was an easy process! I attended another CBT course run by Mind which was a great help, but sadly then my husband lost both of his parents within a short time and my own Mum fell ill, I started to gain weight again; I was trying to support and look after my husband and Mum, and the only way I could cope was returning to comfort eating. Ultimately, I regained much of the weight I had lost. This was typical behavior for me and, as I hate doing what people tell me, everyone’s good advice was ignored as I slipped back further and further: I stopped attending medical appointments, gave up the gym and Weight Watchers group and kidded myself that this was OK! Mobility problems then kicked in with inactivity, I was just about at rock bottom, and I ended up being put on insulin, which I hated. At this time I was keeping my regular appointments with the nurse at my GP’s practice. The nurse was a truly wonderful support to me, eventually persuading me to give the Oxfordshire Diabetes Weightwise program a try.

I was initially skeptical, thinking “Oh here we go again,” but it has been the most marvelous approach, combining much of what I already knew but had failed to put into practice without the right support, and adding in things such as dealing with thoughts, feelings and emotions, mindfulness and accountability. I was recommended to try the MyFitnessPal phone app, which provides easy ways to track food and exercise, has recipes and a blog with support online. Being in a group of people all struggling with the same condition really helped, though sadly most dropped out over the months, leaving just two of us—and we have both done very well.

I have now lost nearly 4 stone in less than 1 year, and my aim is to lose another stone and to keep it off! The group also recommended new activities, such as Go Active, and I re-joined a gym and walk as much as possible. Following this weight-loss and fitness regime, I have reduced my Levemir from 74 units daily to just 6 units.

I cannot thank the organizers enough for presenting the course, supporting and encouraging us, listening to us and advising us. I also recently attended an excellent day at Diabetes4Ward that was very educational, especially regarding new medications that may become available in the future and reinforcing the nutritional advice provided by the Weightwise program. If only the Weightwise course could have continued for a year!

Altogether I feel so much better, look better and have more energy. I am trying some things I used to find scary, making other small changes in order to maintain this new lifestyle which I have realized I have to do for the rest of my life.

In all of this, I have also been helped greatly by my family, especially my husband who has now retired, and I see him every day! Our life is so much calmer, mostly! The birth of four grandchildren makes our family life so different from the stresses of old, and they are our joy.

However, I am firmly of the opinion that I could not have achieved all of this until I knew what being at rock bottom felt like. I realize I was on my “final warning” and after 62 years I learnt to accept the right help from the right people. I now realize these changes have to be for the rest of my life.

I really hope that hearing my story will encourage others in my situation and wish them very well.

Name: Pamela A. Dyson

Affiliation: Oxford Centre for Diabetes, Endocrinology and Metabolism (OCDEM), University of Oxford, Oxford, UK.

In the UK, weight reduction is recommended as the primary therapy for the 90% of people with type 2 diabetes who are overweight or obese [1], and Carole’s story indicates that this was the case for her once diabetes had been diagnosed. A simplistic view of obesity states that it results from an imbalance between energy intake and energy output, and that weight loss can be achieved simply by reversing this imbalance. In reality, the etiology of obesity is far more complex and includes genetic influences, physiological and biochemical factors and environmental and behavioral effects [2, 3].

One aspect of obesity treatment that is frequently overlooked is that of eating in response to cues other than hunger. This is often referred to as emotional eating and includes binge eating, external eating and eating in response to food cravings [4]. Carole eloquently describes how emotional eating became her coping mechanism during times of stress.

Binge eating disorder (BED) is now a formal diagnosis and is characterized by eating large amounts of food in a discrete time period while experiencing a lack of control over eating [5]. Prevalence rates of BED are estimated to range from 1 to 4% of the general population, and approximately 40–50% of individuals with BED are obese [6]. External eating is characterized by eating in response to the sight, smell or taste of food rather than to internal hunger cues [7], and food cravings are defined as obsessive thoughts and the compulsive consumption of specific foods [8]. Although little is known about the prevalence of these different manifestations of emotional eating, there is evidence that disordered eating generally may affect around 40% of people with type 2 diabetes [9] and that they are more common among obese individuals than among those of normal weight [10].

Emotional eating is associated with eating as a means of dealing with negative emotions, in an attempt to regulate these emotions [11]. For many people, a typical reaction to stress is to seek out and consume energy-dense foods, often referred to as “comfort foods” as they evoke a psychologically comfortable and pleasurable state [12]. It is intuitive that high levels of stress would be associated with obesity, but the evidence for this is inconsistent, although a recent meta-analysis reported that stress was positively associated with increasing adiposity [13]. The prevalence of emotional eating is unknown, but a recent study in the USA reported that 38% of adults engaged in unhealthy eating behaviors in response to stress [14], and 57% of overweight adults self-report frequent emotional eating [15].

In the case study described above, Carole reports a significant degree of emotional eating and describes comfort eating during her pregnancy and when diagnosed with postnatal depression. She recognizes that during times of stress, for example, when solely responsible for her children’s upbringing when her husband was working abroad and after her mother became ill, her coping strategy was to turn to food. She also describes how she could successfully lose weight for short periods of time, but as soon as she experienced any considerable amount of stress, her comfort eating would return.

In common with many people’s experience, Carole’s story illustrates that emotional eating is a significant factor both for promoting obesity and preventing long-term weight loss. Weight management programs which fail to address these specific eating behaviors are unlikely to have successful outcomes, especially over the longer term.