By: Reuben R., Lagniappe Wellness Dietetic Intern

The world of dietetics is constantly evolving. Newly emerging research on how nutrients impact our bodies and health is constantly scrutinized and the efficacy of new diets regularly discussed. Macronutrient ratios, meal timing, food composition, weight cycling, meat or meatless, organic or GMO—all topics endlessly discussed to find an eating pattern which will achieve maximum health for our patients, clients, and communities. What is not frequently discussed, however, is how we communicate and form relationships with our patients and how it impacts their health and lifestyle.

As a community of experts, if we could develop the best diet, complete with a comprehensive list of micronutrients and food properties, it would mean nothing if we could not communicate the idea with the public and would have no value if we could not develop meaningful and impactful relationships with patients. An analysis published in the International Journal of Preventive Medicine found that self-body perception, self-motivation, and behavioral improvements were key drivers in helping people lose weight and keep it off.¹ In other words, successful weight loss had more to do with factors related to intrapersonal skills and abilities than a specific methodology of eating. Yet, our conversations in dietetics still revolve almost entirely around the latter. Much to the detriment of our profession—and to the health of our patients—not enough time has been spent on creating effective methods of empowering clients.

  This reality is playing out in front of us now. We know more about food, nutrition, and its impact on human physiology than ever before, yet more Americans are obese and suffering from largely preventable chronic diseases such as cardiovascular disease and type 2 diabetes.² The problem that we face now as a profession is not a lack of information, but rather, barriers to implementation.

One possible method to help us close this gap is Motivational Interviewing (MI). Originally pioneered by William Miller in the 1980s to help individuals break the cycle of substance abuse, motivational interviewing takes a patient centered approach with an eye toward facilitating behavior change. Research from the early 1980s showed that, “therapist empathy during treatment predicted a surprising two-thirds of the variance in client drinking 6 months later” and that the “alcoholism counselors’ client-centered interpersonal functioning accounted for a substantial proportion of variance in the relapse…of assigned clients.” Findings such as these combined with collaboration with other colleagues in his field led Miller to develop a framework for what eventually came to be called Motivational Interviewing.³

Behind the technical aspects of implementing Motivational Interviewing lies the spirit of MI—the foundational tenets that the other portions of the technique are built upon. The Motivational Interviewing Network of Trainers outlines the spirit of MI as follows:

MI is practiced with an underlying spirit or way of being with people:

o   Partnership. MI is a collaborative process. The MI practitioner is an expert in helping people change; people are the experts of their own lives.

o   Evocation. People have within themselves resources and skills needed for change. MI draws out the person’s priorities, values, and wisdom to explore reasons for change and support success.

o   Acceptance. The MI practitioner takes a nonjudgmental stance, seeks to understand the person’s perspectives and experiences, expresses empathy, highlights strengths, and respects a person’s right to make informed choices about changing or not changing.

o   Compassion. The MI practitioner actively promotes and prioritizes clients’ welfare and wellbeing in a selfless manner. ⁴

Stemming from this “way of being with people” flows the processes and core skills utilized to help evoke patient centered change.

Over 1,000 peer-review articles have been published exploring the impact of Motivational Interviewing.⁵ In its original arena of helping to treat substance abuse, research points to higher retention rates in treatment as well as close to double to the rates of abstinence from alcohol or drugs compared to controls in some studies. Additionally, MI was even more effective when combined with other treatments or interventions.³ This may be attributed to the fact that Motivational Interviewing is really more “a method of communication rather than intervention, sometimes used on its own or combined with other treatment approaches.” ⁴ Although substance abuse and poor dietary patterns produce different consequences for patients, interventions for both have the same underlying goal in mind—changes in behavior designed to improve patient outcomes. This lies directly within the main strength of motivational interviewing, something which makes it a prime candidate to be co-opted into dietetics professional practice. The synergistic effect of MI when combined with other interventions means that dietetics professionals can combine the core concepts of MI with other validated tools like nutrition education to help empower and improve patient outcomes.

Although not as widely studied in the discipline of nutrition when compared to other areas, studies that have investigated MI on nutrition-related diseases and topics have found that it can help lower HgA1c in type 2 diabetics (see table), increase weight loss compared to controls, and assist in improving health related lifestyle factors such as exercise.^{6, 7, 5} 

Nutrition professionals need to continue to explore how Motivational Interviewing can improve our ability to reach patients.  Beyond that, we need to understand that our relational skills are as important as our technical ones and need to be evaluated, refined, and tested with the same eagerness. We need to take time to understand and explore emerging research on communication methods and techniques and how they can apply to our practice. Dietetics is more than nutrition—it is a field centered around the good of the patient and as such, it is our responsibility to capitalize on any tool available that will make us more effective practitioners and lead patients to happier and healthier outcomes.

References

Gupta, H. Barriers to and facilitators of long term weight loss maintenance in adult UK people: A thematic analysis. Int J Prev Med. 2014 Dec; 5(12). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4336981/ Published December 2014.

About Chronic Diseases. Center for Disease Control and Prevention. https://www.cdc.gov/chronicdisease/about/index.htm. Last updated July 21, 2022. Accessed December 2022.

Rose, G. Miller, W. Toward a theory of motivational interviewing. Am Psychol. 2009 September ; 64(6): 527–537. doi:10.1037/a0016830. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2759607/pdf/nihms146933.pdf

Understanding motivational interviewing. Motivational Interviewing Network of Trainers. https://motivationalinterviewing.org/understanding-motivational-interviewing. Accessed December 2022

What is motivational interviewing. USDHHS. https://eclkc.ohs.acf.hhs.gov/mental-health/article/what-motivational-interviewing#:~:text=Q%3A%20What%20is%20the%20evidence,studies%20 published%20on%20 motivational%20 interviewing. Last updated September 22, 2022. Accessed December 2022.   

Berhe, K. Gebru, H. Kaysay, H. et. al. Effect of motivational interviewing intervention on HbA1C and depression in people with type 2 diabetes mellitus (systematic review and meta-analysis). PLoS One. 2020; 15(10): e0240839. Published online 2020 Oct 23. doi: 10.1371/journal.pone.0240839. Published  

Welch, G. Rose, G. Ernest, D. Motivational nterviewing and iabetes: What is it, how is it used, and does it work?Diabetes Spectr 2006;19(1):5–11

https://doi.org/10.2337/diaspect.19.1.5

By Mara B., Lagniappe Wellness Dietetic Intern

On January 10th, 2020 the covid-19 outbreak was announced in Wuhan, China. By March and April, the “world [began] to shut down” (2). This closure brought about drastic changes such as school closures which forced children to stay home. Because of the shelter in place, children had fewer opportunities for physical activity, less access to balanced meals, and disrupted daily routines, among other detrimental outcomes. As a result of this, rates of childhood obesity have increased. 

As we address the covid-19 pandemic, it is important to discuss the epidemic of childhood obesity. Currently, 1 in 5 children are affected by childhood overweight and obesity. More than 30% of children are now considered to be overweight or obese (6). The Centers for Disease Control (CDC) and Prevention define overweight as 85-94 percentile of the CDC sex-specific weight for age growth charts. Obesity is considered to be within the 95-98 percentile and extreme obesity is classified as anything greater than the 99th percentile. 

Covid-19 and obesity overlap as obesity is a risk factor for increased severity of covid-19. Both diseases are influenced by ecological and biological factors. The figure below outlines how environmental factors such as an obesogenic environment, less physical activity, and weight bias/stress affect obesity (1). In comparison, environmental impacts from covid-19 such as shelter-in-place orders, decreased physical activity, and disruptions in the household can have deleterious outcomes for children. Additionally, a person’s genetics also impacts how both diseases affect children. Both obesity and covid-19 can alter the immune response, lead to states of stress, and cause inflammation. 

An important implication of school closures was that children wouldn’t have access to balanced meals provided throughout the school day. During the pandemic, many families experienced food insecurity. Food insecurity is defined as the “consistent lack of food to live a healthy life because of your economic situation”. Some parents were laid off from work meaning less money for groceries. As a result, cheaper foods high in calories and low in nutrients may have been more affordable options for families suffering from food insecurity. These cheaper food options put children at higher risk for obesity. The National School Lunch Program emphasizes the importance of incorporating meats/meat alternates, fruits/vegetables, grains, and fluid milk. The program has daily and weekly requirements for each food group to ensure children are receiving proper nutrition for their age group and reducing the risk of chronic diseases (4). Some families may not have the proper nutrition education required to provide balanced meals for their children especially when income is reduced. Proper nutrition is essential for growing children and should be of high importance to pediatricians as well. In order to create change, nutrition education should be a covered service for families to support the development of their children. 

Programs such as the Women, Infants, and Children (WIC) program can help families receive nutrition education and supplemental food assistance. The program is designed for pregnant moms and children up to the age of 5. However, during the pandemic enrollment for WIC only increased by about 2-3%. Participation in the program has been steadily decreasing within the past decade and did not drastically increase during the pandemic despite the need for supplemental assistance for families. Currently, WIC is trying to make enrollment and continued participation as easy and convenient as possible for families. The program is pushing for more video appointments making nutrition education more accessible for families. This “modernization” of WIC helps retain participants and supply supplemental assistance for children to have increased access to healthy foods (5). The WIC program also focuses on anthropometric data such as body mass index (BMI) and height to identify overweight, obesity, and proper growth in children. Referrals to WIC are of the utmost importance to support this valuable program and its efforts to reduce childhood obesity. Advocating for WIC by going to their website for advocacy https://www.nwica.org is also a great way to support the program. 

Physical activity in children was also significantly reduced as a result of school closures. Children were forced to stay home during the pandemic which reduced the amount of hours spent outdoors (3). With more time spent indoors the amount of screen time increased. It has also been noted that some children do not have access to a green area where they can exercise. Limited play area has been seen to disproportionately affect low-income populations as their households may be smaller meaning less space for children to play. Most children also began remote or hybrid schooling where their physical activity was done remotely during the day. However, not all households may have an area where physical activity can be done comfortably. Limited access to an environment conducive to movement increases a child’s risk for obesity. Providing education to parents on physical activity requirements, ideas for movement, and using daily child exercise videos can help get their children to be more active and reduce their risk for obesity. 

Clearly, the effects of the covid-19 pandemic have superimposed the epidemic of child obesity. Extended periods of isolation from school and social interaction have had lasting implications on the rates of child obesity. Consequences of covid-19 discussed for children include reduced access to healthful meals, less opportunity for movement, food insecurity, and immune system suppression. Children are one of the most vulnerable populations. For this reason, it is important to advocate for them by providing education on nutrition and physical activity to parents. Additionally, promoting community programs such as WIC provides supplemental assistance to families to reduce food insecurity. These strategies can lower rates of obesity in children to allow them to live a healthy balanced life.  

References:

1. Browne, Nancy T, et al. “When Pandemics Collide: The Impact of Covid-19 on Childhood Obesity.” Journal of Pediatric Nursing, U.S. National Library of Medicine, 2021, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7657263/.
2. Katella, Kathy. “Our Pandemic Year-A Covid-19 Timeline.” Yale Medicine, Yale Medicine, 9 Mar. 2021, https://www.yalemedicine.org/news/covid-timeline. 
3. Covid-19 and childhood obesity – researchgate.net. (n.d.). Retrieved December 31, 2022, from https://www.researchgate.net/profile/Ray-Marks/publication/359601351_COVID_19_AND_CHILDHOOD_OBESITY/links/6244aab17931cc7ccf0603a9/COVID-19-AND-CHILDHOOD-OBESITY.pdf
4. FNS nutrition programs. Food and Nutrition Service U.S. Department of Agriculture. (n.d.). Retrieved December 30, 2022, from https://www.fns.usda.gov/programs
5. USDA makes major investments in WIC to improve maternal and child health. Food and Nutrition Service U.S. Department of Agriculture. (2022, October 19). Retrieved December 30, 2022, from https://www.fns.usda.gov/news-item/usda-0224.22
6. “Childhood Overweight & Obesity.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 1 Apr. 2022, https://www.cdc.gov/obesity/childhood/index.html. 

By Makayla B, Lagniappe Wellness Dietetic Intern

Binge eating disorder is the most common eating disorder in the United States.¹ This disorder will be experienced by 2.8% of the US population at some point in their lives. To put that into perspective, it is 1.75x more prevalent than the two most well-known eating disorders combined, Anorexia (0.6%) and Bulimia (1%). According to the DSM-5-TR², Binge Eating Disorder is diagnosed by episodes of Binge Eating with some additional criteria:

• At least 3 are met during a binge episode:
  • Eating much more rapidly than normal
  • Eating until feeling uncomfortably full 
  • Eating large amounts of food when not feeling physically hungry
  • Eating alone because of being embarrassed by how much one is eating
  • The feeling of disgust, depression, or guilty after overeating

• Is not associated with any regular use of EXCESSIVE compensatory behavior (purging, fasting, excessive exercise).
• Occurs over the course of at least 3 months. 

The Binge Restrict Cycle

Binge Eating often appears in a cyclic form often referred to as the Binge-Restrict cycle [pictured below]. It usually starts off with some sort of food restriction (often in the form of dieting). Although this is usually less severe than compensatory behaviors associated with Anorexia or Bulimia. Dieting is a form of restriction that decreases caloric intake and/or eliminates entire food groups as a way to control eating patterns. This very quickly leads to intense cravings and combined with a triggering event leads to a binge. Triggering events often tie into an internal stressor such as negative self-talk, negative emotions or an external stressor such as a tight work deadline or family stressors. Shame and guilt occur after a binge which leads to restriction, starting the cycle anew. The cycle continues over and over again until the cycle is broken. Intuitive eating aims to end the cycle by eliminating restrictions with ten major principles which will be discussed further in a minute.

What Started the Cycle?

As with any cycle there was always a beginning. It is important to note the potential root causes of the binge-restrict cycle as a way to understand it more in depth. Factors affecting Binge eating are often an interplay of many factors that have occurred over the course of a lifetime. They are complex in nature and cannot all be covered here. Three predominant ones include emotional overeating, internalization of diet culture and traumatic life events. 

Emotional Eating

An individual partakes in emotional eating when food is used to relieve stress to cope with often difficult emotions. Research has shown that individuals who eat emotionally are at risk for binging behavior.³ These patterns of behavior usually develop in childhood and express themselves throughout the lifetime if untreated. If a child grows up in a family that did not express emotions, a child may learn that it is not safe to express emotions and therefore turn to food as a way to distract. Secondarily, the parent may have expressed their love for their child through food. This may lead the child to seek food as a coping mechanism when uncomfortable emotions arise.

Diet Culture

The urge to restrict after a binge is perpetuated by diet culture. Diet culture is harmful to people of all weights and all sizes encouraging a particular appearance as the ideal standard. It perpetuates the notion that a person should do anything to attain this unrealistic standard of beauty and that self-worth is based on it. Some children may have grown up in a household that assigned worth based on physical appearance. If a child grows up in an environment where bodies were commonly critiqued and criticized, value and worth might now be linked to appearance. Diet culture then enforces this notion that appearance is based on self-worth. The connection between appearance and self-worth influences increases feelings of guilt and shame after a binge and the desire to then restrict. 

Trauma

People who have PTSD or have a history or experiencing traumatic events typically are at greater risk for all types of eating disorders.⁴  People who have experienced significant trauma in their life tend to struggle with emotional regulation and have high rates of dissociation⁵. Dissociation is defined by the American Psychological Association as, “a defense mechanism in which conflicting impulses are kept apart or threatening ideas and feelings are separated from the rest of the psyche”.⁶ This essentially means that one separates themselves from their psyche and memory as a form of self-protection to distance oneself from the trauma. In trauma survivors, the binge episode may be a form of dissociation. The triggering events (often strong negative emotions or thoughts regarding the trauma) lead to a binge. This intake of food feels uncontrollable, almost an out of body experience. It is easy to see the psychological symbolism of the food as a way to fill the void at that moment. 

What is Intuitive Eating and Why Does it Work?

Intuitive Eating is a term coined by two registered dietician nutritionists, Evelyn Tribole, MS, RDN, CEDRD-S and Elyse Resch, MS, RDN, CEDS-S, Fiaedp, FADA, FAND. It is the name for a framework of eating centered around a mind-body approach to health. Through the ten principles, it aims to reduce obstacles to body awareness and guides the individual in how to make choices that will support the physical and psychological needs of the body. 

10 Principles of Intuitive Eating⁷

Reject the Diet Mentality

It is important to realize how diets often do not work and leave the dieter often worse off than at the start. They often result in weight cycling and a feeling of failure and disappointment. Rejecting the notion that you need to change your body and focusing on choices that lead to well-being is a cornerstone of intuitive eating. 

Honor your Hunger

Nourishing your body to keep it fed with adequate calories and nutrients is key. It is important to respond appropriately when hunger is present and not to get overly hungry as this can trigger a primal drive to overeat. 

Make Peace with Food

Categorizing foods into ones that are “good” and “bad” naturally leads us to crave the ones that are off limits. Unconditional permission to eat any foods and removing labels from them gives us food freedom to listen to what foods our body actually wants. 

Challenge the Food Police

The food police is an internal dialogue governing what you think you can and cannot eat. It is formed through social conditioning and diet culture. 

Discover Satisfaction

When we only focus on choosing foods based on nutrition, we often forget about pleasure. When making food choices, remember to select foods you really want to eat. This will maximize satisfaction.

Feel Your Fullness

Check in with your hunger cues before, midway and at the end of the meal. It is often helpful to use a rating scale to numericize your feeling of fullness as a strategy to help get in touch with your body. 

Coping with Emotions

Discover ways to cope with difficult emotions other than through food. Food may offer short-term comfort but in the long term may cause more harm than good. Instead, look for alternatives rooted in self-compassion such as meditation or dealing with the root cause of these emotions. A licensed therapist may be helpful in offering guidance through this journey.

Respect Your Body

Respect your body and its differences from others. Each body is genetically different and will never look the same as someone else’s. Accept and even celebrate your unique differences. 

Enjoyable Movement

Exercise should not be a punishment or something that is obligatory. Focus on how you feel after exercise and focus on movement that makes you feel good.

Gentle Nutrition

Everybody needs different foods. There is no single eating pattern or lifestyle that is suitable for everyone. Focus on making food choices suitable for your overall physical and mental wellbeing.

Conclusion

In summary, intuitive eating is a great tool for those struggling with binge eating disorder or the binge restrict cycle. It is a strategy to end the cycle of binging, guilt and restriction and lets the user tune into what is best for their overall wellbeing in a holistic way. Practicing intuitive eating takes time and is a skill to be developed. It counteracts years or even decades worth of behavior patterns and is often very difficult to practice. Working with an eating disorder dietitian and therapist within a team of qualified medical professionals is suggested to assist you along your healing journey. Healing your relationship with food takes time, be kind to yourself. 

Resources:  

Search for qualified dietitians: https://iaedp.site-ym.com/search

NEDA helpline: https://www.nationaleatingdisorders.org/help-support/contact-helpline

EAT 26: https://psychology-tools.com/test/eat-26

References

1. Hudson JI, Hiripi E, Pope HG Jr, Kessler RC. [Published correction appears in Biol Psychiatry. 2012;72(2):164.] Biol Psychiatry. 2007;61(3):348-358.
2. Diagnostic and Statistical Manual of Mental Disorders DSM-5-TR. American Psychiatric Association, 2022. 
3. Černelič-Bizjak, M. and Guiné, R.P.F. (2022), “Predictors of binge eating: relevance of BMI, emotional eating and sensivity to environmental food cues”, Nutrition & Food Science, Vol. 52 No. 1, pp. 171-180. https://doi.org/10.1108/NFS-02-2021-0062
4. Brewerton, Timothy D. “Eating disorders, trauma, and comorbidity; Focus on PTSD.” Eating disorders 15.4 (2007): 285-304
5. Ehring T, Quack D. Emotion regulation difficulties in trauma survivors: the role of trauma type and PTSD symptom severity. Behav Ther. 2010 Dec;41(4):587-98. doi: 10.1016/j.beth.2010.04.004. Epub 2010 Jun 30. PMID: 21035621.
6. “Apa Dictionary of Psychology.” American Psychological Association, American Psychological Association, https://dictionary.apa.org/dissociation. 
7. Tribole, Evelyn, and Elyse Resch. “10 Principles of Intuitive Eating.” Intuitive Eating, 19 Dec. 2019, https://www.intuitiveeating.org/10-principles-of-intuitive-eating/. 

By: Kelsey H., Lagniappe Wellness Dietetic Intern

So what exactly is an eating disorder?

Inconsistent with mainstream belief, eating disorders (ED’s) are characterized by behaviors, rather than anthropometrics (one’s general measurements) alone. When assessing individuals for a potential  eating disorder diagnosis, doctors use terms such as, but are not limited to bulimia, binge eating disorder, anorexia nervosa, etc. In order to hone in on the purpose of this post, it is important that we focus on the bulimia and binge eating disorder.  

Karolina Grabowska / Pexels

Bulimia Nervosa

According to the National Institute of Mental Health [5],  those experiencing the effects of bulimia nervosa (BN) have “recurrent and frequent episodes of eating unusually large amounts of food and feeling a lack of control over these episodes”. This style of disordered eating is followed up by compensatory behaviors such as forced vomiting, excessive use of laxatives or diuretics, fasting, excessive exercise, or a combination of these behaviors [2]. It is nearly impossible to diagnose someone with BN merely based on their size, as this aspect amongst sufferers varies within such a wide range. 

Miriam Alonso / Pexels

Binge Eating Disorder

Moreover, binge-eating disorder (BED) is a condition in which individuals lose their sense of control while eating and continue having reoccurring episodes of eating unusually large amounts of food [1,4]. Binge eating disorder differs in the absence of compensatory behaviors listed above. With that, physical determinants come into play much more efficiently and therefore those suffering from the effects of this disorder appear to be overweight or obese— terms of which I may add are fairly arbitrary given the mountains of information proving its inaccuracy in determining health.

Tim Samuel / Pexels

Society’s Idea of Eating Disorders

Society looks, hears, and talks about eating disorders through one lens— one that’s focusing only on anorexia nervosa (specifically the restricting type). Social media, early education, and day-to-day interactions amongst friends gravitate towards the idea that thinness past social acceptance equates to eating disorders, and that their aversion to food is what categorizes someone as having an eating disorder. According to this same idea, there’s absolutely no way that someone with an eating disorder can weigh any higher than the “normal” weight justified by the bogus Body Mass Index (BMI)!

The Facts 

According to NEDA [5], the National Eating Disorder Association, only 14.5% of all eating disorders are diagnosed as anorexia nervosa. This is extremely low compared to the incidence of bulimia nervosa at 21.5% and binge eating disorder at 51.9%! In fact, 80% of eating disorders go undetected or never receive treatment. 92% of frontline clinicians admit in hindsight to potentially missing an ED diagnosis. Additionally, 3 out of 10 individuals seeking weight loss treatments inevitably show signs of experiencing BED. According to research, individuals with a binge eating disorder and those who classify as ‘obese’ exhibited a significantly higher BMI, waist circumference, hip circumference, waist/hip ratio, and fat mass, and a lower lean mass as compared with non-BED ‘obese’ individuals [3]. As previously mentioned, it is possible to live in a larger body while battling an eating disorder. Through copious amounts of research, it’s been found that this specified population is actually susceptible to more complications than in those living in smaller bodies. 

My Clinical Rotations at an Eating Disorder Treatment Facility

As a recent graduate of Johnson and Wales’ Dietetics and Applied Nutrition program, I can honestly say that I left with very minimal interest on the subject of eating disorders. There’s such a massive amount of research around eating disorders— so much so that it’s shocking to have not learned nearly as much during my undergraduate education! While conducting research on eating disorders during my Medical Nutrition Therapy (MNT) rotation of my internship, I was shocked to realize how both society and my own undergraduate education had actually encouraged disordered thoughts and behaviors around food!  It is not to diminish the academic excellence provided by my alma mater when I say that eating disorders were merely glanced at in comparison to other dietetic-related specialties. In fact, many dietitians I had previously spoken to will agree with that statement even after having completed their undergraduate education elsewhere. So during my MNT rotation located at an ED treatment center, I took this opportunity to better understand some of the thoughts that develop in conjunction with an eating disorder. The insight that I had gained just by sitting in on and leading group discussions with clients was able to transform my own preconceived notions around eating disorders (more specifically the true functions behind them!)

Challenge Your Own Misconceptions Around Eating Disorders!

I’m writing this post in hopes of eliciting just a quick moment of reflection around some of your own misconceptions around eating disorders. Consider why the question “I thought you had an eating disorder?” is wildly incorrect and principally rude.  Just like plenty of other diseases, eating disorders are not solely defined by the way that an individual may present, but rather the behaviors that they participate in. With that, it is important to move forward without any predisposed judgements if approached by an individual sharing their experience of having an eating disorder. 

References

1. From the Department of Medical and Surgical Sciences (ES. (n.d.). Obese patients with a binge eating disorder have an… : Medicine. LWW. Retrieved October 9, 2022, from https://journals.lww.com/md-journal/fulltext/2015/12280/obese_patients_with_a_binge_eating_disorder_have.5.aspx
2. Kuntz, L. (2021, October 15). A life and death measure: Eating disorder treatment. Psychiatric Times. Retrieved October 9, 2022, from https://www.psychiatrictimes.com/view/a-life-and-death-measure-eating-disorder-treatment
3. Nicoletti, C. F., & Delfino, H. B. P. (2019). Role of eating disorders-related polymorphisms in obesity pathophysiology. Retrieved October 10, 2022, from https://www.researchgate.net/profile/Heitor-Delfino/publication/332059782_Role_of_eating_disorders-related_polymorphisms_in_obesity_pathophysiology/links/5c9d587892851cf0ae9e2345/Role-of-eating-disorders-related-polymorphisms-in-obesity-pathophysiology.pdf
4. Palavras, M., Hay, P., Filho, C. A., & Claudino, A. (2017). The efficacy of psychological therapies in reducing weight and binge eating in people with bulimia nervosa and binge eating disorder who are overweight or obese—a critical synthesis and meta-analyses. Nutrients, 9(3), 299. https://doi.org/10.3390/nu9030299 
5. Statistics & Research on Eating Disorders. National Eating Disorders Association. (2021, July 14). Retrieved October 9, 2022, from https://www.nationaleatingdisorders.org/statistics-research-eating-disorders
6. U.S. Department of Health and Human Services. (n.d.). Eating disorders. National Institute of Mental Health. Retrieved October 9, 2022, from https://www.nimh.nih.gov/health/topics/eating-disorders 

By: Dallas G., Lagniappe Wellness Dietetic Intern

Mornings spent fishing on the lake, afternoons spent tubing behind the boat, and evenings spent on the back porch of my grandparent’s house were the summers I looked forward to as a child. I knew that once I arrived in Texas Hill Country, I would be fed Grandma’s biscuits and gravy and have unlimited trips to the back fridge where I could find my favorite orange soda in a glass bottle.

 

As the youngest of my sisters and my cousins, I was always trying to keep up. If suddenly I looked up, and I was left behind, I knew I was never truly alone. There was always Grandpa, sitting on the far right side of the brown leather couch near the window with his wooden cane, TV channel guide, and Judge Judy playing on the TV. It was a pleasure to play Grandma’s helper. I would transport Grandpa’s freshly made coffee to him as carefully as I could. However, when it came time for Grandpa to inject his insulin, I had to watch from afar. 

In my eyes, Grandpa’s insulin injections were part of his identity. My young mind couldn’t fathom the list of stressors that came with his T2DM diagnosis.Fourteen years and four college degrees later, the little girl running around her grandparent’s lake house is on the path of becoming a Registered Dietitian and I can’t help but wonder if my grandpa has ever experienced burnout while managing his diabetes. So, in memory of my grandfather and with the pursuit of enhancing the lives of others around me, this week’s blog post highlights diabetes distress and offers tips and tools on how to manage this common emotional state shared by people with diabetes.

 

Living life with diabetes is more than just a medical diagnosis. For most, life with diabetes feels like a constant balancing act, juggling things like glucose monitoring, carbohydrate counting, exercise regimen, medication administration, and doctors appointments. As the balancing act becomes increasingly more burdensome, feelings of emotional distress may occur. Diabetes distress can be defined as an overwhelming feeling that occurs when managing diabetes. 

The American Diabetes Association considers Diabetes Distress to be a psychosocial implication that can negatively affect self-care practices. In an article discussing the approach to treating psychological comorbidities of diabetes, Kathyrn Kreider makes a clear distinction between diabetes distress and major depressive disorder. Some of the symptoms of diabetes distress include burnout, denial, fear, shame, guilt, and lack of adherence to the diabetes regimen.
Just under half the population of people with T2DM in community settings suffer from diabetes distress (Kreider, 2017). When diabetes distress is left undiagnosed and unmanaged it may negatively impact the health status of individuals with diabetes. The first step in managing diabetes distress is to be properly screened and diagnosed. To assess the level of distress you or someone you know may be experiencing in relation to their diabetes diagnosis, take the diabetes distress survey here.
Once the diagnosis has been made, management can begin. One article highlights an approach to managing diabetes distress by, “minimizing the impact” using four pillars of management 

1.  Minimize discomfort associated with change 
   1. Break change into discrete bits 
   2. Prioritize actions for change
   3. Focus on essentials 
   4. Make full use of resources including human resources and technology 
2. Optimize coping skills
   1. Acceptance 
   2. Optimism 
   3. Planning 
   4. Action 
3. Strengthen self-care skills
   1. Diet 
   2. Physical activity 
   3. Self-administration of oral/injectable medicines 
   4. Self monotring 
   5. Get involved in a DSMES (Diabetes Self-Management Education/Support) program
4. Other support 
   1. Health care professionals 
   2. Family
   3. Community 
   4. Health care system 

The first step in managing diabetes distress is opening up with your care provider. Once your care provider is aware of the emotions you have been experiencing, they will be able to point you in the right direction of care. If the costs of your medication are too high, communicate this concern with your care provider. Communicate your worries and concerns with the people you trust. Having a support team will help minimize feelings of distress and may offer space for connection. Join support groups online or in person. Make an action plan and to-do list to lean on when things feel overwhelming. Make goals that are achievable and realistic. Lastly, consider engaging in hobbies, meditation, or other activities that bring you joy.

References 

Centers for Disease Control and Prevention. (2021, August 10). 10 tips for coping with diabetes distress. Centers for Disease Control and Prevention. Retrieved January 1, 2022, from https://www.cdc.gov/diabetes/managing/diabetes-distress/ten-tips-coping-diabetes-distress.html 

Centers for Disease Control and Prevention. (2021, August 10). Diabetes self-management education and support (DSMES) toolkit. Centers for Disease Control and Prevention. Retrieved February 18, 2022, from https://www.cdc.gov/diabetes/dsmes-toolkit/index.html 

Kreider K. E. (2017). Diabetes Distress or Major Depressive Disorder? A Practical Approach to Diagnosing and Treating Psychological Comorbidities of Diabetes. Diabetes therapy : research, treatment and education of diabetes and related disorders, 8(1), 1–7. https://doi.org/10.1007/s13300-017-0231-1

Diabetes distress assessment & resource center. Diabetes Distress Assessment & Resource Center. (n.d.). Retrieved January 1, 2022, from https://diabetesdistress.org/ Journal of Pakistan Medical Association. JPMA. (n.d.). Retrieved January 1, 2022, from https://jpma.org.pk/article-details/8412?article_id=8412

By Hannah B., Lagniappe Wellness Dietetic Intern

Over 31% of people with diabetes are prescribed daily insulin injections

The Humble Origin of Insulin

In 1921, Canadian medical scientist and physician Fredrick Banting discovered what would be known as the most significant medical invention of all time (NATAP, n.d.). His breakthrough research would enable insulin to be extracted from various animals to be used therapeutically for individuals with diabetes. Insulin is a peptide hormone that aids in carbohydrate metabolism by allowing glucose uptake into cells. Prior to the discovery of insulin therapy, those with type 1 diabetes were given a life expectancy of three years. Banting sold the patent for insulin to the University of Toronto for just $1 to become affordable and accessible to the masses. The physician thought it unethical to profit from a therapy that could save lives. Despite its charitable origins, insulin has become a prime example of medical price gouging, making this life-saving medicine less accessible to those in need.  

An early model of clinically used insulin (Iletin) in its original packaging (Wendt, 2013).

The National Cost of Diabetes

The CDC 2020 National Diabetes Statistic Report found that over 1 in 10 Americans (34.2 million) have diabetes. This staggering statistic indicates that a significant proportion of the American population relies on medical intervention for blood sugar management. Among these interventions is insulin, which will have its 100th anniversary for human clinical use in January 2022. Diabetes costs the United States more than $327 billion per year with the many intensive medical therapies for blood sugar management and diabetes-related complications (Cefalu et. al, 2018). Without proper management, diabetes can result in complications including neuropathy, kidney disease, retinopathy, poor wound healing, and cardiovascular disease.

The Deadly Cost of Price Gouging

The price of insulin has skyrocketed over time. The Healthcare Cost Institute reports a rise in the annual cost of insulin from $2,864 in 2012 to $5,705 in 2016 (NATAP, n.d.). With just three major companies controlling 96% of the global insulin market, the price of insulin has become severely gouged (Cefalu et. al, 2018). These pharmaceutical manufacturers can produce a vial of insulin for just a fraction of the average market price. Regardless of the increased awareness, the cost of diabetes-related medications continues to rise.

Rising list prices of diabetes medications and supplies from 2014 to 2019 (Mui, 2019).

This high cost may deter many from following an appropriate insulin therapy regimen, leading some to split or skip doses to ration their insulin (Commonwealth, 2020). Insufficient insulin can lead to diabetic ketoacidosis: a severe and sometimes fatal complication of diabetes occurring with inadequate insulin. Thirteen deaths occurred between 2017 and 2019 from insulin rationing due to lack of accessibility and affordability. The price gouging of insulin has become a deadly consequence of big pharma that Banting worked hard to avoid. 

A Solution for the Insulin Crisis

In recent years, the struggle of insulin affordability has gained traction in many journals and news outlets. The price gouging of insulin keeps those who struggle to afford their medications at acute risk of death (Battino, 2019). This now calls into question the responsibility and morality of our current healthcare system. How can we deny Americans access to life-saving medical treatment?

There are several proposed solutions to the extreme prices. Eli Lily, a major manufacturer of medical insulin, announced plans to produce a generic form of original medicine at half price (Battino, 2019). Although a step in the right direction, the list price of $137.35 will still pose a burden to many American families. The creation of generic forms of these medications becomes complicated by patents and allows for the monopolization of pharmaceuticals. Granting the FDA and other pharmaceutical companies permission to develop quality off-patent forms of these medications is an essential next step in responding to this insulin crisis. Another solution is to create reforms that block the increase in the list price of drugs unrelated to increased production cost or cap out-of-pocket spending (HCCI, 2021).

Many healthcare providers and patient advocates are beginning to respond to the plea of a financially burdened population. There is a moral struggle amongst these medical representatives about where the responsibility falls and how to control the pharmaceutical market without setting dangerous precedents. The bottom line remains: consumers need access to affordable insulin. As Frederick Banting once said, “insulin does not belong to me, it belongs to the world.” Although insulin therapy has changed the world, we have strayed far from his vision for this 1921 invention.

References

“The Absurdly High Cost of Insulin” – as High as $350 a Bottle, Often 2 Bottles per Month Needed by Diabetics, https://www.natap.org/2019/HIV/052819_02.htm. 

Battino, Gabby. “Policy Solutions to Address the Rising Cost of Insulin.” NCHC, 21 July 2020, https://nchc.org/policy-solutions-to-address-the-rising-cost-of-insulin/. 

“Capping out-of-Pocket Spending on Insulin Would Lower Costs for a Substantial Proportion of Commercially Insured Individuals.” HCCI, https://healthcostinstitute.org/hcci-research/capping-out-of-pocket-spending-on-insulin-would-lower-costs-for-a-substantial-proportion-of-commercially-insured-individuals-1. 

Cefalu, William T., et al. “Insulin Access and Affordability Working Group: Conclusions and Recommendations.” Diabetes Care, vol. 41, no. 6, 2018, pp. 1299–1311., https://doi.org/10.2337/dci18-0019. 

Mui, K. (2019). Diabetes Medications and Supplies. The GoodRx List Price Index Reveals the Rising Cost of All Diabetes Treatments – Not Just Insulin. Good RX. Retrieved December 12, 2021, from https://www.goodrx.com/healthcare-access/research/goodrx-list-price-index-rising-cost-of-diabetes-treatments. 

Mulcahy, Andrew, et al. “Comparing Insulin Prices in the United States to Other Countries: Results from a Price Index Analysis.” 2020, https://doi.org/10.7249/rra788-1. 

“National Diabetes Statistics Report, 2020.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 11 Feb. 2020, https://www.cdc.gov/diabetes/library/features/diabetes-stat-report.html. 

“Not so Sweet: Insulin Affordability over Time.” Commonwealth Fund, https://www.commonwealthfund.org/publications/issue-briefs/2020/sep/not-so-sweet-insulin-affordability-over-time. 

Wendt, D. (2013). A bottle of 1920s Iletin (Lilly insulin), which is the finished product seen below being labeled and packaged. Two tons of pig parts: Making insulin in the 1920s. National Museum of American History Behring Center. Retrieved December 12, 2021, from https://americanhistory.si.edu/blog/2013/11/two-tons-of-pig-parts-making-insulin-in-the-1920s.html. Rajkumar, S. Vincent. “The High Cost of Insulin in the United States: An Urgent Call to Action.” Mayo Clinic Proceedings, vol. 95, no. 1, 2020, pp. 22–28., https://doi.org/10.1016/j.mayocp.2019.11.013.

By: Ivette L., LW Dietetic Intern

         When it comes to people with diabetes, folks assume all are type 2 and it is associated with old age and/or excess weight. While this observation is not wrong, it is quite far from the entire picture. There is actually more than one type of diabetes, but in order to understand them, let’s begin with what diabetes actually is. Diabetes is defined as, “a disease where the body cannot make or doesn’t make enough insulin (a pancreatic hormone) resulting in high blood sugar in the bloodstream.” Type 2 diabetes, the most recognized form, is a condition where the body isn’t producing enough insulin or is insulin resistant causing high blood sugar (hyperglycemia). It normally occurs in adults but can affect children. It is also preventable. Similar to type 2, there is gestational diabetes which only develops during pregnancy. Pregnant women are usually tested between 24-28 weeks. Gestational diabetes should go away after giving birth but increases odds of developing type 2 diabetes in the future. (CDC 2020)

Type 1 diabetes, which is less common and therefore often misunderstood, is an autoimmune disease during which your body does not produce ANY insulin. It is formerly known as juvenile diabetes but can be diagnosed at any age. Unfortunately, there is no research on prevention. Currently, the only approved medical treatment for type 1 diabetes is insulin therapy consisting of a combination of short or fast acting and intermediate, or long-acting that is administered via a syringe, pen, or through an insulin pump. Newer insulins include Afrezza which is an inhalable fast acting insulin. The only permitted alternate medication is the oldest type 2 medication, metformin, or Symlin (injectable anti-diabetic medication that acts like a hormone to lower blood sugar) combined with insulin. (Janssens, Caerels & Mathieu 2020)

Everyone thinks they can tell type 1 from type 2 if the person is overweight. The heavier ones are people with type 2 diabetes, and the type 1’s are leaner. However, recent research is demonstrating that this isn’t always the case. Over 50% of people with type 1 diabetes are now in the obese category. Excess body weight is linked to inconsistent blood sugar levels, overcorrection of low blood sugar episodes, unhealthy diet, and lack of physical activity. It can lead to increased risk of insulin resistance, cardiovascular disease, chronic kidney disease, and other diabetes related complications. In recent years, a term known as “off label use” has been applied to diabetes care. This occurs when medications used and approved to treat one thing are prescribed to treat another condition. In this case, the off label drugs are the type 2 diabetes medications that are being used to treat type 1 diabetes. The latest drugs being used are: SGLT-2 inhibitors (sodium-glucose cotransporter-2 Inhibitors). Some known examples are Invokana, Jardiance, and Farxiga. In Europe, this is a widely used practice as it has been officially approved there. Unfortunately for Americans, the FDA has not authorized  the use of SGLT-2 inhibitors for type 1 diabetes. (Hage et al 2019)

How do SLGT-2 inhibitors help people with type 1 diabetes anyway? The medication, in pill form, blocks the SGLT-2’s (transport proteins in the kidneys) ability to trap sugar, or glucose, in the bloodstream and is instead filtered out of the kidneys leaving the body in our urine. This then lowers A1C levels, requires less insulin, increases insulin sensitivity, and decreases chances of cardiovascular disease. Another useful bonus is that it produces weight loss. The idea is that by losing all that sugar that comes from the food we eat, we are cutting down our calorie intake. (Janssens, Caerels & Mathieu 2020)

This all sounds so incredible and easy so why aren’t endocrinologists running to call all of their patients with type 1 diabetes who may be overweight and insulin resistant? For one, there simply isn’t enough research for doctors to determine if it’s safe enough to prescribe. Secondly, despite the wonderful benefits discussed here, there are concerning side effects. The biggest concern is that usually when a person with type 1 diabetes also takes a type 2 medication like Invokana or Farxiga, they are more likely to get DKA which for any person with diabetes that you ask is their absolute worst nightmare. 

Diabetic ketoacidosis , DKA, develops when your body doesn’t have enough insulin to allow blood sugar into your cells for use as energy. Your energy deprived body tries to get fuel from the liver. When the liver breaks down the fat in order to make energy, it produces an acid in your blood. When this goes on for a prolonged time, the acidic buildup in your blood becomes a very risky situation. Think of insulin as the key needed to unlock your blood cells to let the sugar in. You can force open with another key but this can only work for so long. (Meena 2020)

SLGT-2  inhibitors tend to cause euglycemic DKA which is like a sneaky and deceptive type of DKA. It is DKA but with blood sugar numbers under 250. Euglycemic DKA is more dangerous because it can be hard to detect if you’re only testing your blood sugars. This is why it is so important to watch out for other telltale signs such as vomiting, lethargy, large amounts of ketones in the urine, and extreme thirst. Euglycemic DKA is rare and typically only happens to people with type 1 diabetes using SLGT-2 inhibitors.(Meena 2020) Because the medication is causing you to release excess sugar through your urine, it tricks your body into thinking it needs less insulin, when our bodies require insulin 24/7 in order to stabilize our blood sugars. So you can have what you think are “decent” blood sugars and your body still needs more insulin! Other possible side effects include frequent urinary tract infections due to excessive urination and hypoglycemic (low blood sugar) episodes. (Geerlings et al 2014)

Now to the question of the hour, is it worth the risk? Depends. As a person with diabetes for over 20 years who also happens to be insulin resistant and obese, my endocrinologist has suggested SLGT-2 inhibitors several times. While it’s an unconventional treatment, my doctor is confident it will help bring down my blood sugars, reduce my overall insulin requirements, and help me lose some weight. I’ve resisted because of the intense fear of euglycemic DKA. Luckily, I’ve never experienced ketoacidosis, but from what other fellow T1Ds have said, it’s horrible. Because of my hectic lifestyle with grad school, work, and my dietetic internship, I preferred to wait until I had more time to closely monitor myself for any signs of euglycemic DKA. Now that I am done with grad school, I will begin using Invokana with my insulin pump. Am I scared? Yes, but after having done the research and trying the traditional method of increasing physical activity, I am willing to cautiously forge ahead. That being said, I wouldn’t recommend it to all  people with type 1 diabetes. If you are able to lose weight the old-fashioned way and are NOT significantly insulin resistant, I would caution against it and stick to what we know works for us. It requires additional planning and discipline. If you are someone who may not be able to handle the added stress of having yet another diabetes red flag to watch out for, then maybe reconsider. After all, we cannot forget that these medications were not intended to treat type 1 diabetes.

References 

Geerlings, S., Fonseca, V., Castro-Diaz, D., List, J., & Parikh, S. (2014). Genital and urinary tract infections in diabetes: Impact of pharmacologically-induced glucosuria. Diabetes Research and Clinical Practice, 103(3), 373-381. doi:10.1016/j.diabres.2013.12.052

Hage, L. E., Kashyap, S. R., & Rao, P. (2019). Use of SGLT-2 Inhibitors in Patients With Type 1 Diabetes Mellitus. Journal of Primary Care & Community Health, 10, 215013271989518. doi:10.1177/2150132719895188

Janssens, B., Caerels, S., & Mathieu, C. (2020). SGLT inhibitors in type 1 diabetes: Weighing efficacy and side effects. Therapeutic Advances in Endocrinology and Metabolism, 11, 204201882093854. doi:10.1177/2042018820938545

Meena, P., MD. (2020, September 14). SGLT2 Inhibitor-induced Euglycemic Diabetic Ketoacidosis. Retrieved October 9, 2020, from https://www.renalfellow.org/2020/09/08/sglt2-inhibitor-induced-euglycemic-diabetic-ketoacidosis/

What is diabetes? (2020, June 11). Retrieved October 8, 2020, from  https://www.cdc.gov/diabetes/basics/diabetes.html

By: Laura B., LWDI Intern

Hello! My name is Laura B. In my free time, I enjoy riding on my brother’s boat, fishing, listening to music, walking 5ks with my mom, and spending time with my family including my dog Kelly.  I was diagnosed with T1D in April 2000 and wow has it been a long roller coaster of emotions and highs and lows since then. Having T1D for as long as I have, I have learned and grown a lot from my experiences. I am currently on a Tandem t-slim X2 pump, and I have a Dexcom sensor to monitor my blood sugars. In 2020, when my diabetes management was at its best, my world got flipped around with an additional diagnosis of Celiac Disease. Living with Celiac has taught me a lot about my body and how to listen to it to stay healthy.  I have used my time with T1D and my short time with Celiac to explore some good, healthy recipes along with some snacks to enjoy. While my diagnoses have been really hard on me over the years, I have enjoyed using them to meet new people, grow in life, and expand my understanding of food and my body.  

Type 1 Diabetes (T1D) is a chronic condition in which the pancreas produces little or no insulin.  Insulin is a hormone needed to allow sugar (glucose) to enter cells and produce energy; therefore, people with T1D must manually inject insulin.  Type 1 is usually diagnosed in children, but it can occur at any age. I was diagnosed with T1D at age three, 21 years ago. As if living with T1D was not hard enough, I was also diagnosed with Celiac Disease in 2020. Celiac Disease is a serious autoimmune disease that occurs in genetically predisposed people where the ingestion of gluten leads to damage in the small intestine which can affect the ability of the gut to absorb nutrients resulting in nutritional deficiencies.  Unfortunately, a person with T1D is significantly more susceptible to Celiac as well because they are both autoimmune diseases (Meadows 2014) .

There is currently no cure for T1D or for Celiac Disease, so the only thing that can be done is to manage it. For T1D that includes taking insulin and testing your blood sugar every time you eat; however, the only management for Celiac is a gluten-free diet (GFD), so the intestine can repair itself. As one could imagine, managing both of these conditions at the same time can be very difficult because they both revolve around the diet, and they require a different set of rules on what can and cannot be eaten. Having a combination diagnosis like this can be very daunting in the beginning, but it becomes second nature once you do it long enough. So what should someone with a combination diagnosis of T1D and Celiac Disease eat? The best place to start is to understand each condition separately before trying to manage the diets of these conditions at the same time. 

Being a person with T1D and Celiac Disease does not mean you cannot eat the things you love ever again; however, you will have to make adjustments. Many of the nutrition intake recommendations for T1D are consistent with the recommendations for the general public; however, there are still some slight changes because carbohydrates significantly affect the blood sugar of a person with T1D. The diet for someone with T1D should consist of carbohydrates from fruits, vegetables, whole grains, legumes (beans, peas, nuts, etc.), lean meats, and low-fat milk to have the best success with blood glucose control (Delahanty 2021). While carbohydrates should come from fruits, they should not come from fruit juice because juices contain a large amount of sugar. As a result, people with T1D should avoid sugar-sweetened beverages altogether. The diet should also be low in sodium, high in fiber, and contain high quality proteins. 

I have often encountered people who think that as a person with T1D, I should never eat any sugar.  It is much more complicated than that because your body needs sugar to function. Foods consumed get converted to sugar (glucose), regardless of the source; therefore, it is more important to know what kind of sugar you are consuming and to get it from sources that actually benefit your health.  However, it does not mean you can never ever eat a small slice of cake ever again. It is also important to realize that all people with T1D are not affected in the same way by certain foods. As a result, a T1D diet can be a bit of trial and error. Carb counting is vital to a person with diabetes. In a study done to see the impact of a low carb diet in people with T1D, it was shown that a diet with 70-90 g of carbs per day is beneficial in lowering blood sugars overall without causing health problems like hypoglycemia, etc. (Nielsen et al 2005).

 

Insulin improvements and technology advancements have revolutionized diabetes management, but have not eliminated the need to focus on a good diet. Counting carbs, with the help of nutrition labels, is essential to maintaining healthy glucose levels.  But there are additional factors to consider when dealing with Celiac as well. Now not only will you be looking at food labels for carb info, you will also be looking for ingredients that contain gluten. 

Diabetes distress is a real thing that occurs in people with T1D, and is often triggered by the overwhelming number of food choices to make and the sense of defeat when your glucose levels are not good.  The additional complication of Celiac can add to that overwhelming frustration, so it is important to get help when you feel too stressed about your condition or the things going on in your life. 

 Since Celiac Disease is a condition in which the individual is impacted by gluten intake, the first step in a Celiac diagnosis is to cut out gluten altogether and go on a gluten-free diet (GFD). Gluten is found in products with wheat, barley, and rye, so it is very important to stay diligent in food label and ingredient list reading (Basina 2020.). I was lucky that at the time of my diagnosis, I had just finished my undergrad in dietetics, so I knew what gluten was and how many food choices would be affected. However, I could also understand how overwhelming it could be for someone who did not know what gluten was. When I was first told of the risks of eating gluten, I fell into a puddle of tears because I love pasta, pizza, rolls, and an occasional piece of cake. It is easy to focus on what you will lose.  However, the technology and food science developments over the years have made it significantly easier for individuals with Celiac to find many replacements of these things and still enjoy them.

 

The best way to live a happy and healthy life with Celiac Disease is to consume foods that are naturally GF. Some of the foods in this category are fruits, vegetables, meat and poultry, fish and seafood, dairy, beans, legumes, and nuts (Celiac Disease Foundation n.d.). These are also good choices for a person with T1D. It will be hard at first to adapt and feel okay with your diagnosis, but it will get easier. It may take a lot of trial and error to find what foods you like and which ones you do not, but there are many good GF alternative foods out there worth trying. I encourage all people with Celiac to branch out and take this moment to try new things because that will be key in your journey with Celiac. One of my favorite meals for breakfast before Celiac was peanut butter and banana toast with a glass of milk, and I was afraid I would not be able to enjoy that anymore. However, I found gluten free bread and all the other ingredients are naturally GF, so I was able to continue enjoying one of my favorite breakfast treats. Look at the things you love to eat as opportunities to explore and find the GF alternatives, or replace them with healthier, naturally gluten free options. 

It can be hard enough to manage just Celiac Disease, but the factor of adding T1D on top of that can be exhausting. Foods that contain large amounts of gluten also have a lot of carbs and sugar in them, which is unhealthy for people with T1D and people with Celiac. The good thing is, there is a huge overlap between which foods are naturally GF and which foods are good to eat if you have T1D (“How Gluten Intake is Linked to Type 1 Diabetes” 2020).

Healthy choices for a person with T1D and Celiac include a lot of fruits, vegetables, fresh meat and seafood, and dairy products. As there can be many harmful side effects to not adhering to a GFD when you have Celiac Disease and many extremely harmful side effects to not taking your insulin and counting carbs correctly with T1D, it is vital that people with both of these conditions strictly monitor their food intake to keep themselves happy and healthy. Below are some recipes that I have found to be very delicious and have all GF ingredients! It is important to get help if you feel overwhelmed with the burden of having to care for yourself with 2 very tiring and time consuming conditions like T1D and Celiac Disease. I know for myself, it has been super helpful having friends, family, and a third-party to talk to when things get to be too much with my conditions. I hope you are able to find someone like that in your life to help be that rock for you. If not, I am always here to help and answer any questions you have that I can answer on this topic. It’s so important to know that you are loved and while you may be unique, you can do anything you set your mind to even if you have both Celiac Disease and T1D. Don’t let your conditions stop you from following your dreams and doing what you love, I sure know I have not. Good luck, and you got this!!

GF Green Bean Casserole: https://www.bettycrocker.com/recipes/gluten-free-green-bean-casserole-with-fried-onions/74dac433-d6db-46c1-9003-6d7a4d5c03b7

GF Tater Tot Bacon Cheeseburger Casserole: https://www.mamagourmand.com/cheeseburger-casserole/

GF oreo Truffles: https://www.whattheforkfoodblog.com/2014/12/03/gluten-free-oreo-truffles/

Eat This, Not That! GF recipes: https://www.eatthis.com/weeknight-gluten-free/

References

Meadows, K. (2014, January). Living gluten free with type 1 diabetes. Today’s Dietitian. Retrieved February 18, 2022, from https://www.todaysdietitian.com/newarchives/010614p34.shtml 

Delahanty, L. M. (2021, June 15). Patient education: Type 1 diabetes and diet (Beyond the Basics). UpToDate. Retrieved February 18, 2022, from https://www.uptodate.com/contents/type-1-diabetes-and-diet-beyond-the-basics 

Jørgen Vesti Nielsen, Eva Jönsson & Anette Ivarsson (2005) A Low Carbohydrate Diet in Type 1 Diabetes, Upsala Journal of Medical Sciences, 110:3, 267-273, DOI: 10.3109/2000-1967-074

Basina, M. (2020, October 7). T1D & celiac disease. Beyond Type 1. Retrieved February 18, 2022, from https://beyondtype1.org/celiac-disease/?gclid=Cj0KCQiA5aWOBhDMARIsAIXLlke3yURWVchA3SKU27oO4M0YIRPaGms6BMtECnlZallYtAuoZ55n2yoaAtZCEALw_wcB 

Meadows, K. (2014, January). Living gluten free with type 1 diabetes. Today’s Dietitian. Retrieved February 18, 2022, from https://www.todaysdietitian.com/newarchives/010614p34.shtml 

Gluten-free foods. Celiac Disease Foundation. (n.d.). Retrieved February 18, 2022, from https://celiac.org/gluten-free-living/gluten-free-foods/ 

How gluten intake is linked to type 1 diabetes. Byram Healthcare. (2020, January 15). Retrieved February 18, 2022, from https://www.byramhealthcare.com/blogs/how-gluten-intake-is-linked-to-type-1-diabetes 

Check out the AMAZING work Hannah has been doing during her Food Service Rotation.  Way to go, Hannah!

The high school district I interned at hires a third party company, Chartwells, to handle a part of their food service operations. ‘Discovery Kitchen’ is something that Chartwells hosts throughout their schools. It was created to help promote healthy eating and nutritional education for all students, faculty, and parents. Due to the pandemic, they have newly added “Discovery Kitchen – At Home’ to involve the parents in learning about a healthy and happy kitchen. I was able to perform a ‘Discovery Kitchen’ at all 7 of the high schools within the school district. I helped create the recipe for sampling (caesar kale salad) as well as surveying and educating the students on the meal. Due to the positive feedback, the Director of Food Services let me know that they will be adding a variation of my salad to the school lunch menu next month – which was a great accomplishment! I was just invited by the Director to attend the Discovery Kitchen Board meeting to talk to all the Board members about my experience and answer any questions the Board may have!