[Redacted]
December 13, 2013
Catherine Herrick
Diabetes Prevention Program
Holy Cross Hospital Senior Source
8580 Second Ave.
Silver Spring, MD 20910
Re:
Proposal for Program Enhancement – Mindful Eating
Dear Ms. Herrick:
I am pleased to present to you a proposal that I believe will enhance the
effectiveness of the Diabetes Prevention Program at Holy Cross Hospital. As you know,
I am a Dietetics student at the University of Maryland, and I have been a volunteer with
the program since July of 2013. My research regarding mindful eating and its application
for preventing diabetes has convinced me that incorporating instruction in mindful eating
into the curriculum for the program would substantially increase the program’s
effectiveness.
Thank you for taking the time to read and consider my proposal. If you have any
questions or comments, please do not hesitate to contact me, and I would be happy to
discuss this matter with you further.
Regards,
[Redacted]
Preventing Diabetes with Mindful Eating:
A Proposal for Enhancing the Holy Cross Hospital Diabetes Prevention Program
Prepared for Catherine Herrick
By [Redacted]
December 13, 2013
Table of Contents
Introduction ................................................................................................................................. 1
Overview of the Diabetes Prevention Program .................................................................... 2
How Effective is the Diabetes Prevention Program? .......................................................... 3
The Challenge of Change ........................................................................................................... 5
Mindfulness: a Tool for Transformation ................................................................................ 7
Research on the Effectiveness of Mindfulness-Based Strategies ..................................... 7
Why Does Mindfulness Work? ................................................................................................. 9
Recommendations ....................................................................................................................10
Training Instructors ....................................................................................................................... 11
Meditation .......................................................................................................................................... 11
Mindful Eating................................................................................................................................... 12
Yoga ...................................................................................................................................................... 13
Curriculum ......................................................................................................................................... 15
Conclusion ..................................................................................................................................16
Appendices:
Sample Handouts ............................................................................................................................. 17
Works Consulted .............................................................................................................................. 21
Interview Transcripts .................................................................................................................... 24
Introduction
Reducing the incidence of diabetes continues to present one of the major
public health challenges of our time. According to the Centers for Disease Control
and Prevention’s 2011 National Diabetes Fact Sheet, about 26 million people in the
US are living with diabetes, and about 2 million more are diagnosed every year.
Diabetes afflicts almost 27% of those over the age of 65 and more than 11% of
those over 20. About 35% of US adults over 20 are estimated to be prediabetic.
Type 2 diabetes accounts for more than 90% of cases of diabetes, according
to the 2011 CDC Fact Sheet. Luckily, Type 2 diabetes is a disease that is highly
responsive to lifestyle interventions. The Diabetes Prevention Program at Holy
Cross Hospital (hereafter, the “DPP”) has the potential to make a significant impact
on this critical public health issue by providing effective guidance and motivation
for prediabetic individuals to make long-term behavioral changes that may slow the
progression of their disease to full-blown diabetes, and possibly even reverse their
disease process.
Unfortunately, lifestyle changes are notoriously difficult to make, and even
more notoriously difficult to sustain over the long-term. Physiological,
psychological, and environmental factors can impede an individual’s ability to
choose new behaviors and to commit to making those choices for the rest of his or
her life, even given a life-altering medical diagnosis such as prediabetes or diabetes.
Given these challenges, how can the DPP maximize its effectiveness at preventing
and reversing the progression from prediabetes to diabetes?
1
This report explores the particular challenges faced by individuals
attempting to make long-term lifestyle changes in order to manage prediabetes and
prevent progression to diabetes, and proposes that the practice of mindfulness, a
concept drawn from Eastern spiritual traditions such as Buddhism, may offer a tool
for addressing these challenges. After presenting the evidence for the effectiveness
of this tool, I will describe in practical detail how it can be incorporated into the
existing curriculum of the DPP in order to enhance the successfulness of the
program.
Overview of the DPP
The DPP is modeled after the lifestyle intervention used in the landmark
study by the Diabetes Prevention Program Research Group, published in the New
England Journal of Medicine in 2002, which demonstrated that lifestyle changes
could reduce the incidence of diabetes by 58% among prediabetic individuals. The
lifestyle modification program in the study provided one-on-one personalized
support and education to participants, and encouraged them to reduce their body
weight by 7% and perform 150 minutes of physical activity per week. This
intervention was more effective at preventing progression to diabetes than a drug
treatment, metformin, which only reduced the incidence of diabetes by 31%
(Diabetes Prevention Program Research Group, “Reduction in the Incidence of Type
2 Diabetes,” 393). The curriculum of the DPP is designed to resemble that used in
the 2002 study, although the one-on-one, personalized method of the original study
is replaced by weekly group instructional sessions.
2
How Effective is the DPP?
Statistics from the most recent fiscal year suggest that the DPP at HCH is
moderately but not overwhelmingly successful. In the 2013 fiscal year, about half of
participants exhibited reductions in fasting blood glucose levels immediately
following completion of the program; the other half exhibited slight increases.
About two-thirds of participants exhibited reductions in HbA1c levels immediately
following program completion; the remaining one-third exhibited slight increases.
Data was not available on how many participants achieved weight loss or physical
activity goals. Because data is only collected at the start and end of the twelve-week
program, the long-term impact of participation can not be assessed. Based on this
admittedly limited data, we can reasonably conclude that, overall, somewhere
between one-half and two-thirds of participants are at least temporarily successful
in slowing or possibly reversing their disease progression from prediabetes to fullblown diabetes.
Based on the data available to us, it is impossible to say with certainty
whether these gains are maintained beyond the end of the twelve-week program.
We can, however, look at the follow up research conducted by the Diabetes
Prevention Program Research Group on their participants. Ten years after their
original study, the Diabetes Prevention Program Research Group examined the longterm impact of their interventions on participants in their study. Individuals who
lost weight during the original 2.8 year study period subsequently regained some,
but not all, of that weight. Rates of diabetes incidence among individuals who
received the lifestyle intervention, those who received metformin, and those in the
3
placebo control group were similar in the years following the intervention, although
overall diabetes incidence remained reduced in the lifestyle and metformin groups
(Diabetes Prevention Program Research Group, “Ten Year Follow Up,” 1677).
Another study, by Davis and colleagues, examined the energy and fat intake
of participants who received the lifestyle intervention nine years after the original
study. Initially, participants receiving the lifestyle intervention reduced their energy
and fat intake during the intervention. In the 9 years that followed, energy and fat
intake increased, although they never returned to baseline, pre-study levels. Those
participants who were most successful at reducing their energy and fat intake
during the original study showed the most continued success in the nine years that
followed, while those who were less successful during the period of the initial study
continued to exhibit less reductions in the years that followed (1461-1463).
These results suggest that participants who successfully make lifestyle
changes and who experience delayed or arrested disease progression during the
period of the original 12- or 16-week lifestyle intervention program may continue
to successfully manage prediabetes, and that lifestyle changes, although they are not
maintained at the level achieved during the initial intervention, may continue to
exert a lasting effect.
How can we broaden the impact of the diabetes prevention program so that
more than one-half to two-thirds of participants achieve significant reductions in
disease progression during the period of the intervention? And how can we help
participants maintain their lifestyle changes beyond the period of the initial
intervention? In order to answer these questions, it is useful to consider the
4
obstacles that commonly prevent individuals from making and sustaining lifestyle
changes.
The Challenge of Change
The lifestyle changes that bring about weight loss and reduced chronic
disease risk are notoriously difficult to make and often unsustainable. Why is this
the case?
Dorothy Van Buren and Meghan Sinton, in their commentary on the research
regarding the psychology of weight maintenance published in the Journal of the
American Dietetic Association, note that our bodies evolved to cope with scarcity as
a survival strategy. Thus, the body’s homeostatic system, which controls appetite,
and the limbic system, which regulates emotion, are evolutionarily programmed to
be averse to weight-loss behaviors, including reduced calorie intake and increased
physical activity. In practical terms, this means that individuals who attempt to lose
weight are likely to experience discomfort, both physical and psychological (Van
Buren and Sinton 1994). This discomfort must be addressed in order for
participants to make permanent lifestyle changes.
Not surprisingly, research shows that high levels of emotional stress and the
presence of significant stressors such as major life changes generally correlate with
more difficulty losing and maintaining weight (Elfhag and Rossner 71-72). In an
interview, Julia Mutter, dietitian and Certified Diabetes Educator, who has been an
instructor for the DPP for a number of years, identified the presence of stressful life
circumstances as one of the main obstacles that prevents some DPP participants
from meeting goals:
5
… sometimes people have a really bad family dynamic, they have a lot of
stress going on so they can’t focus on their health in particular. We have
people dropping out because they have to take care of other people, you
know, if someone else in the family is sick or they have kids.
Eating provides us with nourishment, not just physically but psychologically as well.
Lifestyle changes that involve reducing overall food intake may be experienced by
program participants as painful self-denial. Often, individuals who are diagnosed
with diabetes or prediabetes already have a strained relationship with food, as
evidenced by the high prevalence of binge eating disorder among those diagnosed
with type 2 diabetes (Crow, Kendall, Praus, and Thuras 222). It is not unusual for
individuals with weight-related health problems such as prediabetes and diabetes to
cycle through a pattern of a period of overly restrictive eating followed by a period
of excessive, unrestrained eating, and each turn of this cycle can result in intense
feelings of guilt, self-judgment, and powerlessness (May and Fletcher 17).
The current DPP curriculum provides ample information on nutritional
topics, covering calorie balance, food groups, calorie and fat content of various
foods, portion control, and other similar nutritional topics. Practical advice is
provided on how to go about incorporating physical activity into one’s daily life.
Certain behavioral strategies, including awareness of social and environmental
eating cues and problem solving, are also offered. However, these strategies may be
insufficient to address the profound psychological challenges that are inherent to
the weight-loss process. How can the psychological challenge be addressed?
6
Mindfulness: a Tool for Transformation
Mindfulness has its roots in the meditative traditions of the Buddhist
religion, particularly in Japanese Zen Buddhism, but in the West it is often taught
and used in a secular fashion. Definitions of mindfulness generally contain two
components: (i) a sustained attentiveness to the present moment, and (ii) an
attitude of openness and non-judgmental acceptance (Bishop, et al, 232).
Mindfulness can be used as a technique for traditional seated meditation, in which
the practitioner sits in silence and practices training his or her attention on his or
her moment-to-moment experience. As thoughts or bodily sensations arise, they
are acknowledged without being labeled “good” or “bad,” and then the practitioner
releases the thought and returns his or her attention to the present moment.
Mindfulness can also be practiced in all of the activities of daily living. Walking,
engaging in conversation, eating, performing work or chores, and any other task
may be performed with the same attentiveness to the present moment, and the
same open, accepting attitude towards any and all experiences and thoughts. Most
instruction in mindfulness, whether religious or secular, emphasizes the importance
and the mutual complementarity of both the traditional meditation practice as well
as the use of mindfulness as a tool for the activities of daily life (for example, in
traditional Zen Buddhist religious services, which incorporate both seated and
walking meditation).
Research on the Effectiveness of Mindfulness-Based Strategies
In “Mindfulness Training as a Clinical Intervention: A Conceptual and
Empirical Review,” Ruth Baer describes the growing use of mindfulness strategies in
7
the context of mental health treatment, where it has grown in popularity since the
late 1970s as a treatment for wide range of conditions including chronic pain,
borderline personality disorder, bipolar disorder, addiction, and eating disorders.
The success of mindfulness instruction in treating eating disorders (Kristeller and
Wolever 58) led to increased interest in the potential of mindfulness as a strategy
for addressing other diet- and weight-related disorders.
Dalen, et al., successfully used the MEAL (Mindful Eating and Living) program
to achieve reductions in the weight and BMI of obese study participants (263). The
MEAL program exposes participants to seated meditation, yoga, and “eating
meditation” in order to increase their awareness of their own eating-related
experiences, emotions, and self-judgments (261). Similarly, Tapper and colleagues
found that obese women who attended educational workshops on mindfulness and
mindful eating and who reported applying the principles learned during the
workshops lost more weight than a control group of women who did not receive the
workshops (396).
Most relevantly, a study published in the Journal of the Academy of Nutrition
and Dietetics entitled “Comparative Effectiveness of a Mindful Eating Intervention to
a Diabetes Self-Management Intervention among Adults with Type 2 Diabetes: A
Pilot Study,” compared adults who received a traditional educational intervention
(similar to that used in the DPP) for type 2 diabetes with adults who only received
training in mindful eating (a protocol called MB-EAT). The mindful eating group
performed as well as the traditional intervention group in weight loss and
8
improvements in lab values, without being put on a diet and exercise regimen
(1837).
Why Does Mindfulness Work?
Dieting, in general, can cause emotional stress, and tends to have a
deleterious effect of mental health and body image, for the reasons explained
earlier. Mindfulness practices, including mindful eating, do exactly the opposite:
they offer practitioners psychological support and healing. Mindful eating offers a
different way of thinking about managing prediabetes through diet and exercise,
one that eliminates the traditional focus on self-control, self-judgment, and the
dichotomy between good foods and bad foods or virtuous choices and lapses.
Instead, making healthful choices becomes an expression of an inner attitude of selfacceptance and compassion. For example, in their book Savor: Mindful Eating,
Mindful Life, Thich Nhat Hanh and Dr. Lilian Cheung write, “When we look at all
beings, including ourselves, with eyes of love and compassion, we can take care of
ourselves better. With mindfulness, we can nurture ourselves with greater ease and
interest, and our effort will come more naturally,” (30-31).
In my interview with DPP instructor Julia Mutter, Julia identified a pattern of
negative thinking (“I can’t do this,” “I’m a failure,” “This is too hard for me,” etc.) as
one of the significant obstacles that she believes prevents participants from
experiencing success in the program. Mindfulness is a practical tool that can be
used to enable participants to become more aware of their own negative thinking
and how it is affecting their emotional state and their ability to reach their goals.
9
Mindfulness offers participants the chance to experience an attitude of
openness and curiosity about their own experiences. Jan Chozen Bays writes:
In mindful eating we are not comparing or judging. We are simply
witnessing the many sensations, thoughts, and emotions that come up
around eating. This is done in a straightforward, no-nonsense way, but it is
warmed with kindness and sparked with curiosity. (2)
In my interview with Megrette Fletcher-Hammond, an expert on using mindful
eating to treat diabetes, she spoke at length about the importance of cultivating an
attitude of curiosity, and encouraging patients to approach the management of their
disease as a science, in which they perform experiments and nonjudgmentally
observe the results. She explained how this attitude of curiosity can contribute to
managing blood sugar levels: “Mindful eating sparks curiosity, and curiosity is a
lifelong behavior that contributes to blood sugar control. We are curious about
what we care about, and we care about what we are curious about.”
Recommendations
Incorporating instruction in mindfulness practices into the DPP has the
potential to help participants slow or reverse their progression from prediabetes to
diabetes by addressing and alleviating the psychological challenges inherent to the
process of making long-term lifestyle changes regarding physical activity and food
intake. In order to implement this change, I propose (i) providing training for all
instructors in mindfulness practices, including mindful eating in particular; (ii)
incorporating instruction in traditional seated meditation practices and brief guided
meditations into weekly sessions; (iii) incorporating instruction in and guided
practice of mindful eating, also known as “eating meditation,”; (iv) incorporating
hatha yoga instruction into the physical activity component of the program; and (v)
10
adding to the curriculum activities specifically designed to enhance participants’
ability to apply mindfulness to their decisions around physical activity and food.
Training Instructors
Before any of the other recommendations can be implemented, instruction in
mindfulness practices and mindful eating must first be provided to the instructors.
In order to teach the participants, the instructors will need to learn about and
develop some familiarity with mindfulness practices. Trainings in mindfulness and
its application to eating are available through organizations such as the Center for
Mindful Eating and the UC-San Diego Mindfulness-Based Professional Training
Institute.
Meditation
Providing participants with instruction in and opportunities to practice
traditional silent seated meditation will build the foundation for all of the other
work with mindfulness practices. In the first weeks of the program, instructors can
offer participants basic instruction on seated meditation. This would cover how to
sit in a comfortable, upright posture; logistical matters, such as what to wear, how
long to practice, setting a timer, and minimizing disruptions; and the basic
technique – attending to one’s present-moment experience with openness and
acceptance. Each weekly session could include a five-minute guided meditation led
by the instructor, either at the beginning or the end of class. Participants should
also be encouraged to develop a regular daily meditation practice on their own, with
an emphasis on making it an easy, manageable, convenient part of his or her daily
routine. Similar to starting an exercise routine, attempting to suddenly start a forty-
11
five minute per day meditation practice that involves an elaborate set-up of candles
and incense and chimes and absolute silence of the entire household is usually
doomed to failure because it is too impractical, unsustainable, and extreme. Instead,
encourage participants to start small—for example, five minutes of sitting quietly in
a chair before bedtime—and to think of this as an opportunity for “me time,” an act
of self-care.
Mindful Eating
In my interview with mindful eating and diabetes expert Megrette FletcherHammond, I asked how to teach someone to eat mindfully. Fletcher-Hammond
immediately responded, “You eat with them.” She was emphatic about the need for
diabetes educators to eat—and enjoy—food with clients, and to guide clients
through the process of mindful eating, or what is sometimes called “eating
meditation.”
This is actually the simplest part of this proposal to implement, since weekly
program sessions currently include a healthy, balanced dinner complete with a
portion-controlled, delicious dessert. Currently, instructors delve right into
discussing the topic of the week while participants are eating, which actually
encourages mindless eating, since participants’ attention is necessarily divided
between eating their dinner and paying attention to the material that the instructor
is covering. Instead, the instructors could talk participants through a guided eating
meditation. For example, the instructor would begin by inviting the participants to
pay attention to the appearance and aroma of the food, and inviting the participants
to observe their bodies, noticing if there are any physical signs of hunger or thirst.
12
Next, the instructor could invite the participants to take just one bite of food,
noticing its flavor, its temperature, and its texture. As participants continue to eat,
the instructor could encourage the participants to observe their emotional
responses to their food or the act of eating, noticing if they feel happy and
nourished, or if they feel worried or guilty for eating, without passing judgment on
those thoughts. It would be worthwhile to offer some quiet time, in which
participants can silently enjoy their food and practice observing their own
sensations, thoughts, and emotions. As the 12-week session nears completion, an
increasing amount of time could be devoted to the act of silent eating, as
participants become more familiar with and skilled in this process. However, not
every meal should be silent. It would be beneficial to have some “off” weeks, in
which participants are encouraged to converse while they eat, in order to emphasize
that eating is a pleasurable social activity as well as an opportunity to practice
mindfulness.
Yoga
Currently, each weekly session of the DPP includes about 15 minutes of
aerobic walking, guided by a fitness DVD. Adding yoga to the physical activity
component of the program would augment the effectiveness of the instruction in
mindful eating by training participants to be more attentive to the internal cues that
can guide them in mindful eating.
Our bodies are equipped with mechanisms that naturally help us regulate
what, when, and how much to eat. However, social conditioning (such as learning to
clean one’s plate at dinner), environmental factors (such as the ready availability of
13
delicious junk food, even when one isn’t hungry), and the frequent use of food for
emotional comfort teach many of us to tune out the physical sensations that indicate
hunger and satiety. One aspect of mindful eating is re-learning how to attend to
these internal cues in order to avoid over- (or under-) eating. Research has shown
that yoga practice correlates with improved body awareness and improved capacity
for intuitive eating (Dittman and Freedman 273).
In practical terms, incorporating yoga into the program could involve a
combination of:

Hiring a qualified yoga instructor (preferably someone registered
with yoga alliance at the RYT-200 level or above) to provide thirty to
forty-five minutes of instruction in basic, gentle yoga at one or more
program sessions. This would probably cost less than $50.00 per
session.

Having DPP instructors lead a few gentle, easy breathing exercises
and movements for five to ten minutes at each weekly session.

Providing yoga mats to participants as freebies or prizes, an
investment of approximately $10.00 per mat, if purchased at
wholesale bulk rates.
14
Curriculum
There are a variety of activities, handouts, and discussions that can be used
to instruct participants on how to cultivate more mindfulness in eating as well as in
daily life. The suggestions that follow are just some of the many possibilities.
The classic activity used to introduce the concept of mindful eating is a
guided group eating meditation in which each participant eats one very small food
item; the following explanation is loosely based on that provided by Jan Chozen
Bays, MD, in her book Mindful Eating: A Guide to Rediscovering a Healthy and Joyful
Relationship with Food. Most often, one Hershey’s kiss is distributed to each
participant; one grape, a single raisin, one cherry tomato, or one pretzel are other
alternatives. The instructor begins by inviting the participants to observe their own
initial state: are they hungry? Eager or reluctant to eat? Participants are then asked
to observe the food item with their senses. What does it look like? What does the
texture feel like in the participant’s hand? If it is packaged, what does the wrapper
look like, and what sound does it make while it is being unwrapped? Participants
may then be asked to observe whether their level of hunger and/or desire for the
food item has changed. After all this, the participants are then finally invited to eat
the food item. At first, they are told just to hold it in their mouths, and to observe its
flavor and its mouth feel. They are then invited to chew, slowly, noticing if the flavor
or the texture changes. As the participants continue slowly chewing and, eventually,
swallowing, the instructor continues to ask guiding questions: how does the
participants’ body feel in response to the food? Is there any emotional response?
Afterwards, participants are invited to discuss the experience (11-13).
15
Certain behaviors make eating with mindfulness easier to practice. For
example, if a person divides the food on his or her plate in half, it creates a visual
“speed bump” that can remind him or her to pause halfway through, notice if his or
her mind has wandered away from eating, and if necessary, refocus his or her
attention. A sample handout containing a list of similar tips is included as Appendix
1A.
As explained in the previous section on yoga, participants who are
accustomed to eating mindlessly may have lost their natural awareness of what
hunger feels like. Thus, instruction on mindful eating may include an explanation of
the sensations and feelings that typically accompany hunger. The instructor may
also invite the group to brainstorm other sensations or feelings that they
experience. An example handout to facilitate this explanation and discussion is
included in Appendix 1B. A numeric Hunger/Fullness Scale, such as the one in
Appendix 1C, may also be useful in helping participants understand and respond
appropriately to their own internal cues.
Conclusion
Incorporating instruction in mindfulness practices into the curriculum of the
DPP may enhance the program’s effectiveness at helping participants make the longterm lifestyle changes necessary for preventing progression from prediabetes to
diabetes. Mindful eating, meditation, yoga, and a philosophical framework that
emphasizes self-awareness, self-acceptance, and compassion may help participants
cope effectively with stress and address the psychological challenges inherent to the
weight loss and lifestyle change process.
16
Appendix 1
Sample Handouts
17
Appendix 1A
Mindful Eating Tips & Tricks
Before you eat:
 Pause and be grateful. Take a moment before you eat to think
about where your food came from, all of the work done by so many
people to bring it to your table, and all of the resources that went into
making it.
 Choose your portion size with care. Before you serve yourself,
notice how hungry you are, and make a mindful and appropriate
choice. Err on the side of serving yourself a little less than you might
need, since you can always go back for more, if you deliberately
choose to.
 Create ambience. Eating is more satisfying and enjoyable if you
take the time to set the mood! Play some soft music, light a candle, or
just take your time to set the table elegantly.
While you eat:
 Use a “Speed Bump” to remind yourself to slow down. After you
serve your food, divide your food in half on your plate. When you
reach the halfway point, take a moment to check in. Has your mind
wandered away from eating? If so, what were you thinking about?
(Remember, there’s no judgment here, just observation!) How is
your body feeling – are you still hungry, or are you starting to get
full? When you resume eating, recommit to your practice of mindful
eating.
 Just eat. Turn off the TV or the computer, put down your book or
your newspaper, and put your phone out of reach. Let yourself enjoy
single-tasking for a little while!
After you eat:
 Observe. Are you satisfied – Physically? Emotionally? Spiritually?
Where would you place yourself on the Hunger/Fullness scale?
Adapted from: Eat What You Love, Love What You Eat with Diabetes, by
Michelle May, MD, and Megrette Fletcher, M.Ed., RD, CDE
18
Appendix 1B
What Does Hunger Feel Like?
 Hunger pangs
 Growling or grumbling in the
stomach
 An empty or hollow feeling
 A slightly queasy feeling
 Weakness or loss of energy
 Trouble concentrating
 Difficulty making decisions
 Irritability or crankiness
 A slight headache
 Light-headedness
 Shakiness
 Feeling that you must eat as soon
as possible
Adapted from: Eat What You Love, Love What You Eat with Diabetes, by
Michelle May, MD, and Megrette Fletcher, M.Ed., RD, CDE
19
Appendix 1C
Hunger/Fullness Scale
1 – Ravenous
2 – Starving
3 – Hungry
4 – Pangs
5 – Satisfied
6 – Full
7 – Very Full
8 – Discomfort
9 – Stuffed
10 – Sick
Adapted from: Eat What You Love, Love What You Eat with Diabetes, by
Michelle May, MD, and Megrette Fletcher, M.Ed., RD, CDE
20
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Crow, Scott, David Kendall, Barbara Praus, and Paul Thuras. “Binge Eating and
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21
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22
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Interview with Megrette Fletcher-Hammond, cofounder of the Center for Mindful
Eating and author of Eat What You Love, Love What You Eat with Diabetes, dietitian
and certified diabetes educator.
11/15/13 10:30 am
What do you think are the main challenges people deal with when making
lifestyle changes in order to manage pre-diabetes or diabetes?
There’s the first challenge which is knowledge, that’s pretty typical. The second one
is finding changes that fit our lifestyle. We have a conflict [trying to go from] facts
or knowledge to behavior. There’s a difference between what I know and what I do.
How you integrate those two things? How do you integrate knowledge with
behavior? It takes practice. You have to do a lot of trial and error. If you think you
have to do it “right” that prevents us from trying and experimenting. Good science
isn’t saying here’s how to get a good outcome. It’s saying how do I get a good
outcome?
So the big challenge that I see… [is that] a lot of times we believe what we should a
achieve the standards. [This is what I have to do.] But the standards are just the
standards. So as an individual – an individual needs to say that’s what the
standards [are]. [Now] what am I doing? What are my lab values? What am I
eating? Instead of this is what I should do… the analogy is a map. Maps are very
useful if you have two piece of information: where you are and where you’re going.
You need both. If you only focus on where you’re going, and you never know where
you are [it’s not helpful]. Mindfulness is asking where are you? Mindful eating is
saying what is the experience of this bite in your mouth? So you know “My
experience is x. My experience is Y.” So many times patients come back and say “oh
I thought I could only do it this way.”
This is interesting that you focus on awareness of where the client is starting,
because the other dietitian I spoke with mentioned that denial is a big
challenge for people.
You can’t deny it this way. There’s no denial there. The thing is, I don’t care where
you start. Once you know [what your starting point is], I can come up with a plan to
get you where you want to be.
In my counseling I say this to my patients: you have to start from a place of I’m a
bright able person. You can’t start from this place of I’ve failed, I’ve caused this. I’m
a bright and able person, and I’ve dealt with other life challenges, I can deal with this
too. Psychologically we have to start from a place of I’m abler rather than I’m not
able. We can say I’m able and I also eat a diet that’s high in carborhydatate or that’s
contributing to diabetes… that’s very different from a not-able mentality. When I
say I’m not able, I caused this, it’s all my fault… you’re stuck in the quicksand of an
unpleasant place. Start in the place of I’m a bright and able person, I can do this…
it’s amazing how people really respond when they use their map. If they start from
that place, it’s amazing how much more willing people are to acknowledge “My diet
is really contributing to my blood sugar.”
How can mindful eating help with management of pre-diabetes or diabetes
and prevention of disease progression?
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Again, what I tell my client is I will say a lot of things in the next 50 minutes to an
hour. I usually take my hand and go “blah blah blah.” You know you’ll go back to
your doctor and you will say I don’t remember much of anything Megrette said, but
you ‘ll remember Megrette asked me to be curious. That’s what diabetes is about.
Mindful eating sparks curiousity, and curiousity is a lifelong behavior that
contributes to blood sugar control. We are curious about what we care about, and
we care about what we are curious about.
What makes mindful eating different from dieting or just “watching what you
eat”?
The aspects I believe are important are mindful eating asks individuals to evaluate
internal and external information. Internal information is info only you the
individual has. There’s no machine that can tell me your hunger, your fullness, your
appetite, your likes and dislikes. External information is information that is
available to all people – calories, time and place where you eat. Could include
observations like how quickly you eat . Mindful eating is asking each individual to
incorporate internal and external information when making food and eating choices.
When we make food choices that’s different from the act of eating. A lot of time in
nutrition we focus too much on selection and we’re not helping individual process
information once the food is in their mouth. Because for me in mindful eating were
including a different information set.
There’s also the nonjudgmental aspects of mindful eating. There’s no good or bad
food. Ultimately it allows freedom of choice to emerge.
How do you approach teaching someone how to eat mindfully?
You eat with them. You have to eat with people. You have to have them eat food.
You have to create direct experience. I know it’s hard, but it’s really important. It
isn’t so much about somebody coming in and teaching them. That’s too cerebral.
We have to create direct experience. We create experiments, we ask people to
actually taste this cookie. We eat chocolate. We engage in mindful eating at every
class. And every single class when we eat with people—it’s the most amazing thing
that happens. They light up. They are so excited by the experience. They start
making connections like you wouldn’t even believe. It works for everybody. There’s
no judgment. It’s very funny when they go back to their doctor and say she had me
eat chocolate! We eat crackers and there’ s lots of different food experiences. In the
[program] we talk about eating food, going out for dinner, potlucks , stuff like that.
It’s an important and necessary aspect of how we teach mindful eating. So the
analogy I use in my writing is it’s a lot like trying to watch baseball. You can watch
baseball your whole life and it doesn’t make a good player… you gotta put a glove
on, you gotta grab a bat, you gotta see what it’s like to actually get out there and
play.
Do you have any good stories from your own practice about how mindful
eating helped your clients?
I have lots of stories of people who got a lot out of mindful eating. Asking a
gentlemen to create an experiment where he ate something and then took his blood
sugar. He had a blood sugar of about 253 [at one point], and I asked what happened
here? He said I ate a bowl of raising bran. What did you get from this? Raisin bran
jacked my blood sugar. Then later his blood sugar [was less elevated]. What
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happened there? I had three glass of wine, four cookies and a beer – who would’ve
guessed that didn’t jack my blood sugars? You’ve got to learn: what does food do
for you? And that’s the thing that’s so interesting for people – they say things like
wow, I wouldn’t have guessed this would have happened. I had a lovely young
man… really elevated blood sugar, very high , 400 or 500. We talked and came up
with a plan, he came back in three months, he had been exercising, he lost 15
pounds. When his blood sugars were high, foods behaved differently than after he
lost the weight, and now that his blood sugar was down, he saw he could eat
[previously problematic] foods successfully. I love that he figured out how his body
responds to food changes due to lots of variables – weight, exercise, medication .
Here’s a person who did a really great job creating experiments re: how he could
manage his blood sugar. And I give him an inordinate amount of credit. And it
really was curiosity. He really is a curious person.
So it sounds like one of the key points is that this gives a sense of agency back
to the client, instead of telling them what to do. Would you agree with that?
And I think that’s really what we’re talking about. I really feel like when I present
mindful eating, when I go from the scientific perspective, let’s do this like good
science, let’s experiment and find out what works. We’re so hooked into telling
people this is what you need to do. That’s not good science. That’s not good
research. You have to ask people what happens when you do this? That’s good
sicence, that’s good research.
Any final thoughts?
This stuff is becoming mainstream. This isn’t woowoo stuff. This is pretty
mainstream. More people are seeing the usefulness of mindful eating.
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Interview with Julia Mutter
Thursday November 14, 2013, 1:59 pm.
We know that making lifestyle changes is an effective way to prevent the
progression from prediabetes to diabetes, but those challenges are hard for
people to make. What are their main obstacles, in your experience?
Mainly, people just aren’t ready. Either the health challenge isn’t the motivation
they need to get started, or sometimes people have a really bad family dynamic, they
have a lot of stress going on so they can’t focus on their health in particular. We
have people dropping out because they have to take care of other people, you know,
if someone else in the family is sick or they have kids. Having to take care of other
people hinders people’s ability to stick with what we ask them to do, the stuff that’s
required in order to beat this.
Sometimes people have other medical complications. Like for example, one of my
current people has MS, so it’s challenging for her to walk, to meet the [physical
activity] goal… other health obstacles sometimes prevent them from being able to
exercise at the level that we ask.
For people who successfully make lifestyle changes, do you notice that they
have particular characteristics?
Their likelihood of getting diabetes really has clicked for them. They’ve very
motivated to not get diabetes. Like “I saw diabetes kill my brother” or “I saw [what
diabetes did to] my friend, and I am NOT getting it.” A personal experience with
diabetes that is motivating. … people who do the work, do the exercise, and stay in
the range of calories that we ask them to have a lot better results than people who
sometimes do it, sometimes don’t. Attendance is a big factor. It shows their level of
commitment to the program.
What sort of complaints or concerns do you hear that come up for people a
lot? What makes it challenging for people to stick with lifestyle changes?
Especially long term?
I can kind of tell who will stick with [the lifestyle change] long term. For example,
my day class right now is very challenged, because I don’t know what their long
term motivation [will be] without the weekly support. There are some things that
come up again and again. We do this class on negative thoughts, and that’s a big
thing. I can’t do this. I’m a failure. This is too hard for me. People get in the
mindset of the negative thoughts. Another things that hurts people is excuses . It’s
too cold to walk. My metabolism is too low. Someone told me that this week. And
it’s like, actually, most peoples metabolism falls in a normal range. If you have a
thyroid issue, that’s different, but most people can build the lean muscle that they
need to lose the weight. Any kind of excuse people come up with. Another thing is
denial. I’m doing everything I can, I worked really hard this week. When you look at
their book, it’s like, this isn’t what we talked about at all. When you have any kind of
lifestyle change, people come up with excuses. Same thing for smoking cessation.
What is your subjective impression of how well people do with making longterm changes? What happens to people after the program is over? What do
you observe in the support groups after people have completed the class?
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340 people have come through the program in the last five years. We do three
sessions a year. We average like ten per class. [I] have between 20-25 in my night
support class, and it really ranges as to who comes. I have six people who always
come. And a bunch of people who sometimes come. I have about ten in my day
support class. I think the night support class-- I’ve found the people who come to
the night class struggle more. The day class usually they’re retired. A few times
there are moms or people who work at night. But typically the day class is older,
over 65. Night class ranges between in their 40s to in their 60s, and a lot of them
are still working. I think that’s why they struggle, because they’re managing [so
much]… you know, they work, and someone has a six year old, eight year old, and
it’s a lot to manage, taking care of the diagnosis and taking care of other people.
Anything else you’d like to add?
As for ways to improve program-- Right now we currently don’t [collect] lab
[results] [after the end of the program]. Which I think is a huge issue. Like if you
can’t get the data, once they stop coming, they’re less likely to get the data
themselves.
I’d like to see a second class, like a graduate class. The DPP in Pittsburg is 22 weeks.
It’s actually double the length of our class. 1.5 hours for first four weeks, then [less
than that for the rest of the 22 weeks], then month to month for the long term. They
knew that an extra 12 weeks was required, it might make them come and make
them more accountable to get their labs done. I would also like to see insurance
companies cover prediabetes, they’d save millions of dollars cause it’s easier to
prevent the disease rather than treat it. Slowly insurance companies are starting to
cover like gym memberships and that sort of thing.
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