Is 'Diabetic' a Dirty Word? A Doctor and Patient Debate

Interviewer: Eugenia Yun; Interviewees: Kelly M. Rawlings, MPH; Richard M. Plotzker, MD

Disclosures

June 13, 2019

Is "diabetic" a dirty word? Cynthia Rissler says it is, explaining that her son has diabetes, but he is not a diabetic. "Just because you have diabetes, it does not mean that the disease is allowed to name you," she told Diabetes Daily." It can never change who you really are."

Laura Kronen, on the other hand, has never found anything offensive about being called a diabetic. "I am proud of saying I am a diabetic," she writes in her blog. "It shows strength and dedication. It shows determination and perseverance. It's a badge of honor that I wear proudly."

So which is it? Last year, Medscape asked readers whether the term "diabetic"—used as a noun to refer to a person—should be retired from clinical use. Only 27% of respondents agreed that it should, whereas 66% disagreed; 7% of respondents said it depends on the circumstances.

To get some more insight into both sides of the argument, we invited Kelly M. Rawlings, MPH, a journalist living with type 1 diabetes, and Richard M. Plotzker, MD, an endocrinologist with 40 years in practice, for a friendly chat.

How do you feel about using the word "diabetic" to refer to people living with diabetes? Is this a term that should be banished?

Kelly M. Rawlings, MPH

Rawlings: What an opportunity! Two humans who care intensely about the art and science of healthcare get to converse about a meaningful topic.

Should "diabetic" as a noun be eradicated? Of course, other things are far more important to eradicate first: malaria, domestic violence, trans fats.

Yet the words we use in health-related interactions directly and indirectly affect individual experiences and population-based healthcare. So, readers, please think along with us, even if you don't think like us.

Richard M. Plotzker, MD

Plotzker: Nomenclature has always had its bright and dark sides. Mark Twain described Jim and Joe sympathetically with words that in some libraries keep Huckleberry Finn and Tom Sawyer under the librarian's desk, but they are still literature. In some of our Jewish liturgy, "forefathers" have become "ancestors" in English translations, though the original Hebrew texts remain untouched.

Means of identification change with the sensibilities of the times, sometimes with disruption. I think the upside of identifying a person with diabetes as a diabetic remains mostly helpful to the people who have this increasingly common disease.

Rawlings: I'm a wordsmith by profession and inclination. I don't believe in banishing words, or books. Instead, I support consideration of context. I ask healthcare professionals—and all word users, for that matter—to think about how they refer to people living with diabetes. And that means doing so when people living with diabetes can hear or see the word choices as well as when they can't.

Kelly, as a person living with diabetes, have you had any negative experiences associated with this word?

Rawlings: I am now going to roll out an "n = 1" flashback. Picture a neighborhood in a suburb of Kansas City. The boy across the street pedals by on his bike. I will neither confirm nor deny that a preliminary sidewalk talk occurred. I don't remember his name. But I do remember his taunting words: "Diabetic, diabetic, diabetic!"

Plotzker: There is no disagreement that people with diseases, dysmorphic or not, should not be taunted because of it. Most of us are familiar by now with a successful Presidential candidate publicly ridiculing a man with a contracture while adults in the room cheered him on. And as a man who is 5'4" tall, I've been called "Shorty" on occasion, which is generally not done in the kindest spirit.

Anyone missing a limb can describe public stares. However, that is not what we teach our children to do. Most parents would scold their child when they learn of this type of conduct.

It is among the roles of advocacy organizations, such as the American Diabetes Association, to minimize these gratuitous attacks on people with diabetes, and to remind the public that diabetics include Hall of Fame athletes, heads of state, Supreme Court Justices, and highly visible entertainers.

Nomenclature doesn't really change the taunts, especially when they go from one child to another. Were it not the term "diabetic," it would be the witnessed hypoglycemic episode on the playground, incontinence from polyuria in the classroom, or—even in this day—exclusion from a class trip by a teacher unprepared to deal with what might happen. This is the role of advocacy, not terminology.

Rawlings: I ought to have recited the "sticks and stones" adage more often!

I agree that advocacy organizations have a role in investing time, money, and volunteer hours in public relations and campaigns that show that it is possible to manage diabetes and live full and rich lives. Those efforts tend to be sound bites, however, easily lost in the clutter of our media-rich world. Plus, there are many other advocacy areas in need of investment: access to insulin, disproportionate heart and kidney outcomes, high-deductible health insurance plans.

Rich, Kelly shared a personal story to demonstrate how this word can be harmful to patients. Do you see any advantages to using "diabetic" as a noun?

Plotzker: Identifying people as diabetic immediately and compactly enables people to think about their needs.

From the perspective of the person with diabetes, the label acculturates them to eat properly, track their glucose levels, take precautions from medicine misadventures, and take control of their reality in many other ways.

From the perspective of associates, most people know friends and neighbors who are diabetics. When they invite them to dinner, they will go out of their way to accommodate dietary menus. At public events, anticipation of diabetics in attendance will generally result in sections on the refreshment tables labeled "sugar-free," and often with culinary parity to the sweets-laden pastry table. Organizations put sharps containers in their restrooms as the public becomes more aware that people with diabetes need to inject themselves while on site.

Rawlings: Yay for accommodations, especially those that enable people to fully participate and that protect the public from blood-borne illnesses. But I don't see how calling people "diabetics" rather than "people with diabetes" necessarily encourages them to do their self-care tasks on a regular basis.

There are also a lot of assumptions made with such things as sugar-free desserts—they typically lack in flavor, and still require use of endogenous or exogenous insulin and assessment of where they fit in the daily calorie budget.

Sure, I appreciated Tab and Dream Whip and sugar-free Kool-Aid sweetened with Sugar Twin as a kid. Today, I appreciate choices with information. Simply supplying nutrition facts for food served (and considering whether anyone actually needs selections with added sugar for breakfast, snacks, or other meals) is more helpful. That gives all people, including those with insulin resistance or no insulin production, important information that can be used to make informed choices.

In our Medscape poll, about two thirds of respondents answered that this term should not be banished. Is the use of this word different in the clinical setting?

Plotzker: Perhaps the most compelling reason to preserve the all-encompassing term "diabetic" might be its effect on the medical community. When a patient at hand or in discussion is labeled "diabetic" at presentation, the mind of the healthcare professional expands to address special possibilities regarding infection, and fine-tunes questioning and examination of the patient from general to focused (eg, not overlooking a foot inspection).

The standards for lipid control and blood pressure are a little more meticulous, so the healthcare professional automatically thinks in terms of targets and whether they are achieved. All of these aid in efficiently focusing care, much to the benefit of the people who already have diabetes in various stages of management.

Rawlings: I do hope that naming and recognizing diabetes and its related conditions encourage gold standards of care in our too-short time together as patient and healthcare provider. Yet I think that solid clinical protocols are more likely to ensure that.

When the term "diabetic" is chosen by a healthcare professional as a noun to refer to or describe a person living with diabetes, it's probably just shorthand. I respect that the conscious intent is not disregard of our individual situation or all the qualities we have and the roles we inhabit, but rather efficiency and effectiveness. But what about implicit bias?

To counteract the unfortunate stigma, shame, and blame that greet nearly any chronic condition or disability, I'm in favor of person-first, strengths-based terms. Descriptors (adjectives) are fine. When used without invitation, however, nouns based on diseases, conditions, and disabilities set up an "us" and "them" polarization.

Plotzker: We pretty much concur on all of the elements needed to enhance the lives and futures of those with diabetes. People with this disorder have an obligation to themselves to become its master to the extent that medical capacity will allow. Friends and neighbors have an obligation to keep them in the mainstream and make accommodations to their diets and medical needs.

Employers and educators have increasingly recognized the many talents that these people possess. The medical community provides care in a thorough and kindly manner. All of these are shared goals—greatly advanced in my professional lifetime—that transcend terminology.

The more challenging element, though, is when common descriptive classifications should be abandoned in favor of different words. Much depends on connotation and intent, as they reflect public sensibilities.

Much of our racial and ethnic terminology has transformed, replacing what was condescending or hostile with something more neutral. Some patients still call the women at the clinic front desk "your girls." In another era, that grouping intended to convey a status gradient and probably a capability gradient. Yet, as my patients—both men and women—refer to my staff that way, they are invariably respectful of them and appreciate their office operational skills (which I lack). They have just retained an imprinted colloquialism.

I think referring to somebody with diabetes as a "diabetic" fits into that category. Our behavior toward these people remains steadfastly benevolent.

In my professional lifetime, that same terminology has transformed from a classification of fear (as in, can I handle this child on a class trip or should she stay home?) to one of inclusion in social activities, sports, and professional opportunities. We have identified a group of people with special needs, abandoned much of the fear, and welcomed them into the mainstream. To change that, I think, would be more disruptive than helpful.

Follow Eugenia Yun on Twitter: @EugeniaYun

Follow Kelly Rawlings on Twitter: @KellyRawlings

Follow Richard Plotzker on Twitter: @rmplotzker

Follow Medscape on Facebook, Twitter, Instagram, and YouTube

Suggested Reading

The Use of Language in Diabetes Care and Education

Diabetes Australia Position Statement: A New Language for Diabetes

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