Dr. Eric Westman: It’s my great pleasure to introduce Dr. Jen Unwin. I’ve known Jen for several years and met her at international meetings. I’m thrilled to have you on.
Dr. Jen Unwin: Thank you so much, Eric. It’s lovely to be on. It’s my favorite subject that we’re going to talk about, so I’m sure it’ll be fun.
Introducing Dr. Jen Unwin
Dr Eric Westman: Well let’s assume the people you’re talking to know about sugar and carbs in general, and the people that we have taught know about keto diets. The saying is that it may be simple, but it’s not always easy. How did you get into this?
Dr. Jen Unwin: My name is Dr. Jen Unwin. I’m a clinical psychologist by background, I trained to work in the National Health Service in the UK. I specialized, I’m saying specialized because I actually don’t work in the NHS anymore, but I specialized in helping people with all kinds of chronic health conditions to live the best life they could. It was my job to help them focus on their quality of life and mental well-being because we know that can help them manage chronic pain, disfigurement, or life-threatening conditions. That was my role, usually in a hospital setting. I wasn’t your typical psychologist focusing on a mental health setting. I worked in general hospitals and tertiary centers, with, for example, burn patients, cancer patients, and patients who’d had amputations – that’s what I did my doctorate in – trying to help them live the best they could.
Dr. Unwin’s food addiction
Dr. Jen Unwin: I knew quite a lot about behavior change and hope and quality of life. At the same time, in my personal life, looking back now, I understand that I had a food addiction problem – really, a carb addiction problem. That had always been the case. Looking back through the eyes that I now have, I don’t remember a time when I wasn’t loving carbohydrates, refined foods, sweets, or anything as a child that I could get my hands on. That led me to be an overweight child, which was quite an unusual thing in the UK at that time. There weren’t so many. I was the only kid in the class that was.
That wasn’t so great. I was in a girls’ school, and, it would be the same these days, that girls get a little bit obsessed with dieting and body image and all of that. I learned how to do all of that and was rather a good dieter. I could lose four stone (56 pounds or 25 kg). I did that when I was 16.
So, I was successful but that wasn’t the answer. I would go on this diet, lose the weight, and then, of course, once I stopped doing whatever the “diet” was, the weight would all come back on. As a trained psychologist, it was embarrassing not to be in control of what I was eating, or I didn’t feel I was unless I was on a very strict regime. That went on really until about 15 years ago now. I read a book that January. Picture the scene, a miserable January day, and I’m miserable because it’s post-Christmas and I’d probably put on a stone or some amount, and I was feeling, I’m just not in control of this behavior. What’s going on? I was wandering around the supermarket, and there were some cheap books. One of these books was called Escape the Diet Trap, and I thought, “There’s a book that I need.” And it was. It was by a British author by the name of Dr. John Briffa.
The start of a new beginning
Dr. Jen Unwin: Lucky me. That was the day that everything changed. I went home and read this book, and it makes total sense to me. It’s all about, as you say, carbohydrate is sugar, sugar puts your insulin up, you’re going to be hungry, it’s going to drive these cravings, why don’t you eat protein and fat and some vegetables? Having done many diets, I dove straight in, cut everything out, and went cold turkey. You can only imagine how bad I felt for about eight days. I was in major sugar withdrawals. Fortunately, in the book, he’d said, you’re going to feel bad for about a week, and I did. Then the lights came on, and I actually couldn’t believe how well I felt and how energized I was. So I told David – for those in the audience who don’t know, my husband is Dr. David Unwin. He’s a general practitioner here in the UK. I’m saying to him Dr. Briffa says that there’s more sugar in cornflakes than there is in sugar. And he’s going, well, that can’t be right, that makes no sense. I keep drip-feeding him these bits and pieces, and he can see how well I’m feeling suddenly, how cheerful, how energetic. So he gets a little bit interested.
Before low-carb, I suffered from a bit of Seasonal Affective Disorder. Now I never get that, so that’s been another side benefit. This goes on for a while, and David’s ignoring me because he’s seen it all before. He’s seen me do the diet and then put the weight back on, do the diet.
Dr. Eric Westman: I’ve never heard this detail of this story. I thought you were both on board at the same time. This is great.
Dr. Jen Unwin: He thinks it is another crazy scheme, but then I think he could see the logic of it. I could see the physiology was right and what was happening and that I was losing weight, and feeling more energetic. It coincided with a time when he’d got disaffected with general practice. He thought people were just getting sicker and sicker and there were more and more people with obesity, and more people with diabetes, and it was coming to the end of his career, as he thought, and he was a bit fed up with it. Looking back, we think he was probably pre-diabetic or type 2 diabetic. His blood pressure was going up, he was putting on a bit of weight, and he was very sleepy in the afternoons and liked a little nap in the afternoons. That was going on, and I was so energized by it.
I said to him one day, we’ve never combined our knowledge and skills into a project, and before you retire, and I finish with the NHS, how about we do a project that’s fun and we’re just doing it out of interest and putting our skills together. What we did then was we started a group in his practice with patients with pre-diabetes. We were a little bit nervous about doing something new. We just wrote to all the patients with pre-diabetes in his practice and said who wants to come along and maybe do this lifestyle intervention for patients with pre-diabetes. That was about 13 years ago now, I think. I don’t know if people know, but that’s just been the most incredibly successful project. He’s well known now all over the world. He spoke on the international circuit about diabetes remission without drugs. I think we’re nearly up to 150 patients now in diabetes remission without drugs, and lots of others who’ve massively improved their condition, and come off all kinds of medications. They just haven’t necessarily got right over the line for the definition of remission and he’s probably got the best results.
A lifestyle approach saves money
Dr. Jen Unwin: We were able to assemble the money savings from the payer, being the patient, on diabetes drugs alone. His practice saves, I think it’s now £70,000 a year compared to the other practices in the area. It’s not just diabetes drugs that people come off, it’s antihypertensives, it’s antidepressants, and there are all kinds of other drugs that get de-prescribed. The practice probably saves over £100,000 a year on drugs.
Dr. Eric Westman: The practice is a general practice, it’s not obesity medicine specific?
Dr. Jen Unwin: Anybody and everybody in a geographical area gets a general practitioner in the UK, and you would go to them, they’re your primary care physician, you’d go to them with any health concerns, and then they might refer you to the hospital. David told me the other day that he has not referred a single patient to the hospital for a foot ulcer or anything like that in the last 15 years.
A choice between lifestyle and medication
Dr. Eric Westman: You’re giving patients a choice. Most doctors in my area never give a choice; they just give medicines. What was the uptake, or interest, among these general patients?
Dr. Jen Unwin: Fantastic. It’s been amazing. Since that project, it’s grown. The other doctors have come on board and the practice notices have come on board. It’s taken years for it to filter through, but now that the whole practice practices in that way. If a blood test comes back and it’s either borderline or just into the diabetic range, we’ll give the choice and say you could start lifelong medication today or we could try a lifestyle approach, are you interested? Again, David says, I think in the whole 15 years, he’s had one person say that they weren’t interested and they just wanted the drugs – out of all the hundreds that he had seen.
Teachings in the clinic
Dr. Eric Westman: There’s a perception that it’s going to be hard. What approach do you use?
Dr. Jen Unwin: Some of the patients probably end up doing keto. It’s more of a go as low as you need to go to feel good and to get the results that you’re looking for, usually with diabetes. Since then, he’s expanded it to other things like heart failure or other conditions like PCOS (polycystic ovarian syndrome), which we know low-carbohydrate approaches can help with. He has this one simple sheet which he gives to people, then, he talks it through, and in the group, we usually have a bit of a topic. We might talk a bit about insulin, or fats, or we cook food with people, and we answer their questions. It’s all very informal and chatty. We did start at the beginning with a bit of a curriculum, but now we do it based on who comes, what they want to know, and what they need to know because everybody starts from a different point.
Dr. Eric Westman: Some people don’t want to know the details of glucose and insulin; they just want to be told what to do.
Successes
Dr. Jen Unwin: A sheet with what I can eat on it. Obviously, people share local information, like where you can get cheap almond flour or something else. Interestingly, in terms of uptake, some of that original group from 15 years ago still come to our monthly group. They’re still super engaged and they are also so inspiring to the newcomers. I’m sure you have that in your community. There’s one guy called Chris. He’s been written up and David often features him in his talks. He lost a massive amount of weight and came off loads of medication. He still comes, and he still brings his photos, he shows people his graphs and encourages them. It’s really nice to have those expert patients along.
Identifying sugar addiction among patients
Dr. Eric Westman: When did it occur to you that there was a subset of folks who had sugar addiction?
Dr. Jen Unwin: Alongside that, there I am on my low-carb journey as well, getting all the benefits but still having times when I would struggle to make the right choices even though I knew 100 percent that they were the right choices. Some of the things that I was doing were definitely the wrong choices. I still had my struggles. I say it’s simple, but even that simple advice isn’t always easy to implement. I knew there was a little bit more to the story.
I heard about Bitten Jonsson, who’s a Swedish nurse by background. She’d done some videos for the Diet Doctor website about food addiction. I just happened to be on the Diet Doctor website and I thought that’s interesting, I’ll click and watch that. That was the second epiphany. There is an addictive aspect to some people’s relationship with food, including mine, and in a way that explains all my previous struggles. How stupid did I feel? I was a psychologist with a doctorate, I worked with people with addiction, and I hadn’t put two and two together that sugar, a carbohydrate, could act in just the same way as other substances like nicotine, caffeine, and alcohol. Since then that’s what I’ve been focusing on in terms of how do you help people with that problem. For some people you give them that sheet and the information, they get it intellectually and off they go and you never need to see them again. They come back in a year and they’re still doing just as well as they ever did. Some people struggle a bit in the middle and then there’s this other group which I think are the hardcore food addicts. They really struggle with cravings, volume eating, and transferring what had been a problem with carbohydrate sugars to maybe sweeteners, maybe dairy, maybe nuts. They’re the usual suspects. I consider how we help them to understand that behavior and do something.
The prevalence of sugar addiction
Dr. Eric Westman: What is the prevalence and how common is sugar addiction?
Dr. Jen Unwin: It’s pretty common. There was a nice meta-analysis, I think it was in 2022, where they looked at all the studies using a thing called the Yale Food Addiction Scale. It is a scale that they developed, based on the DSM (Diagnostic and Statistical Manual of Mental Disorders) criteria for addiction to alcohol, drugs etc. They reworded the criteria and applied it to food. That was done by Ashley Gearhardt and colleagues. They found a prevalence of about 20 percent, but a lot of those papers were clinical groups like patients with obesity, eating disorders, and mental health problems. In the clinic, it’s going to be pretty common. It might be 20 percent or more. It’s probably more with type 2 diabetes and obesity because those are the two likely outcomes of eating in that way. In general, population studies tend to be, let’s say, 10 percent, but the scary thing is that in young people it seems to be higher. I suppose that is scary but not surprising because their food environment has been much worse than ours was when we were growing up. Young people, and certainly young people with obesity, seem to have pretty high rates of this.
Weight-loss surgery and the negatives thereof
Dr. Eric Westman: In fact, I think if someone has gone for weight loss surgery, that’s like they couldn’t control this. They had to have someone operate on them for this.
Dr. Jen Unwin: It doesn’t solve the addiction problem and we know that one of the unfortunate side effects, for some people of that surgery, is that they develop an alcohol problem because they can’t get the dopamine from food and sugars and processed foods. They are looking for other outlets and that’s a known thing. Sometimes people develop alcohol problems post-surgery. It’s amazing to me that people aren’t screened on the whole. Most of these bariatric services won’t be screening for food addiction and that’s because it’s not an official disorder in the DSM or the ICD (International Classification of Diseases) which we’re using in Europe.
That’s a problem because then there aren’t services, there isn’t research, and people aren’t talking about it and recognizing it in the clinic. People are then getting the wrong advice and treatment and have become more physically and mentally sick than they need to be. Like any addiction, for some people it’s a matter of shame and embarrassment; they can’t control their behavior. It really helped me to understand it as an addiction problem because then there’s something you can work with. People have been working with addiction for hundreds of years because alcohol and other addictive substances have been around for hundreds of years so we know a lot, in addiction medicine, about how to help.
Addictions
Dr. Eric Westman: The striking similarities between tobacco addiction and nicotine hit me. I spent 10 years helping to develop new treatments for smoking cessation. We would always add to the behavioral “cold turkey” day, some kind of medicine. I studied nicotine gum, nicotine patches, nicotine sprays, and nicotine inhalers, and I worked with an inventor of the nicotine patch.
Looking back, my parents smoked and everyone smoked in the 60s and 70s in the U.S. Then the Surgeon General’s report came out, and a lot of people quit. 30-40 percent were still smoking. My father was a doctor, it didn’t occur to him that it was an addiction. Everyone smoked. I now feel it’s a similar process we’re going to have to go through with for food and sugar.
Dr. Jen Unwin: Absolutely, and there are a couple of points there. One is that when the writing was on the wall for the cigarette companies, they brought up all the food companies. It is really sad. Then they brought their marketing and the food science side of it. How can we make these foods irresistible in the shop but also irresistible to our palates? They brought that approach to food manufacturing. We were a bit doomed there.
How to know whether you have a sugar or starch addiction
Dr. Eric Westman: How does someone figure out if they have a sugar or starch addiction?
Dr. Jen Unwin: In four ways. What’s interesting is when we were recruiting for the study that we did, we had done a treatment intervention study – a bit like David and I did – but I’ve done it with some other people around food addiction. We asked on social media for people who thought they were food addicts. When we assessed them, they were all correct, they knew. One simple way is what David does in the clinic, when his patients have perhaps struggled a couple of times, he’s given them the advice they need, they’re perhaps diabetic and he’s given them the sheet and they’re really struggling to follow, he will say, “I wonder if you know. Do you feel like some of these foods are a little bit addictive for you?” Then they’ll say yes. He said to me, you won’t believe how many people cry when he says that because nobody has said it before. It’s not always sweet things; it’s often bread or cornflakes. That’s one way.
The other way is you use the Yale Food Addiction Scale. It’s a little bit tricky to do in a clinic, and it was developed as a research tool so we developed a simple screening tool called CRAVED, which is based on the ICD World Health Organization’s criteria for addiction of which there are six. CRAVED stands for the six different symptoms. It’s reasonably easy to remember for a clinician or we’ve got a one-sheet tick box that they can use in the clinic. A few people like Dr. David Cavan, who’s an endocrinologist here in the UK, has been using that in the clinic to see how it works and it seems to work quite well.
The six criteria
Dr. Jen Unwin: The six criteria are:
C for cravings and compulsions – which are obvious. People get these urges that they can’t resist, eating certain foods that they don’t want to be eating.
R stands for reaching for more. That’s the idea of tolerance that everybody understands from alcohol, that the more you drink the more you need to drink to get the same effect is exactly the same with food. Maybe a couple of biscuits would have done the job at one time but now it’s a whole packet.
A is for activities neglected. This picks up on the idea that in addiction you get more and more focused on the substance and it blurs out other things in life. Things like hobbies, work and activities. The thoughts and compulsions are so much about the substance that other things go by the wayside.
V is for volume. That’s the idea of losing control of the amount that you eat. Intending to have two biscuits and never be able to stick to that. That’s a common one for us addicts. We say well, it’s fine as I’ve not had any for a while, I’ll just have a little bit and it’ll be fine. It’s never fine. It always becomes a binge.
E is for exclusion. That’s the idea of withdrawal symptoms. When you try and cut out sugar, carbohydrates, and processed foods, you get withdrawal symptoms, and that can be things like mood changes, shakiness, dizziness, gastric problems, sleeplessness, headaches, all the things that people typically report when they, as I did, try and go sugar-free in one fell swoop.
Comparison of different withdrawal syndromes
Dr. Eric Westman: That’s very practical and memorable. For an individual going through it, it is sometimes hard to see. I had someone who came, in all earnestness, back in the smoking cessation days, and said, “Doc, I know how to fix my craving for cigarettes.” I said this could be a new treatment and I started to write it down. He said, “When I smoke, my cravings go away!” To me, as a practitioner, it is like, duh, but people come in thinking, I crave it, I need it.
What is remarkable about cold turkey sugar and starch withdrawal, or abstinence, is that for most people the cravings don’t go on very long. Has there ever been a comparison of different withdrawal syndromes? It seems to me the carbohydrate one, for most people, is relatively short.
Dr. Jen Unwin: I think the actual physical withdrawal is about a week. There can be these intense, huge cravings and that’s the problem with food. We have to eat, and unfortunately, our food environment is so crazy. You go to a gas station, and you are confronted with all those drug foods, as with fast food places. It’s just everywhere. Advertising, it’s on the television and, I think if you’ve got a drug or alcohol problem, I’m not saying it’s easy, but you can stay out of the bar, you can not have booze in the house. We have to have food in the house. The food that is safe for us is always very individual. There are some obvious culprits that people always need to cut out – sugar, refined carbohydrates, ultra-processed foods, they need to go. Then there are all these gray areas around dairy and nuts. Alcohol is another example. Should people with a food addiction drink alcohol? It gets complicated.
In social situations, certainly in the early days, this is what people really struggle with. People know that they love cake, or have loved cake, so they offer them cake, they bring them presents that are foods that they don’t want to be eating anymore. They have to have all those conversations. I think if someone is giving up alcohol or drugs, all their friends and family go, “Yay! Good for you!” and when we give up cake and fries some people say, “Yay! Good for you!” and some of our family members and friends feel threatened by that or don’t agree with that, and we’ll be trying to push back against it. These social situations can be a challenge for people.
Practical pointers for navigating social situations
Dr. Eric Westman: Any practical pointers for the person who goes to the holiday gathering and, if you don’t eat grandma’s pie or cake, their perception is that they don’t love you. How does that get mixed up and how do you deal with that?
Dr. Jen Unwin: It is a complicated thing. I usually say to people if it’s a gathering like a buffet situation, nobody minds if you take something as an offering. Just take something that you would be okay to eat, and then you don’t have the panic. In some of those buffets you go to there is literally nothing for a food addict, or a low-carb keto person, to eat. Take some cold meats or some deviled eggs, or whatever it is that you can offer to the party so that you’re not anxious that there’s no food for you – there’s something there that you can eat and there’s usually a salad or something that you can eat.
David’s mom is an amazing cook and a lovely, lovely person who always loves to cook for everybody and she took a long while to understand because she in no way had this problem. She’s one of these people at the other end of the spectrum. She has chocolate in her cupboard from the 1970s that she’s not eaten. It just doesn’t bother her at all to be in the presence of these things. She can have a tiny bit. We just had to sit down and have an honest discussion that, for me, that wasn’t possible just to have a small piece or one bite. That always led to wanting more and having to eat more, and for me, abstinence was so much the easier thing to maintain. I use the example that just like we understand the person with an alcohol problem, we wouldn’t say, “Have a little whiskey because it’s Friday night.” I think people really understand that. You can compare it to that and just say, “That is how I am with food.”
Putting this into practice at home
Dr. Eric Westman: How do you handle the grandkids, kids, parenting, and grandparenting? I have lots of comments and questions about that.
Dr Jen Unwin: We’re so lucky – when we started it our youngest child was still at home, a teenager. I would leave him; if he wanted a bag of microwave rice with his dinner – he could do it, that was up to him. We didn’t force it on him, but eventually, he and the other three all came along. The older two, over time, realized that if I cooked them a meal, and they enjoyed it, they felt better afterwards. They didn’t feel so great when they ate a lot of wheat and cakes and things. Over the years the family at large has adopted our way of eating. We’ve got four grandchildren from our eldest daughter and they’ve been brought up pretty much low-carb kids. They have the odd real foods. They do have baked potatoes, but on the whole, they eat meat, vegetables, cheese sauce, cream, berries and yogurt – stuff like that and they’re fine. That’s all they’ve known.
How to strike a balance
Dr. Eric Westman: What is it in human nature that a lot of people go from one extreme to the other? I’ll have people who can’t have anything and yet we grew up having mounds of candies and we survived. It’s not like it’s an immediate poison but often there’s this reaction to go to the other extreme and be almost neurotic or obsessive about it. What is that?
Dr. Jen Unwin: I think that the danger of that is, with people with food addiction, and we hear this sometimes from people when I do assessments, they’ll say when they lived at home their parents were so strict. They were super healthy parents, everything was locked away or you couldn’t have it. What happened then was when they left home, and they had their own money, if they had a bit of a tendency to like sweet foods, they just went crazy and that’s when the symptoms started. They would be about 17 or 18. I think it’s important to explain to children why you’re limiting sugary food. Everyone has to find their own way but in our house, it isn’t a total bound. If they go to a party at a kid’s house, they might eat some food at that house that they wouldn’t normally have and that’s okay. Interestingly, usually, they feel a little bit unwell, so you’re able to say, “That food didn’t do you any good, did it?” It is a very delicate line to walk for parents and grandparents. You could be over-permissive. Obviously, we don’t want kids just growing up eating a pure junk food diet but, as you say, there are also some risks to being super the other way. I think they have to work it out themselves. That’s what happened with our kids. They worked out for themselves that they felt better.
Dr. Jen Unwin’s book
Dr. Eric Westman: Tell me a little bit about your book, Fork In The Road. I assume a lot of this wisdom and advice is in this book.
Dr. Jen Unwin: It’s all in the book. It was my lockdown baby. Not long after I left the NHS I started to think about this. I wrote a little book, Fork In The Road, and all the profits go towards furthering this whole field’s work and trying to get food addiction recognized as a condition. Myself and a colleague, Heidi Giaever, who’s a nutritionist, are trying to coordinate a resubmission to the WHO (World Health Organization). We’ve already made one submission that was rejected but we’re going to resubmit. In the U.S. you’ve got Ashley Gearhardt and colleagues and they’re going to make a submission to the APA (American Psychological Association) so that the DSM includes ultra-processed food addiction.
Dr. Eric Westman: I highly recommend this book. It is very practical. When I hear you and David speak at meetings it’s so down-to-earth and clinic-based. That is so important. As people consume information off the internet, you want information to come from people who have been in the clinic if it is at all possible. If you’re asking for clinical advice you don’t ask the bodybuilder in the gym how to reverse diabetes. Have you received any negative pushback from having this sugar addiction concept?
Dr. Jen Unwin: Just a tiny bit on Twitter, as we used to know it, on X. Occasionally there are people on there who are anti that message but on the whole a great deal of support. When you tell people about it they say that’s me or I know somebody. The book is supposed to be simple and practical. I often recommend that if you’ve got a relative who doesn’t understand it they could read it as well because it’s only a small book. It’s not a great big scientific tome, it’s just the basics.
We have come a long way
Dr. Eric Westman: We’ve come a long way. A long time ago doctors would get into trouble for talking about food or sugar, or telling the mother that you could eat real food when you were weaning a baby – that was Professor Noakes. I think in general there’s acceptance of this now. Don’t you feel there’s more acceptance now than there was some years ago?
Dr. Jen Unwin: We’ve noticed a big change. The first few conferences that David spoke at he actually got booed and people wouldn’t talk to him. Some of the dietitians said he was harming people. It was all he got, quite a lot of negativity. But that’s a long time ago now. I really feel the tides turning. We’ve got the Australian Diabetes Association who have just accepted that low carbs are an acceptable treatment and there was a paper here in the UK that David was on, with the British Diabetic Association as well, saying that low carb is a fine thing to recommend to people with type 2 diabetes. Things have really come a long way.
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