Over 10 years ago, my mom was diagnosed with diabetes. She was referred to a diabetes educator who taught her about foods that affect blood glucose levels and those that don’t. The educator recommended a carbohydrate intake of 45 grams of carbs for meals and 15 grams of carbs for snacks. She didn’t keep up with carb counting but always ate a wide variety of foods, and is one of the healthiest eaters I’ve ever known.
Last year after my mom’s second knee surgery, she lost a noticeable amount of weight. It made sense the weight loss was the result of healing and her dedication to physical therapy. However, during a follow-up procedure, the anesthesiologist reviewed her chart and noticed her blood glucose was consistently above 200. After a 6-month checkup, her A1C was 9.5. When she was first diagnosed, excessive weight loss was a symptom of hyperglycemia and her recent weight change signaled high blood glucose once again.
Weight loss is not a reliable measure of good health. Rapid and significant weight loss can indicate an underlying issue. If eating habits and medication haven’t changed, it’s crucial to consult a healthcare practitioner for an evaluation.
My mom’s doctor, again, referred her to a diabetes educator. She received the same carb-counting education as before, including the proverbial cut-a-banana-in-half speech. Bananas sold in stores are usually larger than what’s recommended on diabetes exchange lists. Patients are encouraged to eat one half and save the other for later. From a behavioral health perspective, how the patient interprets this advice is important. Do they see it as increasing food variety, or an opportunity to consume fewer calories?
If the diabetes educator is unaware a patient is struggling with an eating disorder, the advice may encourage food restriction. If this patient is encouraged to eat half a banana, this validates disordered thinking, “Eat less food so you don’t gain weight.” The eating disorder doesn’t care about diabetes or the patient’s health, only the fear of weight gain. Without screening for and addressing disordered eating, diabetes care is like a band-aid that comes off in the water.
Diabetes educators teach patients about foods that raise blood glucose. The goal of this education is to improve their diet, so it trends within a healthy range. But unfortunately, traditional carb-counting diets put food into distinct categories like eating disorder thought patterns. In simplistic terms, the carb-counting diet has 2 major lists of foods. 1. Foods that don’t affect blood glucose. 2. Foods that affect blood glucose. 3. The eating disorder will see them as good and bad foods while sifting through them to find safe foods that won’t cause weight gain. The result is usually less food intake while raising the risk of malnutrition.
Eating disorders aside, carb-counting diets are not easy to follow, especially when preferred foods are not available. Science proves behavior change is difficult. Not everyone will adapt well to a new diet as people tend to move toward what’s expedient. When feeling stressed, some patients might stop seeking treatment altogether or seek unproven alternative care treatments that can make diabetes worse.
After her appointment, what my mom said later that day is something I hear all too often in my practice, “I don’t know what to eat.” While revisiting the education booklet at home she said, “I’ve forgotten about the carbs. I should get back to that.” Yet she was confused about the difference between a carbohydrate and a protein. Her desire to change perceived incorrect eating behavior insinuated by the diet was evident. She also wasn’t happy with the idea she couldn’t have her oatmeal for breakfast when it was suggested she try to eat something different in the morning.
In my mom’s case, carb-counting education disrupted her healthy relationship with food by causing her to second-guess her choice to eat a banana and oatmeal. Later, she began giving away foods she loved because she believed she could no longer eat them.
As a dietitian specializing in disordered eating, I’ve observed how a carb-counting diet can overwhelm some folks more than it can help. It encourages perfectionistic dieting behaviors that are difficult to follow in real-world situations. The diet requires the patient to learn a lot of information in a short amount of time. There are numerous ways a patient can misconstrue what they’ve learned at first. For example, a newbie to carb counting may decide to “avoid” instead of “balance,” and take an all-or-nothing approach. Then the language becomes, “I can’t eat that, it has too many carbs,” which sounds just like a punishment for bad behavior.
Screening for disordered eating behaviors can help practitioners become aware of treatments that may do more harm than good. Diabetes educators should create an environment that’s all food inclusive while encouraging patients to consume healthy fruits and vegetables as nature intended. The longer I’m a dietitian the more it seems like this diet inadvertently blames the patient for their diabetes instead of giving them the help they need to better manage it.
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Green Apple Dietitian 
I’d hate to think that diabetes education contributes to or triggers ED when it can help people understand how food affects their blood sugar and help them to manage BG along w/ exercise and meds or sometimes even w/o meds. I think the most important point here is to be aware of the signs of ED and any potential history your pt may have and proceed accordingly.
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