Episode 103: What’s Missing from Diabetes Management Education with Nikki Estep

Hola amigos! Welcome back —–

Why is diabetes management so difficult?  Whether you have diabetes, are caring for someone with diabetes, or are a healthcare provider for people with diabetes, you don’t want to miss this cutting-edge approach from Nikki Estep. Listen in and learn about the role of emotion in diabetes management.

First a little intro about our guest

Nikki Estep is a Registered Dietitian Nutritionist (RDN) and Certified Eating Disorder Registered Dietitian (CEDRD) and owner of Mindful Eats Nutrition. She (and everyone at Mindful Eats Nutrition!) practice from a Health at Every Size (HAES) lens. She has expertise in eating disorders, pediatric nutrition and feeding issues, diabetes, pregnancy, PCOS, and intuitive eating. It is her greatest joy to help people make peace with food and their body.

Nikki grew up in Louisiana and moved to Texas when she attended Baylor University for her undergraduate education. She received her Bachelor’s of Business Administration from Baylor University, her Bachelor’s of Science in Nutrition from Sam Houston State University, and her Master’s of Public Health in Health Promotion and Behavioral Sciences from the University of Texas Health Science Center in Houston, TX. Nikki completed her training to become a dietitian through UTSPH and also had the opportunity through UTSPH to complete the LEAH Fellowship, receiving specialized training in treating eating disorders and adolescents.

Nikki uses a relational, humanistic, embodiment, and emotion-focused approach to her work with her clients. She  helps clients explore their inner landscape around food and body and establish first safety and then peace with both. She has advanced training in Emotion-Focused Family Therapy and also offers parent coaching using the EFFT model for parents and any caregivers supporting loved ones with an eating disorder. Her work is trauma-informed. Mindfulness is also at the center of my work and is a daily practice I engage in myself.

Nikki is also a mom to 3 kiddos and lives in the Houston area. She is forever curious and always learning, personally and professionally.

Highlights of topics we discussed on today’s show

• Emotion-Focused Family Therapy
• Client-Centered Care
• Adverse Childhood Experiences
• Social Identity Threats
• Trauma-informed care
• Diabetes Management Without Judgment

Full Description: 

What is Emotion-Focused Family Therapy?

[2:46] Nikki’s clinic, Mindful Eats Nutrition, takes an emotion-focused family therapy (EFFT) approach to heal clients’ relationship with food. This approach honors the client’s emotion combined with behavioral therapy to make therapy more effective. Nikki works with adults and children.

What’s Missing with Diabetes Management Education?

[9:40] Nikki expresses, “with a traditional weight-centric approach, I never felt great about what I was doing.” Based off her experiences, traditional diabetes education didn’t feel like a person-centered approach. When you come into a patient’s room with lists of dos and don’ts, the person’s body language changes. You can tell they are guarded. People feel shamed, and shame can create engagement, while others shut down completely.

Nikki worked with families with limited resources, which makes the health picture complicated. She turned her focus to learning about adverse childhood experiences (ACE) and the effects of poverty. At a pediatric clinic, Nikki received weight loss consults from the doctor and later, parents would come back in with worries about their child not eating. Nikki wanted to stop using weight as a metric and started asking, how can we help people live a life that is meaningful? Instead of weight screening, how about food security screening?

Asking questions like this creates trauma-informed care. This care understands that clients’ access to resources varies and providers need to be sensitive and mindful to that. Get consent, stop just giving out pamphlets, and have a conversation.

[21:00] What other metrics can we use besides weight? How about asking questions like, “what is it about your life that is not aligned with your values?” “What is happening in your life that feels out of line?” “Is that what you think you should do or are you being told what to do?” Nikki validates her clients’ emotions and stays with her clients’ values. She helps people experience their body with trust rather than sending the message that their body is wrong and broken. With Nikki’s approach, clients learn what feels good to them. There’s not one thing that is right for every single person.

What Healthcare Providers Get Wrong

[26:10] Many providers operate on a hierarchal relationship. The provider is the expert and the client does not a say in treatment. This creates a social identity threat.

For example, provider places the client on a diet. Diets are traumatic. The person is following another social identity and this threat creates a flight or fight response.

With understanding the brain’s limbic system, we can guide our clients through their emotional response, stop the threat, and then learning can happen. We should not create a situation of hierarchy. When a person feels trapped and does not have a choice, that is how healthcare creates trauma.

Weight is set of hierarchical standards. Shame around larger bodies is constant. Trauma-informed care acknowledges the patient is the expert of their lives and asks for patient consent. But what if the patient sees the provider as the expert? Nikki explains, they have to careful not to push their own agenda. Nikki wants a partnership with clients, this is a new healthcare trend that is becoming possible now.

Social identities like weightism or ageism, are social constructs. In a healthcare setting, social identity threats can increase the risk of death by 60% independent of body mass index (BMI). Studies have shown racism and stigma increases trauma and risk of death. See links below.

How to Approach Care Considering Adverse Childhood Experiences (ACE) 

[30:40] Nikki recommends healthcare providers read The Deepest Well, a book that discusses ACE and diabetes risk. Depending on the definition of trauma, trauma is ubiquitous. Part of the trauma experience is when the person is powerless. Healthcare providers have to be thoughtful by asking for consent to talk about client’s issues so the client won’t feel trapped. By asking, the client has choices.

David also recommends reading Running on Empty, a book about emotional neglect, which is similar to ACE. He points out that emotional neglect can be subtle, or take the form of permissiveness.

One of the pillars of EFFT is that every parent is doing the best they can with the resources they have at the time. The provider validates the emotions of the client. In traditional dietetic training, we are not taught how to deal with client emotions. When you tell clients what to eat, you set off an emotion response.

How Intuitive Eating Honors Personal Identity

[36:20] David points out that leaving dieting behind can also be leaving behind an identity. If I am not dieting, who am I?  Leaving the clutches of diet culture can provide personal freedom, which can be scary. Part of what makes us human is feeling like we have to fit inside a box that someone else dictated for us. We want to protect ourselves from shame and embarrassment when we don’t fit into a box.

Health at Every Size (HAES) and Intuitive Eating offer us a bigger box, or landscape to play in. It gives us permission to operate as who we are.  Nikki offers counseling without judgment, giving people choice, and body autotomy.  The “box” is safe, a comfort zone. Coping mechanisms are safety, so that is why there is no judgment. EFFT allows a space to create new coping mechanisms if the person is ready and gives consent.

[47:55] 3 Ways to Approach Diabetes Management with Trauma-informed Care

1. Validate the client’s emotions.

Many clients come into counseling with a desire to lose weight and cut carbs. Our culture says that if you don’t do those things, bad things are going to happen. If you don’t do it, then it’s your fault. You are to blame. It’s your weight that caused this.

Nikki tells clients it is not their fault. Diabetes is super complicated. Genetics are a huge part and there are other pieces too. You cannot start the educational piece without validating the client. This is a principle of emotion coaching. When emotion is on the top floor, logic and problem solving are impossible and take a backseat.

2. Treat the physiology

The best thing we can do is treat the underlying influence systems and have the client move in a way that makes sense to them. Nikki begs, can we treat the physiology please?  There are four types of Type 2 Diabetes. We have to stop pushing the idea that diabetes is because of weight gain.

Reducing carbs is only treating the symptom of insulin resistance. Use the new tools available, like medications, to treat insulin resistance. Metformin is widely available. A supplement, inositol, assists with cell signaling to help insulin function. Movement – such as walking – is huge insulin sensitizer.  Anything counts when it comes to movement. Doing household chores, breathing exercises.  Going to the gym and getting a personal trainer is only an option for some. Seeing movement in a whole different way. How can we use movement as a way to connect to the body? This can be triggering for people at first.

How This Dietitian Helps Diabetes Management

Nikki provides education on diabetes pathology and how nutrition can help management. She advises, you can only get to the eating part after the emotions are processed. Questions she likes to explore are, “what is your blood sugar doing after eating?”  Nikki recommends non-judgment curiosity with the blood sugar and food logs. What questions do we have after gaining this data?  Does this mean I cannot have pizza or pancakes?  Nikki slows down jumping to conclusions and looks at the bigger picture.

Where do I go from here?

Nikki’s clinic, Mindful Eats Nutrition, provides free blogs for further reading, such as “Four Reasons Diets Don’t Work.”

Links

• Nikki’s private practice: Mindful Eats Nutrition
• The Deepest Well, book
• Running on Empty, book
• Study: Weighed down by stigma: How weight-based social identity threat contributes to weight gain and poor health
• Study: Weight Discrimination and Risk of Mortality
• Study: Overcoming Weight Bias in the Management of Patients With Diabetes and Obesity

Big Ask: Leave a Review

Please, take a few minutes and leave me a review. Each review helps other listeners find the podcast, which provides me with the ability to continue bring you unique content. So spread the love. Loss for words? Just write what you like about the show.

Stay Connected!

Come and join our new One Small Bite Facebook community! Take part in the great conversation and become a member of a community that’s chopping diet culture, asking thought provoking questions about health at every size, and building positive relationships with food.

Interact with us on social media channels: Facebook, Instagram, Twitter, or feel free to message me. You are also welcomed to go to my private practice, Orozco Nutrition website to reach me there.

Once again, I greatly appreciate you for listening and supporting my show. Remember, it really only takes “One Small Bite” over time to transform your life, so let’s – Chop the diet mentality; Fuel your body; and Nourish your soul!