Three months ago I got some crappy health news: an A1C level of 5.9, which is officially in the prediabetic range. (5.7–6.4; 6.5+ is officially diabetes).
The A1C test represents your average blood sugar level over the previous three months. So last week I repeated the test.
This time it was 5.6, the maximum level considered normal. I am no longer prediabetic.
I wrote about the first part of this journey. It was scary for me to write about issues as personal and revealing as health, diet, and body image, but the payoff to being vulnerable was so worth it. I received so much positive feedback and support, including a friend who stocked my freezer with meat that he had hunted since I had said I wanted to start eating humanely raised meat. I had so many good conversations with people as a result of that piece; I became closer to friends and professional acquaintances alike. I realized that almost everyone has thoughts and concerns about food and health and it makes us feel more connected to share it — at times and places that are appropriate, of course.
Here’s what I did that resulted in a lower A1C :
- Tracking: I tracked everything I ate faithfully for about 80 days/11 weeks total. Initially I set a target of 2000 calories and 150 grams of total carbohydrates.
- Nutritionist: about 6 weeks in I went to see a nutritionist. She recommended a calorie target of just 1600 a day. This seemed incredibly difficult. I was often hungry, often exceeded the limit, but I cut my daily average to within shouting distance of that target. I also continued to limit processed carbohydrates as much as feasible. And over the course of 3 weeks I lost 5 pounds. If this is the main reason my blood sugar improved, the change probably won’t stick. Only time will tell.
- Exercise: I recently radically simplified my exercise routine, to 100 air squats and 100 pushups every morning. Plus either: walking ~5 miles, running ~5–6 miles, or 30–45 minutes on the elliptical (when I’m in the gym I throw in a few ab moves and 2 pullups, which is my max :)). Once a week I go to yoga. I don’t take any days off.
- Reading: I read two really important books during this journey. One is currently on the New York Times bestseller list: Always Hungry, by David Ludwig, who researches weight control at Harvard Medical School. The other was Women, Food, and God, a self-help near-classic by Geneen Roth published in 2010.
Ludwig, the doctor, presents the obesity epidemic of the last 30 years kind of like a whodunit. Why are so many people overweight and why, oh why, do most diets fail? Most of the conventional explanations turn out to be transparently thin (no pun intended). Is it because of our increasingly sedentary lifestyle? Probably not, because human metabolisms adapt exquisitely well to whatever level of exercise we impose. If you bust your ass doing cardio, you’ll probably sit around more the rest of the day or even fidget less to compensate.
Is it because of the “hyperpalatability “ or addictive potential of processed food, with all that sugar, salt and fat overcoming our willpower? Palatability, he points out, is pretty culturally determined, and it’s a mite bit jingoistic to claim that a Big Mac is inherently more delicious than salmon sashimi or for that matter, natto.
Is it a simple matter of calories in, calories out? Well, no. Again there’s the tricky issue of metabolism, which slows down when you cut back on calories. That means you have to cut even more calories or you’ll plateau. You also get extremely hungry.
Ludwig is an endocrinologist by specialty, so he’s interested in hormones, the body’s signaling system. His smoking-gun explanation for the rise in obesity is one word: Carbs.
I apologize to scientists for this oversimplified explanation, but basically: Processed carbohydrates flood the bloodstream quickly with glucose. This triggers the pancreas to flood the bloodstream with insulin. Insulin pushes calories from glucose into fat cells, so they’re stored instead of used for energy. It also makes the “gateways” to these fat cells sticky, so it’s hard for the calories to exit fat cells.
When insulin clears sugar from the bloodstream and stuffs it into fat cells, the brain, which relies on glucose, gets the message that it’s starving. We get hungry again quickly and are driven to eat more than we need.
Over time, a bunch of bad things happen: the body gets less sensitive to insulin because of chronic exposure to such high doses. Fat cells, which are highly patrolled by white blood cells (because the calories within fat cells are enticing to bacteria) get overstuffed, which triggers a chronic inflammatory response in the body, which leads in turn to heart disease and even, potentially, cancer. Ludwig speculates that by chronically tricking the brain into thinking it’s starving, over time the hypothalamus gland, which sits in the brain and regulates hormone production all over the body, may become permanently deranged. This is how come overweight children so often grow up into overweight adults; and why once people become extremely overweight they are extremely likely to stay that way, almost as if their healthy “set point” weight is replaced with a new, unhealthy one.
(By the way, you can be healthy at a wide range of body sizes and set points. “Overweight” is really bad shorthand for what I should probably be calling metabolic syndrome. I was a non-overweight prediabetic and this is actually becoming a more common diagnosis. No fat-shaming is intended here.)
Working off this systems-based explanation, Ludwig’s had a great deal of success in short studies helping people lose weight and keep it off with a gentle diet and exercise program. The diet has an initial phase that avoids almost all grain based foods & sugar, and emphasizes whole foods and big, luscious dollops of fat. The fat is for keeping you satiated and satisfied. Your blood sugar stays steady and you don’t have to eat as often. Unlike the joykillers of the Whole30, (an otherwise similar, and actually great plan) Ludwig is a fan of whole-fat dairy, and I wanted to hug him for including small pieces of dark chocolate even in the first phase of the plan. (The book has surprisingly good recipes for a diet book, developed and tested by Ludwig’s wife, Dawn, who is a chef.)
Over phase 2 and phase 3 you gradually add in, first cooked whole grains like steel-cut oatmeal, and then very small portions of processed carbs and added sweeteners, based on what your body can tolerate. His recommended maximum for maintenance is “two modest portions of processed carbohydrates per day.”
Another expert who really helped me reframe the role that food items such as bread, bagels, biscuits, scones, pasta, cookies, challah, shortbread, pie, doughnuts, croissants, cronuts, cragels, cupcakes, cornflakes, cinnamon rolls, pretzels, crackers, pita, tortilla chips, granola, brownies, muffins, French toast, pancakes, waffles, and wafers ought to play in my life going forward, is Robert Lustig. I heard him in an interview describe sugar, specifically fructose, as a “chronic, low-dose hepatotoxin” — that is, on top of everything else it does, it’s toxic to your liver.
Like alcohol, right? Oh, so, I know what healthy, moderate drinking looks like. It looks like a small nip at the end of the day. Maybe a couple of larger portions on the weekends. Not three, four, five servings a day.
But there’s a problem. My emotional relationship to food as a reward is far more deeply ingrained than the one I have to alcohol. (I have to cite the brilliant Caitlin Moran here on all the reasons that so many women’s drug of choice is food. “By choosing food as your drug — sugar highs, or the deep, soporific calm of carbs — you can still make the packed lunches, do the school run, look after the baby, stop in on your parents and then stay up all night with an ill 5-year-old — something that is not an option if you’re regularly climbing into the cupboard under the stairs and knocking back quarts of scotch” .)
So, the situation I’m in right now is that research and experience has made it abundantly clear that limiting processed carbohydrates is essential for my current and future health. And, by emphasizing protein, fat, and highly nutritious food, I’m not finding myself overly hungry. I feel well nourished most of the time and capable of making good choices most of the time. I don’t miss toast with my eggs or noodles with my Thai food.
But, I had a piece of pie today (it was Pi day!). I had a Pinkberry topped with Nutella yesterday (I was stuck in the airport and I was lonely!). I had a brownie the day before (I was annoyed at a work thing!) You get the picture.
Is this habit really moderation? Is it going to keep me out of the prediabetic danger zone? It’s iffy, even though I choose small servings and don’t always finish them anymore.
It’s undeniable: I’m extremely emotionally attached to the rewards provided by sweets. This is where Roth comes in. Her book is telling me that I need to go deep, with compassion, to understand this relationship so I can come to a detente with desserts. I can’t white-knuckle my way out of this. It may take a lifetime. But there’s a lot to gain: my health, a confrontation with mortality, maybe even some spiritual insight. I’m trying to approach the path with curiosity and interest instead of dread.
I’ll leave you with a quote from her book.
“If I tracked the impulse to eat when I wasn’t hungry to the core, I’d find every single thing I believed about loving, living, and dying right there, in that moment.”