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How to Eat?
This is some information, and some advice, about mindful eating. I briefly considered calling this post "How to Eat" because when I left my doctor's office on December 15th, 2006 an hour before lunch time with a diagnosis of Type II Diabetes (T2DM), it occurred to me that I needed to re-learn what to do about eating.
I did not think that I'd eaten my way into the disease - and I have some things to say about that, but not in this post - but I did know that eating differently would be part of managing the risk factors that the doctor had ticked off for me that accompanied T2DM: high blood pressure, good cholesterol low, bad cholesterol high, and of course chronic high blood glucose (BG) levels. These are chronic symptoms with deadly impact if left untreated. In the immediate term, I knew I had to eat in such a way as to control my BG levels. That was the key to preventing immediate vascular damage and, managing those levels over the longer term would bring my cardiac risk factors in line as well.
But how in the heck do you eat to manage blood glucose? Even as a well-educated person, I didn't know. Now I do know some things about it, and I think I can offer others some advice. I'll tell you how I learned and what I learned. And I'll share with you a theory or two about how you can use this information to get to or maintain a healthy weight, which is also a very effective way to manage cardiac and BG-related risk factors.
A disclaimer: this is not medical advice. It is just plain ol' advice. I am not a medical doctor. I'm a bio-hacker. I am a Ph.D. who has studied the research literature carefully and I actively manage risk factors related to T2DM in my daily life. You should always talk about your health and any plans to improve it with your primary care doctor. If you find that hard to do for any reason, seek out a new doctor. For those confronting a new diagnosis of T2DM, you may also find it helpful to see a certified diabetes educator. The American Diabetes Association has a finding tool that may help. If you are covered by insurance, your doctor may be able to prescribe an education program that your insurance will cover. These programs are clinically proven to improve outcomes in patients. They are good medicine.
Step 1: Pay Attention
By far, the most important thing you can do to make a change in your health related to eating is to pay more attention to what you eat and drink. And by this I mean that you should be able to account for everything that goes in on a given day. Every. Thing.
This is a challenge at first, so I recommend writing it all down: items, amounts, and time of day. You might have heard of a food diary? This is what we are talking about. The U.S. National Institutes of Health has a good format you can get for free. So does diabetes.co.uk. And there are lots of smartphone apps, etc. you can find too.
Eventually, you'll want to track carbohydrates as well if you are managing BG. To do that carefully, you'll need to read some nutrition labels. Those of us doing diabetes (rather than "having diabetes") count carbs 15 grams at a time, and we call each 15g one unit. This lets you figure out a "budget" for your meals and snacks that keeps your BG levels where they should be. More on that below, but first a bit about carbohydrates.
Q: What Raises Your Blood Sugar? (and what doesn't)
A: Carbohydrates are the only thing that directly raise your blood sugar. Almost everything else you eat does not. (Fat is a bit more complicated, because it has a systemic effect that can mess with the signals your liver gets about the need for more glucose in the blood. And so eating a high-fat meal may well contribute to longer-term rises in blood glucose levels. But it is not a direct cause.)
Step 2: Get Data (You can't hack code you can't read)
|Used by permission of Flickr user DeathbyBokeh|
Now the reading you get from a glucometer doesn't tell you how well you are doing over the long term at managing your BG or those nasty risk factors I mentioned. It can only tell you what's going on in the moment. And the levels it reads are subject to all of the metabolic things going on right then and immediately before you test. So if you just ate a high-carb meal, your BG will be elevated no matter who you are. After a couple of hours, the body should adjust BG levels provided that that person's insulin response is normal. For those with DM (of any sort), it may take more time and more direct intervention to make that adjustment.
Get a glucometer and learn to use it. Test yourself a lot and write down the results. Chart them too if you know how to do that (see example below). When you first start, test more often. This will be expensive because the test strips are a huge racket. That's yet another post... But your doctor may be able to up your Rx for these as you first learn to manage your symptoms - ask for more - ask for lots of free samples too. The more data you can get the better in the early going.
Q: What is "Normal" BG?
A: Not to be evasive, but that's a difficult question if you read the stuff above. Why? Because it depends on when you test and what happened before that. Did you eat? Did you run a mile at a brisk pace? Your body dynamically and rapidly adjusts levels of BG to respond to the need for energy (or the lack of it). This "insulin response" is complex and involves multiple systems: nervous, digestive, endocrine, circulatory, musculo-skeletal. So normal is different for different people. What doctors agree on, though, is that after an 8 hour fast, normal adult BG should be below 125 g/ml.
Step 3: Work the Trends
Once you can account for what you eat and test your BG, you can start to see trends. These trends can tell you how what you are eating affects your BG. Over the long term, they can also tell you if you are doing what you need to do to manage risk factors. There is another very important test for that called an HbA1C that is the gold standard for diagnosing DM, including T2DM. These are done every three months and they give you an extremely accurate measure of your blood glucose levels over that period of time. If you haven't had an A1C and your doctor is prescribing diabetes-related medications, go ask for one. It is essential information for managing your risk-factors.
But back to those trends...you should be able to produce a picture that looks something like the one below. Have a look and then we'll talk about why this picture is valuable for losing weight (yep, I said it)...
First, let me say that these are made up numbers. But they are reasonable and not uncommon for me today. They track BG every waking hour of two fictional days. The red line represents a day when I eat in a way that manages BG well. I stay in a zone between 90 and 130 BG. This level, by the way, corresponds with an HbA1C in the normal range over three months (below 6).
Here's another fascinating fact...the red line also stays inside the green zone, which is a "sweet spot" in my own metabolism when I lose weight (if I am trying to do that) or maintain a healthy weight (if I am trying to do that). To maintain weight, I need about 75 minutes of moderate exercise per week with one or two short intervals (15 minutes) of intense activity thrown in now that I am very fit. To lose weight, I would double that to 150 & 30 minutes. Do that, and the lbs. come off at a rate of about 1.5/wk unless I eat differently or exercise less.
So what is the blue line? That's a strategy I see lots of people trying when they are "on a diet." Follow along...it goes like this: wake up a bit low, but not overly so, and have only coffee for breakfast maybe with a touch of cream. BG stays below 90. Stomach grumbling, you eat one little thing from the candy bowl at work at 10 (17g carbs, one unit). Ridden with guilt, you eat only a salad and an unsweetened ice tea for lunch. BG continues to slide through the afternoon until you are starving at dinner. You've been "good" all day though, so you eat a low-fat meal of pasta primavera with garlic & olive oil only, some garlic bread, and a glass of wine. You also have two thin mint cookies for dessert. BG goes up after dinner and as you watch TV you can't resist a couple more cookies before you turn in. All in all, it's been a successful diet day. Or has it...
How much time do you spend in the zone on that kind of day? Not much. Compare that to the red line which goes something like this: Breakfast 2-3 carb units. Lunch 4 carb units. Dinner 4-5 carb units. After dinner snack 2 carb units. With that "carb budget," I'm in the zone all day.
I'll offer some more thoughts about what this zone is and why being at that level is likely good not just for folks with T2DM but for anyone trying to lose or maintain their weight in Part II when we talk about exercise.
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