Here’s a repost of a popular entry from last December — it’s that time of year!

This month, a lot of people weigh more than they did in the fall at their last appointment.  The problem is so widespread that, especially in people who are working to lose, I make it a point to applaud their efforts even if they have simply maintained their weight at the same number over the last few months. That’s because December is probably the single time of year in which people are most likely to eat large amounts of sugar and white flour.

Some folks don’t want to know what they weigh, so we make an agreement.  I get the number, and I don’t tell them what it is.  I remind them that I don’t really care about the number itself; I’m just looking for changes, up or down, from the last visit.  I really care a lot more about how their pants fit.  Are they looser, or tighter, or the same?  That’s a lot more important to me.   

Why is December such a problem?  It has to do mainly with the amount of desserts.  What happens when you eat a lot of sugar or starch?  You use a lot more insulin.  What happens when you use a lot more insulin? You store fat more efficiently, and you lose the ability to tell when you are full.  Then you increase your food intake accordingly.  In other words, you eat more. 

In my experience, about three days after you start eating a diet that requires less insulin, you notice that your appetite decreases a little bit.  Here’s why:  When you eat a diet like the standard American diet, which requires a lot of insulin, the high insulin levels coat the satiety centers in your brain and make it very hard to tell that you are full.  When you make changes like the ones in my “Four Recommendations,” you end up using less insulin.  On the third day after you start using less insulin, your body finally gets the message that it doesn’t need so much insulin anymore.  That’s how long it takes your body to begin to respond to the fact that it doesn’t need as much insulin.  Then your pancreas “downregulates” insulin production.  Then you’re not as hungry anymore.

Less insulin means less hunger. Three days after you start eating an “insulin-conserving” diet, you wake up noticeably less hungry than you used to be. 

So don’t worry about what you weigh.  That the number will take care of itself as you get back on track making smart choices.  And it does.  It’s okay to celebrate the holidays.  It’s okay to have a piece of wedding cake.  Or birthday cake.  It’s probably okay to have a slice of pie every weekend.  But you can’t have it every day.  Our insulin levels will manage fine if we let them spike only once in a while.  The problem comes when we eat foods that make them spike every day.  Every meal.  Because when your insulin levels are rising every day, they are no longer spiking.  Now they are just high. 

That’s why I say that what happens in December stays in December.  It’s not what we do once in a while that gives us trouble.  It’s what we do all the time.  You can’t live in December and expect to remain healthy.  But you can visit it from time to time.

My mom doesn’t take any diabetes medicine.  She keeps her blood sugars normal through a combination of common sense and careful carbohydrate consumption.  A few months ago, she had to be hospitalized for what she calls a “minor procedure.”  The procedure went fine, but not the food.  The first meal they brought her consisted of breaded fish (frozen), mashed potatoes (instant), corn (canned), a dinner roll (frozen), and tea (2 sugar packets on tray).  “If I ate that, my blood sugars would have gone through the roof!” she told me.  She drank the tea, and called my dad, who arrived shortly with chopped salad, roasted peppers, and meat loaf.  This week’s post is about hospital food, if you can call it that.  You are not going to believe what it’s like to order meals for hospitalized patients.

Let’s imagine, for example, a diabetic guy in the intensive care unit.  His blood sugars have been completely out of control, up and down, up and down.  He is recovering slowly from a very serious pneumonia, and is only now beginning to eat again.  The nurse asks if I’d like to order an 1800 kcal ADA diet, which I do not.

An “1800 kcal ADA” diet means 1800 calories total each day, in accordance with the recommendations of the American Diabetic Association.  Their recommended diet is loaded (and I am not exaggerating here) with processed carbohydrate items guaranteed to make it nearly impossible to control one’s blood sugar.  No thanks.

Instead of an 1800 kcal ADA diet, I order a “low-glycemic diet,” which is not actually one of the approved options in the hospital.  I know I’m setting myself up, but there are no other options I can order in good faith.  Real food?  High fiber and protein?  Low-processed-carb?  I wish.  The kitchen sends fake scrambled eggs (beaters) and a large blueberry muffin.  I kid you not.  This is what Sodexo, which supplies the hospital food where I work, actually sent for my diabetic patient a few weeks ago.

It should surprise no one that his blood sugars spike into the 400’s after lunch.  I ask the nurses if we can just get the patient a hard-boiled egg.  No, we cannot.  The hospital does not actually have eggs.  Just beaters.

Patients aren’t the only people who eat in hospitals.  A few years ago I decided to get a cup of coffee in the hospital cafeteria.  I looked for the milk, but there was none.  There were only single-sized servings of flavored liquid non-dairy coffee whiteners.  I don’t use those; they are not food.  I asked for milk and was told I would have to purchase it.

Patients who are less ill than my intensive care unit patient are permitted to choose their own daily meals.  They are provided with printouts, or “menus,” as the Dietary Department calls them, which are simply lists of all the items available for consumption in the hospital.  Patients choose what they like, and a version is prepared that attempts to meet their dietary restrictions.

A common scenario for me, as a physician, is one in which I work to control a patient’s blood sugars in an attempt to heal a leg infection and avoid an amputation.  High blood sugars interfere with healing because they prevent white blood cells from working correctly.  Now, imagine me walking into a patient’s room and seeing that patient eating a bowl of Raisin Bran (one of the highest sugar-containing cereals) on a tray that also contains a glass of orange juice, tea with sugar packets, and 2 slices of toast with margarine.  I know these options will spike my patient’s blood sugars and make it nearly impossible for me to get them under control.  I am wondering why those options were on my patient’s “menu” in the first place.

If it weren’t so serious, it would be comical.  Like putting a humidifier and a de-humidifier in the same room, and letting them duke it out (thank you, comedian Steven Wright!).  I don’t want to duke it out.  I want to be able to ask for, and receive, the tools I need to do my job successfully.  Assigned the task of healing patients and controlling their blood sugars, I expect to be given the tools to do so.  Different kinds of professionals use different kinds of tools.  My first tool is food.

If you’ve been reading along, you know that my friends and I spent a gorgeous October day at Washington’s Grist Mill, on Dogue Run Creek, 3 miles southwest of Mount Vernon.  The current mill is actually a reconstruction of the mill that Washington built in 1771 to replace one his father built on the same spot forty years earlier. 

At Washington’s grist mill, wheat flour and corn meal were made for the plantation, and a super-fine flour was made for export to Europe and the West Indies.  The mill’s power supply came, then and now, from water that is diverted into Dogue Run Creek from Piney Branch, above the mill.  The additional waterflow significantly increases the mill’s production capacity. 

My friends and I also investigated a nearby threshing building.  The round, two-story building, built into the side of a small hill, was constructed with a central post.  Horses walked up a short ramp to the building’s upper level, where the floors were covered with large amounts of cut wheat stalks.  The horses were tethered to the central post.  As they trotted around the post, the stalks broke apart and the straw and chaff became separated from the grain, which slipped through spaces between the floorboards down to the lower level.  Trotting (instead of walking) kept the grain cleaner by preventing horses from passing waste as they moved.  Behind the building, ground level doors opened to rising mounds of whole grain, which were then collected and brought to the mill for grinding. 

Washington’s grist mill, for which Oliver Evans was awarded U.S. Patent No. 3, is the only operating “Oliver Evans Automated Milling System” in America.  Power is supplied by a 16-foot water wheel whose spinning motion turns the shafts, gears, and belts that propel the machinery.  Elevators move the grain vertically between the floors in small buckets attached to an endless belt running inside a closed shaft.  The small buckets dump their contents into a hopper, or container, which sits directly above two large, horizontal millstones.  Grain drops slowly into a central hole leading to the tiny space between the millstones, where it is ground into flour.  If the operator chooses, the freshly ground flour may then be moved into a long, rectangular sieve that retains the coarser materials and allows only the smallest, finest particles of flour to pass through.

Washington’s mill produced a finer, drier flour than had ever before been made.  Previously, hard-wheat milling produced a coarse, brown flour that retained the bran, with its essential nutrients, but Washington’s new automated mill produced a bran-less, superfine flour that was much lighter.  Unfortunately, without its bran it was also less nutritious. 

Washington’s horse-driven threshing house, combined with Oliver Evans’s extraordinary automatic mill, dramatically increased the availability of grain and flour.  The improved efficiency allowed many more people to be fed with less work.  Bread and flour, both coarse and fine, could now be obtained with comparatively little human energy. 

We were starting down a road whose destination we could not see.  At a certain point, the benefits of increasing the quantity of food are outweighed by compromises to the quality of that food.  It would be a couple of centuries before we would reach that point.

For now, Washington and Oliver Evans had figured out how to substitute horsepower and water power for elbow grease. 
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Last week I talked about my October visit to DC with three old friends, and our visit to George Washington’s grist mill.  You might say that it wasn’t exactly at the top of their list, but they are great sports, and we are still friends!  Actually, they agreed it was pretty interesting, and Ronnie even sent me a copy of The Gastronomica Reader (Darra Goldstein, ed.) yesterday. 

This week we continue talking about how the past 200 years of food-related inventions (which decreased markedly the work of gathering, preparing, and metabolizing food) have finally caught up with us.  Less work means easier to digest, which means more insulin.  That’s not what you want.  The more insulin you use, the hungrier and heavier you get.  If your insulin levels are high, you are more likely to be having problems with your blood pressure, fertility, and triglyceride levels.  And the button on your pants.  Not to mention that your blood sugars begin to rise the minute your insulin supplies start running short, which starts to happen about 10 years before you are actually diagnosed with diabetes.  That’s why diabetics usually have about 10 years worth of damage to their blood vessels by the time they are formally diagnosed. 

The 20th century was a time of mergers, acquisitions, efficiency experts, and assembly lines.  Someday, it will also be remembered as the time when we learned how efficient is too efficient, how big is too big.  Too big is when one company’s failure threatens the stability of an entire economy.  The 20th century was a time of substitutions, when we learned to use Crisco and margarine instead of butter and lard, beaters instead of eggs, soda pop instead of milk and water, boxed cereals instead of breakfast, and TV dinners instead of meals.  In contrast, the 21st century is when we began to realize that, at a certain point, food can be so easy to manufacture, acquire, and eat that it becomes costly in an entirely different way. 

Healthwise, we are now paying a very hefty price for the privilege of being the land of good ‘n’ plenty.  Our bodies and metabolisms were not designed to be spoon fed to the extent that we are.  I’m not saying we should thresh our own grain.  I’m saying that since we don’t, we need to eat less.  How much less?  Well certainly no more than our ancestors, who actually worked very hard for it.  Just because refined (stripped) flour is now available in bulk doesn’t mean we should eat large amounts at every meal.  Remember, everything in moderation.

The 20th century was when we learned to take large-scale advantage of the production efficiency of the combine harvester, one of the greatest labor-saving devices ever invented.  Why is the combine harvester, patented by Hiram Moore in 1834, called a “combine”?  Because it combines several operations (reaping, binding, threshing, and winnowing) in a single machine, and drastically increases the rate and efficiency of harvesting. 

Before the introduction of the combine harvester, wheat was harvested by a group of people, several reapers plus a binder.  The reapers would slice across the ripe grain stalk with hand-held scythes.  Next, the crop would be bound together for drying and storage.  Later, dry grain or seed was separated from the straw and the chaff.  It was laborious as well as inefficient, for a large amount of the grain fell to the ground.  That grain became the equivalent of today’s food banks.

In contrast, a combine harvester first gathers and cuts the standing stalks, and then feeds the cut stalks, with their attached grain, to a threshing unit.  Inside, kernels of grain are separated (threshed) from the straw and chaff, which are blown (winnowed) out the rear of the machine.  Threshed grain is cleaned and collected for storage or transfer. 

Many seeds (soybeans, canola, and flax) and grains (wheat, corn, oats, barley, and rye) are universally harvested in bulk by combine harvesters.  The relatively sudden availability of virtually endless amounts of grains and seeds set the stage for an explosion of processed, food-like, edible products.

Next week:  Washington’s grist mill.
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What does low-carb mean?  Well, the first thing it means is that something else has more carb.  So what are you comparing it to?   Breakfast cereal?  Angel food cake?  The standard American diet (sAd)?  Anything would be low-carb compared to those. 

A whole bunch of folks at the Nutrition & Metabolism Society have been working hard to help people understand that carbohydrate, and not dietary fat, is the main dietary component causing our obesity and diabetes epidemic.  They say we all need to be eating a low-carb diet, and they have the research to prove it.

I agree with a lot of what they say.  But I disagree about what to call it.  I’m sort of saying the same thing as them, because I do believe that carbohydrate [especially refined carbohydrate, manufactured carbohydrate, processed and stripped carbohydrate] is one of the major players in the obesity epidemic.  I just don’t think we should be calling it a low-carb diet.  I admit it; I’m mincing words (instead of garlic).  But if it’s called a “low-carb” diet, that would mean that a high-carb diet is the normal default.

If you call something low-  then there must be a high somewhere.  If you call dessert “blond brownies,” there must be a not-blond type.  And there is.  If you call someone pro-, then everyone else can be presumed to be con-.  So if people advocate a low-carb diet, then what does a high-carb diet look like?  And the answer is — the American diet.  The standard American diet (sAd) consists mainly of illness-producing amounts of refined carbohydrate.  Cereal and toast for breakfast, sandwich and chips for lunch, pasta for dinner.  You want fries with that?  No wonder America has an obesity and diabetes problem.  That diet, the sAd, is profoundly unhealthy.  It causes diabetes, obesity, high blood pressure, arthritis, heart attacks, and strokes.  That’s not okay with me or my patients.  So why would I pick a name that presupposes the sAd is some kind of normal?  I wouldn’t.  That’s my point.

This perspective highlights the difference between absolute and relative comparisons.  Let’s pick an example from something quite familiar to me, the medical industry.  Imagine, for example, that a new medicine came to market that decreased the chance of developing a rare and horrible side effect (say, a severe rash) from 2 in 10,000 to 1 in 10,000.  For every 10,000 people who tried the medicine, the chance of getting the rash would be halved, from two to one.  You could say that the medicine was “twice as safe.”  That’s called a relative comparison.  And while it is true, technically speaking, it’s not the whole story. 

The other way to look at this is that, in fact, the chance of developing the horrible rash is already very small, and it becomes slightly smaller if you switch to the new medicine.  That is the conclusion I reach from evaluating the absolute, or actual, numbers.

When we call smart eating a low-carb diet, we are making a relative comparison.  And relative comparisons are notoriously undependable because they don’t take into account where you started.  They tell you where you landed, but not how far you went. 

I don’t want to call a diet with healthy amounts of carbohydrate “low-carb.”  What then?  Smart-carb?  Natural-carb?  Garden-carb?  Pre-industrial carb?  I’ve heard some people talking about the Paleo [PAY-lee-oh] (short for Paleolithic) or caveman diet, which presumes that the right amount of carbohydrate would be the amount that the average human ate in that pre-agricultural era.  Why pre-agricultural?  Because that’s before humans began to grow and domesticate grain, especially wheat.  Wheat (along with corn and soy) is the grain used to make large amounts of the processed, food-like products that may be found at the American supermarket.  But Paleo doesn’t feel right either, unless I don’t mind eating the Industrial Revolution diet.

It’s important to remember that all carbs aren’t all-bad.  Not for everyone.  It’s certainly true that some folks are so sensitive to carbs that even an apple a day will make their pants too tight.  Practically the only carbs this group of people can eat comfortably are green vegetables.  But there are lots of other people who can eat all the peaches and lima beans they want.  So, instead of low-carb, I’d like to hear people start saying they eat a low-grain diet, or a low-processed-food diet, or even a low-grain and low-fruit diet.  That’s going to tell me a lot more about how well this person understands his or her own metabolic needs. 

When we call a diet “low-carb,” we are making a comparison with the sAd.  And the sAd is so high in processed carbohydrates that virtually every other diet is an improvement.  Low-carb, therefore, doesn’t tell us much.  It doesn’t say whether the recommendations target all grain, or only processed grain, or all grain and fruit, or all four categories of carbohydrate:  grains, fruits, beans and vegetables.  And it presumes that the sAd has a normal amount of carb.  Which it does not.
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