29: "Store Bought Insulin Works Really Well" with Erin Phillips

Hey and welcome to the Can I Have Another Snack? Podcast.

This week I’m talking to specialist diabetes dietitian Erin Phillips about all things insulin resistance and type 2 diabetes. Erin shares some background on what happens in the body that leads to type 2 diabetes, why ‘prediabetes’ is a dubious diagnosis and the things the keto-bros often leave out this conversation. We talk about why sugar and higher weight aren’t the cause of type 2 diabetes, and how there is so much more we can do to care for diabetes outside of cutting carbs and losing weight, especially if you have a background of an ED or disordered eating.

Lots of you have requested more content around this topic - let me know what questions you still have after listening to this episode!

Find out more about Erin’s work here.

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Here’s the transcript in full:

INTRO

Erin: I think sometimes a diagnosis of prediabetes or type 2 diabetes can be a traumatic event, especially when it's not in the presence of someone caring and that you trust. Or especially if you have a family history of diabetes where you've seen…maybe some scary things. Which I will – now that I said that – I will add that it's, that's not a definite outcome either, those scary things, yeah.

But it can be, that can be really stressful, and that's the opposite of what is helpful for blood sugars.

Laura: Hey and welcome to the Can I Have Another Snack? podcast where we talk about appetite, bodies and identity, especially through the lens of parenting. I'm Laura Thomas, I'm an anti-diet registered nutritionist and I also write the Can I Have Another Snack? newsletter.

Today's guest is registered dietitian Erin Phillips. Erin's work is grounded in health at every size and fat positive nutrition. She has an advanced certification as a diabetes specialist and has spent most of her career working with people living with all types of diabetes. She has a private practice that focuses primarily on the intersection of diabetes and eating disorders. She works with people living with diabetes through individual counselling, as well as providing consultation to clinicians looking to be more grounded and confident in supporting their clients and patients with co-occurring diagnoses of diabetes and eating disorders. 

So I've had a lot of feedback from newsletter readers and people who listen to the podcast saying that you'd like more information about weight-inclusive approaches to so-called prediabetes – which we'll get into in a minute – insulin resistance and elevated glucose levels as well as type 2 diabetes. Most of the advice out there centers on carbs. So I was excited to talk to Erin about why these approaches are not only unhelpful for a lot of folks, but how they can be harmful. And why you don't need to get sucked into diet culture to care for yourself. 

In this episode, we discuss why type 2 diabetes isn't caused by too much sugar or having a bigger body, why pre-diabetes is a fake diagnosis, and why you don't need to cut out carbs to manage your blood sugar. I'm so excited for you to hear this episode. 

But before we get to Erin, I want to remind you that the Can I Have Another Snack? universe is entirely listener and reader supported. If you get something out of the work that we do here, please help support us by becoming a paid subscriber. It's £5 a month or £50 for the year. And as well as getting you loads of cool perks, you help guarantee the sustainability of this newsletter, have a say in the work that we do here and help ensure I can keep delivering deeply researched pieces that provide a diet culture-free take on hot nutrition topics like ultra processed foods, the Zoe app, and the deep dive on folic acid and folate that I just did recently.

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So yeah, it's £5 a month or £50 for the year. You can sign up at laurathomas.substack.com or check out the show notes for this episode. And if you can't stretch to a paid subscription right now, you can email hello@laurathomasphd.co.uk for a comp subscription. No questions asked. You don't need to justify yourself. Just put ‘Snacks’ in the subject line. 

This is actually going to be our last podcast of the year. I'll be back in your ears in January with brand new guests. Paid subscribers will continue to hear from me in your inboxes and in the group chat, where I'm going to be holding space for all the venting and screaming at diet culture shit that gets dredged up over the holidays and into January. If you'd like to join us, you can sign up at LauraThomas.substack.com. Otherwise I'll speak to you in January. 

Okay, team. Over to Erin. 

MAIN EPISODE:

Alright, Erin. Can you please start by telling us a bit more about you and the work that you do?

Erin: Yeah. I am a registered dietitian. Well, in the United States, based in, um, the Seattle, Washington…I was gonna say, the ‘state of Washington’! And I'm also a certified diabetes care and education specialist. It used to be a certified diabetes educator and they wanted to add more letters. So I'm in private practice and I focus on working with people with diabetes and eating disorders at the same time, or people who had a history of an eating disorder and then were recently diagnosed with diabetes but don't want like It wouldn't be helpful or safe for them to go to just any diabetes educator.

So those are the folks that I work with.

Laura: Okay, so you're kind of working at that intersection between eating disorder care and diabetes care. And I think, like, what's important to highlight, which people might not be...aware of or familiar with is the idea that people who have type 2 diabetes, I would say in particular, but all forms of diabetes are at a heightened risk of disordered eating and eating disorders. And does that relationship…? No, it doesn't go the other way, does it?

Erin: I think it does.

Laura: You think it does?

Erin: I think it does. There isn't a lot of research on it, but clinically, I absolutely see that.

Laura: Okay. That's interesting. 

Erin: And eating disorders and gestational diabetes. I was talking with a colleague about this, that we see people with a history of, of an eating disorder, it feels like are at much higher risk of gestational diabetes.

But the research…I don't, I haven't looked into the research on that, but we definitely see it clinically.

Laura: Yeah, that's an interesting observation that you've noticed. So, you use this term diabetes educator. We don't have that here so it might be helpful to just kind of explain a little bit about what that is and then maybe we can unpack what exactly we're talking about here when we talk about diabetes and sort of associated terms.

Erin: Yeah, yeah, yeah. Thanks for clarifying that. I love talking to people in other countries to learn about like, what do things look like there? So, a diabetes educator, I know they have them in the States and in Canada, maybe Australia, but basically what it is, is...

Laura: Just to clarify, like, okay, in case my, like...dietetics colleagues are all like yelling at me right now. We do have dieticians that specialise in diabetes, but it's like the diabetes educator title is kind of a, like a bolt on right to your, your like baseline nutrition training. Is that right?

Erin: Yes. Yeah. Yeah. Yeah. So here to become a. a certified diabetes care and education specialist – that's such a mouthful! You, yeah, you need, I think it's 2000 hours of working with people with diabetes after you've become, become a dietitian or you can be a social worker, you can be a pharmacist, you can be a nurse. There's lots of nurses that are diabetes educators. So you get those practice hours, you get continuing, I don't know how many hours of continuing education a lot. And then you take an exam, right? Then it's like, well, at least here, like the dietitian renewal where every five years you renew by getting enough continuing education credits.

Laura: Okay, so it's safe to say you know a lot of stuff about diabetes.

Erin: Yes, I think so, yeah.

Laura: It's kind of your thing. So, I really wanted to talk to you specifically about type 2 diabetes today because, 1) there seems to be a lot of confusion about it. 2) It kind of gets bundled up with a lot of anti-fat bias and carb-phobia and diet culture. And then 3), it's something that listeners of the podcast and readers of the newsletter have requested that we talk about. 

Would you mind starting by just telling us what exactly type 2 diabetes is, and how it relates to concepts like prediabetes and insulin resistance? So that's a big question. Where feels like the best place to start?

Erin: I think actually starting with insulin resistance, because I think of that as kind of an umbrella and then prediabetes and type 2 diabetes fall underneath that umbrella. Yeah. So, insulin resistance is a term that means…so all humans have glucose floating around in their blood at all times. That is the main source of fuel. It's so funny to look at you while I'm talking about this because I'm like, you know this! 

But anyway, all humans have glucose floating around in the blood. It's our main source of fuel for the body. And then for glucose to get into our cells, we need insulin. And I always use the analogy of: insulin is the key that unlocks the cell to let the glucose in. And so insulin resistance is where that key gets a little, like, sticky or…kind of like the key to my car right now that I have to wriggle it the just the right way. So it can take a little bit longer for the glucose to get into the cell. It still happens but it just takes a little bit longer.

So that is insulin resistance and that is one of the key features of both ‘prediabetes’ and type 2 diabetes. Often, when I say ‘prediabetes’, I do bunny ears or air quotes because it's a misunderstood term and we can totally get into that later. But so type 2 diabetes is where a body has either lived with insulin resistance long enough or something else has happened that has made, in addition to insulin resistance, glucose levels get high enough in the blood to meet this diagnostic criteria.

And we've actually…this is something I love sharing with people because often type 2 diabetes is just like, all we focus on is insulin resistance, but there's actually at least 10 other changes in the body that lead to elevated glucose levels that are going on in addition to insulin resistance.

Laura: Okay, before we go on, I want to actually reverse and back up a little bit here, because…so you talked about how we have glucose in our bloodstreams that needs to get into our cells all the time.

That's like everybody, always – even if you're like a keto bro. What I just wanted to make really clear for anyone who's totally new to these conversations is that glucose…it gets into our bloodstream from the food that we eat and it's a sugar, right? 

So I think those are two important points to clarify, that we consume food, it gets broken down and digested and absorbed across the gut lumen. And that's what raises our blood glucose levels. And then insulin is the hormone that's secreted by the pancreas that unlocks the door to the cell, to let glucose move into the cell, so we have energy, so we can do things, so we can go about our business as being humans. Sometimes what can happen is that the door gets a little rusty, or the key gets a little rusty, and it's harder for that insulin to get into the cell. Is that like a fair summary of... Wow. What's going on?

Erin: That was beautiful. I was nodding furiously.

Laura: Yeah. Yeah. Yeah. It's almost like I know something about this! Right. So then can you tell us a little, like – I think you alluded to this – but maybe speak to it a little more to how the kind of the cells get rusty and how it's harder to shift insulin into the cells.

Can you talk to us about what happens next? Maybe some of the symptoms people might experience and then what's going on physiologically as well.

Erin: Yeah. So when a body is experiencing those like rusty cell doors, there's a lot of different hormones that are actually involved in not only glucose regulation or blood sugar regulation, but just metabolism.

So glucose regulation is just one part of metabolism. And when I say metabolism, I mean using energy from food and turning that energy into energy for the body and then using energy to the body.

Laura: Yeah, thank you for clarifying that because this is something I come up against a lot where like metabolism is used as this kind of catch-all phrase to mean how quickly your body burns energy or it's like this really diet culture-y kind of thing.

But when you and I are talking about it... I think we're talking about all the biochemical processes that are going on inside your body, all these cascades of reactions and like how a nutrient that we ingest in food or in a supplement winds its way into our body and becomes part of these chemical reactions that are going on, like, deep inside our tissues.

Erin: Yep. Yeah, that good old Krebs cycle. So when the cell door gets rusty, that's a big kind of flag for the body, I guess you could say, for the metabolic process. So, I think you mentioned the pancreas already. 

So the pancreas is the organ in the body that produces the hormone insulin, along with other hormones. When the pancreas notices the cell doors getting rusty, the pancreas will say, Oh, that's cool. I got this. And we'll start producing more and more insulin because the signal that the pancreas is getting is from the cells. The cells are saying, we're not getting the glucose that we're wanting, that we need, that we need to survive or not getting it as quickly or as much. And so then the pancreas starts producing more and more insulin.

Laura: So it's trying to, it's getting the message that there's not enough insulin to, to get the glucose from the bloodstream into the cell so it starts to produce more. And can you maybe speak to the impact that this can have on the pancreas? Is it helpful to explain that a little bit?

Erin: Yeah, yeah, I think so, because I think that's also something that people don't think about or aren't explained. Yeah. So the beta cells are the cells in the pancreas that produce insulin, and as they produce more and more insulin, they start to, after... I should say after decades of producing more and more insulin, those beta cells start to kind of poop out.

Laura: Yeah, they get exhausted.

Erin: Yeah. That's a better word.

Laura: Crap out, poop out, exhaustion. Yeah, like ultimately they're working really hard for a really long time and that takes a toll, I think is what we're saying.

Erin: Yeah, they start to go on strike, like they're doing the work of more…

Laura: Like the teachers and the nurses and the doctors and the train drivers and yeah, we're having a lot of strikes here at the moment.

So yeah, it's almost as though governments are failing globally, right? Almost.

Erin: Yeah, you have to laugh because otherwise you cry! 

So the pancreas starts to get exhausted, in the research that's called beta cell exhaustion or beta cell failure. So the pancreas isn't able to produce quite as much insulin anymore.

And after decades and decades and decades, the pancreas will not be able to produce enough insulin to meet the needs of the body. And that's when I say, store bought insulin works really well for that.

Laura: Store bought! I love it. I love it because to me that just feels like a much kinder non-judgmental framing of what I think is…often a condition that is attached with a lot of shame and judgment. Like, yeah, there's, there's a real narrative that if you get to the point where you need the store bought insulin, that that's a failure.

And there's a lot of research and a lot of conversations at the moment about this idea around ‘remission’ and, you know, ‘reversing diabetes’ and, and all of those kinds of things, which we're going to speak to a little bit in a minute, but I think that just adds so much to the shame of needing the store bought insulin. So yeah, that just feels like a really kind kind of framing around that. 

So let's see, we've talked a little bit about the mechanisms whereby we find it harder to get glucose into the cells over a long, long, long period of time that can kind of exhaust the pancreas, which means that we might need to get that store bought insulin. But there's kind of a wide spectrum between, like, the cells starting to get rusty and getting to the point where you might need insulin...endogenous? Exogenous! Exogenous insulin.

Erin: That's why I say store bought!

Laura: Store bought, yes. And I think that's where maybe this idea of like prediabetes comes in. And we've, you've talked about how that's maybe not the most helpful label.

I suppose what I'm trying to say is that there's a period where somebody might have some insulin resistance, might have elevated blood glucose levels. But it's not considered high enough for a type 2 diabetes diagnosis. So could you explain what's going on there and why that's a contested term?

Erin: Yeah, yeah. So if we think about a timeline of a body experiencing insulin resistance, the first thing that will happen is the insulin resistance And then the next thing that will happen…I shouldn't say will, that's the biggest thing that I don't like about the term pr diabetes is this, that it, it makes us think that it will happen.

So what could happen, a body experiences insulin resistance. What could happen is that their glucose levels start to increase to a level where they meet the prediabetes diagnostic criteria. And then, the assumption with the term prediabetes is that that means eventually, unless you do something, like in big, bold, scary letters, that eventually, your body will meet the diagnostic criteria for type 2 diabetes.

But what research shows is that that's not, that's not the case. I'm maybe I'm getting ahead of myself.

Laura: No, I know. That's absolutely…I think it's a really important point. And so I have, and Erin, you can tell me if this isn't quite right, but my understanding is that progression from prediabetes to type 2 diabetes is less than 2% per year or less than 10% in 5 years.

And I also have another statistic that 59% of people with prediabetes return to normal blood glucose values between 1 and 11 years with no treatment at all. Does that corroborate with your understanding? .

Erin: Yeah, yeah, I recently was looking into this research and that sounds like exactly what I found. And it really depends on where you look and what study you look at and what population they were looking at. But the, the biggest takeaway for me was that it's not…

Laura: It's not a done deal.

Erin: Yeah, someone's body can just be in that prediabetes range forever or um, either forever or they can go back to below the prediabetes range that it…by focusing on the blood glucose values, we're looking at a symptom and we're not really looking at what's going on underneath.

And so it's, I find that less, less helpful for that reason.

Laura: Yeah, absolutely. So I think what we're saying is that prediabetes is somewhat of a dubious diagnosis, and I'd be interested to hear your thoughts on this too, but my sense is that like, giving that label can create a lot of shame and create stigma.

It freaks people out, is my... experience of working with clients who their doctors have flagged that they have elevated blood sugar levels, let's say, and then….we know that stress and anxiety is not great for blood sugar management, so like, I mean, yeah, do you have anything to add to that? Like, what are your thoughts on that?

Erin: That's exactly what I see in my practice and what I saw when I worked in a GP's office as well, that people are freaked out by either, either one of those labels and…yeah, stress and worry and anxiety and trauma. I think sometimes a diagnosis of prediabetes or type 2 diabetes can be a traumatic event, especially when it's not in the presence of someone caring and that you trust, or especially if you have a family history of diabetes where you've seen maybe some scary things, which I will – now that I said that – I will add that it's, that's not a, what's the word? That's not like a definite outcome either of those scary things. But it can be, yeah, it can be really stressful and that's the opposite of what is helpful for blood sugars.

Laura: Yeah. Tell us a little about what the difference between a ‘prediabetes’ diagnosis is versus a type 2 diabetes diagnosis? Is it just a difference of the level of sugar in the blood?

Is it, is there a factor of time or like, is time factored into that? Like how long it's elevated for? Can you maybe speak to how, you know, you go from ‘prediabetes’ as it were to type 2 diabetes?

Erin: Yeah, that's a really good question. The way that I think about it is just in the diagnostic criteria, which is for a type 2 diabetes diagnosis, your blood sugar needs to get so high in the States, we usually diagnose it based on an A1c.

So an A1c is usually what we use in the States to diagnose both prediabetes and type 2 diabetes. And here a type 2 diabetes is diagnosed at 6.5 and prediabetes is diagnosed at 5.7 up to 6.4. So ours is actually lower than yours in the UK and lower than Canada and lower than the rest of the world, basically.

Laura: I feel like that's probably a really important and intentional thing, and we could probably go off on some conspiracy theories there.

Erin: I have many. Yeah.

Laura: Yeah, maybe it would be helpful to just briefly explain what HbA1c is, or A1c, and how it's measured and, like, what, what it's measuring.

Erin: Yeah. A1c, I call it A1c, but you guys call it HbA1c. Should I say HbA1c?

Laura: No, it's, it's fine. And I don't, I don't know why I call it that because I did my dietetics training in the US but I, I dunno, who knows, who knows?

Erin: I've noticed everybody calls it something a little bit different.

Laura: So, because I guess the HB refers to it being the hemoglobin is the hemoglobin one. But it's the same thing. A1c is easier, so let's just go with that. 

Erin: Okay, okay, cool. So A1c is a measurement of average glucose levels over the past two to three months. And the reason that it's average and two to three months is that as hemoglobin, so hemoglobin A1c is the full name of the lab value.

As hemoglobin is part of our red blood cells, so in our veins and arteries, our red blood cells are floating around and glucose is also floating around. And so as glucose is bumping up against those red blood cells, it leaves a little bit of stickiness of glucose on the red blood cells. And then red blood cells live for 60 to 90 days, so that's 2 to 3 months.

So then when they draw blood to check an A1C, they measure what percentage of the red blood cells are…kind of have this glucose levels on them or glucose on them. And then they can give us that A1C measurement in percentage form. So like 5.7 means... That according to the United States, we're classifying that as prediabetes and then 6.5 is type 2 diabetes. 

And the reason that we diagnose type 2 diabetes or all diabetes at a 6.5 is that long, long, long term research…or we followed, not we, I'm not part of it, the fancy researchers have followed thousands of people for decades and found that if blood sugar stays kind of in that 6.5 to 6.9 range, risk of those scary things like blindness or kidney disease or circulation problems is very, very, very, very, very, very low, basically the same as people without diabetes. So that's why we diagnose it at that, what I think of as like a pretty conservative level, because we want to keep people from experiencing those scary things.

Laura: Absolutely. HbA1c is a sort of medium-ish term measurement of your average blood glucose levels, whereas if we were to just do a blood test randomly at any point in the day, there are like a bajillion different factors that could influence, you know, whether it's a high reading or a low reading, like how recently you ate, it can, you know, it can vary according to a whole bunch of different things.

So a better way of measuring blood glucose is to look at that value over a slightly longer period of time and get that average, even though there are still some issues with looking at that number, but it's, it's a better number than, than just doing a random blood glucose test. 

So we've talked a little bit about insulin resistances, what prediabetes is and what type 2 diabetes is. There is this really pervasive myth that type 2 diabetes is caused by eating too much sugar. What do we know about that? Is that true?

Erin: Absolutely not. Absolutely not.

Laura: That was such a leading question, right?

Erin: Is that true? Tell us! The way I think of that is that it's a real, just a misunderstanding of, of the complicated nature of type 2 diabetes – and when I say complicated, I mean, like referring back to those 11 different changes in the body that I mentioned earlier.

Laura: Oh, so tell us about that because you, we said we were going to come back to this. What are the different changes?

Erin: I can't even remember them all off the top of my head, but some of them are…the insulin resistance is one, the kidneys are responsible for filtering out our glucose when there's too much. And in type 2 diabetes, the kidneys start holding on to more glucose than we would want them to.

Another is a decreased level of incretin hormones. So, GLP 1 is an incretin hormone. GIP is another incretin hormone, and those hormones are responsible for helping regulate glucose levels. And, and many people with type 2 diabetes and someone with prediabetes, they have a decreased level of those hormones.

Laura: Okay, so I guess what, what you're saying here is that we often just focus on the changes to the pancreas and insulin, which is what I was asking you about before, but actually there are systemic changes that are going on throughout the whole body, right? Is that what we're saying? 

Erin: Yeah. 

Laura: Okay.

Erin: Yeah. And those are absolutely not caused by eating, quote, too much sugar or eating sugar.

Laura: Right, right, right, but because what we're dealing with is elevated blood glucose levels, the sort of obvious, or what people think of is the obvious pathway, as well…it's too much sugar in the diet, therefore your blood sugar level is too high. But what I'm hearing you say is it's just not as straightforward as that.

Erin: Absolutely, yeah.

Laura: Okay. Anything else that you wanted to add about, like, that particular myth, or?

Erin: I wish I had more, like, definitive, like, it, that is not true because X, Y, Z, but you can't disprove a myth with research, you know what I mean?

Laura: Yeah, yeah.

Erin: Like, if somebody was like, yeah, unicorns exist, I'd be like, I don't know how to prove that to you. Because I can't show you, like, there is not a unicorn here.

Laura: Yeah. Yeah. Yeah. No, I hear you. But I guess, like, what I would want people to take away from this and understand is that, like, you didn't cause your type 2 diabetes, like, you're not to blame. And, you know, similarly to how there are all different changes in the body that take place when somebody has type 2 diabetes, there are all sorts of factors that contribute to and help explain why somebody might develop type 2 diabetes. And they are everything from, you know, stress and sleep and things that, you know, often get called like lifestyle variables, even though that in and of itself is problematic, all the way through to experiencing racism, homophobia, transphobia, anti fat bias, you know, all of these like discrimination and prejudiceracism, homophobia, transphobia, anti fat bias, you know, all of these like discrimination and prejudice. 

Those things are also going to play a part in our blood glucose regulation, but we don't think of that. We don't think about the social determinants of health. We just think about like, well, you ate too many carbs. Therefore you need to cut out carbs. And this is the advice that people are given, we hear this idea that like carbohydrates cause, in inverted commas, type 2 diabetes, but we've…we also hear that it's caused by being a higher body weight.

So, I'd love to hear you unpack that a little bit and, and kind of…yeah, is it a similar thing to what I just said about carbohydrates or is there anything else that you would add to that?

Erin: So the thing that I go back to a lot with that, I guess, argument is that there's a really big difference between a correlation and a causation.

So the example that I give with that is that as soon as ice cream sales go up, there's also an increase in shark attacks. Like, those things are correlated, but we can't say, we can't draw from that that correlation.

Laura: Yeah, that ice cream causes shark attacks.

Erin: Shark attacks, yeah. Right. And with that one, there's a really obvious, you know, third factor, which is weather, that contributes to both of those things going up, and it's not quite so clear with weight and, and type 2 diabetes.

But there's one theory, which is that weight gain can be a symptom of type 2 diabetes. Another problem with that argument is that it really ignores just the natural body diversity that exists and occurs in the world. There are plenty, plenty of people in higher weight bodies who don't have diabetes and If it were true that higher weight causes type 2 diabetes, then all people in larger bodies would, would have type 2 diabetes, and that is...absolutely not true at all and the research shows that

Laura: And I guess the inverse is also true, right, that people who have a lower body weight, a lower BMI also get type 2 diabetes. And so it's, it's again, not looking at the, the correlation and drawing kind of the cause and effect conclusion, but also thinking about, okay, what other factors are going on that we're not seeing?

And I think, to my mind, at least, it goes back to some of the things that I talked about before, some of the things that are, well, a lot of things that are outside of our control, like again, how we are treated in society, and how that, you know, that has been shown to like..even things like the Whitehall studies.

Are you familiar with the Whitehall studies? 

Erin: No.

Laura: So the Whitehall studies are kind of what I think Michael Marmot's work on the social determinants of health are based on, whereby they studied like civil servants who worked in Whitehall, which is like part of the government in the UK. And basically they stratified, I think it was mostly on men. Whitehall 1 was mostly done on men, because, of course, we need to know more about men, but this was, this was, these studies were done, done a while back and they have since added women. 

But effectively they stratified people by like their pay grade essentially, and they found that people who were in a lower pay grade, you know, they all worked in the same place. There was a lot of factors that were very similar about these men. But one of the key aspects was how much like autonomy they had in their job and what their income was. And they found that the people who hadl ess autonomy, so they were like a lower pay grade, basically, even though they had sort of overall similar working conditions, that the people in the lower pay grades had, I think, higher risk of cardiovascular disease compared to upper management and that kind of thing.

And so it's a similar sort of effect here. And we also see it with like racism and anti-fat bias that there are all these structural things that contribute to our health in really, really complex ways. So I feel like that is a big part of what happens with type 2 diabetes that again, like kind of just seems to get overlooked by the keto bros.

Hopefully some of that rambling made sense, but I'd like to maybe now think about...For anyone who has received this prediabetes diagnosis or a type 2 diabetes diagnosis, like, one of the first line pieces of advice that a GP or even a dietitian might give is around weight loss and around limiting carbohydrates in the diet.

Where to start, really, Erin? Like, in terms of both of those. But basically, I would be interested to hear from you. Is that where you would start with someone? Or like, even putting it another way, are those helpful places to start? I mean, again, a leading question.

Erin: The short answer is no, I do not find that to be a helpful place to start.

You know, I'm really looking at this from the perspective of the population that I work with, who are people who have, who have restricted their eating many, many, many times throughout their life, or engaged in intentional weight loss many, many, many times in their life.

Laura: Sorry, I just wanted to clarify as well for anyone who's like newer to the podcast that you say intentional weight loss and when you say that someone who has restricted their food for whatever, like, who has restricted their food, that doesn't necessarily mean someone who has an eating disorder, right? Like, like, what I'm trying to get at that people might not immediately realise is that that applies to people who have been chronic dieters, like people who have been dieting their whole life, right? That also kind of falls under that umbrella, right?

Erin: Yeah, absolutely. And most people fall under that umbrella versus the, like, the full eating disorder umbrella. So yeah, it really applies to…most people who have been socialised as female, I would be so bold as to say that most, most people who have been socialised as female and many others have, have restricted their eating or dieted or gone on a lifestyle change, many, many times.

And. So, because…I'm trying to think of how to say this without getting too into the weeds of, of, um, like clinical weeds…but because the body is hardwired against famine, what will happen if someone tries this again or says like, okay, I've been told to lose weight and restrict carbs or eat less carbs because I've had this diagnosis of prediabetes or type 2 diabetes, what will happen is things will look, quote, better for a little while.

And so that's why, that's why the research shows like, oh, yeah, that's the thing that we need to do is because for 12 to 24 months, things are gonna get better. And when I say better, I mean, glucose levels will go lower.

Laura: I was just gonna say because research in this area is generally done over like a fairly short term period where maybe If you're really, like, persistent, you can diet for that length of time, but yeah, so that's kind of, I guess what I'm trying to say is that over that shorter time frame, people, especially if they're given lots of support, like in a research study setting, might be able to continue with a restrictive diet for a bit longer, right? But then what happens?

Erin: Yeah, but then the body…since the body's hardwired against famine, the body will start to engage in all of these compensatory mechanisms. Yeah. Basically like that, that carb restriction or yeah, any kind of caloric restriction, but especially carb restriction will kind of start the spring loading effect for the body to protect against that famine at all costs, which means that glucose levels will go up higher than they were before, and weight does the same thing, insulin level, same thing. So If we follow people longer than that 12 to 24 months, what we see is that these metabolic health markers are worse than they were at the beginning.

Laura: Interesting. Yeah. So, I guess what, what you're saying is... And I see this in practice as well, is that people, yeah, in the shorter term, they might be able to restrict their eating, they may even lose a little bit of weight, or maybe even a lot of weight in some instances, and then in the short term, those biomarkers might seem as though they're improving.

But then, because the body is, as you said, hardwired to, yeah, to protect itself, to move, like, protect itself against starvation, and the body can't really tell the difference between, you know, famine. And self imposed or medically imposed dieting and restriction, it eventually fights back against that in the form of like, it dials up cravings for these foods.

It might also…like your metabolism, like all of that, those metabolic functions that we talked about right at the beginning, they start to slow down, which means that you start to maintain your weight or, or even put weight on. And what I see – and I'm, I'm curious if you see this as well – is that that degree of restriction that is often asked of people in these very low carb diets that sometimes get prescribed, certainly here in the UK on the NHS or that a lot that are sort of endorsed by a lot of diabetes organizations even, they cause people to fall into a binge restrict cycle. So rather than having kind of a more…moderate's not the right word, but like having a healthier relationship with food where you maybe are eating more regularly, but maybe in a way that feels more attuned to your body and also caring for yourself in all of these other ways that are really important. I don't want to just put that emphasis on food, but we're talking about food here. That what you end up happening is people restrict, restrict, restrict, but then they can't maintain that restriction forever. 

And so they end up in a blowout, right? Like where they're eating past the point of comfortable fullness, which can send their blood glucose levels sky fucking high, and I don't mean that in like a shaming way. I'm not blaming any individual person who has been caught in this cycle because it's not your fault. But just to illustrate like how kind of messed up that advice is that it can send people sort of, yeah, into this, this downward spiral of binge restrict, binge restrict.

And I think what's kind of important to note here is that you could have someone who has what looks like on paper, perfect A1C, right? But they are binging and restricting, binging and restricting, and that the average blood glucose level over time looks like…you know, on paper, it looks great. But if you were to actually look at what was happening to that person and their relationship with food and how they were feeling, you might see a different picture.

Erin: Mm hmm. Mm hmm. Yeah, that's a really good point. A really good point. And to add on to what you were saying about it not being someone's fault, that binge restrict cycle is, is a very predictable result of the exact recommendations that people are being given. People are being given these recommendations to restrict calories, restrict carbs, and that is…the most predictable outcome of that is weight gain, higher glucose, and that binge restrict cycle when we look at the long, in the long term.

Laura: Yeah, and I think that there's, there's something kind of psychological that goes on here as well when we ask people to really focus on the minutiae of detail around carbohydrates, around what they're eating, that that in and of itself, like that mental restriction can create, like, what I call the fuck it effect, like, or, yeah, just even the threat of restriction and deprivation can kind of trip a switch for people who have had an experience or had a history of disordered eating or chronic dieting or, you know, even, even people who have just tried to maintain a quote, a healthy lifestyle or wellness lifestyle and it really lead to problems for them.

So, Erin, for anyone who's listening to this, who is like, well, my doctor has told me to lose weight. My doctor has told me that I need to cut out carbs or my diabetes nurse or my dietitian. But you're telling me, and actually my lived experience is that that's not a great option for me. Where can people start? Like, or more specifically, like, where do you start with people who come to you with this exact?

Erin: The first place I start is by repeating over and over that you did not cause your diabetes. This is absolutely not your fault. You did all the things right, quote, right. Like there's nothing that you could have done differently to make this different, to make this not happen. 

Because like you were saying, Laura, that's most of the, the biggest factors here are stress, trauma, marginalisation. Those, those are the biggest factors and you don't, those are things are completely out of – and genetics! I didn't, we haven’t even mentioned…

Laura: Yeah, there's the genetic thing too.

Erin: So, I think that's really hard for people to believe because it's the opposite of what they've been told for so long. There's so much of like, if you don't blah blah blah, you're gonna get diabetes. And so I repeat that over and over, that you did not cause your diabetes, it's not your fault. 

And then the next thing that we talk about is actually eating enough. So making sure that you're nourishing your body enough. Mm hmm. There's a lot of, like, biochemical metabolic processes that we can talk about about the why behind that. But I think we've, we've talked a lot about that today so we can take our words for it. That eating enough is just really, really important.

Laura: Yeah, I think there's something there about sort of, you know, if it's available to you, like doing some work maybe around figuring out what your hunger and fullness cues look like, feel like. Because, again, just purely anecdotally, I've noticed that people who are, you know, not so attuned to those signals might, you know, put off, not eat enough throughout the day, so that then it does leave them feeling a bit more vulnerable to bingeing or, you know, like eating in a way that that feels like out of control or chaotic.

Not that eating has to be this like super controlled thing, but also just recognising how unsettling and disturbing it can feel, if it feels like you have no say in what's going on as well. So yeah, I love that that's kind of like your, your starting point is like, hold up, are you actually eating enough?

Erin: Mm hmm. And I say this in, you know, in this blanket way, talking to you today, because way more often than not, I see that people are not eating enough. And people are shocked at like, wait, I eat that much?

Laura: Yeah. And, and I just want to, like, underscore that point. Especially for my clients who are fat or in bigger bodies, plus size, whatever language you feel comfortable using there. When I've said to clients in bigger bodies before, like, I don't think you're eating enough. There is just like a…I don't know, like, just this complete disbelief because it's so counter to what they've always been told, which is like you're eating too much. So, yeah, I just wanted to like flag that as well that like this is not just a thin people thing. That's for everyone.

Erin: Absolutely. Yeah. Thank you for highlighting that.

Laura: Are there any other like, kind of like, I suppose what I'm thinking of is like low hanging fruit, like things that are like, maybe not easy for people, but like, that might feel more accessible. That's maybe the right word.

Erin: Yeah. Yeah, yeah. I think it, you know, really, really depends on the person and their, their experiences with food and movement and the medical system and their body, but some other things that may or may not be low hanging fruit are finding a doctor or a, or a medical team that you really vibe with, or at least that you hate less, we can say, like that feels less terrible. 

Because one of the biggest, most helpful things you can do with any type of diabetes is monitoring. And when I say monitoring, that can be anything from, well, mostly that's just like checking in with your medical team like quarterly or a few times a year, depending on what's going on for you. And if, if you absolutely dread it, that's not going to happen, right? Like you're not going to be able to be monitored.

So finding somewhere that is less terrible, or maybe even someone you vibe with is really important.

Laura: Yeah. That's really good advice. And I'm just…I'm thinking about the pathways that we have here in the UK and as far as I know, and it will probably depend slightly on different NHS trusts, but as far as I know you get an annual diabetes review for type 2 diabetes and I'm just thinking like about that in relation to the point that you're making which is that, yeah, having that check in that support just…you know not necessarily like a full review but like just to, yeah, see how things are going and, and see like what you might need, like that might not be available to everyone, certainly in this country. 

And I'm sure it depends on things like insurance and stuff in other countries, but I guess what I'm learning is just how fucking atrocious a lot of medical…or like not atrocious, that's not what I mean. But like, how under-resourced a lot of medical systems are in terms of like giving people the things that would be most useful, which is again why we're like, here's a diet sheet off you go, and that's not helpful.

Erin: Yeah. No. Yeah. Not helpful at all. Gosh, that's, that's so maddening. t's really easy for us here in the U. S. to be like, uh, everywhere else has it better with healthcare, but it's really grounding to hear that not everybody's figured it out.

Laura: It's like, what, 13 years of a Tory government? So. It's not surprising that our healthcare system has been absolutely obliterated.

And again, it will depend on the area that you're in as to how good that care is. And that's not a reflection on any, like, individual practitioner within that system. Like, we all know how hard they are working and how kind of up against it they are. 

But what I'm hearing you say, really, Erin, is that, like, the going in hard with, like, weight loss and restricting carbohydrates, that is probably counterproductive to the overall aim of, like, caring for yourself, and that there are some other things that we can, like, think about and incorporate that might…Okay, they're maybe not such a like, go hard or go home approach, but that maybe they're more sustainable. Maybe they're like, kinder and gentler. 

And I think that reminds me of something that I will say to people if they come to me and they're like, you know, my doctor has flagged this, I'm feeling really stressed is…this is not an emergency. Right, like this is your arm is not hanging off or whatever it is. We can take a beat. And if there's other stuff that you just need to like, get a handle on, like life stuff or whatever it is, like, maybe this isn't your top top priority right now. Like, what are some like, small things that we can do to help you feel like you're caring for yourself or are being cared for that don't sort of, are maybe not going like full throttle, like, you know, what the common narrative is that we should be like cutting out carbs and losing all of this weight. But what are maybe some like softer things that we can start with? Yeah. 

Oh, well, Erin, thank you so much. This has been really helpful. And I know that you have a ton of resources on your website, on your Instagram that people can dig into. And I'll link to all of that in, in the show notes. I also want to mention that a while back at LCIE, we produced a guide, a weight inclusive guide to insulin resistance, and it has some more information about things like medication, supplementation, and again, some of those like lower hanging fruit things that might be helpful if this is something you're navigating and it has, you know, information about what we talked about today, Erin, the lock and key thing and like the how ‘prediabetes’ is a dubious diagnosis. So I'll also link to that for anyone who's interested in the show notes. 

Okay, Erin, before I let you go, At the end of every episode, my guest and I share what they've been snacking on. So it can be anything, you know, a show, a podcast, a literal snack, whatever it is. I'd love to hear what recommendation you have for the listeners.

Erin: Can I share a couple? 

Laura: Of course! Yeah. 

Erin: Okay, cool. Well, I'm literally snacking on all things peanut butter, which I don't know if you guys like peanut butter, but I. Just had some peanut butter pretzels again recently and I was like, gosh… 

Laura: Whoa, whoa, whoa, whoa, are they the Trader Joe's ones? 

Erin: Yes. 

Laura: Okay. So last Christmas, my brother sent me like a huge ass box of stuff 'cause he lives in Oklahoma. From Trader Joe's. And it had those peanut butter pretzels in them and I hadn't had them before. And we don't have good snacks here. I'm just gonna say like the snack game in the States is just like…it's so much better than it is here, but I know those pretzels and they're so good. They're so good, yeah.

We're gonna do a, like a snack box exchange again this year. So I sent him like, he loves chocolate, so I sent him like a ton of like Dairy Milk and like chocolates from... the UK and he sends me stuff from the US. So like, that's, that's fun. But I'm going to add them to the list because they are so good.

Erin: They are so good. And you can, if you're in the States, you can also get them at Costco. Very similar ones.

Laura: Okay.

Erin: In bulk. Yeah. Big ol thing. So that's what I'm snacking on. My other thing is the podcast Normal Gossip.

Laura: Oh yeah! I have heard a couple of episodes of that. And like, for anyone who hasn't heard it, can you explain the premise?

Erin: Yeah, they get a story sent in from someone, like a true story, and then they share the story, like they're gossiping with a guest on, and they'll pause a lot in the story where they're like, okay, so this is what's going on, what would you do next? And so there's a little bit of like, choose your own adventure that I think is really fun.

And then it's just so silly, but it's really nice to like, have some silliness.

Laura: Oh, 100%. In the mess of everything. Do you have, like, a favourite episode that you would... Is there like a standout?

Erin: Well, I just listened to one that was a live episode that I think it was like the plant story or something like that.

And it was fun because they had a guest where they would ask them what they'd do. And then they'd have people raise their hands if they like absolutely disagreed in the audience. And then. So you just got a lot…there was even more choose your own adventure.

Laura: There's like, yeah, more back and forth. Okay. Yeah. Like the plant story. I'm going to get you to send me the link and I will include it in the show notes because yeah, I am deep down a research rabbit hole at the moment looking at folic acid and folate and I'm like digesting all this biochemistry and I find that that happens a lot that I listen to a lot of like podcasts that are related to my work in some way and I forget the podcast can be fun.

Erin: Uh huh!

Laura: Yeah, I need to get back into that. All right, real quick, mine. So this is just like a fun, festive thing that I came across the other day, which I was looking for some new shoes and I came across gold sparkly converse high tops. 

Erin: Oh my God. 

Laura: And they are so cool. So I bought a pair. I don't know if I'm going to…they haven't arrived yet. I'm gonna try them on, but I feel like gold is a neutral, right? Like, it will go with everything.

Erin: Oh, that's true. When I first heard you said neutral, I was like, are they? Is gold neutral? But it does go with anything.

Laura: Yeah, so I'm gonna try them on, see what they're like, but I will, I will include a link in the show notes because, yeah, from the picture, I haven't seen them in real life yet, but from the picture, they don't look like they're too over the top and I feel like…if you know if like depending on what you're wearing like you probably get away with them at the playground, right?

Erin: Totally. Totally. 

Laura: This is what I'm telling myself anyway. I kind of text them to all of my friends. I was like, what do you think of this? And there was like a lukewarm reception, but I think, I think I need new friends is really…with better taste is what, is kind of where I've come down on it! Maybe I'll put them on my Instagram stories and see what people think. 

Erin: There you go. 

Laura: All right, Erin. This was…uh, I was gonna say this was really fun, that little bit at the end was really fun. Like, all the bullshit around weight loss and low carb diets, not so fun, but I'm glad that we got to unpack, unpack that a little bit.

For anyone who wants to dig into your work and your resources a little bit more, where can they find you and more about your work?

Erin: My website is a good place. I have some free resources there and I try to update my blog with some kind of my push, my pushing back beliefs on kind of diabetes diet culture. And that is ErinPhillips.com. No, erinphillipsnutrition.com. 

Laura: Should we fact check your website?! 

Erin: I tried to buy erinphillips.com, but it wasn't available. So, erinphillipsnutrition.com. And then my Instagram, I think it's @ErinPhillipsNutrition.

Laura: Okay, well we…just make sure you click on the link in the show notes because Erin's not a reliable resource on her own social media! So we'll make sure people get there in the end.

All right, thank you so much, I really appreciate it Erin. 

Erin: Yeah, thank you, Laura. Thanks so much for having me.

OUTRO:

Laura: Thanks so much for listening to the Can I Have Another Snack? podcast. You can support the show by subscribing in your podcast player and leaving a rating and review. And if you want to support the show further and get full access to the Can I Have Another Snack? universe, you can become a paid subscriber.

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Can I Have Another Snack? is hosted by me, Laura Thomas. Our sound engineer is Lucy Dearlove. Fiona Bray formats and schedules all of our posts and makes sure that they're out on time every week. Our funky artwork is by Caitlin Preyser, and the music is by Jason Barkhouse. Thanks so much for listening.

ICYMI this week: Gift Concierge + Mini Gift Guide

* Fundamentals: Helping Kids build a Good Relationship with Sugar

* Here's Why You Might Want to Pass On Getting Your Kid Weighed in School

* The One-upMUMship of Kid Food Instagram

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