While it’s important for people with diabetes to follow a healthy diet, being overly restrictive with food choices can sometimes lead to unhealthy eating patterns. Hear from several diabetes nutritionists about how to have a healthy relationship with food while achieving self-management goals.
Healthy eating is the cornerstone of effective diabetes self-management. However, for some people, close attention to meal planning can cause anxiety and unhealthy eating behavior.
When Attention to Diet Becomes a Health Concern
CJ Walker, a Virginia-based patient advocate and leader for her local Diabetes Sisters Chapter,
said diabetes drastically changed her relationship with food. After a gestational diabetes diagnosis, Walker took steps to prevent type 2 diabetes with a low carbohydrate diet.
However, nine years later, Walker was diagnosed with type 2 diabetes. Believing she needed to be more intentional with her diet, she joined an online diabetes group that promoted a very low carbohydrate “keto” diet, which limited her daily carbohydrate intake to 30–50 grams.
“Seeing the results from the community members convinced me to join for accountability and support,” Walker said. “There were strict guidelines about what you could and couldn’t eat. And you could be blocked if you posted about eating restricted foods. I meticulously followed the guidelines, eating all the ‘safe foods,’ including meat, cheese, eggs, and low-carb vegetables.”
Over time, Walker’s eating habits became more restrictive. She took her “safe foods” to restaurants and other social events. Her A1C dropped from 10.7 to 4.5. “Everyone in the community praised me, and I really believed I was on the right path,” she said.
However, her quality of life and health suffered. She began to avoid social events because it was too much work to bring her “safe foods.” She scheduled her day based on a rigid eating schedule.
“I experienced a severe lack of energy and was unable to complete household chores,” Walker recalled. “There were fluctuations in my weight, and I had acne, brittle nails, and hair loss. There was a huge impact on my mental health. My mood was always depressed and sad.”
In January 2022, Walker found out that she had LADA (Latent Autoimmune Diabetes in Adults) and was initially misdiagnosed with type 2 diabetes. The realization of her misdiagnosis was a shock, and it compelled her to change her approach.
Walker said, “After realizing that there was nothing I could do to stop diabetes from progressing, and that I couldn’t go through life the way I was, I sought help.”
Walker was diagnosed with an eating disorder and malnutrition. She is now under the care of a therapist, a certified diabetes care and education specialist (CDCES), and a registered dietitian nutritionist.
“My CDCES is helping me expand my food choices while staying vigilant about diabetes,” she said. “My therapist helps me eliminate the toxic ideologies I adopted regarding food and carbohydrates, while my registered dietitian helps me adopt an intuitive eating style.”
Intuitive eating is an evidenced-based approach that promotes a diet based on internal cues of hunger and fullness, body acceptance, and making food choices based on health as well as enjoyment. Intuitive eating is also associated with psychological well-being—measured by self-esteem, optimism, proactive coping, and overall life satisfaction.
The Links Between Diabetes and Eating Behavior
The daily grind of living with diabetes—following a healthy diet, counting carbs, monitoring weight, and frequent monitoring of blood glucose – can sometimes lead to an unhealthy relationship with food, disordered eating, or an eating disorder.
Research shows that individuals with diet-related chronic illness, such as diabetes, are at a higher risk of developing disordered eating and eating disorders. These individuals typically put more focus onto their diets than the average person. For example, individuals with type 1 diabetes often report feeling excessively preoccupied with their diet. Emphasis on type, quantity, and quality of foods eaten, as well as timing of food intake, can lead to restriction of food and adoption of dietary rules. People with type 2 diabetes are more likely to report a lack of confidence in their ability to follow their recommended diet.
People with diabetes may feel a loss of independence or a loss of control over themselves or their eating.
“This can lead to denial, rebellion, or perfectionism behaviors,” said Nancy Farrell Allen, national spokesperson for the Academy of Nutrition and Dietetics. As a result, she said, individuals with type 1 diabetes may intentionally take less insulin as a perceived way to regain control. Intentionally restricting insulin is also frequently reported in individuals with type 2 diabetes who are treated with insulin.
Diabetes may also increase body dissatisfaction. For example, people with type 1 diabetes often experience weight loss prior to diagnosis, followed by weight regain after starting on insulin therapy. Body dissatisfaction and concerns about body shape increase the risk of developing disordered eating.
Farrell Allen, who specializes in eating disorders and nutritional psychotherapy said “Insulin injections may lead to unwanted weight gain and result in fear of using insulin,” she said. “So, food restriction may occur in an attempt to limit insulin use. Adolescents with type 1 diabetes are especially at risk here.”
Allison Milch, a registered dietitian nutritionist from Westchester County, New York, recounted her experience when she was diagnosed with type 1 diabetes at 15. “I had a lot of trouble understanding my changed body and how I felt physically,” she said. “I cut out carbohydrates and, not surprisingly, binged on low-carb foods as an attempt to compensate for the energy I was missing. Plus, I feared that any amount of insulin I was injecting would cause weight gain, which I perceived as highly negative.”
Depression and psychological distress are also associated with eating disorders. People with diabetes are twice as likely to experience depression compared to individuals without diabetes. And between 55–98% of people with an eating disorder have depression or anxiety.
Jessica Setnick, an eating disorder dietitian, said social and cultural beliefs can also lead to unhealthy eating behaviors in people with diabetes.
“The mythology of diabetes that’s out there in the world is a real dilemma,” she said. “People associate diabetes with sugar, not being able to eat the things you like, or it’s your fault.” For example, she added, individuals with type 2 diabetes, especially if they have excess weight, are often blamed and stigmatized for their disease. Studies show that experiencing weight stigma makes people more likely to engage in unhealthy eating behaviors.
Eating Disorder vs. Unhealthy and Disordered Eating
Disordered eating behaviors are common among people with diabetes and occur on a continuum from unhealthy eating behavior to an eating disorder. Eating disorders, such as anorexia nervosa, bulimia nervosa, and binge eating disorder, are diagnosed according to very specific and narrow criteria. However, disordered eating is a broader term to describe a range of irregular eating behaviors that may or may not warrant a diagnosis of a specific eating disorder.
Instead of “eating disorder,” Setnick prefers to use the term “dysfunctional eating behavior” because most people with eating disorders don’t meet the diagnostic criteria. “Everyone has eating behavior,” she explained. “If those eating behaviors are functioning and working well in that person’s life and supporting their goals, then great.”
Developing a Healthy Relationship with Food
Traditional diabetes diets are often counterproductive and can lead to psychological distress and unhealthy eating behaviors. Moreover, studies show that non-diet approaches (such as intuitive eating) can be more effective.
Registered dietitian Amanda Ciprich, owner of T1D Nutritionist in Bridgewater, New Jersey, says intuitive eating can be incredibly beneficial for people with diabetes.
“Many times, people with diabetes are told to limit, restrict, or avoid certain food groups. Intuitive eating helps them gain control over their food choices once again,” Ciprich said. “With intuitive eating, people with diabetes are able to pair what they know about their body’s needs and their blood sugar patterns to support their decision-making around mealtimes.”
Preliminary studies on intuitive eating in adolescents with type 1 diabetes and individuals with type 2 diabetes show that it may improve glucose management.
“With my intuitive eating style, instead of limiting all carbohydrates, I am learning how to incorporate them into my meals without feeling guilty and scared of how it will impact my blood sugar numbers,” said Walker. “Instead of skipping meals like in the past, I am honoring my hunger cues. Eating intuitively has allowed me to live life again, to eat at a restaurant with my husband for date night, or an ice cream day with my family.”
Learning to eat intuitively can help you develop a healthy relationship with food. The following strategies can help you get started.
Work with a registered dietitian nutritionist (RDN). If it is within your means, work with a dietitian to find a way of eating that supports your lifestyle and preferences. “I recommend working with an intuitive eating RDN who also understands diabetes. A RDN will provide guidance on expanding the possibilities surrounding food,” said Milch.
Make peace with food. Stop the food fight and create a peaceful connection with food instead. There are no “good” or “bad” foods. Milch said: “I wholeheartedly believe that self-compassion is the key to making peace with food, whether you have diabetes or not. As a result, I have integrated gentle nutrition strategies to prevent blood sugar spikes. For example, I pair carbohydrates with other food groups, including proteins, fats, and fiber. In addition, years of experience have helped me determine how to dose my insulin for these foods.”
Cope with your emotions with kindness. Ciprich explained that when you spend time and energy measuring carbohydrates and calculating insulin, it makes sense that you may feel strong emotions when your blood sugars don’t stay in range. It is easy to blame yourself and the food that you ate. However, there are over 42 factors that can influence your blood sugar—insulin and food are only two of them. “Instead of blaming the food or yourself, consider asking yourself, without judgment, what went well and what could be improved,” she said. “When you take a moment to pause and assess the situation, you are able to use this situation as information and motivation the next time you eat different foods rather than guilt.”
Rely on internal hunger and satiety cues. A common misconception about intuitive eating is that it is just “eat when you’re hungry and stop when you are full.” But, it is a bit more complicated than that.
Ciprich recalls early in her diabetes diagnosis that she would try to strictly limit carbohydrates at mealtimes just to avoid a spike in her blood sugar. “But, once I got started eating, it felt like I couldn’t stop, and I would end up eating seconds and thirds,” she said. “When you listen and trust your body’s hunger and fullness cues, you end up taking your insulin more effectively because you are giving yourself permission to eat based on what your body needs at that moment, not what you think you should be eating for your blood sugars.”
Milch agreed that relying on hunger and satiety cues can be complicated, especially during episodes of lows or highs. “If I am experiencing low or high blood sugar, I know I cannot fully rely on my hunger and fullness cues to regulate my food intake,” she said. “I try my best to nourish myself and ensure physical comfort for my body.”
“Ultimately, food is one part of a positive, health-sustaining, enjoyable life. So, if you feel like the way you’re eating is detracting from that, talk to someone,” Setnick said. “Get the facts and not the mythology around diabetes.”
A healthy relationship with food takes time and conscious effort, but it’s possible—even if you have diabetes. Ciprich agreed, “You can absolutely enjoy food AND manage your blood sugars—you don’t have to choose between one or the other.”
Click here to find a registered dietitian nutritionist near you.
For more information and guidance on eating disorders, visit The National Eating Disorder Association website.