#10 Beyond Gluten (2014)

In Search of Feeling Well

The Golden Fleece for many of our peers these days is feeling better by fiddling with food. During get-togethers with friends when at home, we notice that many are on some weird diet, like we are. The stories are all different, the paths taken are varied, but the seekers all share the hope of feeling better than they currently do.

A friend who was a dedicated Mediterranean Diet fan for 2 decades like we were had recently switched to essentially only eating meat when we had lunch with her in October. I asked if she was doing the Paleo diet and she said "I don't know, I just feel better eating mostly meat." Our 70-something friend in Tucson hopped on the Grain Brain bandwagon and was pleased with the results of her 3 week old, gluten-free, low carb diet when we saw her in March. A man our age was convinced that not eating after 3 pm was the secret to feeling better and sleeping well. Others crinkled their noses and navigated around a finely tuned list of forbidden foods which elicited: "I don't eat that, or that, or that". And through it all, Bill frequently lamented "This is why old people are such (annoyingly) finicky eaters." Too many of us don't feel tip-top and hope that the right combination of foods will solve the problem but can't ever seem to get it quite right.

Bill's life had been dominated by his unruly and unpredictable gut since he was a kid and the uneasy truce with my adult belly was destroyed a number of years ago when I started taking acid reducers (my waist would increase 10" with an upset). But over the course of the last few months, we both have extracted ourselves from the band of the discontented by merging a low FODMAP diet with a low carb one. If you are seeking to improve your 'sluggish cognitive tempo' or belly distress with dietary changes, our recent experience with 3 different regimes might give you some new insights into improving your own sense of well being.

A Tale of Too Many Diets
First It Was Gluten-Free
Late in January of 2013 we very reluctantly gave eating gluten-free a try (OK: we went kicking and screaming the whole way). We were conflicted: we both wanted to feel better but neither of us was keen on being even more restrictive with our compulsively healthy diet. Axing the gluten is a common place to start in alternative medicine circles when tackling GI and mental woes so we did it even though we had no particular reason to think gluten was the cause of our misery.

Two to 3 months of an elimination diet excluding gluten containing foods (wheat, rye, barley) is considered a fair test off of gluten. If you feel better, you then add gluten containing foods back into your diet as a challenge. If the challenge makes you feel bad again, then you can cautiously conclude you are gluten-sensitive, a diagnosis not generally accepted by the allopathic medical community unless you have the associated autoimmune disease. But it took a mere 48 hours of being gluten-free for me to declare I wasn't going to bother with the challenge because I felt noticeably more comfortable, though not dramatically so. Bill had about the same change in symptoms though thought he'd still proceed with the proper elimination/challenge program. But by the end of the first week he too was saying "Why would I do that?" He was already convinced that he'd feel worse adding gluten to his diet.

Pharmacies were the place to go for gluten-free in Italy.
So gluten-free it was. We sadly donated the 40 pounds of Turkish bulgur we'd stowed in our camper for the 4 month trip we'd just embarked upon, along with other gluten-containing favorites we'd stock piled that were harder to buy in the US SW than in the NW. Not entirely satisfied with the palatability of our grain substitutes, we were committed to feeling more comfortable so we pressed-on with the plan. Eating gluten-free during our 3 months in Europe that summer was even more difficult than at home, but we managed. And calming our GI systems down had another desired effect: Bill was quickly and easily able to identify an unexpected gut irritant for him, xanthan gum (a thickener often used in gluten-free food and salad dressing).

Our decision to go gluten-free in January 2013 was triggered by reading a compelling medical journal article only days before heading for the SW in our camper and our second major diet disruption came on the eve of embarking on the next camper trip in October. Once again, it was reading a convincing medical journal article that prompted a major cuisine change at a particularly awkward time. We both felt better with eliminating gluten but we weren't perfect. We both had inexplicable, transient, episodes of feeling slightly ill with a bit of GI distress, so we volunteered to be lab rats again and try the new, even more restrictive regime.

Then It Was Low FODMAPs
The new diet was unheard of and awkward to pronounce: low FODMAP. FODMAP is an acronym coined by a group of researchers at Monash University in Australia who are focused on improving the lives of patients with Irritable Bowel Syndrome (IBS) and they had done a compelling, tightly crafted study. They solicited self-identified "non-celiac disease, gluten sensitive" individuals such as ourselves--people that were convinced that they felt better eating gluten-free even though they didn't have the auto-immune disease triggered by gluten. The individuals were put on a low FODMAP diet while gluten-free and they all felt even better than when only excluding gluten. Next, they were given purified gluten while on the low FODMAP diet and their comfort level remained unchanged. The researchers concluded that it was the FODMAPs, not the gluten, that was giving their guts fits and we assumed we'd experience heightened GI comfort as "low FODies" too.

FODMAP is an acronym for "Fermentable Oligo-saccharides, Di-saccharides, Mono-saccharides And Polyols" though unfortunately, knowing this doesn't add much clarity for most of us. These are naturally occurring sugar carbohydrates in foods like fruits, vegetables, and dairy products. Gluten is a protein; FODMAPs are sugars, but both occur in some of the same foods, like wheat. So according to the Monash U. researchers, when we pulled wheat out of our diet, our GI comfort improved because we eliminated the offending FODMAP sugar in wheat (fructans), but we were still eating the same indigestible sugar in foods like broccoli, so we still had some discomfort.

Eating gluten free is hard; eating a low FOMAP diet is significantly more challenging. There are 4 major sugar groups included in the FODMAP grouping and 2 of these major sugar groups have 2 subgroups. Even worse, the analysis of foods for their FODMAP content is in its infancy so, in addition to there being 6 specific sugar groups to track in your diet, there isn't a lot of data to aid in tracking them. Adding to the frustration is the fact that most of the analysis of foods for their FODMAP content has been done by the Australian researchers, so foods that are more common in the US than in Australia, like iceberg lettuce and black beans, haven't been studied.

The first steps in the FODMAP analysis of foods by Monash U. to date has been done by taking a half dozen samples of a given food purchased in different markets on a single day, grinding them up, and stirring them together. As Bill learned, that process doesn't yield a broad enough range of information for a given food. He discovered that the ripeness matters. He can eat small portions of foods like avocados and bananas when they are a little green and be fine; the same items a little over ripe will upset his gut. Our experience fits with the researcher's recommendations: their analysis is a starting point and then you perform your own trial and error experiments to establish exactly which foods and in what quantities and combinations matter to your gut.

Accompanied By: "What Are We Going To Eat??"
Eating gluten-free while cyclotouring in Europe the summer of 2013 morphed into our "potato chip diet" when we struggled to get enough calories to make it through the day. Potato chips weren't widely available, but we learned where to find them and they were loaded with gluten-free calories in a nonperishable and inexpensive form that was hard to resist, so we didn't. Once at home we diversified into tortilla chips because they were more palatable and not as greasy to the touch. On a big biking or hiking day, we'd devour a pound bag of chips between us to get the extra calories we needed, calories we couldn't readily find on our gluten-free diet.

Kinda how we felt from the stresses & frustrations of so many dietary restrictions.
It was an uneasy truce, however. Eating gluten-free and then adding the low FODMAP twist had meant we were eating high glycemic index/load foods that we'd scrupulously avoided for over 20 years. Those are the foods that cause your blood sugar to shoot up, which then causes a big release of insulin, which triggers a crash or 'bonk' when the big sugar rush is gone. It can feel nasty and even in milder forms is thought to contribute to developing and worsening diabetes. Gluten-free foods that we could eat, like potatoes, rice, and corn, without disturbing our guts weren't really good for us overall because of this glycemic load. (And then there was the issue of high arsenic levels in rice.) In great conflict and despair, we munched away on our chips to keep ourselves fueled while trying to determine how to feel good and eat wholesome foods.

As the months passed and we both improved even more on the low FODMAP diet, we could feel that the sugars in the piles of corn chips we were eating slightly upset our guts. And that general phenomena occurred over and over again: we'd notch down the 'noise' level in our guts enough to identify the next troublesome food and then we'd fiddle with our intake to determine the quantity of it that we could comfortably tolerate. It was and is an ongoing process that demands carefully observation, patience, consistency, creativeness, and time. And it was a process accompanied by its share of tantrums in the kitchen and anguish in the market as we repeatedly said "What are we going to eat?"

The Low Carbohydrate or Near-Ketogenic Diet
A California couple we hiked with in Palm Springs in January 2014 mentioned the "Grain Brain" book and diet which I had heard of but had dismissed. We were long and loyal followers of the Mediterranean Diet, which is high in complex carbs, and we were in no mood for a third big diet change in 12 months that would restrict our carb intake further. But then a medical website I follow interviewed the author of the book, which answered questions about it that other online reading hadn't. Though the journal editors didn't endorse the low carb diet, I was intrigued by seeing a perspective on the topic that went beyond the media spin.

Not being convinced enough to read the Grain Brain, I read further about the premise on the author's website where I found a link to Stephen Phinney's research. Like Perlmuitter, the Grain Brain's author, Phinney is a physician with advanced training in nutrition. Phinney was touting his ketogenic (very low carb) diet for endurance athletes and he made a compelling argument. The significant similarities and small differences between Phinney's and Perlmutter's low carb approaches heightened my interest in both diets.

Coincidently, I reluctantly had been reading about high carbohydrate products for tri-athletes to aid us in our training for our upcoming July 2014 mountain run. These hi carb fuels were inherently high glycemic index foods but they were considered essential by many during peak-output sports. I wasn't keen on tinkering with them but, like the long distance athletes, our hard uphill 'speed hiking' outings were making it next to impossible for us to eat any food at all when we stopped, which was a problem for the hours-long descent before us.

Sensing that Phinney's ultra-low carb strategy might be a backdoor out of the "What are we going to eat?" bind I was in, both on and off the trail, I switched from investigating sports gels and drinks to reading Phinney's e-book about living on an almost no-carb diet. Talk about a clash: we were just starting to pop Trader Joe's sugar gummies (that were lower in additives than sports blocks) during our hard training events and now I was exploring the benefits of severely and permanently limiting carbs altogether. That collision in strategies was literally 2 nights before our 8,300' elevation gain hike in Palm Springs that would be a serious stress to our systems and our diets--an event that we'd planned to support in the final hours of the 7 hour effort with 100% sugar hits.

The Ketogenic Diet
Phinney's ketogenic diet is more extreme than Perlmutter's low carb diet which Perlmutter describes as near-ketogenic. Both are similar to the Atkin's diet but differ from it in that they moderate protein intake and emphasize obtaining most of one's calories from fat--permanently. On Phinney's ketogenic diet, you intentionally deplete all of your body's stashes of glycogen (a form of sugar), forcing your body to activate its back-up system. The body's "Plan B" of mobilizing stored body fat and burning only fatty acids and ketones for energy is a system normally reserved for periods of starvation (often every winter for our predecessors). Currently, it's a diet that is sometimes employed for short periods of time to help the severely obese shed weight rapidly and for children with severe seizures, but it is also catching on with ultra athletes. Distance runners inevitably completely deplete all of their glycogen stores during the first 25 miles of their 50 to 100 mile events so being able to efficiently mobilize their own body fat is a huge advantage. In contrast, Perlmutter's approach drastically cuts carb intake but doesn't aim to tip one over into only burning fats, hence "near ketogenic" instead of "ketogenic".

Both Perlmutter's and Phinney's strategies violently conflicted with my compendium of nutrition knowledge that had its foundation in the college-level nutrition class I took when I was 20. Literally everything I believed about the basis of a healthy diet was thrown out the window on these diets and we were both in shock at the thought of such a radical change that was completely out of step with mainstream medical research. Being ketogenic or near-ketogenic felt so fringe that it made us quake every time we discussed it--for months.

But I was simultaneously horrified and intrigued because the ketogenic diet would solve several problems for us. The gluten-free and then low FODMAP diets had wrenched away our favorite carbs and left us with largely suboptimal alternatives. Whacking the carbs further and emphasizing fat and protein would vanquish the need to use substitute carb sources, would solve the glycemic load issue, and would eliminate the need for sugary snacks when doing speed-hikes. And fewer carbs would mean fewer potential sources of offending FODMAPs in our cuisine.

Bill was practically immobilized by the thought of 'going ketogenic,' wasn't keen on even going low carb, and was seriously concerned about the negative, long term health consequences of both approaches. I had the same reservations but decided I'd give some degree of low carb eating a try immediately. It seemed risky, it seemed improbable, but I was to the breaking point in resolving the problems cropping up from our conflicting diets so I was game for at least a brief experiment. It was even a bit exhilarating to be trying a strategy that promised to eliminate my "Food now!" episodes of sudden, non-negotiable, hunger. And besides, I could literally retreat from the diet with a handful of chips.

Going Low Carb & Maybe Ketogenic
The emphasized menu items on my version of the reduced carb diet appealed to Bill--like chicken, salmon, avocados, and cheese--so he did an about face and hopped on board for a trial run though initially he kept his carb intake about 10-15% higher than mine. I began by targeting 100 grams (g) of carbs per day, the amount Perlmutter "allowed" for athletes. We kept a downward pressure on the carbs in our diets and fairly effortlessly drifted into Perlmutter's ideal carb intake range of 60-80 g/day over the course of about a month. However we were still eating too many carbs to qualify as ketogenic on Phinney's program, which would have required dropping between 25 and 50 g of carbs per day.

Interestingly, at about the 2 week point Bill noticed 2 big changes that coincided with the diet change. One was that his very troublesome "orthostatic hypotension" all but went away. Orthostatic hypotension is the term for becoming dizzy when you suddenly become upright from being bent over. It was a small change but welcome because any time Bill paused to adjust his shoe when hiking, we'd have to wait for his head to clear.

The other noticeable change shorty after switching to our low carb diet was further improvement in Bill's altitude/exertion issues that had moderated with taking ibuprofen. If we biked or hiked much over 6,000' or hiked hard for over 3 hrs at any elevation, Bill would suddenly start lagging. He had recently learned that taking ibuprofen on the trail would pop his energy level and sense of well being back to where he had been. But when on the hard hikes to Window Rock outside of Tucson, he managed without the ibuprofen. We both struggled on the trail and especially as it went higher, but he didn't lag. Time will tell whether those changes are permanent and we'll never know for sure if they were the result of the reduction in carbohydrate intake, but they certainly got our attention. And of course, I teased him about getting benefits from "my" diet before me.

Even though we were both still full of skepticism, we couldn't help but notice the next string of fairly rapid changes associated with being on a low carb diet. About a month after making the shift, I starting hearing "What happened to your butt?" I wasn't trying to loose weight but suddenly my new, slim-fitting pants were baggy and my veins and muscles were popping out on my forearms. It was like I shed a thick layer of long johns from head to toe. Then Bill noticed his winter-weight pants that barely fit when he bought them 3 months prior were suddenly loose. Since we were still traveling in the SW in our camper, we had no way of checking how much weight we'd each lost but we were both losing inches.

And even more welcome than the unintentional weight loss, we both could feel that our brains were better. I had sought the help of a naturopath specializing in mental health care 18 months prior when my menopause-related depression had worsened. Her treatment plan had been to counter brain inflammation triggered by the abrupt hormonal shift. I had gradually been improving in terms of mood, sense of well being, and sleep on her regime and then suddenly on the low carb diet I was a LOT better. And it was probably no coincidence: one of the benefits of low carb eating is purported to be reduced inflammation.

Fleetingly on the naturopath's program I had been encountering deep sleep and suddenly almost every night I was experiencing that 'dead to the world' sleep that can elude one for years. Absolutely divine. I had been diagnosed with pronounced, untreatable sleep fragmentation decades ago and it was effectively gone as well. Bill also noticed welcome changes in his cognitive functioning and sleep. Our intellects couldn't accept that going low carb was good for us for more than a moment here and there, but we had to wonder if there wasn't something to Perlmutter's 'grain brain:' perhaps carbs were toxic to our brains, perhaps the carbs had been inflammatory and the inflammation was now receding.

But as feared, Bill's cholesterol jumped 40mg/dl in a little over 2 months after going low carb, taking him over the alarm-bell 200 mg/dl point. Perlmutter embraces high cholesterol levels as being healthy, though I haven't seen how high is too high in his mind. Bill was nervous with the report and immediately reduced his saturated fat intake to drive his cholesterol down a bit. We were caught between 2 conflicting schools of thought and we didn't expect the science separating the Mediterranean Diet and the low carb diet to be clarified in our functional lifetimes. Like with a number of other conflicting health guidelines (such as sodium intake, use of calcium supplements, and eating eggs) we were left to live with the consequences of our own best guesses.

One of our early successes with the low FODMAP/ketogenic diet: canned salmon, avocado, cheese, & tomato salad.
Down, Down, Down to Ketogenic
Two months into eating low carb diets we were both content to tread water. We felt so much better on a reduced carbohydrate program without going to severely reduced carbs that we were looking forward to some cuisine-calm. But after reviewing some research results one evening we abruptly decided to go lower. The ketogenic diet is quite austere and can involve an uncomfortable transition period of 2-4 weeks of "keto-adaptation" but it promised to bring Bill's cholesterol level back down while still shoveling in fats in the most palatable form: cheese. According to information we'd just learn from Phinney's research, one's body preferentially burns saturated fats on a ketogenic diet, which would 'burn-up' his excess cholesterol. Back to the lab again for the rats--we'd soon know if Phinney's appealing theory worked for Bill.

A quick recalculation of our current carb intake revealed that we could easily drop it from around 70 grams/day to the low 40's the day after making the decision to go ketogenic. By comparison, in our pre-gluten-free days, the pasta alone that was the foundation for our dinners contained about 95 grams of carbohydrate per person--perhaps about a quarter of our total carb intake. Next up would be buying a glucose monitor that also measures ketones, which is the best way to determine if our carb intake was low enough to put us in ketosis. Ketosis, only burning ketones and fatty acids, is where Bill would need to be to selectively burn saturated fats and where I would be free of "Food now!" bouts with hypoglycemia. We hoped to make the transition to being "keto-adapted" in the 10 weeks we had before our July mountain run event that we'd originally planned to fuel with sugar gummies. And we hoped that neither of us would have to drop to 25 g/d of carbs to be ketogenic.

Our Take
Going gluten-free was the easiest of the dietary restrictions we experimented with but we now think it is unimportant in improving our sense of wellbeing. Perlmutter of the Grain Brain fame is adamant that gluten is toxic to the brain and that people will feel better within weeks of eliminating it from their diet. Based on our experience, I would guess that people on his program feel better-in-the-head because of the reduced carbohydrate intake and not because they eliminated gluten. We both felt noticeably better when we tossed out the gluten from our diets, but the improvement was primarily in our guts. Gut upset can definitely affect the brain giving me a transient, hazy, low-energy feeling. But we believe these direct improvements in our guts and indirect improvements in our heads were due to the concurrent reduction in the FODMAP sugar fructans that is also present in wheat and not from the elimination of gluten. However, since the biggest sources of gluten also contain fructans, which creates a digestion problem for both of us, we will inadvertently remain gluten-free. In our minds, Perlmutter's gluten-free diet is a "right for the wrong reason" strategy, at least when measuring how your head feels. However, we have no way of judging if he is correct about the long-term problems that he has linked with gluten intake.

We both believe that the Monash U. researchers have absolutely got it right with their low FODMAP approach to calming our GI distress. We both unquestionably feel better eating our own personalized, low-FODMAP diets, though we still are still actively developing them. With each new refinement in understanding of what we can eat and in what quantities, we feel better and better. Bill is learning for the first time since his pre-teens years what a normal gut feels like. My chronic distention (bloating) and belching is a thing of the past and I now have a hollow-feeling belly all of the time. And that intermittent, hazy-head, mildly sicky feeling that sometimes accompanied the GI upsets is no longer a common experience for either of us.

The low-FODMAP approach is absolutely the hardest diet of the 3 strategies we tried because it must be tailored to you through a tedious process of trial and error. It doesn't take long to know you are on the right track but it can take months to really untangle which sugars and in what quantities are problematic. One first must whack their menus to find a sustainable, comfortable mix of a few foods that will let your gut heal and recover. Only then can you add in a questionable food and experiment with quantities of it over a number of days to restore variety in your diet. I suspect it will be years before the body of research data on individual foods will be great enough to make the task easy for individuals to develop their own low FODMAP diets.

Low Carbs & Ketogenic
We do think Perlmutter is on to something in regards to the effect of a high carb diet on the brain, at least in some people. We'd both had been gluten-free over 1 year when we experimented with a low carb diet and we both had a day several weeks later when it felt like something in our heads "popped." We both had the experience of rather suddenly feeling a lot better. It was the kind of experience with which you don't notice it so much in the moment but instead, after a few hours, you can tell in hindsight that you are more clear-headed, cheerier, and uplifted. And then you notice that that good feeling is not going away--that it is a shift and not a blip. That made believers out of us in the benefits of eating low-carb even though our intellects still think we are batty.

Combining our low-FODMAP diets with a low carb diet left us with frustratingly little to eat. We significantly increased our fat and protein intake to make up for the missing calories while trying to moderate the saturated fat and still felt hungry most of the time. There are limits to how much protein one should eat and it's surprisingly difficult to shovel fat in without carbs: the usual "vehicles" for butter and oils are carb-dense foods like pasta, potatoes, crackers, and bread. And that was a big point in pushing us to go ketogenic: the promise that eating the buckets of fat required on the diet wouldn't increase our cholesterol levels.

Being low FODies on a very low carb/ketogenic diet is an extremely limiting regime that left behind many of our beloved fruits and vegetables but it has been a small price to pay to finally feel and sleep well. We feel like we've hit the reset button on our aging bodies.

Concerns & Cautions
The current body of medical research doesn't convincingly answer the question: "Is a ketogenic diet safe and healthy in the long term for adults?" which is a bit unnerving. But always feeling a little bit sick also has meant that our healthy-by-conventional-standards diet wasn't truly healthy for either of us. And deciding what to do is made more difficult because all authors will cover themselves by stating that you should check with your doctor before starting their diet and there is a 99+% probability that your doctor will say: "Don't do it; it's not safe." So "Wait and see;" Time will tell;" and "I hope it works out" is what we are left with for now.

Online reading reveals concern about increasing one's risk for osteoporosis when on a ketogenic diet but we haven't read anything authoritative about this serious issue. I am suspicious that it was stated somewhere once and others have latched on to it without independently documenting the hazard. Bill presumes that the osteoporosis risk is real in children on the diet for seizure treatment and that someone has assumed that it therefore must be true for adults as well, which doesn't necessarily follow.

Earlier Atkins low carb diet followers did suffer side effects from consuming too much protein but Phinney is very specific about his approach being a "moderate protein, ketogenic diet" with no downside.

Too Much Protein?
While we were doing our best to avoid flying apart in the vortex of dietary confusion, we were hit with yet another new medical study. The newspaper headlines in March 2014 were sensational: "High-protein diet 'as bad as smoking 20 cigarettes a day'"--in terms of cancer risk. Hard not to be concerned while we were doubling our protein intake to compensate for reducing our carbs. It was a small observational study of only about 6,300 people but I was compelled to mull it over.

The take away for us from this alarmist report about protein intake was as follows. Both being 63-ish, we felt like we'd done the right thing (according to this study) for the last 25+ years by eating a moderate/low-moderate amount of protein. We essentially stopped eating beef and pork and favored a relatively vegetarian diet with a sprinkling of chicken and salmon. Ditching the beef all those years ago and eating beans almost every day should have given us the protective effect that the researchers believe is possible with a low protein and plant protein based diet. As we were inching closer to 65 years of age, we were increasing our protein intake, which coincidentally, was also recommended by the same researchers. We were increasing our protein intake largely by eating more chicken and cheese but cheese was not a good choice by their model and chicken wasn't ranked. We'd been intending to eat salmon 2-3 times/week and the "neutral" effect of the fish protein in this study convinced us to push our wild salmon intake to at least 4 times/week. Wild salmon is the darling of many diets and surely we couldn't go wrong with that strategy(?).

Curiously, protein intake is usually computed against one's body weight, not caloric intake as we thought made sense. Our base diet runs around 2,500 calories/day and when we are exceptionally active, our intake jumps to over 3,000 calories. On a low carb diet that is ketogenic or near ketogenic, all of those 500+ additional calories should be consumed as fat. Phinney however breaks from the pack and recommends those on a ketogenic diet consume twenty percent of their energy intake as protein, which for me is about 125 g. By comparison, the protein RDA for me is 45 g and the recommendation for an elderly athlete of my age ranges from 55-85 g. (Egads--I'm already 'elderly' by some definitions!)

Saturated Fats
When reading the latest research on the newest ideal diet, beware of the too-frequent "blending" of details that sometimes goes on. Some researchers, especially if they are promoting their own book, gloss-over critical distinctions. The jury is still out on the Grain Brain in my mind, but a researcher discounting the strategy blurred several important points. He advocated the more contemporary diet darling, a low fat diet, and the studies he cited regarding the evils of fat included saturated fat and trans fat in the same category--a common practice in research studies because trans fats have only recently been banished from most processed foods. But in my mind, treating the 2 fats equally only adds to the confusion. Saturated fats are essential components in our diets and cholesterol is manufactured by our bodies because we need it whereas no amount of trans fatty acid ingestion is considered safe. We aren't really going to know if Perlmutter and Phinney are correct in recommending that we should toss out restrictions on saturated fat intake until new studies are published that entirely exclude the negative effects of trans fats in the diet.

Another consideration about avoiding saturated fats is that some research now suggests that it has been the right thing to do for the wrong reason. According to some studies, it's not the saturated fat alone that is contributing to heart disease but the other compounds that tend to accompany saturated fat in specific foods that are problematic. This theory maintains that the common sources of saturated fat in the American diet, like beef, pork, and eggs, contain substances that change the metabolism of cholesterol when these substances are acted upon by specific bacteria commonly found in the human gut. Our take on this new research is to continue avoiding beef, pork, and eggs but, like Perlmutter and Phinney say, to lighten-up about other foods containing saturated fats.

Should you want to read more about this distinction between saturated fats, their common sources, and which foods increase the risk of heart disease according to this model, the key word is "TMAO". TMAO is the compound that gets created by the action of gut bacteria on dietary carnitine and choline.. The more TMAOs you have, the more likely cholesterol will be deposited in arterial walls.

Grain vs Plant
Another bit of self-serving slight of hand in the discussion of dietary strategies is making "grain" and "plant" synonymous. A researcher ballyhooing the inappropriateness of the Grain Brain diet repeatedly cited his research on the beneficial effects of a plant-based diet. His research showed that plant-based diets were excellent for combatting the common health ills of obesity and diabetes so therefore limiting grains or carbohydrates was a bad idea. But of course, grains are only one category of plant-based food available to us so is eliminating grains really a problem?

Coming from a long history of obtaining half or more of my daily calories from plant based foods and striving to consume 10 servings of fruits and vegetables a day, whacking my total carbohydrate consumption down to almost nothing seemed impossible. I couldn't imagine that I could get the nutrient mix I was striving for with a fraction of my usual carb consumption, but I was wrong. Some of the adjustment came from portion control, such as eating a smallish carrot instead of a huge one and others came from 'redirecting' my attention to things like dark leafy greens that I always considered too much preparation trouble to eat on a daily basis. Perhaps my lower carb diet wouldn't qualify as a plant-based diet, though I haven't seen a strict definition of that, but plants are still well-represented in my revised diet. I ran the numbers and was readily able to meet my targets for specific nutrients and fiber eating low carb fruits and vegetables.

The mountain lion got to this Big Horn sheep before hungry Bill did.
But Not Paleo For Us--At Least Yet
Thankfully, there is a fair bit of overlap between these various new dietary approaches, though we don't embrace them all. My naturopath follows and recommends the Paleo diet that emphasizes grass-fed beef and high quality eggs. I'm not comfortable with eating those foods because of this new TMAO issue discussed above but the overall package of the Paleo strategy is more compelling. Interestingly, the Paleo diet is another strategy that favors reducing carb intake and shunning gluten.

Part of the Paleo argument is that the slow evolution of humans means we should be eating like our distant predecessors, not like the relatives in our black and white photos hanging on the wall. There is a lot that is wrong with what's been dubbed "The Standard American Diet" by the medical community, such as the buckets of sugar that most Americans eat. But, contrary to the Paleo script, there is evidence that humans do metabolically adapt surprisingly quickly to shifts in foods available to them. Bill identified a compelling example, which has to do with sugar. Diabetes is a huge problem among some ethnic groups, such as Native Americans and Pacific Islanders, whereas those of European ancestry handle the stresses of excess dietary sugar much better (though obviously, not perfectly.) The accepted reason is that Europeans have been exposed to refined sugar for about 500 years, whereas these other ethnic groups have only had 100-150 years of exposure. The few hundred years difference in sugar consumption between those 2 populations has been enough time for significant metabolic adaption to at least some of the stresses, such as diabetes, of moderate amounts of sugar consumption by Europeans.

The Paleo's and others also argue that hybridization, domestication, and other agricultural advances have resulted in grains and meats evolving more quickly than humans have evolved so that there is now a mismatch between us and our food which is toxic to us. They conclude that we should revert to eating grass-fed beef and poultry that are dining as the natural carnivores that they are. The Paleo diet advocates believe that the current health issues with beef and eggs go away if the animals are eating these historical diets. But neither of us are sufficiently compelled by those arguments to begin eating beef and eggs. There is this nasty matter of TMAO's that are now hypothesized to be formed after ingesting beef and eggs that increase CV disease risk. Our guess is that the avoidance of beef and eggs has been right for the wrong reason: it's not just the saturated fat they contain but what the bacteria in our guts do with those foods when we eat them. But like with every diet that challenges the gold standard Mediterranean Diet, more research is needed to know what is truly the best dietary strategy. We'll hold-off on the Paleo approach until we know more about the TMAO issue.

Learning More
Eating Gluten-Free
Going gluten-free is getting easier everyday. Many foods are naturally gluten-free and often those foods are labeled as such and, in addition, there are more and more processed foods specially crafted to be gluten free, like pasta and bread. We managed to become almost completely gluten-free by removing 1 food from each of our 3 meals per day. (Gluten-free oats replaced triticale; brown rice replaced bulgur; quinoa replaced pasta.) The next step was outing the more covert sources of gluten.

Wheat, rye, and barley are the primary foods naturally loaded with gluten with oats being a "maybe" food. Some strains of oats have gluten in them while others do not and sometimes naturally gluten-free oats are grown in fields with a few stray wheat plants which then contaminate the oats with gluten during processing. Airlines and restaurants often have gluten-free options. Completely avoiding gluten demands careful label reading and educating oneself so as to be able to read between the lines as well.

But remember: one group of researchers believe that only people with the autoimmune disease, celiac disease, need to avoid gluten. Gluten truly is a poison for them in that it damages the lining of their intestines, which triggers a cascade of health problems. According to the research from Monash, "gluten sensitive, non-celiac disease" folks (like ourselves) aren't the least bit sensitive to the gluten protein but instead are reacting to particular sugars in wheat and other foods of plant origin (FODMAPs). Sorting gluten sensitivity out from FODMAP issues is tricky because foods like wheat contain both the protein gluten and a commonly offending FODMAP sugar, fructans. Others, like Perlmutter, the author of the book the Grain Brain, however believe gluten is toxic to the brain even if it isn't a source of GI upset.

When pursuing a gluten-free diet, beware of the hazards in the alternatives. For instance, "Consumer Reports" extensively studied the arsenic levels in rice and determined that we should all monitor our rice intake. Arsenic is very toxic and never clears from your body once you ingest it so we decided to not buy rice and only eat it when served. Unfortunately, a number of nice alternatives to gluten containing foods are made with rice, like brown rice tortillas and many pastas. Corn is another naturally gluten-free food that is used as a wheat substitute in processed foods such as pasta and cereals. If you are eating gluten-free because of GI symptoms and still have some upsets after eating corn products, you might be reacting to 1 or both of the FODMAPs in corn: GOS and sorbitol.

We also noticed that manufacturers often get the consistency or flavor right in gluten-free foods by using a string of additives. If the list of ingredients is too long or too unfamiliar, you may be ahead to skip the food altogether. We noticed when overseas in 2013 that we often felt sick after eating the gluten-free baked products served at B&B breakfasts. We discovered that some of the items were sold in the local grocery store and were horrified when we read the labels because of all of the additives. We don't know if it was the additives that were upsetting our guts or the FODMAPs that we were yet to learn about.

A low FODMAP diet is outrageously more difficult to devise than a gluten-free one for a number of reasons. FODMAPs include 6 different offending sugar groups; an individual may react to only one of them or all of them; the amount of the sugar can vary with the season in any given food; and one's susceptibility to a bad reaction may vary with how many other irritating foods have been eaten that day. In addition, processing can affect the availability of a particular FODMAP in a food and no food is sold with a FODMAP analysis on the label. In contrast, when avoiding gluten, you are only dodging a single protein and its presence can be deciphered from food labels.

The FODMAPs are sugars that occur naturally in fruits, vegetables, grains, and dairy and they are poorly absorbed by some people. If your gut doesn't absorb these sugars well in the small intestine, then they are metabolized by your gut bacteria and ferment in the large intestine, which produces gas and the symptoms of indigestion. This fermentation is the "F" in FODMAP. Malabsorption in the small intestine can cause diarrhea by pulling excess water into the bowel. These sugars don't naturally occur in meats, eggs, fats, or table (cane) sugar. A diet of only these foods will solve one's indigestion due to FODMAPs without knowing anything more but will of course will result in other issues like malnutrition and constipation.

The most pervasive FODMAP sugars are the oligio-saccharides (the "O" in FODMAP), which includes fructans and GOS. Fructan (fructo-oligiosacchride or FOS) occurs in high amounts in wheat, rye, onions, and garlic and in more moderate amounts in many other foods (like broccoli). GOS (galacto-oliosaccharides) are primarily found in legumes (dried beans). Humans lack the enzymes needed to break these 2 sugars down so they are malabsorbed by everyone but not everyone feels bad because of the malabsorption. The researchers at Monash U. suggest that wheat, garlic, and onions are the biggest sources of fructans in the western diet.

The "D" in FODMAP is for di-saccharide and lactose is the only sugar involved. Lactose is exclusively found in dairy products and can be countered with lactase enzyme tablets , such as Lactaid, when eating dairy. Almost all hard cheeses however are lactose-free because the aging process has depleted the sugar. Fructose is the monosaccharide (the "M" in FODMAP) and is only an issue when in excess of glucose, which occurs in some fruits, honey, and in some high fructose corn syrups. Polyols (the "P") include sorbitol and mannitol, which are primarily found in fruits and vegetables and are used as artificial sweeteners.

We started our low FODMAP journey by obtaining the Monash University app designed for patients and added more information by obtaining several research papers with more detailed food composition charts. Here's the link to the Monash University homepage which is where you can buy their app or book: http://www.med.monash.edu/cecs/gastro/fodmap/. I have a love-hate relationship with the app: it is the only handy, authoritative source detailing the FODMAPs in individual foods but it only contains a fraction of the information I'd like to have. One limitation is that the analyzed foods are the foods common in Australia where the university is located though they are in the process of analyzing foods from the US. Another challenge for us is that many foods are 'safe' at the upper serving size listed but sometimes there is no indication if there will be a digestive issue from eating twice or 3 times the quantity listed. But nonetheless, I consider the Monash app indispensable for developing our FODMAP diets. (The long-awaited update to the app arrived in mid-May.)

We obtained copies of several of the original research articles which are very helpful if you have the patience to shift through them. These articles present some of the detailed analysis that is generalized in the app. Tedious and frustrating to read and decipher, I've found them to be very helpful in refining our dietary changes. (Contact us if you'd like to access these articles.) In addition, online searching provides helpful things to read like personal testimonials, blogs, and summaries from US institutions. Clarity does come from reading statements like "you'll need to experiment to determine what's true for you" over and over again. Do note that some of the information isn't correct, usually because well-meaning individuals over generalize something they have learned and have drawn flawed conclusions.

A Low Carb Diet
Perlmutter's Grain Brain book is the popular source of information for going low carb. You can follow his guidelines and supplement it with volumes of information available online, including his website.

Well under way with our feel-good diet strategy.
A Ketogenic Diet
My primary source of information about the moderate protein, ketogenic diet has been from the e-book version of The Art and Science of Low Carbohydrate Performance by Stephen Phinney and Jeff Volek. Several of Phinney's YouTube videos have also been very informative. This diet, like the low FODMAP diet, initially requires consistent use of a kitchen scale to measure everything you are eating that contains any carb's at all. But on the ketogenic diet, there can be no cheating, no "a little more won't hurt," no "holidays." On this diet, every carb counts. Food charts, a calculator, and a scale will be involved in the preparation of every meal and every snack for the first few days or weeks, depending upon your personal information base. I find nutritiondata.self.com the easiest food chart source to use, though it has some irritating formatting issues like you must search "seeds, flax" and not "flax seeds."

On a ketogenic diet, you'd need to know the number of grams of carbohydrate in each food and subtract the number of grams of fiber (which are freebies) to determine the net carbohydrates for each portion eaten. You will also need to calculate how many grams of protein you are eating, with Phinney's target being 20% of calories eaten, and definitely not more than 30%. For those numbers, you need to know that carbs and protein each have 4 calories/gram whereas fat has 9 calories/gram. It requires some mental gymnastics to keep it all straight when doing the calculations. Additionally, you'll benefit from tracking your fiber intake, which should be about 25 grams for women and 38 grams for men up to age 50, though the more sophisticated recommendation are based on caloric intake. Less than 5% of the US adults meet this requirement so you'll be in an elite group when you make the numbers.

State of Our Art
There you have it, the state of our art in calming our guts and clearing our minds. We're shopping in a continuously shrinking corner of the market and as my internist recently said "Pretty soon you'll have nothing to eat." A man of few words, that's all he had to say about our "low FODMAP/moderate protein, ketogenic diet." It's painfully restrictive, but aside from the occasional tantrum, we are at peace with the sacrifices. Especially once one enters the graying years, you'll do almost anything to feel better and that is what we have done. We just hope that this is the last of the food related changes we need to make for a while.