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Dietitian and diabetes educator Janice Dada joins us to discuss why there’s so much stigma and blame on people with diabetes, the wellness-culture belief that people can “reverse diabetes” by restricting foods and taking a bunch of supplements, why people don’t “give themselves diabetes” by eating too much sugar, the myth that people with diabetes can’t eat sugar or carbs, her new book on intuitive eating for diabetes, and more. Behind the paywall, we get into the myths about diabetes and body size, the harms of trying to lose weight with diabetes, issues with the “prediabetes” label, the GLP-1 craze, and how to practice intuitive eating with diabetes.
Janice Dada is a weight-inclusive registered dietitian with a private practice in Newport Beach, CA. She is a certified intuitive eating counselor, certified diabetes care and education specialist (CDCES), and certified eating disorders specialist (CEDS). She is passionate about simplifying and destigmatizing the nutrition- and weight-based discourse around diabetes. Intuitive Eating for Diabetes: The No Shame, No Blame, Non-Diet Approach to Managing Your Blood Sugar is her first book.
Resources and References
Christy’s second book, The Wellness Trap: Break Free from Diet Culture, Disinformation, and Dubious Diagnoses and Find Your True Well-Being
Subscribe on Substack for extended interviews and more
Janice’s book, Intuitive Eating for Diabetes
Study on the prevalence of diabetes
Christy’s online course, Intuitive Eating Fundamentals
Transcript
Disclaimer: The below transcription is primarily rendered by AI, so errors may have occurred. The original audio file is available above.
Christy Harrison: I'm really looking forward to talking to you about your new book, Intuitive Eating for Diabetes. It is pretty groundbreaking. There's nothing out there like it yet. And I'm excited to dig into your approach to diabetes and how intuitive eating can fit into that. But before we get into all that, I'd love to hear about your history with diet and wellness culture personally and what sort of drew you to this work.
Janice Dada: Absolutely. So my relationship with food has actually always been pretty good, which I know is a rarity, but I think it was likely due to some key fundamental reasons. One being I did not have a dieting mom growing up, and I think without really knowing that she was doing so, she was allowing me to be an intuitive eater. I remember times where we would be somewhere and I'd order something that maybe she thought was a larger portion, but she didn't tell me not to order it. She just kind of let me do what I needed to do with regards to eating.
And then also, as far as I'm aware, I don't remember anything where I had a doctor or anyone else make a negative comment about my weight or my size. And while I certainly had various phases as a kid, as many of us do, where I remember body fluctuating slightly in shape and size as I grew and developed, I did have thin privilege, so that likely helped with that. And in my elementary years, I spent a lot of time with my grandparents, and they immigrated to the US from Greece after World War II, and they'd both experienced food traumas. My grandmother was a survivor of the Auschwitz concentration camp, and my grandfather had been held as a Greek prisoner of war. And because of their past traumatic food scarcities, I think food was really celebrated and strong appetites were encouraged.
So I would say that really, actually, the time period where my relationship with food was the worst was in college. There was always talk of the freshman weight gain before going to college. And then going to college and being a nutrition major made me more preoccupied, really, for kind of the first time in my life. And as a nutrition student, I felt like my eating was always on display. I'd get comments like, "Oh, what's the nutrition major going to eat?" Or "you'd never eat this," or things like, wow, I can't believe you're going to eat that. Fortunately, nothing really came of it. And over the years, I was able to develop quick responses to common commentary that I know many of us get as nutrition professionals out in the real world in social eating situations. I say things like, all Foods fit. Or I say, like, I eat everything, or that's not the kind of dietitian that I am, things like that to just kind of end the commentary there. Yeah.
And over the years, I was able to develop quick responses to common commentary that I know many of us get as nutrition professionals out in the real world in social eating situations. I say things like, "All foods fit." Or I say, "I eat everything," or "That's not the kind of dietitian that I am," things like that to just kind of end the commentary there.
Christy Harrison: And then people are like, what kind of dietitian are you? Very intriguing, I'm sure.
Janice Dada: Right? Yes. Even when I've explained the type of work that I do, sometimes I do feel like it's not quite understood. "Wait, dietitians are supposed to provide diets and they're supposed to be food rolls?" Like, no, I'm actually not in that business.
Christy Harrison: Well, it's so interesting too, that you say your eating was really disordered in college as a nutrition major. Because I think that is so common for so many of us in this field. That the more into it we get, the more obsessive we can become. And it's no coincidence, I think, that a lot of people are attracted to nutrition and dietetics for disordered reasons. I know I was trying to figure out how to manipulate my body and shrink it and keep it shrunk and all of that stuff and be "healthy" in this way. That was very diet and wellness culture conditioned. It was not real wellbeing, I would say.
Janice Dada: Yeah, I declared a nutrition major as a freshman, so I was interested in nutrition before going to college, and I think that had to do with both being a high school athlete. I played soccer and I ran track, and I'd kind of played around with eating different things and drinking different things before track meets. And kind of noticing it actually makes a difference, the types of foods I'm eating and the timing of it all. And I thought that was interesting to me. And then also my grandfather, who I mentioned already, he did have type two diabetes. And he was diagnosed in his late 60s, I believe. He ended up living to be 92, but he had several strokes in his last years. And I was about 17 when he passed.
And, of course, at that age I didn't really know anything about diabetes or nutrition, but it kind of sparked my interest, especially when I'd hear people talk about his diabetes and talk about what he should and shouldn't eat or the way that he ate. And as I kind of learned more about the way his diabetes was managed over the years, it was sort of curious to me that he'd never been on medication. And my mom had shared with me that he was very into trying to do things naturally. And it's really funny. In his stuff, I found an old Ancel Keys book. It was a nutrition book. I think it was him and his wife that wrote it. And so I saved it as like an artifact essentially.
But he had stuff like that, which he never talked to me about any of that, but I think he was just always reading and always researching. And of course, diabetes care has evolved immensely over the years, and so I don't even know what medication would have typically been prescribed at that stage. Diabetes medications have also evolved tremendously. Those are sort of the things that kind of spurred my interest in nutrition. So I don't think it came from a disordered place where I wanting to go into nutrition. And actually I didn't know what a dietitian was. I just thought nutrition sounds cool and interesting and I eat and I like to run. And so I entered the major and thought, I'll do something in the health careers.
And it wasn't actually until I was in graduate school getting my master's in public health that I met some really good friends that are good friends to this day who were doing the dietetic internship and master's program combined who were like, if you want to do anything in nutrition, you better become a registered dietitian. And so I actually did my internship to become a registered dietitian after I finished my master's degree.
Christy Harrison: Yeah, that's how I did it too, actually. I got my master's first and then did my dietetic internship. You said your relationship with food was sort of the worst it's ever been at that point. What do you feel like changed for you in that process and what, what helped you come out of it?
Janice Dada: I think just more experience. I did start out my career as a dietitian in a more weight centric manner. I did my internship with the Veterans Affairs Administration. And as you can probably relate to, it was very weight centric and very "do this and you'll prevent this disease." And I think over time and reading more research, it really became clear that you can't really control everything and you definitely can't control everything with food. And so when I would see patients at the VA, so I did my internship there and then I also worked there for a couple years in the Long Beach location. At the VA, there's a large population of people with diabetes. And I found the advice that we were sort of trained to give people with diabetes to be very cookie cutter.
It didn't make sense that we would be telling people of various sizes and levels of activity and just different individuals to be eating the same thing. There was this sort of standard recipe that we were said supposed to use for diabetes patients, and it really didn't vary much from person to person. And so, of course it didn't work right. And actually, I do remember in my internship, I was told as an intern, take this and follow it for a week. And I came back to my supervisor and I was like, I can't do this. I do a lot of activity. I'm hungry. This is not gonna work for me. And she kind of looked at me like, really? And I was like, yeah, this is not something that you can just do across the board.
So I, unsurprisingly, didn't stay in kind of that healthcare setting for very long. I stayed there for about two years and then went into private practice and started teaching college nutrition classes. And I think it was really in private practice that I got so much more exposure to what people were really struggling with with food, because I got to spend more time with them. They really shared with met became very clear that we're very disordered.
And I also, without advertising myself as an eating disorder dietitian, because I wasn't one at that point, would get people with eating disorders in my office. So I did more training in eating disorder and also in intuitive eating. And I'm very privileged to be in the same area as Evelyn Tripoli, one of the co-authors of Intuitive Eating, and also Elise, who's just down the freeway in LA. But Evelyn and I are both in Newport beach and actually have shared an office space for the last 10 years. But at that point, we were just in the same city. And so I did some of the in person trainings that she had, and eventually, you know, became an intuitive eating counselor as well.
And that finally felt right. We were really kind of allowing people to use the wisdom of their bodies and also understanding that people have their own unique needs. And even with a health condition that we need to make adaptations for that, we can't just say, "You have this condition. Everybody eats in this particular way."
Christy Harrison: Because there's this real myth out there that people with diabetes can't eat sugar or many carbs at all. And they have to just cut out these foods they love. Or in some cases, it's taken to this real extreme of they don't eat carbs at all or that they need to go keto or something like that. I feel like that's become kind of standard recommendations in some corners of the world, and certainly I think in wellness culture spaces, there's this sense of, if you just eat the right foods, you're gonna not need medication or something like that. With diabetes, what would you say to someone who has heard that sort of rhetoric and gotten the advice to cut out sugar, to drastically limit carbs, maybe even to go keto or fully cut out carbs?
Janice Dada: Yeah. And that's a conversation I've had many times with clients who have been to a provider who said, you have pre-diabetes, or I'm concerned about your blood sugar, or they have diabetes and they've been given those same kind of cookie cutter recommendations to extremely limit carbs or sugars or do one of those drastic types of diets.
I've had one client that I will never forget. She would go out to eat with her husband, and her husband would order a meal and she would sit and just not eat anything. And she'd wait until she got home to eat a very small amount of food, which I won't mention. Well, this doesn't make any sense. People should be able to go eat and enjoy themselves and eat food with other people socially and not have to feel like they cannot participate. That's extremely limiting to quality of life.
Christy Harrison: And I feel like some people think that that's how it has to be with diabetes. That diabetes is such a serious condition. “I'm never going to be able to have pleasure in food again” or to be “normal” with food, like being flexible and able to go out and eat at a restaurant or whatever.
Janice Dada: Right. Yes. And I think the common narrative around diabetes has become so damaging, right? Because with many other conditions, it's like, oh, bummer, I have this condition now. I have to take this medication for it. But with diabetes, it's like, “Oh, look what you've done to yourself. Now you have to do all this to undo what you've done and please do everything you can to avoid medication,” which makes no sense and is absolutely not true because diabetes is not something people do to themselves. There are so many factors that go into why somebody may develop diabetes. Many of which have nothing to do with anything that somebody's done in terms of their own life choices.
Social determinants of health being a huge one. Where you lived and where you grew up and what kind of neighborhoods you had access to and what kind of grocery stores you had access to and what kind of air you were breathing in. Did you live next to the freeway? Were you exposed to endocrine disrupting chemicals? Were you told as a kid to go on diets and then you weight cycled for decades? Your own genetics and family history. There's just so many things that are completely out of one's control.
And yet diabetes feels like this disease that really has the personal responsibility narrative attached to it, which is just unfair. I have people that come into my office and they want desperately to reverse things. And of course, they've heard the word reverse diabetes in popular culture. And of course there's books written about reversing diabetes and people who talk about that, but that's actually not an established thing.
We can get diabetes numbers into a range that's considered controlled, or their numbers are in a range where they technically fall into the diabetes range anymore, but really they still have diabetes or they're still at risk for it at some point in their life. And I think when people see that maybe they've taken drastic efforts and they've seen a change in their numbers, they want to stay with those drastic efforts even when their quality of life is really suffering.
Christy Harrison: Let's talk a little bit more about that piece, because I feel like there is such pressure in diet and wellness culture to “reverse it” or put it into remission and do it “naturally” without medication. I think part of it is that personal responsibility thing, like you said, people are made out to have given it to themselves by eating too much sugar or too many of the wrong things or by being a high weight or something.
Why is it that people can't “reverse” diabetes by restricting foods and taking a bunch of supplements and things like that? What is really going on when people believe that they've reversed it or when they're making these drastic changes and seeing changes in their blood work? I can understand why people would think, okay, well, that's what I have to do in order to make this change. But it seems to me they're ignoring some other aspects of their quality of life and sort of their overall well being.
Janice Dada: Right. If we think about the way that blood sugar works in the body, we eat carbohydrates, it digests into glucose, our blood sugar rises, and then we should get an automatic release of insulin from the pancreas, and then the glucose should be used up by the cells so that they can do their work. And so with something like type two diabetes, there may be a mechanism that is faulty somewhere in there which can be that the insulin is being released, but the cells are not recognizing it. Kind of like a lock and key kind of mechanism.
So if we think, okay, the insulin is the key to unlock the cell so that the glucose can get inside. If the insulin is there and it's not getting inside, it's kind of like the locks got changed and the insulin does not have the new key. So instead, insulin builds up outside the cell, and glucose builds up outside the cell. And that's one way that blood sugar can get elevated in type two diabetes.
But in addition, there can be another mechanism at play, which is when the body is actually secreting too much glucose from storage. And actually, one researcher writes about eight different things that may be going on in terms of type two diabetes. Ironically, is also a very kind of weight centric researcher, but even at the same time, it's like talking out of both sides of his mouth, right? That there's these eight different things that can cause it, but also sort of purporting a number of different typical ways.
It's possible that people might see some improvements in their blood sugar by restricting carbohydrates. It is also likely in many cases that if we restrict carbohydrates, we will then have more desire for them. Right? And so that may lead some people to binge on carbohydrates, and then they may get this vacillating blood sugar where sometimes it's actually very high and sometimes they're able to control it. Kind of akin to an eating disorder, right? Where somebody may see some potential “benefits” from some of the disordered eating things that they're doing, but at what cost?
And so kind of the same idea with trying to reverse diabetes or control blood sugar without meds and only with drastic measures, at what cost, when there is also medication and some of which have been out for many decades with proven track records that may actually help and allow you to eat in a manner that is more typical of meeting needs, Right?
Christy Harrison: That makes so much sense. That's the piece that is missing, I think, from so much of this discourse, too, is that there is a medication that could help in those situations where people are having to make these drastic changes in order to see a change in their blood sugar. I think of an analogy like high cholesterol. It's sort of a similar thing where if people have really high cholesterol, often it is genetic, it's familial, it's something that they're not going to change by just making small changes in their menu that could be easy and sort of fit into things. It would take really draconian measures to make any change.
And even then, I've seen people who were severely orthorexic, who still had cholesterol levels off the charts and weren't making any progress. It didn't touch the cholesterol levels to make all those dietary changes because they just needed to be on statin. They needed to be on medication, and that was what helped them bring the cholesterol levels down. And it wasn't really going to move any other way. And there was probably also, for some people, some amount of restriction at play as well, which can drive cholesterol levels up.
But I feel like that might be a similar thing here, where there's only so much you can do through dietary changes, and it's going to have a severe cost to your life if you take it really far. And if that's the only way that you see your blood sugar come into a normal range, isn't it worth considering medication and bringing that into the mix so that you can have a more flexible, peaceful, easy relationship with food and your body?
Janice Dada: Absolutely, yeah. And also, diabetes is often progressive, and so sometimes people are starting to feel upset with themselves when their blood sugar is no longer in the range that it used to be, when they're doing maybe the same things and without sort of realizing that actually, it's very typical for diabetes to progress over time, especially type two diabetes, where more medication is likely to be needed down the road.
And a conversation that often comes up with clients is if their doctors are wanting to put them on insulin, because they have type two diabetes, which is now kind of needing that additional medication, that they are feeling like this sense of personal failure. They are feeling like they want to do anything they possibly can to avoid it, when we could also kind of consider a different perspective on it. In that, thank goodness there is a medication that can help as blood sugar is changing, as diabetes is progressing over time, so that numbers can stay in a range that is most likely to prevent complications of the condition.
Christy Harrison: Right. And it's just so interesting that more and more conditions are stigmatized in this way. But I feel like diabetes is particularly stigmatized and has been for a long time as something that people “should be able to control” themselves and without medication. Why do you think that is? Why do you think there's such intense stigma and such intense blame on patients with diabetes?
Janice Dada: Unfortunately, I think it's our healthcare system. And of course, while I think people go into healthcare wanting to help individuals and with the desire to help people live better lives and to optimize their health, and oftentimes the things that they are sharing with clients or their patients are not actually helping them to feel motivated in the ways that they might think that they are.
I remember working with a doctor at the VA and the diabetes clinic, and her tactic was scare tactics. And I think she was pulling things out of her bag of tricks like, how do I get patients to have better blood sugars? And she's like, well, I've tried this and I've tried this and now I'm onto scare tactics and telling them all the potential complications. And because we have such a weight normative healthcare system, meaning that weight and weight loss are really the focal points of the intervention for most practitioners, that really puts an emphasis on body weight in the office. There's also a lot of push for restriction.
And in addition, I can feel for providers who only have 15 minutes or so with a patient that they're feeling like, well, let me just completely unload anything I've ever heard or anything that might stick on you so that hopefully this lands right. So you really can't get a physical exam accomplished and some counseling accomplished and really hear a patient's requests and concerns in that period of time that's just a setup for failure.
And so I think a lot of things really ideally need to change in order to have a system that is more patient supportive and also will help us get better outcomes. And then we also know that medical schools that train medical doctors really don't have nutrition curriculum in their training. I researched this when I was writing my book, and I think it was something like most schools include like 11 hours of education and the recommendation is to get at least 25 hours, which still seems like way too little. I used to teach college nutrition classes and I used to tell my students, you are getting more education on nutrition in this one semester class than most doctors have gotten in their entire four year medical training, which is really mind blowing. They were always like, what?
And so unless a medical provider has gone on and done their own additional training in nutrition, they really don't have the same kind of ability to help individuals with their nutrition needs. And then also, of course, as we know as nutrition counselors, a certain way to kind of come across with patients and really telling patients what to do is often not a way that helps them feel real motivated.
Christy Harrison: And it's interesting too that so many doctors will give nutrition advice so confidently and just say this is what you need to do or you need to lose weight or just cut out these foods, cut out sugar, cut out carbs, whatever. And they're just sort of spouting that long standing myth that we talked about and not giving any attention to the nuances of people's relationships with food or the new science and evidence that shows people don't need to just cut out these things completely and all of that.
It's really a shame that that is the nutrition “education” that so many people get with diabetes. And not to denigrate doctors because doctors do so many amazing things and they really are so knowledgeable in their areas of expertise, but this is not one of them and I think people need to kind of stay in their lane and unfortunately doctors don't often.
Janice Dada: Yeah, absolutely. I think doctors and other healthcare professionals are well meaning and well intended and all of the factors that we talked about, the time, the lack of knowledge, really get in the way of being able to do a good job of letting patients leave the room feeling motivated with any recommendations that they're giving in terms of nutrition or weight.
I've certainly had many patients tell me that they've had visits where they've been told to do things without being asked if they already do them. Like you need to exercise more. It's like, well, you didn't ask me if I'm exercising. Or I had a patient tell me, my doctor told me to stop eating cake. I don't even like cake. It's just bananas to make those types of assumptions.
And again, I understand that the amount of time in a visit is too short and there probably isn't adequate time to ask those questions. And so if there isn't adequate time to ask the questions, they just shouldn't be touched. It should be like, I think you should go see another provider so that you can have some time to talk about this specific thing with this person who has that specific expertise.
Christy Harrison: Yeah, that's such a good point. Because there can be so much more harm done, I think, with a flippant comment about food or weight or just or the blanket diet advice that people sometimes get, than if the doctor were to take the time to say here's a referral, or look for a dietitian in our healthcare system or on your insurance or whatever and see someone who has experience with diabetes or whatever and just make sure that you get the support that you need rather than like, oh, you should just do keto or whatever it is.
Janice Dada: Right. Or come back. Can we schedule another visit so we can talk about X, Y and Z a little bit more? If they feel like they have the expertise and knowledge to talk about that.
Christy Harrison: Right, exactly, just not to shoehorn it into a 15 minute visit, because that's going to probably do more harm than good. Speaking of the healthcare system and the weight centric paradigm especially, we have to talk about the myths about diabetes and weight. And the belief that higher weight “causes” diabetes and that weight loss can fix it. Why are those beliefs incorrect and what are the harms of trying to lose weight with diabetes?
Janice Dada: Yeah, this is a topic that really gets me fired up.
