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Thoughts on PCOS and Nutrition/Lifestyle

Carol Fenwick, RD, LDN

The first step in discovering what "diet" is going to be supportive of your body and your individual metabolic needs is to learn to be mindful. Mindfulness starts with awareness — awareness of who you are, where you came from, and how that shaped the person you are now. Mindfulness will be discussed in terms of eating and physical movement in later columns.

As a private practice dietitian in Asheville, I find people who seek my services are tired of dieting. They have tried every old and every new diet, have been to support groups, and used diet pills. Most have dieted on and off most of their life, and have lost and gained hundreds of pounds. Many have successfully dieted themselves up to over 200 pounds. Some have lost and maintained weight through restriction or intense exercise. Most are tired of being hungry all the time and of having food and their body weight as the focus of their lives. What they are asking me is how can they lose weight without giving up everything that tastes good or starving themselves and exercising excessively. What I am showing them is how mindfulness will allow them to achieve their natural body weight and enjoy eating and physical movement.

As my private practice grew, I began to notice similarities in my clientsâ complaints – low blood sugar (hypoglycemia), carbohydrate cravings, menstrual disturbances, eating disorders, mood swings, and anxiety and depression. Many spoke the same mantra "I used to be thin, but one day I woke up fat," depicting an extremely rapid, relatively large, uncontrollable, weight gain. They gained although they ate high carb-low fat, low carb-high protein, no carb-high fat, lifted weights, ran, rode bikes, took diet pills, read diet books, prayed, and/or made sacrifices to ancient diet gods. They did everything known to cause weight loss and still have not been able to lose weight.

I learned of PCOS from the women's resource director at our local hospital. It dawned on me that many of my patients were probably undiagnosed with PCOS. I can identify with my patients because I, too, inherited the "thrifty gene" from my family. I, too, like the woman who has PCOS, experience hypoglycemia and the ravenous hunger that results. I would eat what I thought was an adequate breakfast of cereal and milk. Then an hour or so later, I would become shaky, dizzy, break out in a cold sweat, become nauseated, and have a "sick" headache, and the only thing that would make me feel better was to eat. On some days, the symptoms were more severe. Pancakes and syrup, which we often ate on Sunday morning during my childhood, literally made me sick enough to go to bed. I hated them, but had to eat what was served. I did not understand what was happening to my body until I became a nutrition student. What a difference it made in my life to begin to balance my eating.

Keeping a food journal (click on the link to download the PDF, or open it in your browser) will teach you about yourself and your individual nutrition needs. For example, some foods may give you longer lasting energy and more satisfaction than others. Certain foods may cause you to feel more hunger after eating them. Writing down what you eat and your experience with eating will help you to discover your uniqueness. Most importantly, the food journal will show you that you don't have to diet to lose weight and in fact, that you must STOP DIETING for a number of reasons.

Why did we diet in the first place? We did what everyone, our doctor, our mother, father, sister, brother, the government, friends, enemies, everyone, told us to do - go on a diet, exercise, and lose weight. But do we really lose weight when we diet? According to Polivy, who has been exploring the psychological consequences of chronic dieting in women along with Herman for more than 20 years asserts that on and off dieting does not lead to any significant weight loss. Dieting leads to overeating or even binge eating. Furthermore, dieting has undesirable psychological consequences.¹ (I'll bet if you have been on a diet, you have experienced some of these "consequences.")

Dieting is starvation. Take for example the classic study on the psychological effects of starvation, conducted by Keyes et al.² Conscientious objectors of World War II volunteered to restrict their food intake for six months until they lost approximately 24% of their body weight. What Keyes found was that the effects of starvation had extraordinary psychological consequences. The men, who were happy, normal, individuals at the onset of the study, became paranoid, suspicious, withdrawn, depressed, and anxious. They lost interest in sex, hoarded food, and binged on food at given opportunities. They became focused on food, changed careers to be food-related such as that of a chef, collected recipes, and even replaced pinups of their girlfriends with food pictures. Once the experiment was over, the previously normal eaters binged on foods and reported feeling obsessed and out-of-control with food. (Does any of this sound familiar?)
So much confusion exists about how to lose weight and a plethora of information is available, yet none has been scientifically documented. Former Agricultural Secretary Dan Glickman decided to do something about this and begin a program to evaluate weight loss diets. Early this year, Phase 1 of the project was completed. This included analyzing data collected on people's food intakes and a review of existing literature. A white paper is on the USDA home page under news releases at http://www.usda.gov/news/releases/2001/01/whitepaperexe.htm.

The findings are any weight loss diet limiting calories to 1500 will produce short-term weight loss. But if you want to lose weight and keep it off, go with the traditional food pyramid diet — moderate fat, around 30% of total calories, protein less than 20%, the rest in complex carbohydrates — fruits, vegetables, and whole grains. However, the report went on to say that the effect of eating behaviors, psychological and physiological factors, environment, and physical activity is not known. Further research is needed to assess the impact of these variables. (Keep that in mind - further research is needed.)

Again, consider the Keyes study. Starvation will produce weight loss - no doubt about that. The men were put on a diet that reduced their calories by about 25% of their normal intake. As their weight went down, less calories were needed to lose weight so calories were further reduced to cause a weight loss of 76% of their former weight. The longer the "diet" went on, the more severe the disordered eating behaviors became. (An estimate of what a 230-pound woman would have to eat to maintain her body weight is 2600 — 3700 calories per day, depending on her physical activity level³). Can you imagine the psychological consequences of reducing calorie intake to 1500 or less, approximately half of what is needed to maintain weight as recommended by many diets? The Keyes study showed severe psychological effects with a 25% reduction in calories.)
No wonder diets don't work. A severe calorie restriction leads to binge eating, a natural consequence of dieting. Binge eating is the body's effort to save itself from starvation. Binge eating causes weight gain. The dieter now feels she has failed. Self-esteem is damaged and she feels like she can't trust herself. She is out of control with food. No wonder we have so many eating disorders. Diets lead to eating disorders. Good health comes with a balanced approached to life. With dieting, we are caught in a cycle of eating, cravings, gaining weight, feeling guilty, and restricting. Yet we do not make much headway in our weight loss efforts. Health means giving up this unhealthy trap of dieting and becoming mindful of our own internal cues of hunger and satiety cues. We must learn to trust our bodies and ourselves even though we have been told we are untrustworthy. We must believe in ourselves. We must realize that our bodies know more about what we need to eat than a "fad diet expert." We must listen to our bodies. We must observe our eating behaviors and how they affect us. We must learn to be mindful.

To begin our journey back to normal eating through mindfulness, try using a food journal. When we record information on paper, we can see patterns more clearly than when we leave it in our heads. Karin Kratina, MA, RD, LD, has developed this food journal to help identify hunger and satiety cues.⁴ Each page of the food journal is to be used for one day and has several columns: Time food is eaten; Food and Quantity; the section with the food groups listed as DP = dairy protein, B/MP = bean/meat protein, F/V = fruit and vegetables, G = grains, and O = others such as sweets and fats; the Hunger Scale; and the Mood, Thoughts, and/or Feelings column. At the top of the page, the date and day are noted, along with an affirmation, a positive thought or goal for the day. At the bottom, exercise can be recorded.

The food journal is not to judge or criticize your food intake, but rather for discovery of your eating patterns and of your relationship with food. The food journal is designed for "Hungerwork," as developed by Kratina and King and will help you discover physically-connected eating.⁵ To begin reconnecting with your internal hunger cues: Steps in recording food intake:

1. Record time of day.
2. Before you eat, pause and be mindful. Are you hungry? Using the scale of 0 to 10, how hungry are you? I like to think of 0 as a car out of gas, completely empty, running on fumes and 10 as a topped off gas tank — another drop and the tank would overflow. A 5 is neutral — neither empty nor full, but halfway — neither hungry nor not hungry, just neutral. Fill in a block that indicates your hunger level.
3. After eating, determine on the hunger scale, where your hunger level falls now. Fill in all the squares between your start level and your finish level.
4. Use the Mood, Thoughts, and/or Feelings column, to journal.
5. At the end of each week, review your journals. Look for patterns. Where do most of the bar graphs fall? Are they centered in the middle? Do you start eating at a 2 and finish at a 9? What are your moods, thoughts, and feelings around times that you eat? Are you meeting pyramid guidelines? Are you getting regular physical activity?

We will add to the food journal in the next column. Practice becoming aware of your hunger and satiety levels and how your mood, thoughts and feelings affect your hunger and satiety levels and vice versa. Notice how your hunger levels affect your mood, thoughts, and feelings. If you allow yourself to get too hungry, how does this affect your mood? Do you become short-tempered or sleepy?
Some combinations of foods cause more hunger, which appear as carbohydrate cravings. As we are all wired for survival, we eat, as the carbohydrate cravings are merely a signal from the brain that our blood glucose (blood sugar) is low. Our brain must have blood glucose to operate. If we start our day eating a meal that will leave us with low blood glucose an hour or so later, we are going to need more food, especially carbohydrate, as it is most readily broken down into blood glucose. This may set us up for another low blood glucose in another hour or so and we need to eat again. No wonder it's so easy to gain weight.

Next column, how to analyze your food journal.

Notes:

1. Polivy, J. Psychological consequences of food restriction. J Am Diet Assoc. 1996: 96:589-592.
2. Keys A, Brozek J, Henschel A, Mickelson O, Taylor HL. The Biology of Human Starvation. 2 vols. Minneapolis, Minn: University of Minnesota Press; 1950.
3. Davy, B. Managing Body Weight. In: Rosenbloom, CA, ed. Sports Nutrition: A Guide for the Professional Working with Active People. 4th ed. Chicago, IL:American Dietetic Association. Sports, Cardiovascular, and Wellness Nutritionists Dietetic Practice Group;2000:430.
4. Kratina K. The Food/Feelings Journal. In: Disordered Eating Assessment and Treatment Tools. Plantation, Fl:Reflective Image, Inc.; 1993.
5. Kratina K, King N, Hayes, D. Hungerwork: Discover Physically-Connected Eating. In: Moving Away From Diets: New Ways to Heal Eating Problems & Exercise Resistance. Lake Dallas, TX: Helms Publishing; 1996.