Ben Tzeel, T1D Registered Dietician, Strength Coach, Founder of Your Diabetes Insider

[00:00:02] Rob Howe: Welcome back to another episode of Diabetics Doing Things. It's going to be me solo on this episode, and I'm very excited to introduce to you, returning to the podcast, Mr. Ben Tzeel. He is a registered dietitian. He is a certified strength and conditioning coach, and he lives with type 1 diabetes on social media. Just passed the 20K mark on Instagram. Congrats to you, my bro. He's Man of Tzeel. That's with the silent T. And Ben, man, welcome back to the show.

[00:00:27] Ben Tzeel: So Rob, I'm so glad to be here. I've been looking forward to this for a hot minute.

[00:00:32] Rob Howe: Yeah. So just to give the guests a little bit of behind the scenes, you and I are, are not only like friends in the diabetes community and collaborators, but also just homies and buddies. So we talk pretty regularly and I sort of just had this bolt of lightning idea in the middle of the day one day. And so I texted you, I was like, Hey, I think you and I, the bros that we are, uh, and the the bros with diabetes that we are really need to get on this podcast and discuss eating disorders and diabetes from the male perspective. Because I think when eating disorders at large are discussed, there's a connotation that it only applies to women. And what I would say is that women are leading that discussion for the most part, and they are, you know, leading with that vulnerability and opening themselves up to that discussion. But there seemingly is a lack of that in the diabetes space, at least from the male perspective. So I thought it'd be really important for you and I to do that. And I've actually have diabetes.org. So this is the American Diabetes Association's website here about healthy living, mental health, and eating disorders with diabetes. And what I see here on the site, and this is a direct quote, there is no data on eating disorders in men and boys with type 1 diabetes. So right off the bat, man, I think we found something that we can contribute to. So the next step after this is for us to fund a study. But anyway, I've done a lot of talking, uh, man, welcome back to the show. And, uh, you know, give us a little about what you've been up to lately and then let's get into some hot takes.

[00:01:58] Ben Tzeel: Oh man. I mean, there's, I feel like there's so many different things and then, you know, obviously the time of year is crazy and there's so much to do for this community. And I just, I think back with this topic, especially to my training as a dietician, I had a choice and it was a really difficult choice. I'm sure you can imagine. I got to pick my final rotation and I I had an offer to work with NFL combine athletes who were going to be drafted. I think it was 2018. So it would have been a pretty good class or I could have worked in an eating disorder center outpatient facility. And I really thought about it long and hard. And I chose the eating disorder center because I knew from a diabetes perspective, there's so much of that within diabetes in both men and women. But I feel like what we're talking about, the guy side of things, it's so not talked about to the extent that it needs to be. And I figured what better experience than immerse myself in the trenches with something that is such a need for our community.

[00:02:54] Rob Howe: Man, I love that background because if you guys follow Ben, you know what a big NFL fan you are. And you're going to road games to follow your Vikings around on an annual basis. And that's part of what you really love to do. So props to you for playing against type and challenging yourself with that different experience. And that's one of the reasons I'm so excited about this today because now we can, because you've gone and you took that step, we can open up this conversation. And so I'd like to do that with a hot take. And so here it is, ladies and gentlemen, the hot take machine is engaged now and I'm firing it up. My hot take is if you live with diabetes, type 1, type 2, Lada, MODY, whatever, you live with disordered eating. And what I mean by that is counting carbs, dosing insulin, taking oral medication, walking before and after meals, trying to optimize how your body responds is different. It's disordered. It's not natural. And so I don't want us to take disordered as a total negative connotation today. I want us to look at it as like, yes, we are disabled living with diabetes. There's a lot of things that we've got to do that general able-bodied people don't have to. And that makes us more susceptible to eating disorders. So anyway, let's, let's, that's my hot take. Let's dig in and let's talk about

[00:04:11] Ben Tzeel: eating disorders and diabetes. I was going to say that, that take for better, for worse, after that experience that I had in that rotation, it made me realize that everybody has it. Everybody has some sort of disordered eating. If you live with diabetes, because you have to be paying attention and you can't take any days off. You can't, you know, if it were a football game, you can't take any plays off. Oh, I want to just not mess with this meal. Well, then you're going to pay for it later. And then you're thinking about your blood sugars later on when you're three 25. So there's so much that goes into it and it's constantly on our brains because it has to be. And then we're only thinking on the carb level most of the time when the reality is the protein and the fat are part of it too. So then it becomes this whole calculus equation that drives people crazy. And if it's not on your brain, then are you even paying attention? And you sort of just

[00:04:56] Rob Howe: summed up what many people with diabetes deal with like day in day out. So much of our culture is centered around eating. And I mean, as human culture in 2022 and for us in the West. So, you know, we're, we're gathering where it's about to be the holidays, families gathering around meals, but also, you know, weddings and celebrations always have some sort of meal component. So you're balancing being present in that situation with also all the calculus going into, I just want to eat these chips at the table or have this dessert or eat the main course. What do I need to do. So let's talk about all the things just from a high level for, for listeners who, you know, are either new to diabetes or are caregivers, or just learning a little bit more about diabetes. What are all the things that a person with diabetes going into a meal has in their mind and are balancing and what you see as well from some of your patients?

[00:05:48] Ben Tzeel: Well, and it's, it's interesting too, because everyone has that different level of education and different experience you'd expect out of the gate. You think of diabetes. First thing you're taught is carbs, right? Carbs, you have to count carbs. You have to pay attention to carbs are the one thing that's going to make your blood sugar skyrocket as fast as possible. And so you're constantly thinking, how many carbs am I having? How much food am I having? You know, how do I measure and determine how much this portion size is? Then, you know, you go onto that secondary level of, is there fiber? Is there fiber? I have to think about subtracting potentially. Is there any other sort of, you know, sugar alcohol or something that could be related to carbs. And these are just the carb side. Then we go into the next level, the protein, the fat, how much fat is there? Is there enough fat to cause a spike in three or four hours? Is there enough fat to cause a spike in six or seven hours? And again, this is still just the food. We haven't even talked about the alcohol, the beverages, is the carb, a simple carb or a complex carb? You know, there's still so many different things, glycemic index, where you're having to plug and play all of these things in and it becomes a lot and it becomes a lot because it's not just, Oh, I do this once a day. It's I do this every single time. I want to put anything

[00:06:55] Rob Howe: into my body at all. So this is why I love having you on the podcast, man. You've already dropped like three knowledge bombs here that I, that I picked up on. So first of all, you're right. Uh, at, at the beginning, generally we get some sort of carb counting education and it typically stops there no matter how in-depth your education is. Um, just because there's so much information to gather, right? Carbs at the base level, probably the most important thing to learn to count, But you also mentioned fiber and you also mentioned fat and protein. So talk to me a little bit about, for our listeners, the impact of fiber, first of all, because you said subtracting from your carbs and then fat and protein, which you also said adding to your ratios. So how do you help your patients account for fiber, fat, and protein?

[00:07:38] Ben Tzeel: There's so many different things. I could go so in depth, but I would bore everyone to tears. So I'm going to just try to rein it all in. But with fiber, there's, you know, the concept of, Hey, your body may not digest the fiber. So you have 26 grams of carbs in this particular food. There's six grams of fiber. Some people's bodies may not digest those six grams. So then if you dose for all 26, you're going to go low. So ultimately you subtract it. Some people choose to subtract. Some people don't. I tell them stay consistent, just whatever you pick, stay consistent. More often than not, people will find that subtraction is necessary, but that's that next level on the carb front. Then with the protein and the fat, what tends to happen is they both tend to similar to fiber. They both do slow digestion a little bit. They both can stabilize blood sugars a little bit, which is great. But with fat, it basically slows it down so much that six hours, five hours, seven hours, some timeframe in the future, if there's enough of it, it will start to have your blood sugar rise. And there's been research that's demonstrated on average. And there was one study, it wasn't huge, but people needed on average about 40 to 50% additional insulin just from having a high carb, high fat meal. So if you're just taking for the carbs, you're missing a huge chunk of the equation. And that's when people go to bed at one 25 and wake up at three 35, because they don't understand that there's fat that they have to

[00:08:57] Rob Howe: account for as well. Well, and I think now, you know, I get fortunately benefit from being able to see that CGM graph. So I think of my life before the CGM and having to just guess and, And, you know, like you said, wake up in the middle of the night, mouth is dry, sweaty, not feeling good. You're like, okay, well, what happened here? And you, and you see that fat bomb hitting later, later in the evening. So let's talk about that because I think there's like three types of food that come to mind for me, uh, when, you know, we're talking about fat, uh, you know, whether it's a dual or a square wave bolus back in the old pump days or additional, uh, kind of insulins that you're using or additional doses. Uh, for me, those types of meals are Chinese food. So when you think of like Panda Express is a good example, that's pretty much everywhere. Even when I went to Hawaii, there's a Panda Express there pretty well. And so you're eating rice carbs, you're eating a protein and fat in the chicken, and you have like a lot of sugar in the in the sauce. And I'm no way advocating for Panda Express. But let's be honest, I'm a person and I have eaten it and I do enjoy it. So Chinese food on one hand, Mexican food on the other. And there was a great video on TikTok actually shout out our mutual friend Lauren Bongiorno uh, about how we don't really realize how many carbs are in all those chips that we're eating at the table when we're having Mexican food. Uh, cause all those chips are tortillas are broken down and you eat, you know, a couple, you start to mindlessly kind of consume those. And before you know it, your blood sugar is through the roof. Uh, but you're also looking at, uh, fats and proteins and extra carbs, tortillas, uh, rice, uh, you know, beans, all of those things kind of playing into. And then number three, which is a sort of the memeable one, which is pizza. Uh, and we're all trying to figure out, you know, what the ideal ratio of carbs to fats to proteins is, uh, on those pizza slices. So, you know, for you and when you're working on strategies with your patients, like what do you, you know, how do you approach those kind of high fat, high carb meals?

[00:10:49] Ben Tzeel: Oh, I feel like in pizza, do we get to count Italian food in there too?

[00:10:52] Rob Howe: I think we do. I think we got to.

[00:10:53] Ben Tzeel: Cause I was going to say, I feel like the two of those to me, I'm thinking a giant plate of chicken, Alfredo pasta, that's going to be the same type of situation. And then of course, you know, the classic dessert side, the donuts, all of that, but any of those things, they're all, you know, the same common theme, high carb, high fat. So not to say you don't approach any of them differently, but you really don't have to, it just becomes a matter of saying, Hey, am I going to take the carbs up front? Because a lot of people think, Oh, I split the dose and I do half of it now and half of it later or whatever. That's cool. That's great. But then you're almost setting yourself up for a high. That's going to then just sustain for hours, which never made sense to me. I don't know if maybe that's just me, but I'm thinking, you know, Hey, are you going to take the carbs up front? Like you normally would. And then from there, how are you going to address that fat and protein later on? Whether you're using, you know, similar to the study I cited earlier, whether you're doing something else where you have your own formula or own calculation, you work with, you know, our team or with another dietician that might be able to help guide you, but knowing you're going to do what we jokingly call the now and later dosing technique you're dosing. Now you're dosing again later intentionally, instead of just reacting, correcting, because your number's high. If you know, I'm going to dose at this time because of the fat, you're usually in a much better spot than, oh, I'm 320. And now I have to correct six times before I come down.

[00:12:08] Rob Howe: And it's like you said earlier, you know, just staying consistent and kind of going into a meal with a plan and executing the plan and then being able to optimize it based on those results.

[00:12:19] Ben Tzeel: Yeah, it's all, it's all about having the game plan. And the hardest part I feel like, and if we go into the eating disorder side again, it's, or, you know, disordered eating, eating disorder side, it's really the having the plan, but being able to execute when there's these external factors around. When people might be asking you, why are you, you know, counting all this up? Why are you thinking about all this? Like, why are you doing these things and not feeling that social pressure to say, well, I don't actually have to because other people are going to judge me. That becomes hard in and of itself. And that's a battle. A lot of the people I work with face, they get pressure. Oh, just have this cookie, just have whatever. Oh, it's no big deal when And we have to input that into the giant mathematical equation. I think of Jimmy Neutron with the think thing going on, we zoom in real deep. That's how I feel like our brains have to work half the time.

[00:13:05] Rob Howe: Well, and that's what I wanted to focus on. We have only been recording this podcast for 20 minutes, not even in the first half of what we're going to talk about today. And we talked about carb counting. We talked about fiber. We talked about protein. We talked about fat. All of these things are balanced in all of our heads at every meal. And guess what? we eat multiple times every single day. And, uh, I've been reading studies later. I'm trying to get more, uh, educated on my, on my diabetes takes is, you know, sleep, uh, exercise walking. There's a study right now. Uh, it's not published yet, but it's basically, uh, you sign up. And if you're in the, in the group, you walk 10 minutes before a meal and walk 10 minutes after, and they're measuring the impact on blood glucose. And, you know, just from experience, we all know, we see it in the diabetes community all the time. You clean your room, you brush your teeth, you move some boxes, your blood sugar is going to come down. I mean, it's just kind of, it's just kind of how the law works. And, you know, so being able to see like, oh, like being consistent and adding some of these little strategies to your eating routine, a can help you get those better results, but also is another thing to add to your list. And so when you're coming to the table and somebody says, oh, just eat this thing, it doesn't matter. Like, it'll be fine. They don't see all that, that you're bringing all those burdens, all that mental health burden. And we know that people with diabetes are three times as likely to suffer from anxiety and depression. I'm reading here on diabetes.org that research suggests that eating disorders are probably more common among people with diabetes than just people without. So we're already set up to, you know, be in this position that can be really compromising to us and really be very dangerous. And so with that, I'd like to issue a content warning for our next part of our discussion, we're going to talk about eating disorders and diabetes. We're going to talk about diablemia. And if that makes you uncomfortable, that's okay. You can skip towards the end. But what we're doing this for is to really demystify some of these concepts and show that you shouldn't approach these with shame. We're working together to try to continually educate. So I would encourage you to keep listening if you can. And we've had an amazing guest before on this podcast. It's been a few years now, but Erin Akers from the Diabulimia Helpline, there's also an episode that I will link in the show notes. So if you haven't heard that episode, highly encourage you to get in and dig into that topic as well. So with all that, now we've kind of approached the disclaimers. Let's get into talking about diabetes and eating disorders. And so you and I are some dude bros. We're some bros. And honestly, I wear it with pride. My camera's a little bit out of focus here trying to get that back. Uh, there we go. Um, you know, you are an athlete, uh, you've been a bodybuilder, you've been a baseball player. You're, you know, now I think, uh, I would classify you and I as like weekend warriors. We stay in shape because we know it's good for us and we like to feel good, look good, feel good, play good. The whole, the whole nine. Um, I bet that most people, when they saw this podcast, didn't think that you and I would be talking about eating disorders. Uh, so for guys like us, uh, let's talk about disordered eating and eating disorders, because I want to, I want to say like, it can happen to men. There is sort of this, uh, I think connotation we talked about a little bit earlier that diabulimia is, is something that only women with diabetes deal with. And I would like to ask you, uh, as a registered dietitian, have you encountered diabulimia in your male patient populations?

[00:16:34] Ben Tzeel: I do periodically. And I wouldn't say it's always diagnosed formally per se, but diabulimia hasn't been defined so far. It's basically from, you know, my understanding from what I've seen people that are withholding insulin so they can run their blood sugars higher, whether that's for the intention of weight loss, whether that's because they're afraid of hypoglycemia for some reason, they're withholding the insulin. They know that they are supposed to be taking. So it's not, not to confuse it with people that, you know, in the events they have to ration insulin for some reason, it is truly because they do not want to out of a fear of something.

[00:17:09] Rob Howe: Yeah. So on the diabetes.org page, it defines it as an eating disorder characterized by intentionally withholding insulin to result in weight loss. And just to give some stats on, uh, the amount of people worldwide who struggle with diabulimia, uh, it's actually really common as many as a third of women with type 1 diabetes, uh, report insulin restriction, uh, and higher levels between the ages of 15 and 30, which we know in the diabetes community as the sort of the 15 to 30 range, uh, teen to young adult are the most critical times for someone with diabetes. And they typically result in the highest A1Cs. A lot of that is just lifestyle and hormones and being a teenager and a young adult and just kind of rebelling against the system. But obviously these are bigger issues at hand as well.

[00:17:54] Ben Tzeel: Well, and then also think about, you know, where they're at in life. You know, if you're going off to college, you have this freedom, you have this lack of structure that you're used to having. And like you said, that in the rebellion is all, it's the perfect cauldron for becoming an eating disorder. Well, and I think, you know, that's one

[00:18:11] Rob Howe: of those challenges again, of living with diabetes is even things that should be exciting. And for other people kind of like learning on the fly and like making these mistakes and like learning who you are as a person and, you know, having a grocery shop for yourself for the first time, maybe, or, you know, provide for yourself, like those might be exciting to somebody without a disability like diabetes. But, uh, you know, for us, it can be oftentimes, you know, result in, you know, poor outcomes result in bad labels from, from your HCPs or your care teams, like non-compliant, uh, people feel like they're rebelling against their diabetes. And, you know, we've heard many stories over the years, uh, and you know, it's, it's a very critical time. So all of the, all of this to say, uh, these are very present in our life with diabetes. And, you know, for you from the male perspective, uh, what, what have you seen working with your patients who are male and are living with some sort of disordered eating related to their diabetes.

[00:19:06] Ben Tzeel: Well, it's interesting you say that because obviously the emphasis, like we talked about, tends to be on the female side, but the male side, it tends to be sometimes they don't even realize that they're doing it. There's times where it is completely, they're just unaware. And I've noticed it almost as a manifestation of I'm worried about my number going super low, or I want to lose this weight, but I'm more so worried about the low. And then it becomes this like double edged sword that they don't know they're doing it, but they totally are. So that becomes a conversation of where is this coming from? Why is this happening? The ones who intentionally do it, that's where it gets a little more dicey because they know exactly what they're doing. And I almost get concerned as a provider to even bring up the concept because I also don't want to plant the ideas in their head that they've never potentially heard of before, because I don't know about you, but until I was doing my training and until I really started immersing within the diabetes community, I don't think I even heard of diabulimia until I was 25, 26 years old. So, and I've had it since I was seven. I had, I had never heard of it either.

[00:20:10] Rob Howe: And I think you're right. And I think probably by design, like you're saying, most providers don't necessarily want to introduce the idea of that concept to people. But I think what's interesting about that is that it sort of has a reverse effect that people think that they're onto something new. And I've heard people on this podcast even talk about, you know, I discovered, you know, quoting these people, I discovered that I could lose weight or I could have a better, more positive body image that I wanted if I ran my blood sugars higher. And, you know, in those moments, you know, when you're young, you don't really necessarily think about the long-term complications that you could be exposing yourself to. So I think it's important to have that discussion. And for people like us, especially who are in the community, I imagine, because I was surprised, someone listening to this podcast would be surprised to learn that one in three women with diabetes deal with some sort of diabulimia or diabetes-related eating disorder. But we need to have those conversations because in order for us to educate, we need to de-stigmatize that it's something wrong. So I'm kind of rambling here, but again, back to the topic is restricting insulin for weight loss or body image, or, you know, just trying to fit in or kind of

[00:21:22] Ben Tzeel: kind of avoiding diabetes is very common. Yes, it is very common guys and girls. And for the guys, like I said, sometimes they don't know exactly what they're doing. And same with the women, but with the guys, especially the times that they do know exactly what they're doing, it does become difficult because bringing it up, you know, as you mentioned, we're bros, we're not trying to, you know, have this thing where it's like, Oh, let's talk about how you're feeling. Let's talk about why you're doing this, guys just want to push it aside and say, no, I'm doing it. I'm okay. It's fine. And I'll be like, your blood sugar is 425. It's obviously not okay. Well, this is what I feel like doing, et cetera. And it almost becomes this barrier that we put up because we don't want to explore that side that might be a little more vulnerable or a little scarier because we'd rather have that protection and say, you know what? It's fine. I'm getting the result that I want. And what I find is a lot of times I've talked to people that have recovered from diabulimia, And then they'll come back and say, hey, I want to do, you know, I want to lose some weight or I want to do it the right way this time. And a lot of them have told me, men and women, I have now experienced things from a, you know, complication, long lasting standpoint that I otherwise would not have had to deal with. But when I was in the perfect age group, right, that 18 to 24 where people were in college or people really cared about, I need to lose weight for whatever reason. Or when I was diagnosed, I lost all this weight and I felt amazing. So I just kept doing it that type of timeframe. They tell me they regret more than anything else because now they're facing, you know, Hey, I'm, I'm losing some of the feeling in my toes or I'm, you know, having issues with my kidneys and I'm only 36 years old.

[00:22:57] Rob Howe: Well, we often don't talk about the, let's call it the C word complications. Um, when you're talking about, um, you know, whether that's retinopathy, uh, or, you know, losing some of that feeling. What are, you know, you said 37 or 36 years old, you know, what, what are those timeframes for when you're, when you're running elevated blood sugars for a long period of time, you know, can you see those complications early on? This is sort of a today thing,

[00:23:24] Ben Tzeel: not a tomorrow thing. Well, and the earliest I've ever seen, I don't think it was a male example, but I remember it was the first time I'd ever even heard of somebody who had one that someone that I knew, cause you know, you always hear as a kid, they try to scare you all. This is, if you don't control your blood sugar, this is what's going to happen. And you kind of just let it go in one ear and out the other. I was 17 or 18. I knew a girl that was a couple of years older than me, but for six years, she had ran her blood sugar super high, likely again, same age range. And with that, she was already experiencing neuropathy, peripheral neuropathy. And she was 19 or 20. And that was the earliest I had ever seen. And that was the first time to me, again, I'm not a dietitian at this point. I don't really know exactly what's going on. That was the first time it hit home where I'm thinking this is very, very, very real. And then on the dude front, it can be that much more difficult because at least sometimes, you know, the girls are willing to open up or the women are more willing to say, let me, you know, express my feelings. The guys just want to just put a complete, you know, completely just close off, not want to say anything, not want to even dive into it in the slightest, because that's not what we talk about. We don't talk about things. We talk about what

[00:24:33] Rob Howe: we're doing and that's it. So with that in mind to the bros out there listening, what are some ways that you have seen success having those discussions or bringing those things up? Cause talking about tough stuff is hard. Uh, and especially when, you know, I don't know about you, but when I was, you know, either, you know, early on in my diabetes life and I was diagnosed at 16. So I was past a lot of the like, you know, puberty kind of rebellion and just like teenage years, but I had, um, I kept diabetes very close to me and it felt very personal whenever it was discussed. And it seemed to me sometimes, especially with my practitioners, like it seemed like very invasive and uncomfortable. So what would you say to somebody who maybe is recognizing some of their symptoms, but is just afraid or is unsure of how to start,

[00:25:26] Ben Tzeel: having that conversation with their care team? I mean, I think one of the first things is to first be honest with yourself and say, am I ready to even share this with my care team right now? Because you may not, and maybe like you said, it felt very invasive. It wasn't comfortable, but you eventually, I would imagine got to a point where you felt okay talking about it. And that might take a little while. Of course, you know, the goal is once you're comfortable with yourself and saying, Hey, I'm going to bring this up, maybe bring it up in a session. Maybe if, you know, if someone's an adolescent, they're not quite, you know, an adult yet, they're still the pediatric endo say, Hey, you know, maybe I want five minutes with the endo by myself and just bring a couple of things up slowly. Hey, you know, this is what I've thought about, or maybe with, you know, some other trusted healthcare provider and just slowly bring it up and put a couple of feelers out there just to see, is this water that, you know, I can swim in comfortably with this practitioner. And if it doesn't feel, doesn't feel good, there are other people on the care team that you can talk with, whether it's the educator, whether it's a dietician, somebody else likely can commiserate with you. I would start slow, dip your toes in. Don't feel like you have to just launch everything full force because if you do, then there's a chance that if it doesn't go the way you want, you're going to be closed off forever.

[00:26:36] Rob Howe: Right. With that in mind, you brought up something really interesting. We've talked about this age range, 15 to 30. I think the ADA website said, let's even shrink it down 15 to 25. for most people, your parents or caregivers are a part of your life during those years. How would you, if a parent is listening and they're like, I'm thinking that my child may have some exhibiting some of these behaviors of disordered eating, how would you recommend that they approach that in a way that they don't close off that conversation forever in a way that's like with empathy and not necessarily accusatory?

[00:27:19] Ben Tzeel: Well, and that's a great question too, because you don't want to come at, you know, your child at that point saying, Hey, what was the dose supposed to be, or how much are you taking? And I mean, you could go that route, but it's probably not going to end very well. I would just say, again, something gentle, something similar, maybe it is, you know, Hey, let's, you know, look at your numbers or something that, that, you know, super, super low key, low level, let's look at the numbers. And then that way, there's a way of saying, let's review them. I just want to make sure your numbers are doing okay. Oh, the numbers are looking a little higher. Can we talk about that a little bit? If they want to talk, great. If they don't want to talk, at least now you're catching on as a provider, as a parent that has an idea something could be up. And if you just say, hey, I want to make sure you're feeling your best. I want to make sure you're ready for whatever activities are going on in your life. If we can review this every couple of weeks, that would be great. Just five, 10 minutes. They'll probably, I would imagine say or at the very least you have access, hopefully if they have a CGM to their clarity, to their meter, whatever download, that would be my, my way to do it because you're still approaching it, but you're not necessarily directly approaching the problem yet. Get your way in. Great. You're

[00:28:29] Rob Howe: set. That's it. I think having this space to have the conversation and start that conversation is, is probably, you know, especially at the first time out, that's probably the best that you can hope for is just, you know, having a space where that can be received. Right. You, You mentioned having some patients who have worked through diabulimia and come back to you either for weight loss or just continuing to work with you as a dietician. What are the things that on the other side of diabulimia, working through it and being able to overcome, let's say endure a bout of diabulimia, what are the things that you see and that they say to you on the other side that may be helpful for our listeners?

[00:29:12] Ben Tzeel: I think one of the things is when I talk with them, especially in that first conversation, it tends to be a lot of, hey, you know, I worked through this. It was really hard. And not everybody has finished working through it. But a lot of people have done a lot of work to get to the point where they're willing to even chat with me. But at that point, it's I'm sick of feeling really, really lousy all the time because it becomes this constant tradeoff of do I want to, and I'm going to use air quotes, you know, like what I look like at the expense of feeling like absolute garbage all the time. Or do I want to feel better physically, but maybe have to learn the, you know, the proper safe way that's sustainable to lose the weight that I'm looking to lose?

[00:29:51] Rob Howe: Because let's, let's talk about something around diabetes management. And this is something that I think, uh, there's a lot of misinformation about online. Um, but also there are some truths to some of this. So like, um, I'll, I'll put out sort of the headline. I'll let you react to it. Insulin makes me gain weight.

[00:30:10] Ben Tzeel: Yeah, that's, and that's one of the biggest things out of the gate. Do you want me to express why that that is a myth? Yeah, I'd love to. Cause I think a lot of times what happens is, you know, people get diagnosed with type 1 diabetes, especially, and they're put on insulin. And before they were diagnosed, they're losing weight rapidly because their body is literally starving itself. You have all this glucose sitting in your blood. There's nothing that can be done with it. You're peeing it out. So you're basically in effect, peeing out all the food that you're eating. So you're in a massive calorie deficit, you start losing all sorts of weight, all sorts of muscle, all sorts of fat, you get on insulin, you're not starving anymore, but the glucose in your blood can now get processed. So then instead of starving, you start to regain the weight that you lost. So people see it as this negative thing, I started insulin, so therefore I'm gaining weight. The reality is, you're just not starving anymore, you're getting back to the homeostasis, what your body was originally at that you theoretically should want to thrive and do all the things you want to do in life. So there, it becomes this constant, like, I guess, myth for lack of a better term, because then the healthcare providers, a lot of them perpetrate it. They say, well, insulin causes weight gain. So we need to cut your dose down. It's not that the insulin is causing the weight gain. If you're eating excess calories that require more insulin to process, there's your weight gain. It's not so much that your body can gain weight without, without insulin. If otherwise every keto person would be a skinny as a rail, your body has a thing called acylation stimulating protein that allows your, you know, your frame, your body to gain weight without the presence of insulin. And, and really what we're looking at, there is a correlation,

[00:31:42] Rob Howe: not a causation, right? Your body, your body was starving. You're in diabetic ketoacidosis. You add insulin to that, which takes away the ketoacidosis, which takes you out of that starvation state. And as a result, your body refuels. For me, I remember I gained like I, I, you know, my weight swung, I probably lost 20 pounds in two weeks from, uh, you know, before I was diagnosed. Um, and I was, you know, I'm pretty skinny now and I was really, you know, skinny then. Um, so putting on weight over the next 10 days, I gained it all back and some more. And, you know, for me, my body felt healthy. And I think for me as an athlete as well, I was lucky that I saw it as fuel and I saw it as positive. Whereas somebody who, you know, maybe has some different body issues or maybe wasn't expecting that, or maybe had really liked the way that they, their body looked as they were, you know, going into ketoacidosis and, you know, we're enjoying that sort of weight loss. And I think there's a lot of toxic diet culture that goes into that. Um, but like you said, it's, it's a correlation. It's more of a, you know, when you really get into the calorie deficit, uh, you know, that's where the weight loss comes from. Uh, and obviously you want to be able to find that homeostasis. And I think that balance is really what we're looking for, But too often we see either crash diets or we see, uh, you know, headlines and misinformation about, you know, insulin causing gain weight gain. And it was, it was good, but I appreciate you kind of dispelling that rumor.

[00:33:05] Ben Tzeel: Well, and it's something I think I just posted about the other day too. It needs to be said more frequently. And I tried pretty, you know, at least I'd say once every 12 weeks or so to bring up, this is not true. So people stop perpetuating this, you know, not it's a myth for lack of a better term. And because you're going to see it everywhere, but the people that aren't even in the diabetes space, but they want to sound like they're scientific. So then you believe them. And quite frankly, a lot of times, like you said, there's people that wanted to lose 40 pounds. They get diagnosed, they lose 40 pounds. They're thrilled, but then they realize that it's because they were literally having their body starve itself to death because they're getting diagnosed. And that's the part where, like you said, a lot of them have the body image issues to begin with. And then the diabetes just enhances everything. It's kind of like when people say that people are an enhanced version of themselves when, you know, they drink a lot. It's the same type of thing. You're an enhanced version of yourself in this case too, where it's just becoming more and more of a big deal.

[00:34:04] Rob Howe: It's interesting, you know, diabetes is often called, and I've called it a lot on this podcast, a disease with too many inputs. And, you know, like we see it with food, with drinks, with fat, we talked about earlier, carbs, fat, protein, fiber, and that's just on the food side, not just the sleep. not the exercise, not the stress, not the cortisol, not the other hormones. Diabetes also really affects your mind and your mental state. It's a physical and a mental disorder. And one of the things I wanted to talk about related to diabulimia is Google gives you the people also ask section. And so in the Google search that I did earlier, I was looking for diabulimia resources. And a couple of the people also ask questions also, I can't really say also, So that's funny. How can I help someone with diabulimia? And I think you gave a really great example of that earlier. But the next question is, is diabulimia a mental disorder? And what I was interested in that is because, you know, to me, it's a bigger question is, is diabetes a mental disorder? And in a lot of ways, I think it really is just because of all of the math and all of the burden that you come to the table with, like we talked about earlier. It's not just, Hey, I'm counting my carbs in, uh, in my, you know, uh, ratios of 15 and I'm giving my insulin dose and I move on with my life. Uh, it really is something that you take with you morning, evening, and night. And many people say it's like the full-time job that you get no vacation from. Uh, but really that is the, you know, the strain of a chronic illness over a long period of time. Uh, you know, so for you, you know, it just practical advice for, you know, someone with diabetes, uh, you know, what do you, who may be struggling with an eating disorder, Or, you know, what, what are the steps that you would take?

[00:35:46] Ben Tzeel: I mean, if someone's not sure if someone's listening and they're saying, Hey, you know, I'm listening to this. I feel like I check some of these boxes off. And again, like we talked about most people with diabetes, I'd say 99% of them have some form of disordered eating in some regard. Then if it starts to get to that level where it becomes that obsession, where you're constantly thinking about the next meal, you're constantly thinking about the previous meal. And it's not just, Oh, what am I going to dose? it becomes, well, is my blood sugar perfect right now? Is this going on? Am I going to run higher? If I eat this, am I going to lose weight? If you become fixated, if you're so fixated on the weight side of things, on the body composition side of things, that's where I would consider saying, hey, start that conversation off. If you're at a point where, oh, I really just want to sit down and figure out what I'm going to dose for this pasta meal. That's just kind of the standard of

[00:36:36] Rob Howe: care for lack of a better term. I like that you said that because, you know, I I'm, I'm Rob Howe on this podcast. I had a low blood sugar today. Uh, I all, my blood sugar also went over 200 for a little while today. Uh, and you know, mostly because I'm just working on, I just, uh, got a new, I opened a new, uh, long acting insulin pen and this one is working a little bit better than the last one did. So, you know, I'm having to deal with that struggle. So for you, um, I don't know, just demystifying like you Ben Tzeel, I've seen you eat crazy donuts. I know you love donuts. I've seen you eat, uh, you know, your pizza strategies. I've seen your graphs on Instagram, but you as a person with diabetes also count carbs. You also have high and low blood sugars. I just want, I just want to hear you like admit that that's a thing, right?

[00:37:24] Ben Tzeel: Yes. I, I Ben Tzeel, a registered dietitian and 20 plus year diabetes veteran. I do have my days where I have lows. I do have my days where I have highs and it's all about, you know, can you get the time and range reasonable, but also live your life. I would rather somebody say, I'm going to have 80% time and range, not a ton of lows. Maybe, you know, a couple of borderline highs, but actually live and not feel like they're chained down as opposed to, Oh, I have a 98% time and range, but you sit in your house and don't do anything all day. Cause that you're not winning any award for I'm 98% time and range. It's a lot more fun to experience life. And maybe, you know, you have to take your foot off the gas a little and not be such a perfectionist. Like all of us tend to be, we all want to have perfect numbers, but we're not going to ever have perfect numbers,

[00:38:08] Rob Howe: at least as of right now. Type. I I've said this before, type 1 breeds type a personality and like over control. And I think I'm one of those people. I like to, I like to be in range. I'm a better person when my blood sugar is in range. I know that for a fact. And all of my friends and peers can vouch for that for sure. Uh, but also, uh, finding that balance. And I think that the word you used earlier, homeostasis, that stasis and balance in your body. Um, you know, you can talk about it physically, mentally, spiritually, what have you, uh, finding a stasis there with your diabetes and improving it, um, will just add more pleasant years to your life. Uh, I think, and kind of relieving yourself of that burden to be perfect. Um, and you know, you and I, again, going back to that bro perspective, um, you know, we're trying to get our gains in the gym. we're in there trying to crush it. We're trying to go in and, uh, you know, put numbers on the boards, uh, and hang some banners, obviously. Um, but we're not perfect all the time. And I think having given yourself a little bit of grace in those periods where you're struggling, um, and really, you know, whether, whether that's, uh, you got to listen to your, your Kobe Bryant mama mentality, uh, you know, uh, audio books that are out there or sound bites on the internet or YouTube videos, uh, or you've got to, you know, take a step back and say, Hey, you know, I need to talk to my care team, or I need to be a little bit more intentional about how I'm looking at my numbers and give myself a little bit of grace, uh, wherever you fall on that spectrum, uh, my brothers in Christ, I see you out there. I know, I know, uh, I know what it's like. And I think the trickiest

[00:39:39] Ben Tzeel: part is giving yourself first that pat on the back for look how many balls you're balancing right now in the air at one time. And then second, if you drop one of them, pick it back up and put it back in the rotation instead of, oh my God, I dropped one. It's the end of the world. Everything's no, you're fine. You might have a day, you might have a week. That's not optimal. The key is, can you pick up after that and not be getting so obsessed into the weeds about everything? And this goes for the weight loss side with diabetes too. You absolutely can do it and do it in a sustainable way. And quite frankly, as long as your numbers are controlled, it's really not that different than someone without diabetes. It's just keeping the numbers controlled at the same time. But the idea of, you know, not taking insulin for that, it really is, you know, okay, cool. Do you, which way do you want to go? You know, do you want to go the way where you feel lousy, but you might like what you look like, or do you want to go the way where, you know, you might have a little bit slower of a process, but you'll actually feel good the entire time and feel a lot more accomplished and be able to keep it off for good when you're there. That to me is, you know, the big question I would want people to ask once they're comfortable with having the

[00:40:42] Rob Howe: conversation. And I want to add to that because you're also a guy that cares about aesthetics as I am. Uh, but I'm also a guy that likes to do both. So, so Ben, is there a way in your experience to have balanced blood sugars and look the way and feel the way that you want to feel, look and feel optimal, optimal blood sugars, optimal aesthetics and feeling like, is that possible? 100%. Yes. Great. So, um, you know, if you're listening to this, no matter where you are in your diabetes journey, uh, if you've never even thought of diabetes as an, as a disordered eating, or if you are living with an eating disorder and don't know how to share, um, I want to encourage you that no matter where you are, uh, you can, and you can do, you can do this. You can find a way to find that balance in your life. Uh, I'll also say if you are struggling with diabulimia, there is a 24 hour helpline. It's the diabulimia helpline. You can visit their website at diabulimiahelpline.org, or you can call them 425-985-3635, 24 hours a day, 365 days a year. So I want to make sure that we, that we plug that. If you're interested in talking to Ben and some members of Ben's team, yourdiabetesinsider.com, or you can go man of zeal. Again, that's that silent T-Z-E-E-L on Instagram as well. Awesome content on Instagram and TikTok, man. I'm, you know, we're going to talk about that, you know, when we talk offline. But man, you have just really been putting in the time. And like you talked about continuing to educate and reiterate all these really important topics for people with diabetes. So thank you for your time, man, coming on the show today. This was a really awesome interview. I'm looking forward to hearing all of the response from the community.

[00:42:29] Ben Tzeel: This was amazing, honestly. I feel like it's a topic that needed to get addressed. I feel like we did an awesome job with it, but I'm also just excited for the community to get to finally hear about it and bring it to light because that's what it honestly needs.

[00:42:40] Rob Howe: Yeah. And I think, man, I want to just continue to reiterate that people like us living with diabetes publicly, even though it may look like we have everything figured out under the sun, that we were once beginners and that we deal with every single day having to return to that, you know, that work of managing a chronic illness and being a full time pancreas with no backups. So, uh, you know, if you're out there, I see you and, and, uh, you know, I'm proud of, of you getting back up on the horse every day, uh, and, and coming back to fight. So, uh, Ben, man, thank you for your time. And we're definitely going to have you back sooner than later.

[00:43:17] Ben Tzeel: Yes. I appreciate it, Rob. This was amazing. Definitely looking forward to coming back on.