Carbs and doubt, in moderation
Embracing doubt in nutrition, and the resulting challenges in patient care.
My thoughts on diet are always changing. I know less now about what the optimal diet is for reversing disease, and for maintaining health than I did before. While trying to get closer to the truth, I’ve observed that maintaining uncertainty makes behavior change difficult. Strict rules, on the hand, help create behavior change seemingly at the cost of lacking nuance.
I was introduced into the diet/nutrition world with the low carb, high fat diet. I quickly adopted the teachings of the community and reduced my carb intake to less than 50g / day which I kept up for a few months. I was the guy ordering burgers without the bun, and going to Korean restaurants and asking to hold the rice.
I was in ketosis for what I presume was for the majority of the time, and I lost weight as promised. To those who have never bought into this way of eating, eliminating carbohydrates may sound difficult requiring a will of steel. But it didn’t. Rather, ignorance of the alternatives and lack of a nuanced understanding of nutrition removed the need for willpower. I was certain that eating carbohydrates, and any amount of glycemic variation was detrimental to health. So much so that when someone had offered me a small piece of chocolate during the holidays, I felt slight remorse from eating it. I was concerned that this chocolate will break the state of ketosis I worked hard to enter.
As I learn more, I’m realizing that this carb-centric view of health may not be iron clad. I don’t know if sugar and carbohydrates by themselves are the problem. Perhaps instead it’s an inherent property of ultra processed foods that may be to blame. Or the hedonic effects of the combination of sugar and fat. Or seed oils altering metabolism and mitochondrial efficiency.
The low carb community has also shifted to considering alternatives such as prioritizing protein and/or considering satiety. After all the potato diet works to produce reliable weight loss, despite it being antithetical to the low carb model. Same with the rice and sugar diet, or the all fruit diet.
So I also liberalized my carbohydrate intake. Now I have no restrictions on carbs and sometimes go out of my way to include a potato in my meal. But without demonizing a food group, I now had to rely on myself to control what I eat. Unfortunately this strategy of “relying on myself” is vulnerable to biases, emotions, fatigue, willpower, environment, etc. Without a strong belief system, I could see how I might easily fall back into the Standard American Diet.
The more uncertainty I entertained, the more difficult real life applications became, both for me and for patients and clients that I counsel. There is evidence to suggest carbohydrate restriction works to improve markers of health. But data exist also for vegan and vegetarian diets, mediterranean diets, DASH diets, low fat diets, calorie restricted diets, fast mimicking diets, and on and on. Restricting almost anything seem to help. So how am I to advise someone?
I can try to personalize the diet plan to the patient. Avoid carbs, but if you can’t there are other ways. Decrease fat instead though some fat is good. Sugar by itself isn’t necessarily bad. Instead of providing concrete recommendations, I end up hedging and saying everything is okay -- in moderation. Before I know it, I would be making the same recommendations average doctors make, whom the low carb community loves to mock. “Eat less, and move more. Drink more water and increase fiber intake.” Unfortunately generic advice like this works for no one. It’s back to square one for me.
It is interesting to reflect on how my opinions on diet has changed over the years. Operating in the gray may be necessary for good science, but I can’t help but wonder if it can be counterproductive in real life application. I have adopted new nutrition rules for myself, but these rules are personalized based on my experience to fit my goals. I also have the advantage of having a medical background and having had the time to learn over 3 years. When advising someone with no nutrition background, the challenge lies in providing enough context and information so they can make an informed decision, while not giving too many options and nuance so that it becomes overwhelming and paralyzing.
I struggled to lose 15 lbs, and signed up to wear a continuous glucose monitor for 2 months, once in the spring and once in the fall. I am not diabetic, but I learned first hand and in real time how my food choices and exercise impact my blood glucose. It is powerful to see this data on your own body, even though there are many articles describing how these factors impact blood glucose (rice spikes it, exercise brings it down...). I changed my behavior after seeing MY data, and it wouldn't had happened otherwise. If you're interested, check out levelshealth.com (not a paid endorsment, I just like thier product and philosophy).