Eating by the numbers
In early March, 2015, after having a 14-day bout with an exceptionally weird thirst when I was out of the US on a trip, I was pretty sure I had developed diabetes. Interestingly, there was nothing in my medical test record consistent with diabetes (except for me saying it was in the family… both sides…), so my PCP actually just attributed the symptom (a truly bizarre thirst) to some idiosyncratic aspect of my diet during travel. The lack of concern was a reasonable conclusion from the available data, except for the experience of the one who was living it. There are aspects of the medical profession that I continue to find unusual.
I was skeptical. I was the one experiencing this thirst, and it felt like something physical. When I returned to the US, I went out and spent $30 on a cheap OTC blood-glucose test kit and started taking my own AM measurements, as well as doing a pseudo-version of a glucose tolerance test. In fact, my numbers were on the horrid side of bad, and I got in to see my PCP quite quickly when I reported the data.
I had AM values of 200+ and post-prandial values of 300+, and my A1c was 10.6% when it was finally measured. To put this in perspective, these are the kind of values one expects to see in a 10-15 year undiagnosed person. The expectation is that you have physical damage (retinal hemorrhages, extremity neuropathies) when you have been at these levels. But, precocious as I am, I appear to haven achieved those numbers as an early onset person. There is nothing in the literature that I have found about this, so, I guess, in my genetics, once diabetes comes on, it comes on strong. This might be why the diabetes has been so relatively severe in my family: we do not get a 10-year grace period of denial. Who knows?
During the couple of days I was making my own measurements and before I saw my PCP for the first A1c test, I was reading a bunch of the recent medical literature on diabetes, and learned a few things, to say the least. I already figured I would be getting a diabetes diagnosis from the MD, which I did, on March 30.
Some of the lore about diabetes II is evolving. For early onset individuals, in particular, the damage to pancreatic cells that release insulin can be reversed, to some degree, by resting the demand on them to produce insulin (you can look up “beta cell resting” to get the story). Although there is evidence that prescribing insulin right away is perhaps the best drug treatment to induce the greatest amount of resting, this is not clinically advised (at least not yet). Getting your body into its BMI range is extremely important, and perhaps the single biggest correlate with management and possible reversal of the condition. Again, there is some evidence to support pursuing this weight change dramatically: restricted calories and low carb. Although what I am about to describe is not advice you get from physicians or nutritionists, it is what I decided to do based on what I was reading.
But my strategy was set. At least, it might take a bit to dissuade me:
(a) metabolic crash down to the low end of my BMI with 700-800 well-balanced calories a day
(b) use the FDA guidelines with a “paleo” twist – get about 50% of recommended total carbs and nearly completely eliminate the refined grains (flour, rice) as a source
(c) minimize added sugars, period, regardless of the source
(d) keep a detailed notebook/record
One nice leading reference (but there are others): Amy Rothberg is a University of Michigan endocrinologist:
Amy E. Rothberg, MD, PhD, Laura N. McEwen, PhD, Andrew T. Kraftson, MD, Christine E. Fowler, MS, RD, and William H. Herman, MD, MPH J Diabetes Complications 2014, 28(4): 506–510. doi:10.1016/j.jdiacomp.2014.03.014
My simple hypothesis was that I did not know how to eat. So in about an hour, I created a strategy.
The most convincing advice out there, I think, is measuring, monitoring, and recording. All non-fad approaches start this way: keep a diary. The problem is no one tells you what to write down, and I think they miss the mark by not telling you to write down everything.
Here is what I mean. Starting with the “average 2000 calorie/day diet,” and so you see the implicit message to count calories. Others focus on the amounts of an individual nutrient (“low carb”), and so on. Here are the two revelations:
(1) know how the 2000 calories are supposed to be parsed in terms of nutrients;(2) write down everything, just like on a food label, namely, the food product, the calorie count, the individual nutritional contents (fats; sodium; carbs: total, sugar, fiber; and protein).
The numbers are not an exact science, but you can find recommendations from the FDA, etc., and they do converge.
I picked a 750 calorie/day target, which implicitly rolls out the daily nutrient targets listed above. I have since learned that there are studies of restricted calorie strategies for diabetics that use the 800 calorie/day target, so I was in the right ballpark. I also wanted to minimize the amount of added sugar and lower the total carbs to about 55 g/day, in terms of what I would eat.
So I started to keep a spreadsheet with three different sections in it.
The first section is devoted to recording medical information (AM blood glucose, drug dose, weight, blood pressure).
The second section I call “the pantry.” All of the foods I eat are listed here, using the same columns as on the previous page. These data are easy to obtain for everything you eat, either from the label, from the manufacturer (on their internet site), at the terrific site at http://nutritiondata.self.com, by a simple search on the name of the food, or meal, and entering “nutrition data” in the search field (e.g., Google “Mapo tofu, nutrition data”). Everything is out there. The tricky part is eating out, and trying to estimate things like portion sizes and guessing about the ingredients. You will get better at both after a while.
So my “pantry entries” look like this:
I also use the lower pantry area to work out actual meals and make adjustments to ingredients as I figure out what is in them, cut/pasting stuff from the upper pantry.
Pre-heat a toaster oven to 450F. Combine sauce with spices of preference (oregano, paprika, cayenne, pepper flakes). Sprinkle pita with water on both sides and put in oven to soften, about a minute, and remove to a sheet of non-stick Al foil. Spread with garlic paste, top with sauce, 2 oz Mozzarella, 1 oz parmigiano, and pepperoni. Dust with oregano and bake until cheese melts and edges are browned. So for things I eat repeatedly, I have these totals in the pantry, too. No sense in recalculating every time.
This is saltier than I would like it to be, but I lived with it and then looked for lower salt options. I now make my own sauces, for example, and have switched to my own spiced pork sausage. I also have pizza recipes with more traditional (albeit soy or nut-based) crusts, but here I am talking about what you can do in 20 minutes from start to finish. When I was having these pizzas, I watched the salt the rest of the day.
In fact, I like to make large batches of food that I can eat portions of throughout the week. So when I make a tray of 6 pork/pepper/onion/sauce/cheese stuffed peppers, I just measure all of the ingredients going into the entire batch, then divide the total by 6 at the end (instead of worrying about the exact amounts in the individual stuffed peppers; it is close enough); or a gallon of Chili; or 3 stuffed chicken breasts; or a dozen muffins or scones.
I also play with what I am going to eat on a given day. Once I arrive at dinner, I look at the other numbers and try to hit the ranges. Or, if I know what I want for dinner, I adjust what I eat during the day, accordingly. As you can see below, I am not strictly hitting any range, per se, every day, except for paying attention to the carb count. Learning to cook with spices is a key change, too. No sense to be bland.
The only real investment I made was to get a nice kitchen scale with a glass surface and a tare feature.
Finally, for the third section of the spreadsheet, I record what I eat and keep a tally of the numbers, every day. I use the pantry area to add up what I eat in a given day, then move the numbers over. I started eating something at about 7 AM, 11 AM, 3 PM and 7 PM, with a 12-hour fast. I known on a given day exactly what nuts and which amounts, but I just use a placeholder name in the table.
Reminder on the standard 750 cal targets (and a reminder that this is positively insane and requires a super-stubbornness to pull off over the course of months… and you HAVE to like to cook and play with cooking to find the substitutes, and revel in the fun of it all).
You get the idea. For me to hit the 750 cal/day and keep the carbs lower, I am making up most of that difference in a bit more fats. Fiber is tough to get up there with lower carb levels. My pre/post exercise level was unchanged. I am convinced that trying to hit the nutrient balance is what has been the most surprising thing: never had a single hunger pang (metformin might contribute to that because of the way it affects fat metabolism). I do take a daily Centrum multiple vitamin, 2500 mg vitamin C, and an aspirin.
July 20, 2015
To what end? Here are my results from 3.5 months (also on 1500 mg/day metformin)
* dropped to below 90 on the 12th day and never went back over that level again in the AM
Normal humans do not need to aim for 750 calories a day.
Pick your calorie target; calculate what the nutrition targets are; and start measuring, counting and recording. My final recommendation for someone using this as a program for their eating would be to spend two weeks with no change at all in your current behavior and to record a baseline. It will not be 100% correct, because I just about guarantee that you will begin to modify your eating as you start to record everything.
Honestly: eat anything you want. Just measure it and know what it is. If you want to get rid of the flour/rice carbs, you need to do a little work to find the appropriate swaps. They are out there.
But: have a defined target and aim to hit the balance.