For the PWD of any kind, the challenge of finding body positivity is exacerbated by the need to wear medical devices, the struggle with weight control some face, things like scarring on the body, and just the feeling, overall, that your body has failed you.

And there is of course the stigma and “blame” that the general public associates with any type of diabetes.

“Even with type 1 (and often with type 2), others say, ‘Oh, you must have caused your diabetes,’” says Patience.

She points out that her first step with a patient is reminding them that with type 1 or type 2 diabetes: This is not your fault.

“There is no reason to blame yourself,” she says. “Body size is not a direct indication of whether you take care of yourself or not.”

There are other specific other body image challenges that come with diabetes, she adds, pointing to these as just a few:

• Visible devices that draw attention to the person or the body
• How clothes fall on the body around those devices
• Scarring, such as lipohyperatrophy from years of shots and insulin pump sites, which, Patience says, while not always visible to the world, is visible to the person who has them

All this can lead to dangerous reactions in PWDs.

Marcia Meier, program manager at the Patient Services International Diabetes Center in St. Louis Park, Minnesota, has treated over 500 diabetes patients with eating disorders and other body-related struggles since 2005.

The ugly truth, she tells DiabetesMine, is that the impact of negative body image on PWDs, particularly women, can be profound.

“About 36 to 40 percent of women with type 1 diabetes manipulate insulin to control their weight,” she says.

“There is this concept of insulin use equals fat, and right there, you’ve got a predisposition to some of those problems.”

Meier traces the issue back to the general public, of course, but also to a place that may surprise many: the endocrinology office.

“Just about every article you read, all that you can pick up right in your endocrinology office, clearly says that insulin causes weight gain,” she says.

“Most women want to be a body size that is smaller than they are, diabetes or not,” she says.

The dangerous difference between the PWD? Access to a relatively simple yet life-risking way to drop the weight.

“Most people do not have the kind of touch on the body that people with diabetes do,” she says. “All a person with diabetes had to do to lose weight is not do something. They don’t have to exercise or starve. They just have to omit their insulin.”

Of the patients she’s treated, she says negative body image “has been a part of (the struggle) of every single one of them.”

It’s not always insulin omission, though. She’s had a diabetes patient who purposely let her glucose levels run low because “she only gave herself permission to eat when low.”

This drive to be thin does not necessarily stem from being raised in a household judging you. In fact, Meier says, even the person raised with all the right cues can fall prey to public comment.

“That’s a huge challenge I see. You can be raised (with body positivity) in your household and literally delve into an eating disorder from one thing a person says.”

It could be as simple as your aunt saying you should skip the dessert so you don’t get fatter and “worse with your diabetes.” Or a magazine spread with the “plus-sized models” who are actually a size 8 or 10. Or the doctor who tells you your weight is the cause of all troubles. One negative comment is all it takes, she says, to set a person down a dangerous road.

Like so many other things, this takes a village. PWDs need the world, media and yes, their own doctors, to understand and embrace this, experts say. They also need themselves.

Some ways to build body positivity include:

It starts with you. Patience says when a person meets with her for the first time, she’s quick to strike down any self-negativity.

“People come in and make derogatory remarks about themselves because it’s been normalized so much,” she says. “I tell them right away: it’s not acceptable here.”

She helps those struggling learn, understand, and, most of all, embrace seeing that their body does many good things for them every day and that loving it for that helps overall health.

Meier agrees, adding that while society needs change here, “I cannot change the world. What I can do is help them deal with those comments.”

“They need to develop a belief system so that when things are said to them (even by doctors), they can recognize that — even if coming as well-intentioned — those comments may not be healthy for them, or even be the truth. It’s about not believing everything you hear and read.”

PWDs also need to recognize the good that both their body and insulin does, Meier says, as well as the good technology they may wear does.

For example, beauty queen Sierra Sandison was a teenager when diagnosed with type 1 diabetes, and due to body image notions, she pushed off getting a pump and CGM for a period of time.

“I was a senior in high school and already having a hard time with body image when I was diagnosed,” she tells DiabetesMine.

“I was angry at my body before that, and once I was diagnosed, I was angry at it for what I saw as failing me on the inside too.”

She decided to hide her diabetes until she heard about Miss America 1999 Nicole Johnson, who has type 1 and proudly displays it.

That led Sandison to make it into the 15 finalists for Miss America as Miss Idaho 2014, where she walked the stage in the bathing suit competition proudly showing her pump. Thousands followed her lead, making the hashtag #ShowMeYourPump go viral, and more importantly helping others heal as she did herself.

“Now I’m like: if someone does not want to date me because I have a pump, good riddance,” she says.

Finding medical support that “gets it.” Patience is one of more than 17,000 medical providers who have signed on as part of the “Healthy At Every Size” movement that provides resources and encourages healthcare professionals to take a pledge to be aware, respectful, and compassionate of all issues surrounding body size.

More and more providers are adopting this, and Patience suggests you seek them out, or ask your medical provider to check it out.

Hafita said it can be life-changing when you seek out a medical expert who understands that if you are a bit overweight, it makes no sense to focus on fault.

“Weight gain is a chronic disease,” she says. “No matter how many ‘mistakes’ you think you have made, it’s not your fault.”

She asks people to consider this: Some of our friends can gobble down all the goodies, barely work out and be thin. Others walk daily, count carbs and still struggle with weight.

“Seeing someone who can understand is key,” she says.

Avoid rash diets, particularly for children. Keto eating, for example, can be too extreme, Hafita said.

“That is absolutely not normal eating,” she explains, in large part because it is so difficult to maintain. “There are people who think you can eat that way for the rest of their life, but the reality is, much of our social structure centers around food. We celebrate with it; we gather around it. It’s not the best idea to raise a child to think they are failing if they enjoy those moments.”

Know when to take action. If you struggle with body image issues and have ever omitted insulin or starved yourself, you may want to seek a therapist to help you build a better image of yourself.

That can range from a therapist you connect with to a trained expert in diabetes and body image.

In the end, learning to embrace our bodies as they are, big or small; dark or light; tall or short; whatever you are, is key to overall health, all agree.

“It’s important to understand, as I now do, that healthy looks different on everyone,” says Sandison.

“We have to get past this ‘skinny is healthy’ concept and we should strive for all to do that,” she concludes.