IBS

Is non-celiac wheat sensitivity real? A new study says yes.
08/15/2012 - 19:20

 Non-Celiac Wheat Sensitivity Diagnosed by Double-Blind Placebo-Controlled Challenge: Exploring a New Clinical Entity.

Wait, based on some news articles I've read lately, I thought non-celiac wheat sensitives were a bunch of wilting prima donnas intent on eating an annoying hipster diet that excludes wheat, an important nutrient that people have been eating for a really long time or something like that. And since their diet excludes sandwiches and pizza, they must be UnAmerican. 

But in the medical research community, there is growing recognition that non-celiac wheat sensitivity is a real thing that affects quality of life and even mortality risk when it leads to intestinal inflammation. Stephan Guyenet posted about the last promising study.

This new study is very interesting, but highlights some limitations in dealing with problems like this. This study was on patients who already had been through the wringer test-wise and all had

  • IBS-like symptoms (Rome II criteria)
  • Negative serum anti-transglutaminase (anti-tTG) and anti-endomysium (EmA) IgA antibodies (the common blood tests for celiac)
  • Negative duodenal histology (absence of intestinal villous atrophy)- requires a biopsy
  • Negative IgE-mediated immuno-allergy tests to wheat (skin prick tests and serum-specii c IgE — RASTs).
  • Resolution of the symptoms on gluten-free diet and their reappearance on double-blind placebo controlled wheat challenge, which means neither the person nor the patient knew whether or not they were giving or receiving a placebo

Um, how many people here with IBS have ever been offered this standard of care? Anyone had a doctor who offered to supervise a double-blind placebo controlled wheat challenge? Maybe things are different in Italy. 

Once they were in this study, these patients got more tests including biopsies of the duodenum and colon, HLA genotyping, as well as skin-prick and blood tests. Then these people had to eat a minimum quantity of wheat daily as they were observed. Then they did a regular elimination diet that excluded wheat, cow's milk, eggs, tomato, and chocolate. Then they got to do a fun exciting double-blind placebo controlled wheat challenge again.

Wheat challenge was performed administering a daily dose 13 g of flour, equal to about 20 g of bread. A total of 12 capsules daily were given subdivided in three times daily, away from meals.  DBPC for cow’s milk was performed by administering capsules coded as A or B containing milk proteins (casein from bovine milk, lactoalbumin, lactoglobulin – daily dose 6 g, equal to about 200 ml of cow’s milk) or xylose, respectively. A total of 6 capsules daily were given subdivided in three times daily, away from meals.

Patients used a survey to track their symptoms. They used celiac disease and IBS patients without wheat sensitivities as controls. 

Among those who were wheat sensitive, a high number of them tested positive on the cytomteric basophil activation test, and many also tested positive for serum IgG and IgA AGA tests. Many of these patients suffered from anemia and weight-loss. Biopsies showed eosinophil infiltration of the duodenal and colon mucosa.
, despite not having the type of villous atrophy damage associated with celiac. 

There seemed to be two groups of IBS wheat-sensitive patients- those with wheat sensitivity alone and those with wheat sensitivity AND multiple other sensitivities to cow's milk and other foods. The later group was also more likely to also have other types of allergies (non-food allergies, skin allergies, etc.) and a family history of allergies.

Further studies will have to look more into the mechanism in which wheat causes damage in these patients. The researches propose one mechanism in their conclusion

Obviously, other hypotheses must be considered; experimental  models have demonstrated that gluten sensitization of DQ8 mice increases acetylcholine release by the myenteric plexus and this can lead to consequent in vivo dysmotility ( 27 ). In this model, gluten did not cause villous atrophy, but there was evidence that coexistent triggers, e.g., intestine-damaging drugs or dysbacteriosis, can lead to a more severe intestinal impairment ( 28 ). Clearly, wheat  antigens may also act in a similar manner.

Acetylcholine is responsible for ahem, moving things along, so it might explain why wheat causes diarrhea in some people. 

Also, it is notable that this study used wheat rather than gluten, so it might be other components of wheat like fructans that are responsible for the symptoms. 

The researchers say

the very high frequency of self-reported wheat intolerance, which we observed in our patients, should induce clinicians to pay full attention to patient suggestions

I wonder how long it will take the average doctor to catch on? 

 

Home is where the gut bacteria is
05/11/2012 - 21:45

 Ugh, I got back from Europe this week and I feel like I have so much catching up to do. Books to review, emails to answer, projects to finish, mad programming skillz to acquire, apartment to spruce up... and somehow every night I go to bed with so much undone. More about my travels later, as there is an interesting new paper out.

I've written about the need to sample gut flora from different cultures before they are "acculturated" to an industrial diet, so I was delighted to see Human gut microbiome viewed across age and geography. The researchers sampled the gut microbiomes of 115 rural villagers from Malawi, 100 Guahibo Amerindians from Amazonia in Venezuela, and 316 people from the greater metropolitan areas of St. Louis, Philadelphia, and Boulder. They found significant differences between the gut bacteria in these three populations. 

Now while you may be familiar with the standard American diet, the diets of the other populations are bit more obscure. The researchers thankfully provided their diet survey in a table in a zip file. 

Some common foods the Guahibo ate (24 hour recall) were

  • Corn arepas/Bollito
  • Cassava cake
  • Soup (what was in the soup though??)
  • Coffee (haha)
  • Sugar (lol) and sometimes sugar cane juice and soda
  • Milk (I wouldn't be surprised if the government is providing this)

Consumption of meat and fish seems rare. Sadly this diet already seem significantly industrialized. 

In Malawi some common foods (recall over a month) include

  • Nsima, Corn porridge, and pigeon peas are the staple foods
  • Sweet potato, banana, cassava, rice
  • Some fruits like oranges, mango, and papaya
  • Greens like pumpkin, mustard, and sweet potato leaves
  • Vegetables like onions and tomatoes
  • Meat from chickens, cows, goats and pigs pretty rarely, though it seemed that some individuals were eating a lot more meat than others, a few were eating it every day
  • Small fish and eggs more common
  • Biscuits/cookies
  • A few people were using vegetable oil

I wish they had used a consistent method for food surveys and provided more information about the diet. Perhaps there needs to be more collaboration in this field with anthropologists?

Each different community of adults had its own particular microbiome signatures, but the Malawaian and Amerindians were less distinct from each other than the Americans were from the two other populations. Interestingly the researchers said that the differences in functions parallel those between carnivorous and herbivorous mammals. Malawaian and Amerindians microbiomes contained more genes for glutamate production, whereas US gut bacteria seemed more focused on degrading it. US gut bacteria also contained more genes for degrading other amino acids like aspartate, proline, ornithine, and lysine, as well as the use of simple sugars. Richer numbers of genes involved in synthesis of biotin and lipoic acid, processing of xenobiotics, and bile salt metabolism, which the researchers thought was related to the higher fat content in the American diet. Malawaian and Amerindian gut bacteria produced more amalyse, which is important for degrading starch. 

Another thing they found, which has also been found in other studies, is that as people in all the cultures aged, their gut bacterial populations changed. In infants, Bifidobacterium dominate, but their presence declines in early childhood. Functionally, infant gut bacteria had more genes involved in making folate, whereas adults had more bacteria with genes for metabolizing dietary folate. Adult gut bacteria also contained more genes for producing B12, vitamin B7, and vitamin B1, as well as processing of arginine, glutamate, aspartate, and lysine. Not surprisingly, infants microbiomes were enriched in enzymes involved in foraging of glycans from breastmilk. 

The authors concluded that "Together, these findings suggest that the microbiota should be considered when assessing the nutritional needs of humans at various stages of development." I think this is another good reason to question the idea that human breastmilk provides some sort of model for how humans should eat. 

Some genes involving glycan processing were more common in the Amerindian and Malawaian baby microbiomes, which the authors thought might be related to differences in glycan content of breastmilk. While all the samples used were from breastfed babies, I would be curious to know whether or not the babies were being exclusively breastfed. Supplementary formula could be an issue in the US and many other cultures use carbohydrate-rich supplementary foods even in young infants. But the researchers say these glycan processing genes decreases during maturity in Malawaian and Amerindian babies as they transition to diets rich in complex plant-derived polysaccharides, whereas they increase with age in US infants as they become exposed to diets rich in easily-absorbed sugars. However, the dietary survey says the Amerindians were eating a lot of sugar every day, so I'm not sure of that.

The Malawaian and Amerindian infant microbiomes were rich in urease gene representation, which was uncommon in both infant and adult American microbiomes. Urease can be used to produce amino acids and recycle nitrogen, which is important when diets are deficient in protein. 

The supplement contains a comparison of breast and formula fed babies show that formula-fed microbiomes were more focused on carbohydrate (fructose, mannose) and amino acid metabolism, with more genes involved in biosynthesis of B12. 

For me this paper raises more questions than it answers. How plastic are these populations? What happens when you feed an American adult an Amerindian diet? Would the gut bacteria be able to shift or is it too late? 

There aren't any studies on this that I know of yet, but I did read a study recently that was very interesting: Modulation of fecal markers relevant to colon cancer risk: a high- starch Chinese diet did not generate expected beneficial changes relative to a Western-type diet. The study didn't look at gut microbiome genes or populations, but it did examine many of the products of the gut microbiome, such as short-chain fatty acids, as well as other colonic markers associated with lower risk of colon cancer. The study basically wanted to see if they could shift these by shifting the diet. Would Australians eating a high-starch "low-income" Chinese diet have the same favorable products and markers that the Chinese had? Unfortunately, after three weeks all the results besides fecal PH were worse! Too bad the study was only three weeks though and the diets actually seem kind of weird, but then again I've never been to Australia:

I guess processed oil has been used for long enough in China that most Chinese people I know, even older people, consider it a traditional food...

Furthermore, how responsive are the gut bacterial populations to cultural change? It seems like the Amerindians are now consuming a significant amount of processed sugar, yet this doesn't seem to be reflected in the gut microbiome. They don't seem to be getting closer to the features of the American gut microbiome that the researchers theorized might be related to sugar consumption. Will this happen over generations? Or are the gut biomes of cultures as resistant to change as those of individuals? It would be interesting to study the gut microbiomes of migrants vs. the original population the migrants came from. Also, I'd be curious about the outlier individuals from the dietary survey, such as the couple of Malawaian individuals who reported consuming meat every day. Does their gut microbiome reflect this? What would happen if you compared American vegetarians with American omnivores?

Also, this adds another layer of complexity when looking at traditional diets. Can you get all the health benefits of a particular culture's diet if you don't have their microbiome? How many health differences between populations are explained by different microbiome heritage rather than diet? 

The many-venomed earth
03/19/2012 - 14:39

 I've written before on how the typical "paleo" paradigm didn't fix my digestive problems. That's because paleo divides things into good and bad in a somewhat arbitrary manner. The reality is that good and bad are relative to the functioning of your body and your individual biology. As Dr. Ayers said in his latest post:

This suggests that the problem is somehow in the intolerant person, even though there are no genes for food intolerance and very few cases of food intolerance result from an immune reaction. Food intolerance is actually the inability of an individual's incomplete gut flora to digest certain types of food.*

The question becomes whether or not you can figure out which foods you are intolerant of and then whether or not you can become more tolerant. Your malfunctioning gut bacteria probably don't care about whether or not a food is "paleo" or not. 

This becomes clear now that an army of paleo cookbooks have been published that contain nut and coconut flours. My family has discovered the hard way that these flours can be quite harsh on the digestive system. My mother told me she reacted terribly to some coconut flour baked goods she made, but not to plain old bread. I found that I reacted to both about the same, which meant that both seemed to lead to cramping and bloating. That's not really surprising, since it seems fructans are my main enemy. 

Almond and coconut are "paleo" ....why? Because they are not seeds (actually, they are technically seeds, which is pretty hilarious that people don't think of them as such) and grains? Even though there is ample evidence for seed and grain consumption in the actual Paleolithic. And almond and coconut share many of the properties that some "paleo" advocates claim are the problem with grains, such as high levels of phytic acids and potentially-reactive lectins and other proteins. 

For example, Robb Wolf tweeted that he didn't think grains could be a "safe starch" because there are some papers on various immune-system reactions to them. But I can find papers on very similar reactions to our sacred cow. I'm sure in some parallel vegan circle-jerk twitterverse, Dr. Dean Ornish is tweeting those papers to confirm his follower's various biases, but as I wrote about sialic acid from meat, not everyone reacts this way. And in particular, I don't think healthy people are as likely to have such dysfunctional immune responses to food, but Westerners raised on crap in a "hygienic" environment are very vulnerable. 

My mantra is that a sick person can react to ANYTHING. And a very healthy person can tolerate a lot of terrible things. I always like to remember the story of Mithridates VI of Pontus, who was so paranoid about being poisoned that he took small doses of various poisons in order to accustom his body to them (hormesis perhaps). When he was defeated by Pompey, he tried to commit suicide by poison, but couldn't because he was immune to what he had on hand. So he had to have his bodyguard execute him by sword. He is immortalized in an excellent poem by A. E. Housman

There was a king reigned in the East:
There, when kings will sit to feast,
They get their fill before they think
With poisoned meat and poisoned drink.
He gathered all the springs to birth
From the many-venomed earth;
First a little, thence to more,
He sampled all her killing store;
And easy, smiling, seasoned sound,
Sate the king when healths went round.
They put arsenic in his meat
And stared aghast to watch him eat;
They poured strychnine in his cup
And shook to see him drink it up:
They shook, they stared as white’s their shirt:
Them it was their poison hurt.
–I tell the tale that I heard told.
Mithridates, he died old.
– A. E. Housman, A Shropshire Lad

I love the line "the many-venomed earth" and it's one that has struck with me often as I study science, along with Tennyson's "Nature, red in tooth and claw" from In Memoriam.

Interestingly, through self-experimentation I've found that I do not just OK, but much better eating things made with rice and certain pseudograins. My skin improves when I eat finely sifted fermented buckwheat (a pseudograin) and I have much more energy and digestive stability when I have some rice in my diet. 

I also think some of these gluten-free grain-free things are pretty much torture to cook, requiring all kinds of fruit/vegetable purees or five million eggs to produce something even somewhat appetizing. And I don't have any particular interest in eating things that are only somewhat appetizing unless they are exceptionally nutritious. 

Sometimes I get asked what my diet is like and that's a hard question to answer. I'll go through periods where I cook some particular ingredient over and over again, and then I kind of forget about it for awhile. It's like that with buckwheat for me. Perhaps the craving has something to do with buckwheat being particularly rich in magnesium?

Lately, one of my favorite meals is buckwheat pancakes with delicious toppings. My method for making buckwheat pancakes is that I sift the flour and then soak it for a day in sour whey or sour cream. Then I mix in an egg and cook it in fat of some sort. This one I topped with bacon-wrapped elk, REAL lingonberries (not the jam from IKEA, I bought them frozen at Erickson's Delicatessen and they are very sour, so they work very well with savory dishes), and seaweed.

 

* I also agree with Mat Lalonde that reactions to specific proteins can be an issue, though the two things are somewhat interconnected

Why Paleo didn't fix my IBS
01/06/2012 - 00:37

 Now that it's been over four years since I first heard about "paleo" diets, I have been reflecting on how such diets have worked for me. When I first heard about paleo, I definitely thought it was a solution to all my problems and it worked really well for most of them. The original bane of my life in the pre-paleo era, GERD, is gone. But my IBS symptoms were harder to fix and even now I find myself experimenting. In the beginning, I often thought the solution was more "purity" in my diet. I thought if I just were better at my diet, then my problems would go away. But IBS is too complex for that. And it doesn't seem to care about evolution all that much. While evolution can be useful for hypothesizing, my gut is the product of a C-section birth, a subpar diet for almost two decades, and many many courses of evolution. I think of my maternal grandmother who is in her nineties and claims to have only had a stomachache once in her life. Compared to her stomach, my own stomach is a rather unfortunate thing. 

So when I ate a pure "paleo" diet, what happened? My stomach problems got WORSE. 

Luckily I found the SCD (specific carbohydrate diet). It's really for people with worse problems than mine, but it clued me into some of the things that were going on, namely that there was something wrong with how I process certain carbohydrates. Well, not just me, but my own microbiome in my gut. They were taking something I was eating and having a party consuming it and belching out all kinds of bad things. Bloating, cramping, gas, bouts of IBS-C and IBS-D were the result. 

Unfortunately SCD is both too strict and not strict enough. The "legal" list of SCD foods, like the typical "paleo" list, contains foods I cannot digest properly. The specific carbohydrates I'm sensitive to are not the same as those that the SCD concerns itself with. I ended up just going carnivore for awhile, which helped with a great many things, but I had other symptoms on that diet (like extremely low blood pressure) and it is on the pretty extreme of restrictive. I also think that some products of carbohydrate fermentation are important.

I have no idea where I first encountered FODMAPs, which stands for 

  • Fermentable
  • Oligosaccharides (eg. Fructans and Galactans)
  • Disaccharides (eg. Lactose), Monosaccharides (eg. excess Fructose) and
  • Polyols (eg. Sorbitol, Mannitol, Maltitol, Xylitol and Isomalt)

But the theory is similar to the SCD, which is that for certain people, certain carbohydrates aren't processed correctly by the gut and end up feeding bad bacteria. But I think it was more useful for me because it breaks down the issue into a variety of potential baddies to experiment with. Lactose intolerance is the most famous type and all the other types are similar in that they can be dose-dependent. That's why I was so confused at first. Sometimes I'd eat potentially bad food X and feel fine and other times I'd feel terrible. Amount effects it, but that's the tip of the iceberg, because the context can affect it too. For example, with fructose, the amount of glucose ingested at the same time can affect tolerance. 

So far you can see where my experiments have left me vs. the typical paleo diet:

It seems I have some fructose intolerance, but my tolerance is comparatively high. I can eat an apple, but if I start eating a bunch of dried apples (more concentrated fructose), then I start getting into problems. 

Then there are foods that I can tolerate almost none of, such as brassica vegetables like cauliflower. Many "paleo" recipes use cauliflower in place of rice. I am much worse off if I eat that compared to real rice and in fact I've found that rice soothes my stomach quite nicely when it's upset, particularly when cooked in broth as a congee. 

I'm still torn about wheat. I think I've tried every possible type of wheat at this point, including wheat that was fermented to remove gluten and a variety of "heritage" wheats. I still didn't tolerate it, which makes me think that it was never about gluten for me, but about fiber. 

It's also pretty important to self-experiment and not just write entire foods off because they contain something that might be the culprit in causing you problems with another food. Onions are a major issue for me, but I've found I can tolerate them pretty well if they are cooked into oblivion (for example, in a sauce), which frees me to enjoy certain delicious Indian dishes. Tomatoes are only an issue for me raw.

I think this jives very well with the evolutionary idea that cooking was important in human evolution because it transferred digestion to the small intestine rather than the large. That seems to be exactly what is happening here. The large intestine is where fermentation takes place, so if fermentable carbohydrates are the issue, then cooking them to make them more available to the small intestine could help. Of course there is all kinds of fancy cooking science here I'm not getting into, which I need to research further. There is also the issue of tolerance improving if you manage to heal the gut lining and balance the gut bacteria somehow. I think that overall my tolerance has improved as I've eaten healthier. I used to not tolerate spicy food at all, which was practically a tragedy for me since I love it, but now I eat it quite often without an issue. 

But people are always asking me to do an IBS post or series. And I kind of can't because it's been just all one weird experiment of me trying to figure out what I can tolerate and at what level. That's why I'm such a huge proponent of self-experimentation and not such a huge fan of dietary dogma. 

IBS: Bran is bad... when will doctors catch up?
07/06/2011 - 18:47

 In the next few months I hope to write a couple of posts on irritable bowel syndrome. It's interesting because so many (including myself) get relief from IBS by following a low-carb low-fiber grain-free fructose-free diet with probiotic supplementation. There are many reasons this works, but in the long term people following it might want to wean away from probiotic dependence, since probiotics in pills cannot become part of the permanant microbiome of most adult guts. In addition, there are real benefits from short chain fatty acids produced in the colon by fermentation. It's unfortunate so much fiber research has been done on grains, but more and more is being done on the type of fiber that horticulturalists and foragers consume. Here we are getting into self-experimentation since the research is so thin right now. My own goal has been to establish a gut bacterial population that is an asset (har har) rather than a nuisance. I've been trying to do this by feeding my bacterial population appropriately in a way that encourages good bacteria, but does not allow overgrowth. 

On Paleohacks someone said something like "the kind of food you eat cannot affect constipation, just the mechanics of the food, IE, how much fiber and fat." That is the OLD view. The reality is that different gut bacteria react differently to different foods. I've been reading a lot of articles by Dr. Kok-Ann Gwee, who studies IBS in Singapore. His article Fiber, FODMAPs, flora, flatulence, and the functional bowel disorders is a really good one and should be essential reading for all doctors. I'd estimate the majority of primary care physicians are still recommending things like bran to treat IBS when there are mountains of scientific evidence against it. 

The issue was in the 70s some papers came out that said, "huh, looks like this African farmers don't have stomach problems. Must be all the fiber in their diet!" Nevermind their methods for measuring fiber were bad and that certainly wasn't the only difference in their diets. Then some poorly-designed studies were done on bran, which the cereals industry picked up in order to promote BRAN FOR EVERYONE1111!!!!! Dr. Kok-Ann says:

In fact, a number of contrarian studies, which had been largely ignored, had suggested that favorite sources of dietary fiber such as bran and other cereals, and vegetables and fruits, might actually aggravate symptoms in IBS. The symptoms that appeared to be aggravated were flatulence, bloating and abdominal pain.

Yikes, that certainly was my experience. The more I ate the high-fiber stuff my doctor told me to eat, the worst I felt. 

I didn't have Celiac, so that meant wheat was AOK right? Nope, gluten is not the only bad thing in wheat, the fiber in wheat can be quite bad for people with IBS as well. 

Based on the use of an exclusion diet, Nanda et al. from Oxford reported that dairy, grains, in particular wheat and rye, and onions were the major foods implicated by IBS patients, and that patients responding to dietary manipulation were likely to have presented with flatulence as an initial symptom.3 They had also observed that intolerance to either wheat or rye was specifically associated with abdominal distension. Whorwell and Prior from Manchester recorded that 55% of their patients felt worse and only 10% felt better on bran.4 John Hunter's group from Cambridge used a whole-body calorimeter to measure the 24-h excretion of hydrogen and methane in both the flatus and the breath.5,6 They compared the gas production of IBS patients and healthy controls on a standard diet with regular fiber intake, an exclusion diet, and a fiber-free diet. They found that IBS patients had a significantly faster rate of gas production on a fiber-rich diet, which reduced significantly on the exclusion and the fiber-free diet, and this appeared to be associated with an improvement in symptoms. Others have also suggested that malabsorption of fructose and sorbitol, of which fruits are rich sources, may give rise to symptoms in IBS patients.7

So fiber not only doesn't help, it makes you gassy and bloated. This paragraph highlights the foods I found triggered my symptoms through trial and error: onions, grains (esp wheat), and a lot of dairy. These are foods I now know are rich in FODMAPS (Fermentable Oligo-, Di- and Mono-saccharides, and Polyols). Interestingly I've found not all FODMAPs trigger my symptoms. 

In [the Cambridge study], total gas, as well as breath hydrogen production, was similarly reduced with metronidazole (an antibiotic with activity against intestinal anaerobic organisms) treatment despite a fiber-rich diet. This observation brings us back to our recent appreciation that the flora of intestinal microbes is a key player in the development of IBS.10 Even Segal and Walker, two of the early proponents for the high-fiber diet, have recently acknowledged that reduced dietary fiber intake has not resulted in increased colonic diseases in Africans.11 In fact they have now recognized the importance of the “quality of the intestinal bacteria”, and the impact that this has on the fermentation of malabsorbed carbohydrates.12 In their recent paper they have assembled measurements for various classes of immunoglobulins, and other markers of immune activation, that support a high level of exposure to gastrointestinal infections in childhood.11 Their new hypothesis is that it is this early priming that gives the African a more robust gut microflora, better able to withstand the insults in adult life. The corollary is also that if we expect fiber and oligosaccharides that are promoted as prebiotics to enhance the proliferation of ‘good bacteria’, we have to start feeding these substrates to our gut in the early years of life. In the meantime, it appears that eating a ‘healthy Western breakfast’ of milk with high-fiber cereals, whole grain bread with honey, washed down with apple juice, is perhaps the worst way to start off the day for an adult IBS patient!

What about those of us who didn't get that advantage? Is there hope to normalize? In his other article he points to several factors anyone with IBS should think about: 

  • The role of gut flora in their end products, immune mediators, and neuroendocrine factors
  • Beneficial and pathogenic parasites

Then there are some more factors to think about from Irritable bowel syndrome: towards biomarker identification:

  • The gut-brain axis
  • Hypothalamic-pituitary-adrenal (HPA) axis dyfunction
  • Inflammation
  • Stress

More soon!

The Middle Way
06/16/2011 - 08:25

 Last year I met a girl who was trying the paleo diet and complaining she "felt weird" and her stomach hurt. I asked her what she was eating and it turns out she was eating 5 tablespoons of coconut oil for breakfast! I told her that wasn't food, that it was an ingredient you can use to make foods or a supplement and that maybe she should try eating food. Later she said she felt better. 

I guess there is some impression among certain people that because I and others don't think fat is *bad* that you should drown yourself in it. As far as I'm concerned it's a far cry from a certain Paleo cookbook that advocates trimming fat off of GRASS FED meat, throwing away the fat that is leftover from cooking grass-fed meat,  and avoiding grass-fed "fatty cuts" like shanks to eating a pound of bacon for breakfast with a side of heavy-cream flavored coconut milk. Let's be honest: I don't eat that way. I cook with tallow that I save from the whole goats and lambs I buy, I certainly don't ever throw away any "fatty" cut, and sometimes I use some ghee, bacon, butter, or coconut milk as ingredients. I go through a pound of bacon a month, mostly because of my boyfriend, and maybe a can of coconut milk every two weeks and a pack of Pasture Butter a month. I never make any "paleo" desserts anymore and I don't eat very much dairy unless it's well-fermented and raw. Heavy cream makes my digestive system into sludge. I do eat some grains: I find my stomach is happiest when I include some rice in my diet every few days or so. 

I suspect someone who is more athletic or who doesn't have IBS might tolerate more fat. But this is my personal "sweet spot." I do have experience doing almost-vegan paleo: starches, veggies, fruits, no added fats, and only shellfish as protein. Perhaps it could be perfected, but I found that my keratosis really was itchy and red. I also felt more depressed and had bloating. If I tried it again I would probably use some coconut milk with carrot juice or something in an attempt to get vitamin A, but maybe my body isn't suited for it because of my genetics and health problems. Maybe it's also different for people in different life-stages. I'm a woman of reproductive age, so it's possible my need for certain vitamins is higher. 

I also would note that food sensitivities don't care about the paleolithic. It's very possible to be allergic or sensitive to a host of "paleo" foods from types of meat, to nuts, to eggs, to shellfish. I am personally quite sensitive to vegetables like broccoli, onions, and cauliflower. Honestly, they do a number on my stomach worse than any grain. I think people get caught up in the "paleo" paradigm thinking that because we evolved with foods like it, it must be good. But modern food sensitivities don't discriminate. I find that interestingly my stomach feels much better if I get starch from regular potatoes rather than sweet potatoes. The latter is considered "more paleo" though that stems from botanical ignorance. 

Either way, I don't really follow an orthodox "paleo" diet either, though I do use what I learn about the paleolithic to think about what I eat. I think there is tons of room for experimentation, particularly as the evidence for starch consumption in the paleolithic becomes stronger and stronger.

I don't think there is much room for combining "paleo" with various religious philosophies and I'm a little dismayed that Chinese medicine has somehow crept in and become tolerated. I think if I blogged about how I use Christianity to tell me what to eat I'd get about a million angry comments. Remember, the mechanisms behind Chinese medicine are scientifically implausible and even if a few tiny studies show that Chinese medicine works, it's not because of supernatural forces like conveniently undetectable "energy fields" operating outside of the forces of biology, chemistry, and physics. I know plenty of people who follow a "paleo" diet that is compatible with their religion, such as kosher or halal folks, but they don't claim that their diet is somehow better because of it or that it explains their diet's success. 

 

There has got to be a scientific explanation or I'm just not buying it...

Addendum:

It seems that some people were upset with the idea that I was attacking alternative medicine in the last post. No, I was attacking scientifically implausible theories of food being integrated by the ancestral food community. It's because people don't want to believe there are both unverifiable supernatural beliefs AND beliefs worth investigating to find out whether or not they have some natural basis or benefit.

Acupuncture, for example, is a system worth investigating because of the possibility that the ancient literature refers to real physiological processes, as Chris Kessler points out, and not energy fields (scientists have looked for these energy fields and NOT found them).

The idea that some Chinese roommates once told me that going to bed with my hair wet would cause demonic possession leading to pneumonia made me wonder if perhaps people in rural China did get sick from chills, but otherwise it is a supernatural belief.

Likewise, I am a huge fan of traditional Chinese foods, but when my waitress at my favorite restaurant in Flushing tells me I eat too much fatty "Yang" food and will get acne and clog my blood (that would be awesome since I have a mild form of hemophilia) I think it's worth investigating, but most of the time Chinese traditional food beliefs have been investigated, they have found to be incorrect or vast simplifications. I'm impressed at the latter, but I won't be basing my food choices on whether or not foods are "Yin" or "Yang." I suspect these beliefs have very little to do with Taoism anyway, as they were probably added on as Taoism blended with local folk religions.

Some of these folk beliefs lead to some absurdly unhealthy behaviors. I know Thai people who believe it's good to wash down beef, which is a "hot" food, with Coke, which is a "cold" food. And Chinese people who follow their fried chicken with heavily sugared red date tea because it's "Yin" and replenishes their "Qi." Since these beliefs are not based on real concepts, they are particularly vulnerable to industrialization. 

Religions/folk beliefs and food: worth investigating and important tools for believers, but not always scientific. 
 

Beating IBS
03/20/2011 - 18:42

 Mark Sisson posted a link to a sad essay called IBS Is Why I'm Still Single. Every day I'm able to eat and live normally, I am so grateful. You see, most of my life I had painful stomach problems. When I was four I remember crying in the bathroom. I remember at sleep away camp being too embarrassed to use the communal bathrooms and sneaking out in the middle of the night to the isolated outhouse. It wasn't until I was 15 or so that I was diagnosed with IBS. When I was a freshman in college it became so disruptive to my life that I was finally given Librax. At that point I was also on quite a bit of asthma medication. Then I started having serious heartburn. I went on proton pump inhibitors. At my low point I was on Allergra, Advair, Singulair, Albuterol, Librax, Nexium (Prilosec stopped working at some point), and continuously on and off antibiotics for various ailments ranging from yeast to sinus infections. I was miserable. I missed most of my classes. 

The single part of that essay hit home because I remember my first Valentine's day with my first boyfriend. We had a delicious meal, but soon after I was bent double with incredible pain and spent most of the night in the bathroom. I didn't think I'd be able to do anything. 

I honestly thought that my condition was caused by eating fat, tomatoes, and peppers. The handouts my doctor gave me insinuated as much. I really didn't like all the side effects of the medications I was on, but when I complained to one of my doctors he said I'd on them for the rest of my life. I tried all kinds of high-fiber low-fat veg*n diets to no avail. 

I didn't want to live like this. But all the sudden my condition took a turn for the worst. I felt like my whole body was falling apart. One day I collapsed in the hallway of the dorm. I was diagnosed at the hospital with chronic salmonella. That's not something a 19 year old should have. Afterwards I had trouble with constant burping.

I vowed to do more research and found a small study on GERD and low carbohydrate diets. I also discovered Evolutionary Nutrition on Art De Vany's site through the blog Marginal Revolution. I learned about the Specific Carbohydrate Diet and wondered if my symptoms were caused by bacterial overgrowth. My first attempts to get off my medicines didn't work. I tried to eat low-carb in the dining hall, but I guess the foods had too much crap on them. Luckily, I took summer school and lived dining-hall free in graduate student housing, though my "kitchen" had only a microwave. Looking back, my diet wasn't all that great. I didn't know that much about cooking and nothing about meat. The first meat I bought was some sausage, which I tried to cook in the microwave only to get a massive bowl of exploding grease. Gross. I had to eat out a lot, but stayed mostly paleo and very low carb. I tried lots of remedies like probiotics and drinking apple cider vinegar after each meal. I started drinking kombucha. I read everything I could get my hands on about traditional nutrition. It seemed clear my illness was a modern disease. 

I had a goal in mind: as a freshman I had tried spicy food for the first time and learned to love it, but I had thought it was causing all my problems. When it was clear that this was a secondary problem to the inflammation and dysbiosis, I decided to make eating it without pain a goal. I didn't reach that goal until six months into the regimen, but I've been eating delicious curries without incident ever since. 

I've also been able to travel extensively without incident, something I thought I'd never do. 

Unfortunately I still had some residual IBS issues. I realized a year ago that I was going to have to let go of beer and gluten-containing cheat meals. The IBS has been gone ever since, but I really do miss some of those foods. 

So basically the principals I went on were that bacteria was at the root of most of my problems. Being born by C-section, a low-nutrient diet, and constant antibiotic use had put my gut ecology into an imbalanced state. Probably some of my medications made it worse, like Prilosec/Nexium, which is known to allow bacterial overgrowth. My principles were to first starve out the bad bacteria, which was inspired a bit by Hyperlipid, and then gradually try to balance the gut through gentle traditional probiotic and nutrient-rich foods. I suspect I had both hypochlorhydria and small-bacterial overgrowth, which was why I was so excited by the paper I just blogged about. 

I'm still quite fiber-intolerant. I can't really do brown rice, quinoa, or many other fiber-rich grains. But I am able to eat a fair amount of carbs, which I'm happy with. As an aside, even some in the alternative health community are very wrong about IBS. Giving up simple sugar will do nothing, as they are digested in the small intestine, which is a point made by the SCD diet. It's the complex sugars that cause the problems in the lower intestine. 

As for romance, duh it's easier when you aren't a miserable gas-filled bloated cramped up woman who alternates between diarrhea and constipation (with hemorrhoids) every two days... 

So when people say paleo or traditional foods are trivial, I'm just happy I can live a relatively normal life thanks to them. So I thank these things for my good health

  • High fat
  • Low carb
  • Probiotics
  • Acidic foods like pickles, kombucha, and apple cider vinegar that helped make up for my low stomach acid
  • Traditional foods
  • Grass-fed meat
  • Gluten-free

Gluten: It's bad news
09/16/2010 - 20:59

Last month I got some test results back. One of the tests was for the gene that is linked to celiac disease.

Apparently I don't have it. So I thought I'd celebrate with a beer. Predictably I felt horrible the next day. Why? Well, gluten isn't just bad for celiac individuals, it's possibly bad for almost everyone.

First of all, it's got some seriously bad stuff in it. One of these things is a protein called gliadin, which celiac individuals are sensitive to. But it turns out that others are sensitive to it as well: Is gliadin really safe for non‐coeliac individuals?

The answer is NO:

The data obtained in this pilot study support the hypothesis that gluten elicits its harmful effect, throughout an IL15 innate immune response, on all the individuals. This innate response is found in both patients with and without CD, although the triggering of an adaptive response is CD specific.

So for celiac individuals it's really really bad. For most people it's not so bad, it only "induces epithelial stress and reprogrammes intraepithelial lymphocytes into natural killer (NK)‐like cells leading to enterocyte apoptosis and an increase in epithelium permeability" a little. Enjoy your bagels! 

Even though the media has run a slew of wheat-industry sponsored garbage about how eliminating wheat if you don't have celiac is "dangerous," more and more scientific publications have been running articles on non-celiac gluten sensitvity. It's real.

Whole Health Source has many great posts about it. This one on the genetic test I had is enlightening:

Gluten sensitivity is determined in large part by genetics. A gene called HLA-DQ is intimately involved. It encodes a protein that is expressed on the surface of cells, that serves to activate immune cells when certain foreign substances are present. Different versions of the gene are activated by different substances. HLA-DQ2 and HLA-DQ8 are classically associated with celiac disease. Roughly 42% of the US population carries DQ2 or DQ8. According to Dr. Fine, every allele except DQ4 has some association with gluten-related problems! Only 0.4% of the U.S. population carries HLA-DQ4 and no other allele.

Sadly my genetic test didn't tell me whether I carry HLA-DQ4. It just told me I didn't have the celiac markers. But I think it's pretty unlikely I'm homozygous for it. I'll let the symptoms speak for themselves.

"But I eat bread and I feeeel fiiiiiine" I hear people say. Do you really? What about that Claritin you have to take everyday? Or the inhaler you have to carry? Or the bottle of ibuprofen you have to keep by your bed? Gluten is bad news. Try a month without it and see the difference.

Edit: Yipes, here's one for the .4%! Modern wheat also messes your insulin up.

Edit 2: Gluten increases gut permeability (AKA leaky gut) in non-celiac individuals, though not as badly as in true celiac disease.

Comment?: 6
Fresh Week: Fresh Diet to Heal Intestinal Permeability Issues
03/29/2010 - 10:56

Some people wondered about the chemical-free part of Sarah's diet. Of course all foods are made up of chemicals, but Sarah means added isolated chemicals. Her recipes featured flavors from fresh herbs and fruit rather than from dried spices or oils.

My own principle I would relate to people suffering from problems linked to increased gut permeability (leaky gut, though that term has been so dragged down with woo that I hesitate to use it) such as IBS the principle I would relate is: fresh. Personally, I did a zero carb week to minimize the populations of methane-producing bacteria in my gut (which was inspired by Hyperlipid's writings on the subject), but once you do that, you still have to heal. A diet based on fresh foods can minimize things a sensitive gut can react to. These things might surprise you- mold in dried spices/herbs or nuts, histamines and amines in preserved meats, and oxidized fats in oils for example.

A fresh diet works its magic by being as gentle as possible. I would say the principles are

  • Fresh meats (pastured lamb, buffalo, goat, and beef are the best choices) from a reputable farmer or butcher that haven't been aged long eaten raw if you feel comfortable or cooked by steaming, boiling, or low-heat methods
  • Seafood can cause problems for some people, so it might be wise to eliminate it for awhile, but if you know you tolerate it well, wild seafood is great choice for steaming
  • Fresh, not dried, fruits and vegetables. Vegetables should be peeled.
  • Use only fats that are fresh (coconut or avocado) or not susceptible to oxidation (coconut oil and butter are best)
  • Flavor with fresh fruits like oranges, vegetables like celery, or fresh herbs.
  • No fried foods, alcohol, egg whites, fermented foods (take a probiotic instead), strongly spiced foods, high-heat roasted foods, bottled sauces, nuts unless you harvested and cracked them yourself, dried spices, canned/dried/cured meats, olive oil, lard, or vegetable oil.

I have to emphasize this is a diet that can be temporary for most people, but everyone can benefit from including more fresh foods into their diet. I recently had some off seafood (not even raw...just normal cooked mussels that I was either allegic to or weren't kept properly) and right now I feel like doing this recovery diet to get things back to normal.

This week I will be featuring several fresh recipes and a fresh map featuring places in NY with amazing fresh ingredients!

Comment?: 3
Wild Fermentation
03/14/2010 - 20:26

Last weekend the fridge at work was left ajar, which was overall a complete disaster. But I did notice that a jug of apple cider was bulging. Aha! A sign of fermentation. I poured it into a glass. It was fizzy and smelled kind of alcoholic. I took a swig. It was fairly tasty, though later I realized I didn't need the alcohol at 11 AM. 

A few years ago I would have been aghast at eating "spoiled" food like that, but since becoming intimate with fermentation, I am much more daring. The fridge is a recent invention and our ancestors might not have had the luxury to turn up their noses at food that's a little...um...off? But "off" sort of implies the food is bad, when  actually in many cases it's good. 

The status of fermentation in the paleo diet is controversial. Many paleo books do not mention it and Cordain's Paleo Diet newsletter recently knocked kombucha for containing acetic acid and yeast (they also said it causes metabolic acidosis...of which there is one case in the medical literature and the person in question also had other serious problems).  

That's nonsense. Our our bodies are full of yeast and acetic-acid producing bacteria and our natural environment would have also been rich in these. Think about the life of a hunter-gatherer. From birth to death they are surrounded by dirt. Of course this is bad when you have a wound that gets infected, but this immersion in dirty nature probably means their bodies are more biodiverse than ours. 

Contrast that with my birth, which was a C-section done in a clean environment. Science shows that C-sections alter gut bacteria, which is bad news, because largely the species established when you are young are the ones that stay with you for the rest of your life. There is plenty of science supporting the Hygiene Hypothesis, which posits that children growing up in clean environments have higher incidences of allergies, asthma, and other diseases of civilization. There is emerging evidence that gut bacteria plays a role in metabolic syndrome as well.

There is no question in my mind that our modern gut biodiversity caused by our divorce from dirt is a bad thing. 

Having a history of stomach problems, managing my gut bacteria is important to me. I do it two ways: not eating foods that seem to encourage the proliferation of misery-causing bacteria and then balancing my bacteria with probiotic foods. "Cleansing" is a bad idea because it gets rid of both bad and good bacteria and irritates the gut...and an irritated gut can't be a good habitat. 

A few times since starting the paleo diet I've gone off the band wagon. My IBS soon returns with a vengeance. I can tell the wrong bacteria are having a feast at my expense. My strategy for getting it under control borrows a lot from the Specific Carbohydrate Diet, which treats colitis by reducing such fermentation. Last time this problem happened, after a week of staying up late to plan a food event and then eating lots of carby sugary food at the event, I calmed things down by eating zero carb for a week. I particularly enjoyed a tonic of egg yolks cooked in bone broth. 

Soon my stomach was feeling much better, but I don't think zero carb completely solves the situation. I think fermented foods are the missing link, providing valuable bacteria and truly digestible nutrients. 

While the scientific studies show that it's very hard and perhaps impossible to add new species to your gut, probiotics can still have an effect, though it will go away if you discontinue them. Furthermore, fermented foods often are simply easier for your body to digest and contain many beneficial bioavilable nutrients. 

That brings me to Wild Fermentation, which was really a groundbreaking book for me. It taught me to embrace and take advantage of wild crazy bacteria.

 This book is of the post-vegan canon. Sandor was a vegan, but a serious health problem propelled him to become omnivorous. In his case, it was AIDS. 

But Wild Fermentation contains a wide variety of ferments suitable for all diets. The exception is meat ferments, which he does himself, but does not include instructions for in his book. He refers readers to The Indigenous Fermented Food of the Sudan, which apparently tells of how the Sudanese ferment meat nose to tail. Unfortunately that book seems to be unaffordable. 

That's OK with me actually...I'm not sure meat fermentation is something I want to dabble in right now.  The main ferment I consume is lacto-fermented vegetables. It's quite funny because just a few years ago I wouldn't have eaten pickles or sauerkraut if you paid me. I think my tastebuds were to put it lightly, shallow from years of consuming industrial food lacking in complexity. I admittedly had to force myself to eat my first batches of pickled vegetables, but at this point I LOVE them. They are tangy and delicious. The best part is that I now crave sour foods rather than sweet foods.

Pickled ginger carrots vs. Snickers? I'll take the former. The variety of flavors, the spicy and sour ginger with the tart carrots, is just superior. 

An important thing I learned from this book was the distinction between vinegar preservation and lacto-fermentation. You can make pickles by just putting some cucumbers in vinegar, but they will not have the same health-giving or flavor properties as vegetables that have been fermented. 

Sandor particularly praises sauerkraut: he talks about a study that shows that it is much richer in cancer-fighting compounds than plain old cabbage. I personally find that the best sauerkraut is made in a heavy crock with a water seal that allows the cabbage to breath, but doesn't allow mold to get in. Luckily, I have access to one, but if I didn't I would make kimchi, which is just as tasty and more resistant to mold. However, Sandor says not to worry too much about mold, as it seems to be a surface phenomonon that doesn't affect the overall welfare of the cabbage buried beneath the brine. 

One of the joys I experienced when I first ate Korean food was all the delicious pickled vegetables they bring you. I realized after my first Korean meal that you really can pickle almost any robust vegetable. Vegetable fermentation has become trendy in NYC and the local farmer's markets are full of pickled beets, radishes, onions, carrots, peppers, and silky wonderful mushrooms. The most surprising pickle I had recently was pickled beet stems, which is a revelation since I usually throw those away. The pickling process had muted the bitterness, but preserved the crunchiness and added a rhubarb-like tartness. 

Some of the other ferments Sandor addresses are less relevant to the paleo diet, but great if you eat grains to get the full nutrition out of them. Kefir is relevant to everybody since you can make it from ruminant milk, nut milk, and anything that has fermentable sugars like coconut water. 

Overall, my digestion feels better when I consume fermented foods and I have noticed that my seasonal allergies are much better. But of course, the main reason to eat them is that they are delicious and nourishing. 

Comment?: 5
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