Thursday, August 9, 2012

What is this moderation you speak of?

“Even junk foods can be part of a healthy diet  as long as they are consumed in moderation.”
How many times have you read that?  SkepticRD has lost count, because quite frankly, this phrase, and closely related phrases, drive me up the wall.  Why, because the phrase “consumed in moderation” has got to be one of the most vague non-guidelines that I have ever come across.  If you haven’t figured it out, SkepticRD likes to shout at the computer or whatever it is I’m reading when something registers as “bad science” so this is another phrase that has me yelling: “What the hell does that mean?  Who came up with that?”  along with a few other colorful metaphors.
Here’s my opinion, in brief, about how this phrase came about.  Back in the day, Dietitians who focused on education had the reputation of being akin to Catholic school ruler- slapping nuns—“eat this way in this manner or you will suffer the consequences.”  So, of course many people went to see the diabetes educator out of guilt and with a certain amount of dread, then came away with a plan that seemed impossible to the average person (seriously, who eats like this?).  Soon they would feel guilty because they would follow things for a while but then “cheat” and try to do some sort of penance, etc.  This whole procedure caused people to fall into a constant cycle of gain/lose weight or ok blood sugar control/poor blood sugar control, or they would just flat out give up and live a life of hedonic eating.  (Or, to stay with the lapsed church goer theme, only “do things right” when they thought somebody else was watching, “No really, I try to eat right!  At least twice a year!”) 
So, the group of people who decides these things decided that we as health educators were being too harsh.  “People need to have more freedom to fit all kinds of food in, all foods can fit!”  So we  started finding ways to help people fit in their cookies and potato chips and orange juice all in the name of changing our counseling sessions to more of a collaborative effort from a ruler slapping one.  (Side bar #1: Don’t get me wrong, I think collaboration is a wonderful thing.  Adults don’t want to be told what to do, especially when the person is about 20 years their junior.  Sharing information is the way to go, if you are sharing information that can actually work).   I think the relationships between diabetes educators and their patients did improve somewhat  (although sadly I have no objective data), but I noticed something else.  People still weren’t losing weight and keeping it off the way they wanted (or the way I hoped, for that matter), and people were coming to me all the time with statements like “I ate oatmeal in the morning, my blood sugar shot up.” Or “Every time I eat [insert fruit here] my blood sugar goes sky high” or “Who the hell wants to eat 10 potato chips?” (Once again, there were often a few more colorful metaphors thrown in there).  So, I started thinking to myself, “I want people to have choices.  I don’t want people to have to give up everything they love.  But what if this approach is not working?  What if some people simply cannot eat certain foods on a daily basis and keep their blood sugars under control or lose weight?”
(Side bar #2: SkepticRD was not always a skeptic.  SkepticRD periodically blushes at some of the things I used to accept on blind faith, and someday there will be a “tell all” blog post.  But let’s just say my passion for  helping people find something that works has improved my life as a skeptic).
So, what does a good skeptic do when faced with years of doing something that isn’t working?  First, humility and honesty with myself comes in.  I had to say “I might be wrong, and what matters is that I correct it.”  Second comes humility and honesty with others, meaning I had to say “Look, here’s how we’ve been doing things, it’s not working, let’s try to find something together that works instead of running around in circles.”  Third, is to start looking at what the science says, even if I didn’t like it.  And this last one is really, really hard.  When my emotions are running high on a topic, it’s really easy to dismiss something instead of reading it further, particularly when the author of the piece is not writing in a very science based way.  Fourth, one has to try to try it out in the field, so to speak, and keep trying even in the face of opposition.
One of the things I found through my digging was that too many choices can actually be detrimental, which was covered in a previous post..  In brief, when someone is presented with too many choices it can seem overwhelming and people will give up.  One of the other things that I found through my inquiry is that there has been some interesting research done in the past few years on the addictive qualities of certain foods (Link).    Of course, there is still a lot of research to be done on addictions in general, particularly why some people seem to be more prone to addictions and/or relapses than others, but it was enough to at least raise some red flags as far as the practice of “moderation” is concerned.  And I also thought about what people would be missing by not working in their daily ice cream or whatever it was; and from a nutrition standpoint, the person wouldn’t be missing anything.  Of course, we all eat for reasons other than hunger, and it likely wouldn’t be easy to give up certain foods, but then looking for the easy way out can cause its own problems. 
So, when people ask me if a certain food is something they “can have,” I remind them that they are free to make their own choices, but they also have to pay the consequences, whether it be high blood sugar, needing more medicine, weight gain, etc.  Second of all, I ask them to honestly consider whether or not they will truly and honestly be able to eat only 10 tortilla chips and be content.  (Boyfriend of SkepticRD can do this, but many of us, including SkepticRD, just want to eat the rest of the bag).  I also ask people to truly and honestly consider how they feel the rest of the day after they eat that food—any digestive issues, increased hunger, increased fatigue?  If I can get empirical data such as blood pressure, blood glucose, weight I might ask them to check these more often.  Some people acknowledge, “You’re right, if I eat one slice of bread I will eat it all day.  If I take 4oz of OJ my blood sugar goes sky high.”  And all of that information likely adds up to— yes, there are going to be some things that you just cannot consume on a regular basis (or ever) and still meet whatever your health goals are.
(Side bar #3: Acknowledging that you cannot keep certain foods in the house or have it brought to the table is not a sign of weakness.   You are merely acknowledging that there are certain foods that affect your body adversely, and you know there is some evidence that they might affect your brain adversely as well.  There is no shame in that).
Because the concept of moderation is so vague, there are a lot of health education related folks that have tried to find some way to quantify this.  I have heard everything from “have one reward meal per week” to “try to eat the way you ‘should’ 80% of the time” to “pick one day a week to eat whatever you want.”  Sounds really good in theory, but there really haven’t been any studies that I can find that actually back this up, particularly over the long term.  And once again, you have to know your limits.  For example, let’s say you’ve been really “good” for several weeks on your new plan, watching your carbohydrate intake from both your food and drink, etc, and then you decide to have a night out at the pub where you consume most of the appetizers available and several of your favorite beers.  The next morning, you have the worst hangover of your life.  Some people, might consider the nausea, vomiting, and headaches worth it.  Other people, might decide that it wasn’t.  Also, some people, like me, find that if they overdo the tortilla chips that it will take a few days at minimum to regulate my appetite.  So yes, moderation on certain things, even at the nebulous “80%” may not work for everyone, particularly in the beginning.
If you still think that some things can be consumed in moderation, be prepared for me to ask, “Really, how much is that for you?”  And if you tell me you can have one teaspoon of honey in your one cup of tea in the morning, AND you are done with your sugar intake the rest of the day AND you have no adverse affects, I will thank you for providing a quantitative answer.  If you tell me that you have one teaspoon of honey in your green tea, AND you drink about 3 to 6 cups per day, AND you complain to me that you can’t lose weight or keep your blood sugar down or that you’re always hungry, then we will have to have a talk about reality.
(Side bar #4:  Here is where the food diary can come in handy—whether it’s paper and pencil, use of a spreadsheet, software on your desktop/laptop computer, or an app on your smart phone.  You might be surprised at how hard it is to be moderate).

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