A Gentle Approach to a Tough Problem

By Susan Lawrence Rich

From Fall 1995, Radiance Magazine

So you have diabetes. And you're off to see the doctor. Your blood sugar soaring, your energy level ebbing, you drag yourself into the office. Steeling yourself, you face the impending ordeal: the nurse's arched eyebrows as she weighs you in the thoroughfare of the office hallway, the dressing gown that adequately covers... well, your right breast anyway, the stern lecture about faithful testing of your blood sugar level and abstinence from every form of sugar and fat, and the eternal litany of "Lose weight! Lose weight! Lose weight!"

Dealing with Doctors
Tips from King and Armstrong

1. Know that doctors live in a culture that has a biased view of fat. They very likely have such a bias.

2. Discuss your viewpoint with your doctors. Tell them why you haven't made appointments or why you dread them. Share your feelings about the scale and criticism of your weight.

3. You can refuse to be weighed. Or, if you would like to make a point about the humiliation that may accompany the request, tell the nurse that you will weigh in, right after she or he does. Or ask why you are being weighed. There may be a legitimate medical reason. With congestive heart failure, for example, weight can be an indication of the amount of fluid that has accumulated. And weight loss can be an indication of disease in some cases. But does a gynecologist have to weigh you for a Pap smear?

4.If it would make you more comfortable, while being weighed you can stand backward on the scale and face the other way. Or you can ask to be weighed in kilograms.

5.When you go to see a doctor with a problem and that doctor focuses on your weight, ask, "If I were thin and had a heel spur, what would you do?" When the doctor answers that he or she would refer a thin you to a podiatrist for a shoe insert, respond by saying, "I'd like that done."

6.If the doctor says, "Diet," be ready with a response. Dana Armstrong has patients rehearse a set script that goes something like this: "I am no longer dieting. I am working to learn how to eat in response to my hunger and fullness. I am interested in pursuing medical treatment for my problem; however, I am not interested in pursuing weight loss as one of the treatments. What are the other ways you monitor this condition?"

7. Arm yourself with Guidelines for Health Care Providers in Dealing with Fat Patients, a brochure from the National Association to Advance Fat Acceptance (NAAFA). This brochure is packed with practical, sensitive advice for doctors about attitudes, weighing patients, medical procedures, and so on. This brochure is available from NAAFA, P.O. Box 188620, Sacramento, CA 95818; (916) 558-6880. Have enough copies to leave one with a health care professional in need of some practical tips for establishing and maintaining healthy relationships with fat patients.

When it's all over, you humbly back out of the office, genuflecting at appropriate intervals, and vacillate between making promises of a new rigorous diet and faithful blood testing and wondering if you'll ever be able to convince yourself to return for your next scheduled appointment.

What you might not realize is that you're not alone - one out of sixteen people has diabetes, although only half know it - and that your commerce with medical personnel need not be a near flogging.

Within the offices of King, Revers & Winn, a medical group specializing in internal medicine, endocrinology, and diabetes, work two remarkable people with a decidedly radical view of how to treat diabetes and of weight control in general. Allen B. King, the doctor, and Dana Armstrong, the dietitian, combine their efforts to bring joy back into their patients' lives. Their practice is in Salinas, California, and their positive approach makes itself known from the moment you step into the waiting room.

Posted on the walls are flyers for group meetings, announcements of upcoming classes, and cheery observations about life. Patients are reminded from one poster, for example, to sing in the shower regularly. The Frank and Ernest cartoon strip adorning one wall of Armstrong's office has the taller hobo admonishing the shorter, "It's time you did something about your weight." He, pausing to reflect, agrees, "You're right. I've decided to accept it." Beside this is a Patricia Schwarz photograph of a large woman tilted back with her arms outstretched, half in shadow, half in sunlight, her generous curves amply displayed from the daring neckline of her yellow polka dot sundress.

Once inside the office and seated with King and Armstrong, the duo's novel approach to the treatment of diabetes unfolds: Demand feeding. Eat when you're hungry. Carry a food bag with you so that you always have access to food. Eat what you feel like eating - everything is "legal." But pay attention to how your body reacts; pay attention to how you feel.

Perhaps you were referred to Dr. King by your general practitioner, and you just don't feel well. Your introduction to the program starts with some questions: Why are you here? What are your concerns? . King points out what may not be obvious about those questions. "We presuppose no condition." You next schedule an appointment with Dana Armstrong. Or you might find your way to the office on a friend's recommendation to meet with Armstrong.

However you gain entrance to the office, your treatment there begins with a brief course in nutrition. King and Armstrong note that, for the most part, their patients are "veterans of many diets and diet failures." Patients examine their past "failures" and learn about the dangers of dieting. They are taught to measure their own blood glucose levels and to avoid judgments about the numbers: there are no "good," no "bad" numbers. The key is to concentrate on how the body feels after consuming a particular food. Experimentation with food is encouraged. With this open attitude about foods, with the doctor and dietitian refusing to play the role of "food police," accurate records of blood sugars may be taken and reported for the first time by some patients. They no longer have to agonize over whether they'd rather be chastised for high blood sugar or for not testing often enough.

Self-acceptance, the second phase of the process, means putting aside the guilt that diabetes is somehow self-induced. As King explains, with diabetes, "You just drew a bad card out of the deck when you were born. So you have to learn how to play that particular poker hand in life. It helps to understand the disease and get rid of the guilt."

In addition, patients must come to accept their body size. King explains, "If a patient comes in and says, 'My life's goal is to weigh 120 pounds,' we won't be able to deliver. We try to open minds to other possibilities." Patients are encouraged to throw away their scales and give away clothes that are too tight.

From a letter to Radiance from Katherine Gabriel of Bothell, Washington, dated November 1, 1994:

I have diabetes. I weigh over 300 pounds. I have been working gently on compulsive eating issues (not weight issues), using the Overcoming Overeating program. Several months ago, I decided that I needed to go on insulin to treat the diabetes; this was a very difficult decision for me to make, particularly since it felt as though I had failed to take care of myself. For years, physicians had told me, "If only you would lose some weight, your blood sugar would probably be normal." I was also very apprehensive that my doctor would require me to begin restricting foods.

Fortunately, a therapist gave me an article written by Dana Armstrong on the use of demand feeding (no restriction of foods) in the treatment of diabetes. I gave this article to my doctor, and she agreed to support my use of demand feeding. Coincidentally, I was about to make a trip to the Bay Area and was able to get an appointment with Dana. The hour I spent with her has made all the difference in my perceptions both of diabetes and of myself as a person with diabetes. I have been able to make peace with myself and with the disease. Dana encouraged me to keep in touch with her through fax and phone, and she has continued to be extremely helpful.

I urge any large woman with diabetes who has been hassled and blamed by the medical establishment to contact Dana. If you live anywhere on the West Coast, a trip to Salinas for a consultation with Dana could be the best gift you ever give yourself.

Lastly, in this one- to five-year process, patients learn to direct their own lives, based on their own experiments with foods and activity and their bodies' reactions. Eating to satisfy emotional needs and eating to meet the needs of the body are clearly separated. For some patients, psychological and emotional needs may come to the fore. Psychotherapists may join the professional team to assist clients as they normalize their relationship to food. Food intake comes to reflect healthy, conscious, and self-directed choices. Most important for many patients, they learn to take joy in eating again.

Do patients lose weight? No, not necessarily. But they are happier and in control of their own health, their own choices. "When someone comes into the office, we don't weigh them. Some patients want to be weighed. We ask, 'Why?' If they say, 'Please weigh me,' we don't make an issue of it. We practice a new religion: gentleness. People need to be gentle with themselves," King explains.

Throughout the process, several sources are used to help patients understand and control their diabetes: materials compiled and adapted from Overcoming Overeating by eating disorder specialists Jane Hirschmann and Carol Munter; A Core Curriculum for Diabetes Educators from the American Association of Diabetes Education; and the Patient Empowerment Manual (adapted from C. Feste's Empowerment: Facilitating a Path to Personal Self-Care).

Diabetes affects the body's ability to effectively use the food it takes in. After eating, food is digested or broken down into nutrients, among them carbohydrates (which includes starches and sugars), fats, and proteins. The insulin hormone, produced in the pancreas, is required for all three of these nutrients to be used properly. In particular, insulin helps glucose (the digested, simple form of sugar, the sugar carried in the bloodstream) get from the blood into the cells, where it can be burned for energy.

In a two-page handout for patients, King's medical group draws an analogy to explain the disease. "Think of glucose as a fuel being delivered by a truck. In order to make the delivery, the doors of your body cells must be opened. The only key that opens these doors is insulin. When insulin is available and working effectively in your bloodstream, your cells are able to use the glucose in your blood. Without sufficient or effective amounts of insulin, glucose cannot be used by the cells for energy."

All people with diabetes adhere to one of three types of treatment: they rely on their own body's supply of insulin to work with the food they eat, they take medication to enhance their own body's insulin to work with the food they eat, or they take insulin to work with the food they eat. Whichever treatment a patient follows, the game is ultimately one of balance: food and insulin. Demand feeding focuses on maintaining a healthy balance.

If a person is not producing adequate insulin, excess glucose or sugar stays in the bloodstream and acts almost like a poison to the body. Sugar coats everything. The long-term effects can be serious. Directly or indirectly, diabetes is a major cause of death. Atherosclerosis (hardening of the arteries) cohabitates with diabetes frequently: 85 percent of diabetics' deaths are due to this large-vessel disease. Diabetes is the number one cause of renal failure. Diabetes is the number one cause of blindness. Gangrene and amputation are other associates of the disease.

These grim possibilities help explain why parents, spouses, siblings, and doctors often conspire to enforce a regime of strict dietary control on a loved one with diabetes. Although the best of intentions accompany the imposition of a deprivation diet, diets work for diabetics the way they work for the rest of the world: they don't. Allen King and Dana Armstrong know that.

But they didn't always.

Their program evolved through rigorous experience with frustration and failure.

Before Dana Armstrong joined the ranks of King, Revers, & Winn, Dr. Allen King had one established routine. "I handed out a 1200-calories-a-day diet from the American Diabetes Association. Basically, it was a tear sheet, and it was very easy for a busy doctor to hand out.

"Then, behavior modification was popular. So the program was basically, eat less fat and sugar (the 1200-calories-per-day diet) and put your knife and fork down in between bites and eat from a smaller plate." King, interested in the effectiveness of such a program, joined with five other internists who also handed out these sheets to study sixty patients. When looking at those patients one to four months later, their average weight loss was one ounce per week, and half had gained weight. King concludes, with a slight smile, "The study showed that half of the patients who see a doctor who tells them to lose weight, will gain. And I was the least successful, because I was working with chronic dieters."

Living Healthy and Well with Diabetes

1. Find a doctor and a certified diabetes educator who make you feel comfortable and who you can talk to easily, who understand that diabetes is not a character flaw, and who will work with you to achieve your blood sugar goals.

2. See your doctor or diabetes educator often: every three months when your diabetes is well controlled, and right away if it is not controlled or if you are having problems.

3. Work with a registered dietitian to learn about nutrition and to achieve a realistic, healthy, and enjoyable way of eating.

4. Have a hemoglobin A1C (the three-month blood sugar average) test done every three months. Find out the results and be sure you understand what they mean.

5. Have your blood pressure, cholesterol and triglycerides checked regularly. If any of these are too high, talk to your dietitian to learn how food and eating influences these. If you need to take medication, be sure to take it just as your doctor has prescribed.

6. After you have had diabetes for five years, have your urine checked for mircroalbuminuria every year. Bladder, urinary tract, or yeast infections should be treated immediately.

7. Have your eyes checked by an opthalmologist annually, even if you do not need corrective lenses.

8. Brush and floss your teeth daily. Visit your dentist at least yearly.

9. Check and care for your feet every day. Talk to your diabetes educator if you don't know what to check for, have questions, or suspect a problem. Visit a podiatrist regularly if recommended by your doctor or diabetes educator.

10. Wear some type of diabetes identification (a bracelet or neck tag) at all times. Carry a diabetes identification card in your wallet.

11. Do not smoke cigarettes or use any other tobacco products.

12. Get a flu shot every year.

13. If you are a woman of childbearing age, discuss birth control with your doctor. Choose a method and use it faithfully. If you decide to become pregnant, discuss this further with your doctor or diabetes educator. It is very important that your blood sugar be in excellent control before you become pregnant.

14. Take good care of yourself and do something special, just for you, once in a while. It's easy to get so caught up in the day-to-day routine of caring for your diabetes that you forget to take care of yourself in other ways. Here are some ideas to get you started: watch a sunset or sunrise, take a bubble bath, go window shopping, get a massage, plan a vacation, do some leisure reading, plan an outdoor activity, or take a day off just for you.

A second study of the effectiveness of diets, in the mid-to-late 1970s, saw one hundred patients also fail to lose weight. King concluded that more control was necessary, and more artillery.

Next they experimented with liquid diets (of the Slim Fast variety), dietitians, and more frequent visits to the doctor. This group, some five hundred patients strong, were referrals from other doctors. King notes, "Doctors sent us their most unsuccessful dieters. We were the court of last resort."

Armstrong laughs and adds, "Even though he had a zero success rate!"

"We did," King jokingly insists. "As long as we had no follow up, we had an excellent success rate." The statistics on his five hundred patients showed that, on average, patients lost 50 pounds in six months. Unfortunately, a three-year follow-up showed they had gained back 60.

Diet pills, jaw wiring, and then the Garren Gastric bubble. The idea of the bubble was to place a balloon in the stomach so patients felt full. Some patients did lose weight: those who developed ulcers and bowel obstructions.

As the two health professionals continued to discuss their history of disasters, their comments back and forth took on the characteristics of a ping-pong match. In 1985, Armstrong, equipped with her B.S. in Dietetics from the University of California, at Davis, joined King's office.

Armstrong: When I came in, we went on a point system. Seventy-five calories was one point. The diet was sixteen points a day. We restricted all the "good" food. I gave patients books with calorie points. They could eat anything they wanted. They could eat chocolate chip cookies, but when they got to sixteen points, they had to stop. In the end, they regained their weight.

King: One case of carrots - one point; celery - no points.

Armstrong: Then we had the liquid diets. That was 1986 through 1988. These were 100 percent low-cal diets, like Oprah Winfrey's. Six hundred calories a day.

King: We thought the more restrained and restrictive, the more successful we'd be. We created broccoli bingers. Honestly, we had patients bingeing on broccoli!

Armstrong: They were feeling guilty because they were eating salad!

Both King and Armstrong slowly shake their heads, remembering the fiasco. They had seen profoundly demonstrated that what is denied becomes highly desired. Deprivation invites bingeing.

Dana Armstrong reports that she became disillusioned professionally and personally. In her personal life, she had decided to start a family. With her first pregnancy, she gained 70 pounds. Her obstetrician told her that he was tempted to send her to a dietitian. Failure at controlling her weight hit home, and her disappointment was compounded.

Meanwhile, though King too was disillusioned, the office practice boomed. King laughs and confides, "I didn't have time to keep track of Dana. I was very busy. This gave Dana the freedom for Dana to operate."

The breakthrough began when Armstrong attended a conference in 1988 and heard Jane Hirschmann and Geneen Roth speak. She returned to her office and read Hirschmann and Munter's Overcoming Overeating and Roth's Feeding the Hungry Heart and Breaking Free from Compulsive Eating. Soon Armstrong's conversations with patients started to include the observation that diets don't work.

In 1989, both Armstrong and King attended the North American Society for the Study of Obesity conference in Boston. At a particular session extolling the virtues of surgery, a slide was projected up on a screen. The slide depicted a graph measuring the weight of a female patient. At age fourteen, the graph shot up indicating very rapid and extensive weight gain. The presenter commented in an offhanded fashion that at age fourteen the patient had been the victim of incest. At age twenty-four, the graph took a dramatic nosedive. The presenter described the procedure that had "cured" this young woman's ills: intestinal bypass surgery.

Both King and Armstrong were arrested by the downplay of incest. The roomful of doctors seemed to ignore the woman as a human being and focus on only one part of her: her fat, the part they thought they could "fix."

Armstrong continued to search for alternatives to those offered by the medical model. In 1991, the search took her to the National Conference on Eating Disorders - and King went along. There they met with Hirschmann and Munter and with Mary Sue Tierney and Karen Carrier, who worked in corporate wellness programs that moved away from the usual emphasis on weight control. At the end of the conference, Dr. Allen King looked at Dana Armstrong. They shook hands and swore to each other: "We will work together to break the myth that dieting works."

King and Armstrong had decided what not to do. But what would supplant the old approach? The two allocated responsibilities as follows: Armstrong's job was to figure out what to do; King's job was to figure out why it worked. King adds that they had to undergo some powerful self-analysis. The issues were control and responsibility. They had been trying to control their patients - with restrictions, with weigh-ins, with eating journals - and now they had to grapple with returning responsibility to their patients. Writing the guest editorial for the November/December 1993 issue of Obesity and Health, King declared, "I now realize it is not the doctor's role to control the patient."

King: The evolution continues. I am always behind Dana, trying to catch up.

Armstrong: Allen is still the cheerleader. When you speak to nonbelievers, you need the credibility of a physician. It's true when the doctor says it.

King: Which puts me out on a limb, professionally. Some colleagues violently disagree with our position. And we don't have any real data yet.

Armstrong: Yes. The jury's still out about the relationships among size and diabetes and hypertension, because no study so far has controlled for dieting. In this country, it is virtually impossible to study large people who haven't dieted - because we can't find them.

Even without statistics, King and Armstrong know that their medical practices are right. They know that they respond to the humanity of their patients. Not obsessed with numbers - pounds or calories or blood sugar counts, this duo's success is predicated on remembering, first, that their patients are people. They stress that any change in nutrition and way of life as part of treating diabetes should involve a partnership among patient, doctor, and certified diabetes educator.

King and Armstrong empower patients with a simple motto: "Sit down, relax, and start listening to yourself."

If your health care professionals offered you this kind of advice, wouldn't you be inclined to keep your next appointment?

The offices of King, Revers & Winn, (408) 757-3255, are located at 130-D East Romie Lane, Salinas, CA 93901. Health care professionals interested in Armstrong's November seminar should contact the office for information. The seminar will train registered dietitians how to provide better care for people with diabetes.

SUSAN LAWRENCE RICH writes from rural Oakdale, California, with the support of family and friends.

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