#11 BEYOND GLUTEN---A PLAN (July 2014)

Our May 2014 piece entitled "Beyond Gluten" that detailed our saga to becoming "low FODMAP/ketogenic diet" followers sparked several intense dialogues with friends who thought I was talking about them when it came to the symptoms we were experiencing. The process of customizing a starting strategy for each person made it clear that there was a better way to embark on the quest of feeling better through dietary choices than what we had done. We took the long road, below are some ideas to shortcut our process to having a happier belly, a clearer brain, and sleep better by gradually reducing your carbohydrate intake and perhaps your intake of fermentable sugars or FODMAPs.

STEP I: Rein In The Sugar (& Sweeteners)
Eating less added sugar is good advice for everyone and it is the best first step on the path to eating a low carb diet. The American Heart Assoc. recommends that women limit their added sugar intake to 25 grams/day (100 calories) and that men draw the line at about 38 grams (150 calories). Even if you don't intend to switch to a severely reduced carbohydrate diet, ditch the sugar. It's bad for you for many reasons; everyone knows it; so stop eating it. Best to stop the whining and get used to it now.

We whacked our added sugar intake back to 17 grams/day years ago and have recently dropped it to about 10 grams/day. Our only added sugar intake comes from our personal RDA of high octane chocolate. Calories from chocolate are budgeted into our lunch menu and we eat it everyday to keep us smiling. Knowing that we are going to get our bit of sweet each day eliminates straying from the plan or feeling deprived by not eating other sweets. So be intentional: make a decision about how much added sugar you are going to eat, which foods it is going to come from, and then stick to it. Your taste for sugar will recalibrate with time.

Reading all labels is imperative to rein in your sugar intake because food manufacturers sneak sugar into the most unlikely foods, like some canned beans. Balsamic vinegar's yummy taste is in part due to the sugar. Flavored yogurts are loaded with sugar, though you have to do the math to know how much sugar has been added because yogurt contains naturally occurring milk sugar, which is a freebie. Note the total sugar content for a serving of flavored yogurt then subtract the sugar content per serving listed on a tub of plain yogurt--the difference is the added sugar burden. Add in sugar-free items like vanilla or flaked coconut if the flavor of plain yogurt doesn't suit you. Even with the extra gyrations needed to be sugar-aware with foods like yogurt, you can take charge of your intake.

Consider the possibility of not just ditching sugar but all sweeteners, both artificial and natural. Medical research is accumulating on the evils of using non-sugar sweeteners. Some of them confuse the body because the sweetness triggers the message that there is food on board and the body responds accordingly. Not actually delivering food then muddles the body's response. There is thought that some of the sweeteners may actually result in weight gain even though they don't pack any calories because of the metabolic confusion they create. And as Bill knows, some of the synthetic products can cause headaches and GI upset. We've found that it's better to gradually let your mind/body reset to a lower intake of sweet tasting things and leave it at that.

Totally eliminating fruit juice from your diet is another good step towards reducing the negative effects of added sugar. Because the juice is ingested without the fiber in the fruit, it metabolically behaves like added sugar. So, better to eat the orange or the apple than to drink the juice.

Giving up sugar and sweeteners can be hard for many reasons, among them is that sugar is often "the tie that binds us." Making sugary treats, buying them, giving them, and graciously receiving them is deeply embedded in our culture. Rejecting someone's treats, especially homemade, is tantamount to rejecting the person. But like the declining acceptance of cigarette smoke that began decades ago and declining expectation of alcohol consumption that began years ago, with time, politely declining sugar will also become more acceptable. Join us and a small band of others in changing expectations about ritualized sugar consumption by eating less of it socially.

STEP II: Reduce The Variables
Be Meticulous About Hydration
Being a little short on water can make some of us feel headachy and ill. Two quarts or liters of water is the usual recommendation for your minimum water intake per day. Of course, if you are active, sweat more than the average person, or live in a low-humidity region or all 3, you'll need to be chugging much more fluid. Water is my only beverage these days and it all gets poured from my metal bottle so I can monitor my intake every day.

Set your water intake target; find an easy way to track it; and stick to the program. Countless times Bill has relearned that his mildly icky feeling is because he's gotten behind on his fluid intake. Tending to your hydration first is a very helpful step in feeling better and in migrating to low carb eating. Ensuring you aren't dehydrated gets rid of the background 'noise' so you can feel if the later dietary changes are helping your brain. And drinking more gets you poised for a low-carb or ketogenic diet, both of which significantly increase your fluid requirements for some complicated reasons.

And when tracking your water intake, it's not fair to count your coffee and caffeinated tea in your tally because they are diuretics and actually increase your need for fluids. At the very least, don't count the caffeinated fluids as water intake and ideally, you should increase your water consumption to make up for the deficit they create.

Evaluate Your Sodium Intake
Like with making sure you are drinking enough water, if you are having low energy issues and/or headaches, assess your sodium intake. All of the standard recommendations and news in the US are about cutting out the sodium (salt) but there is a quiet, persistent cross-current that disagrees. There are some physicians that recommend 3-4 grams of sodium per day for all of their patients except those with congestive heart failure--even their patients with high blood pressure. And when people are put on very low carb diets for rapid weight loss, they are sometimes stoked with 5 grams of sodium per day. The maintenance amount of sodium for those on a very low carb diet (ketogenic) is 2 grams/day in addition to what's consumed in food. You of course should check with your doctor before increasing your sodium consumption but below explains why we both have increased ours.

I've had borderline high blood pressure for about 15 years and several years ago I decided to put us on a proper, low sodium diet a-la the DASH Diet. We'd had a 'downward pressure' on our sodium consumption for years and I quickly reduced it to the 1500 mg target--a number many doctors consider unattainable. It wasn't all that hard but I practically killed us both in the process.

We each had a different presentation, but we each have a distinctive pattern of symptoms when we don't ingest enough sodium. Bill gets low energy. We'll be biking or hiking and suddenly he'll start lagging and then he complains of feeling awful. Resting, drinking, and eating all help briefly, then he shuts down again. Giving him a "salt bomb" with 600 mg sodium buried in a bite of food flips him out of it in minutes. I on the other hand will have intermittent headaches, dizzy spells, and feel tippy on my bike. If I miss it and I'm low-sodium for weeks, it progresses to depression and caffeine-like jitters when trying to sleep. But my symptoms come and go multiple times a day, making it harder to spot than Bill's sudden shut-downs.

Our low sodium states in which we experience nasty side effects probably wouldn't show up as reduced sodium in blood tests, aren't bad enough to qualify as the well-documented condition known as hyponatremia, and are seemingly completely unaddressed online and by the medical community and yet they are incapacitating to us. Our primary care doctors have each said "Don't do it." in response to sharing our tales of side effects from following a proper, low sodium intake. They don't elaborate, but they definitely don't give us any upper limits for sodium intake.

It's surprisingly tricky for each of us to spot our low sodium symptoms, in part because it happens infrequently. We both had dramatic, horrible side effects several years ago and even with that, we've each missed it in ourselves several times in the last 2 years. We don't eat many processed foods or eat out often, both of which are opportunities to unknowingly shovel in the salt, but seemingly small menu changes at home can disastrously decrease our sodium intake.

In 2013 when we headed for the SW in our camper, we stopped cooking our breakfast grains and ate them raw as we often do when we travel; we lost access to Trader Joe's black beans and ate other brands; and made 1 other innocuous change and 2 month laters I realized my previous month of ill health was due to lack of sodium. We added a little salt to the cooked grains at home but didn't when we ate them raw; the TJ's beans happened to be higher in sodium than most; and the one other food change also dropped our salt intake a bit. They were all small changes but combined with traveling to the warmer, drier SW, they were all it took to sink me. I hadn't noticed the decreased sodium intake with the menu changes and the symptoms came on slowly, both of which made the cause and effect hard to spot.

After a second, briefer episode of insidious-outset of low sodium symptoms when in the SW in 2014, my solution was to add table salt to most or all of my water every day, no matter what. I don't really know how much I need, but this strategy keeps me from getting behind. When in the SW over the winter, I spiked all of my water everyday regardless of our activity level so as to have 1.2 grams of sodium (not salt) in addition to what was in my food. I was even putting it on my yogurt to pour it in. Keeping my intake high on the easy days gave me a little buffer for the bigger exertion days. When I told my internist about my high level of added salt and he didn't bat an eye. When we are in the NW, I seem to do fine adding about total of 700 mg sodium/day, or rounded 1/8 tsp of salt to 2 of my 750 ml bottles of water, on low output days. On a 10-18 mile hiking day in the NW, I spike all of my water for the entire day with 1/8 rounded tsp salt/750 ml water.

Few people seem content with drinking salted water like I do to increase their sodium intake and often one's tolerance for salt doesn't allow adding enough more to food to meet their needs. A slick trick from the ketogenic diet world that works like a charm for Bill is to drink a cup of bouillon, which usually has about 1 gram of sodium. He finds that it goes down easily and he can get his 1-2 grams of extra sodium per day without struggle. Read the labels however: some manufacturers can't resist adding sugar to bouillon cubes and we avoid brands with chemical additives.

Chat with your doctor about also adding potassium to your food or water. I match my sodium doses with potassium because I read that nobody gets enough potassium. You can buy it in the grocery store next to the salt as KCl or potassium chloride. It's marketed as a salt substitute. I've read that you're not supposed to add straight potassium to your food but instead eat a potassium-rich diet. I tried valiantly to match the recommended potassium intake levels with our intake from food and couldn't get our consumption up high enough. People with some kidney conditions shouldn't increase their potassium intake, so the blanket recommendation is for no one to do it. I also mentioned spiking my water with potassium to my doctor and he made no comment. Unlike sodium, I have zero sense that the added potassium does anything for me but it seems to me to be the right thing to do and it's so easy: "1 spoon of this, 1 spoon of that".

STEP III: Tracking Down GI Irritants
Knowing if you are benefiting from a reduced carbohydrate diet or a low FODMAP diet is made easier by eliminating as many other sources of GI upset as possible. A simple but big trouble-maker for a few of us is grill oil or deep-fat-frying oils. When in my 20's I discovered that eating 2 donuts was all it took to shut-down my gut and make me miserable but I could eat the equivalent amount of fat or even more in the form of butter and be fine. Years later my brother commented that fats with high-temperature tolerances that are favored in the commercial food industry are tinkered with to make them durable and heat stable, a process that converts them into something approaching plastic. I don't know if that theory has withstood the test of time, but it's a useful model for me. I can literally guzzle olive oil and butter and be unfazed but grill grease and deep fry grease can shut my gut down for a day or 2. Perhaps those fats are OK for me when fresh, but who can tell when ordering food? So, I just don't eat grilled or deep-fried foods at all and am more comfortable for it.

Polyunsaturated Fats
Who would have thought that my sister-in-law's fresh baked corn bread would make me ill but I started feeling bad before I left the table. I knew it was the cornbread, though I couldn't imagine why. She had made it with a freshly-opened bottle of Wesson oil that wasn't close to being outdated. Later online reading revealed that polyunsaturated fats, such as in the Wesson oil, start turning rancid before they leave the factory floor and people have a varying tolerance for eating rancid oils. Apparently my tolerance is "0". I was the only one at the table that felt ill though telling this tale to a friend shed light on some of her unexplained bouts of belly distress. And more recently I've read that all of the participants in a tightly controlled nutrition study felt unwell when a large portion of their fat intake was in the form of polyunsaturated fats. To be on the safe side, stick with mono-saturated oils like olive oil.

Lactose is a fermentable sugar and it is the only commonly known fermentable sugar of the half-dozen sugars addressed in the low-FODMAP diet strategy. Lactose only naturally occurs in dairy products. For those of us who are lactose-intolerant, even ingesting a little bit of lactose can set-off a nasty bout of abdominal pain and gas. Before going on the low-FODMAP diet, a cup of yogurt or milk was enough to send my gut into intermittent chaos for about 5 days and make me feel generally ill and dull-witted. Now that my gut is healthier, a miss-step with lactose will give me a bout of discomfort on the day of ingestion and the day after and that's it.

There are 2 solutions to lactose intolerance: one is to avoid ingesting lactose, the other is to take lactase tablets when eating lactose. Lactase is an enzyme that breaks down lactose and is a safe and readily available nutritional supplement.

I use 5 lactase tablets of 9000 FCC LU strength for a total of 45,000 units to counter the lactose in 8 oz of yogurt. The recommended starting amount is one 3,000 unit tablet but I need 15 times the recommended amount of lactase to be symptom-free when eating yogurt. So don't give up easily or be shy about taking a lot of lactase to sort out your needs. It may require several weeks of experimenting to get it just right for you. Also, some bloggers have said that the Costco brand is slower to dissolve than the higher priced Lactaid product, so I often take my Costco tablets 15-20 minutes before eating dairy with lactose content.

Milk, and usually yogurt, are full-force sources of lactose whereas most hard or aged cheeses have no lactose in them. For years I took lactase tablets with all dairy but I've demonstrated to my own satisfaction that lactase isn't necessary for me when eating many cheeses. I've heard that cheese that is aged 3 months or more is naturally lactose-free because the bacteria have gobbled it up. I've also read that Brie and Feta are lactose free, which fits with my experience.

Weighing bok choy with a postal scale in Colico, IT to keep the carbs down.
And in case you haven't heard, one's ability to break-down lactose tends to decrease with age. So, if you find yourself saying "But it never used to bother me….", get over it. Yes, it was fine before and now it isn't. Your body has changed and you'll be happier if you change your dietary habits in response to its changes. Living on a low carb and/ or low FODMAP diet is challenging so you want to be clear before you embark on either that you've tended to the easier issues that may be upsetting your gut or making you feel unwell.

STEP IV: Reducing Your Carb Intake
Glossing Over the Details to Get Started
Once you've eliminated dehydration and low sodium as sources of headaches and low energy and have ruled-out certain fats and lactose as sources of belly-upsets, position yourself to reduce your carbohydrate intake to the 100 gram level. You'll be replacing those carb calories with protein and fat, so think "olive oil" and lots of it on anything it will stick to. Going down to 100 g of carbs was sufficient for both of us to think, feel, and sleep noticeably better in a few weeks. It's an annoyingly restrictive diet but we felt so much better that the struggle dropped away quickly even though the complaining and questioning lingered on.

Begin by decreasing and then eliminating your intake of grains as the next step after controlling your refined sugar and juice intake. It's challenging to say the least because many of us, especially Mediterranean diet fans and vegetarians, build their meals around grains. We did it 'cold turkey' but you may want to begin by reducing your portion sizes of grains. That means targeting breads, cereals, pasta, rice, and the like to eventually go away entirely. And to get a jump on the next phase without being too severe, begin reducing your fruit portions because sadly, fruits are high in carbs too.

The next phase will be re-organizing your produce consumption by de-emphasizing fruit and emphasizing low carb veggies. Out will go the potatoes, corn, and peas and in will come kale, dark leafy green lettuces, cucumbers, spinach, and green beans. These low carb veggies are the ones we favor because they are also low-FODMAP (more about FODMAPs below) choices. Carrots and red peppers still show up on our plates daily but in more modest quantities than previously to control the carbs. If FODMAPs don't turn out to be an issue for you, there are many more low carb veggies from which to choose.

One of our favorite new, very low carb menu items is starting with a serving bowl amount of dark salad greens for each of us and adding generous quantities of 3 - 5 amendments like: canned salmon, shredded chicken, shrimp, anchovies, diced hard cheese, crumbled feta, blu cheese, grated parmesan, diced avocado, chopped tomato, walnuts, and black olives. We top it with plenty of homemade vinaigrette made without garlic to keep it low FODMAP. A low carb entree salad such as this can be modified to make it high or low calorie depending on your needs as well as significantly increasing your fat and protein intake.

What?! Using a lingerie bag to wash, then spin, salad greens when traveling in the Dolomites.
There are many low carb recipes available online and in books, though because we also need low FODMAP foods and travel 9 months out of the year, we are resigned to developing our own. Some of our evolving recipes include thin sliced turkey breast lightly coated with mustard and covered with cheese and then topped with fresh basil and tomato. It can be eaten hot or cold though we prefer it hot. A spinach and chicken curry is currently under development in our traveler's kitchen. And when we have access to the reasonably priced frozen wild salmon from Trader Joe's, we eat it almost nightly with a vegetable side. We make up any calorie deficiencies from our meals by snacking on naturally lactose-free cheeses.

Once you've become comfortable eating no more than 100 grams of carbohydrate per day, aim to go lower to 60-80 grams. That's the target number of carbs per day from David Perlmutter of the Grain Brain fame. We found it easy to give up another 25 grams of carbs after about a month at the 100 gram level.

David Perlmutter's book the Grain Brain provides a quick introduction into the why's and how's of low carb eating and he guides the reader into a low carb diet plan without necessitating counting the numbers. However, I've periodically been "running the numbers" on my diet for many different nutrients for decades so I immediately started weighing our food and creating my own spreadsheet to tabulate carbs, fiber, net carbs (the difference between the 2), protein, and calories for the foods we ate. Unlike many who choose to go low carb, our challenge quickly became to get enough calories on the diet to support our age-inappropriate level of exertion. (We are in our early 60's and we each eat 2,500-3,000 calories/day.)

Time will tell whether Perlmutter is spot-on with his interpretation of the research he has analyzed for his no grain/no gluten/low carb diet or if he's right for the wrong reasons. Regardless, we've switched from being hardened skeptics to believers--it works for us--we felt a little better eating gluten-free and feel a lot better eating low carb.

If you want to go even lower on your carb intake and get a heavy dose of theory about ketogenic diets, read one or both of Stephen Phinney and Jeff Volek's books The Art and Science of Low Carbohydrate Living and The Art and Science of Low Carbohydrate Performance. I haven't read the book they co-authored with Dr. Eric Westman: The New Atkins for a New You:….. but it surely is less technical than the other 2.

The ketogenic approach to ultra-low carb eating described in the 3 books mentioned above forces your body to became an efficient fat-burning machine. It is a severe and austere diet but it is a way to control cholesterol levels and to put diabetes into remission. It's not a diet for the faint of heart. Your kitchen scale, food analysis charts, and a glucose/ketone meter will be your new best friends. And pouring in the water and sodium become critical to making this diet sustainable. Going ultra-low, going ketogenic, is the path we have chosen for the health benefits and even by the 2 month point it was delivering fantastic performance results for us, such as increased endurance, decreased muscle soreness, improved recovery time, and the elimination of head-fuzz associated with exertion. We are absolutely stunned with the results, especially since this low-carb journey came up suddenly a mere 5 months ago.

Shhh! What No One Wants To Hear
Along the way, you will likely wonder about the appropriateness of drinking alcoholic beverages on a low carb diet. Perlmutter, author of the Grain Brain cites some of the well-publicized research on the benefits of wine and recommends imbibing in an occasional glass. However, it's now coming out that one of the primary researchers promoting the glories of resveratrol in red wine, a substance viewed as having a cardio-protective effect, falsified data in his research. On top of that, 2014 research from the World Health Organization states that alcohol isn't safe at any level of consumption because the carcinogenic effects of alcohol outweigh the other purported benefits.

Should you choose to imbibe in alcohol on a low carb diet, do your research first. Distilled alcoholic spirits straight out of the bottle usually have zero carbs whereas a single beer or a mixed drink could equal a full day's carb allotment for some ketogenic diets. And I've read that being ketogenic intensifies the side effects of alcohol as well.

STEP V: Becoming a "Low FODie"
Once you've reduced your carb intake, you'll likely be feeling better even if you have FODMAP (fermentable sugar) intolerances. FODMAPs are sugars and sugars are a type of carbohydrate and the fewer carbs you eat, the fewer FODMAP sugars you are ingesting. But if you still aren't feeling as well as you know you should feel after making the above dietary changes, consider delving into a low FODMAP diet.

Ease into reducing your exposure to fermentable sugars or FODMAPs by first cutting out all sources of onions, garlic, and any remaining wheat in your diet. Those 3 foods all contain fructans and together they are considered the biggest sources of fermentable sugars in the Western diet, the biggest food culprits for causing GI distress in susceptible people and producing the associated head-fuzz. If you haven't sorted out if dairy products are irritating to your gut, now is the time to settle that matter. The lactose in many dairy products is also a fermentable sugar, a FODMAP. Lactose is the easiest FODMAP to identify as an irritant and the only one that can be countered with a pill (lactase).

FODMAPs are the most difficult potential source of dietary GI distress to regulate with which we have experimented. FODMAPs are tricky because you must determine which of the various sugars are irritating to you by trial and error and then establish your tolerable intake levels of each. Processing and the ripeness of produce can also change the quantity of a given FODMAP in a specific food. You can read much more about the complicated subject of FODMAPS in the "Beyond Gluten" piece.

Monash University in Australia is leading the way in helping individuals help themselves to identify which sugars and which foods are gut irritants. Their FODMAP app is indispensable and can be purchased from either the Apple or Google app store depending upon the device you use. You can also download the FODMAP guide from their website. I highly recommend using Monash's reference material to guide your journey into the world of FODMAPs. That's what we have done and our GI comfort levels have skyrocketed as a result.

Feeling Better Now??
We've totally transformed the comfort of our guts and our brains by decreasing our intake of carbs and of FODMAPs as well as being consistent about getting plenty of fluids and sodium every day. The changes have resulted in a very limited menu that has made social eating difficult. But we both felt better so quickly and have continued to feel even better that we are committed to eating this new, austere diet. And though many favorite foods have dropped away, we are gradually discovering culinary pleasure and ease by giving neglected foods new emphasis. Life is all about trade-off's and the benefits of this lifestyle change have far offset the shortcomings for both of us. But we are also clear that this style of eating isn't tolerable to all and it certainly isn't necessary for those who haven't developed carbohydrate intolerance.

We have learned that success with the ketogenic/low FODMAP dietary approach requires being stern with ourselves. Giving up favorite foods, meticulously watching what we eat, being consistent, and not engaging in knowing self-deception brings up a lot of whining and protestations from nearly all of us, myself included. The sooner you accept that trading momentary flavor satisfaction or social ease for feeling better for hours and days later is worth it, the better both your belly and your brain will feel. It's an investment in yourself, like saving money and brushing your teeth.

One More Thing….
I've been under the care of a naturopath for about 18 months and she always has one more trick up her sleeve in her quest to make me fully well. Through several analyses performed in the late spring, she diagnosed me with 'dysbiosis', which is an imbalance of the bugs in my GI track. In the fall of 2014, I'll embark on an expected 2 week course of antibiotics to wipe out the undesirable bugs in my small intestine and colon.

The overgrowth of the bad bugs in my small intestine was likely a side effect of using acid reducers for almost 3 years in an unsuccessful attempt to heal my esophageal ulcer. I suffered mightly on the various acid reducers and know that my gut (and GI comfort) have never fully recovered from that escapade. My kind GI doctor wrote me off as one of those people who just doesn't tolerate acid reducers and had nothing to offer me for the seemingly permanent side effects of the medications. So, even though it all seems a little far fetched--like eating a low carb diet did--I'm cautiously optimistic that the naturopath is on a roll and the antibiotic treatment will deliver another layer of healing. So, if you aren't quite where you want to be with your gut health, know that there are other aspects of GI wellbeing that can be tweaked, aspects that often also improve cognitive functioning and sleep.