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(How do I use the OO approach if I have diabetes?)
by Dana Armstrong, RD, CDE
Eating is one of the most basic and important things we do in life. When diabetes is diagnosed, an enjoyable aspect of life—food—takes on new meaning. With diabetes often comes home blood testing, lab tests, doctors' visits, medical bills, and medications. It all seems to add one more aspect of "losing control" in a busy, sometimes complicated, life. However, even though diabetes is life changing, it is an opportunity to make many positive life adjustments, including one's relationship with food, so that management and control can be accomplished.
Traditional dieting requires cutting back on the food you eat. This may involve certain groups of food or just overall calories. The traditional, medically prescribed, "diabetic diet" decides for you exactly what is and isn't allowed. This rarely takes into consideration the times that your body gets hungry or what you feel like eating. It is found that most people eventually give in to their hungers, leading to "the binge." This diet/binge cycle is very common in those who diet frequently, and it also appears in people with diabetes. This diet/binge cycle leads not only to failed weight loss attempts, but to weight regain, yo-yo dieting, poor diabetes control, and feelings of guilt. In addition, some people with diabetes may skip some blood sugar tests in order to try and forget the binge and decrease their guilt. There becomes such a difference between "good" and "bad" foods that when they "cheat," they fail to keep diet records, record blood sugars, or even do blood glucose testing if they think they've eaten "wrong" or will get a "bad" number.
Instead of starting with a diet, which ultimately leads to the binge, start by educating yourself about diabetes and learn how food works in your body. To begin this process, understand that when you eat, food is broken down into three energy nutrients to provide the body with essential materials. The three energy nutrients are carbohydrates, fat and protein. Insulin is required for all three nutrients to be used properly.
Insulin is the hormone that your body makes to help glucose (blood sugar) get from the blood into the cells where it can be burned for energy. Think of glucose as a fuel being delivered by a truck. In order to make the delivery, the doors of your body cells must be opened. The only key which opens these doors is insulin. When insulin is available and working effectively in your blood stream, your cells are able to use the glucose in your blood. Without sufficient or effective amounts of insulin, glucose cannot be used by the cells for energy.
When you have diabetes, there are three types of treatment:
- You rely solely on your own body's insulin to work with the food you eat.
- You take pills to make your own insulin more effective in working with the food you eat.
- You take insulin and/or pills to supply your body with sufficient insulin to work with the food you eat.
In all cases, insulin works with the food you eat. It is this balance that is one of the key aspects of diabetes control. Learning to listen for and understand your body's internal hunger cues are a necessary part of achieving diabetes control, whether taking insulin, taking diabetes pills, or taking no diabetes medications at all.
While this all may sound simple, for many, beginning diabetes control is initially very tough. You generally are not feeling your best. Blood glucose levels may be so high that clarity of thought is affected and the discomfort of blurred vision, constant hunger, overwhelming thirst, never-ending fatigue and depression may impede the road to management and understanding.
These "obstacles" are very real and will interface with your ability to "get with the program." It is not just about "getting control." You need to understand that these real-life, physical conditions may make the first steps to managing the disease a very arduous journey, as feeling lousy doesn't usually lead to inspirational behavior.
While learning to eat in response to hunger and fullness can help keep your blood sugar at a healthy level, it can be extremely hard to focus on this skill initially. On diagnosis, when diabetes is uncontrolled, the disease is sending screeching messages to the brain that it is "starving!" This occurs because the glucose cannot get into the cells, so the cells send the message to the brain to "feed me, feed me!" It is not until glucose levels come closer to the normal range that you can more clearly focus on hunger and fullness.
Only then can you begin to determine the right amount of food for you by listening to your body's hunger cues. This process becomes one of self discovery. In addition, trusting one's medical professional and gaining their support during this time is vital. Using the OO process centers on the fact that there are no good or bad foods. These terms tend to imply guilt and assign emotional labels to food. Instead, this needs to become a journey in understanding the effect of foods on blood glucose levels. There merely are foods that affect your blood sugar in different ways, and some foods will give you higher numbers and some will give you lower numbers. Other foods may have little effect on blood sugar levels at all. It takes a great deal of support to tune out the voices and teachings of professionals (and family members and friends) who insist that a person with diabetes cannot eat whatever is wanted.
You need to start this process by testing your blood glucose levels frequently. You can research, study and muse over how different types and amounts of foods impact blood glucose levels. In addition, learning about food and its effect on glucose levels can help you process the specific impact on your mood and level of satisfaction with an eating experience.
You need to experiment. Begin by discovering the effect of all different types and amounts of food on your blood sugars. Instead of struggling with foods, learn how different amounts affect your blood glucose in different ways. In our diabetes class we conduct the Snickers Bar Challenge. All the students with diabetes check their blood glucose at the start of the class. Everyone then estimates what their glucose level will be in one hour, having just eaten a small, snack-size Snickers. At the end of class, the blood is checked once again. Surprise is a constant factor, as glucose levels after eating the candy are generally much lower than expected.
With time, you will come to understand that any food has the ability to make blood sugar levels rise. Experiment on your own: eat your most favorite meal, have the Hershey Bar at the movies, or enjoy a banana split for dinner. Instead of ignoring the diabetes or automatically assuming that your glucose meter will have a melt down when you test, check your blood glucose levels before, two hours after, and then four hours after eating. Note if you were hungry when you were eating, and if you stopped when you were content, or did you clean the plate? What difference did this have on the numbers? Does it make any difference if you eat when you are hungry and stop when you are full? Try the same foods again, but in different amounts and only when you feel hungry. Then eat these foods again, but only eat them when you are not hungry. Test your blood sugar both times. Try a completely different meal, but with the same amount of carbohydrates. What happens? What food or event had the largest impact for you? If you find that you feel your best when eating complex carbohydrates, choose all different types of foods in this category and monitor the results.
Through testing and experimenting, you will begin to discover and understand the physiology of diabetes and food. In addition, your education must include the introspection and reflection about your own ideas and feelings regarding diabetes, and the influence of friends and families' attitudes and reactions. The long-term commitment to good self care cannot begin to happen if you have not truly worked through "why me?," the anger, the fear, the denial. For many, enlisting the support of a good counselor can help process the feelings that can surround diabetes. It will help wade through the struggles as you find new ways to self care and comfort as well.
As Hippocrates stated, "Thy food shall be thy remedy." In regard to diabetes, nothing is closer to the truth. While food can be our comfort, it is also a major prescription in diabetes. With an understanding of how food affects and interacts with diabetes, it can affect your control in only a positive way, leading to better health and self-care.
Questions to ask and attributes to look for in a medical professional that can support and educate you in regard to diabetes:
- Is the person familiar with OO and diabetes? Understand that the OO approach is a long journey for the dietitian/therapist/physician as well. If they use OO personally and professionally with those without diet sensitive diseases, don't write them off. We all start somewhere and you may be their start. (Someone gave us ours!) If you're comfortable overall with how they support you, stick with them.
- Does the professional talk about success in terms of weight loss and compliance or are they supportive of other goals such as weight stabilization, increased sensitivity to hunger and fullness, and the exploration of new foods and their effect on blood glucose levels?
- Is the professional able to fully educate you in the use of blood glucose monitoring and help you interpret the results?
- Ask the question: "How do you feel about the person with diabetes having pumpkin pie and cinnamon toast crunch for breakfast?" If you hear judgments, and/or recommendations against this question, they may not fully understand OO and diabetes. Look for an answer along the lines of "Is that what you were hungry for that morning?" and "How does that food work with your body in regards to the blood sugars?" or anything else that asks you how you felt or how your body responded.
- Is exercise necessary for "good diabetes?" Is it an adjunct to weight loss and changing your shape and size or is it considered a healthy pleasure in its own right and encouraged as joyful movement?
- Does the professional feel it's OK to "sin" (i.e., eat pumpkin pie and cinnamon toast crunch) as long as you atone for those sins (less fat/sugar the rest of the day, a longer walk, etc.)? If so, be careful. The professional may be moving along and be considered non-diet, but there still is that hidden agenda.
Bottom line, trust your instincts. If you start to hear or feel that old stuff of a large body is a bad body, sugar and fat are bad, etc., call the professional on it! More than once we've been called on what we've said or how we've said it. If the professional will sit and listen, will consider your input, and you feel that a change has occurred for them, hang with them. If not, find a new medical professional. Good self care includes working with a medical professional who respects you and is willing to team up with you to get your diabetes under control.
If you need to make a change in professional support, talk to friends with diabetes, ask how they feel about their care providers. Interview other professionals. Know that "firing" a doctor can be very traumatizing because we feel "the doctor knows best." However, finding a supportive medical team is critical. You must feel safe and respected enough to bring into the office issues that are sensitive and private, which may have a bearing on the disease. You must trust your doctor, dietitian, and diabetes educator to be able to listen with respect and not dismiss whatever form your stress or preoccupation takes. Search out the best. You deserve it!
Dana Armstrong, RD, CDE
Director, Nutrition and Diabetes Services
Salinas Valley PrimeCare