Shifting Gears

Earlier this week I had a meeting with my GI doc in preparation for surgery #7, which will happen on Wednesday of this week. Mostly I wanted to talk to him about managing my remicade infusions with all the surgeries, but I also had a couple of symptoms I had been noticing that I wanted to run by him. All in all he is happy with my progress and not making any changes to my treatment plan for now, except for one thing.

One of the things we talked about was diet and nutrition. I had been keeping a food journal for several weeks, and I was starting to notice some patterns. Some of my suspect foods (for example: dairy, even when properly fermented; tree nuts and peanuts in large quantities; fruit in large quantities) were some of the very same foods that are highly recommended on the SCD diet. Also, when I strayed from SCD, I noticed there were other foods that seemed to agree with me but that I wasn’t “supposed” to eat (for example: rice, sweet and white potatoes, oats). When I told him about some of the triggers I noticed, he told me he wanted me to try something called the low FODMAPs diet and gave me a brief explanation and some materials on how it works.

I have mixed feelings about this transition. On the one hand, I have spent so much time and energy doing my best to implement SCD. It also sort of fits in with my general view of what is good for our bodies (nothing processes, lots of fruit/veggies, nutrient-dense foods, and healthy fats). On the other hand, I wasn’t experiencing as much relief as I hoped while following it. To be fair, from the beginning I was told that to be effective you have to commit 100% to SCD, and I never was quite able to do this for more than a few weeks at a time. So I can’t say that the diet doesn’t work, I can only say that it doesn’t work for me. In my mind, if it is impossible to follow a diet and occasionally travel, go out to eat, or have a meal at someone else’s home, then it’s not a real option for me at this point in my life. Maybe it will be at some other time. Even  following the diet 90% of the time, I was starting to feel too deprived.

So, before I even talked to my doctor, I had thought about trying something else. He told me that the low FODMAPs diet is actually the diet with the most scientific evidence behind it for controlling symptoms of Crohn’s. I’m a scientist, too! I love scientific evidence!

I’m still learning about the low FODMAPs diet, but here is a quick summary of what I have learned so far. Like SCD, it works in part by altering the microbiome in the gut by restricting the type and amount of food available to gut bacteria. And, both diets limit foods that are thought to be difficult to digest. But, the specific foods that are identified as being hard to digest are different. SCD limits all simple sugars, grains, and starches, whereas low FODMAPs limits foods containing specific types of sugars that can lead to fermentation in the gut when too much of them is consumed (the acronym stands for “fermentable oligo- mono- di-saccharides and polyols). Also, whereas SCD requires the patient to completely eliminate these foods during a one-year introductory phase, low FODMAPs encourages patients to eliminate high FODMAPs foods completely for 2-6 weeks, then reintroduce them slowly to identify specific triggers. There are also quite a few foods that you can eat, even during this introductory phase, as long as you limit portion sizes. Best of all, the diet doesn’t depend on 100% adherence–just on reducing your overall FODMAPs load, because high FODMAPs foods are only considered problematic when you eat too much of them at once. In fact, except for the very short introductory period, 100% adherence is discouraged, mostly because many of the high FODMAPs foods are also important sources of prebiotics (compounds that encourage the growth and activity of beneficial gut bacteria).

I made a table comparing the types of foods that are allowed on the diet. This isn’t meant to be comprehensive, just a quick overview. As you can see, the main differences are that low FODMAPs allows gluten-free grains and a wider variety of sweeteners, but limits the type and quantity (usually to 1/2 cup per sitting) of fruits, vegetables, legumes, nuts, and seeds somewhat more than SCD.

Food Group Specific Carbohydrate Diet Low FODMAPs Diet
Grains None All except for wheat, barley, or rye
Meat, Fish, and Poultry All (unprocessed) All, unless processed with high FODMAPs foods
Dairy Hard cheeses and homemade yogurt Lactose-free dairy, low-lactose dairy, all in limited quantities
Fruit All fruit (except canned) Bananas, blueberries, melons (except watermelon), grapes, kiwi, citrus (orange, lemon, lime, pineapple, mandarin, tangerine), passion fruit, raspberries, strawberries, rhubarb, avocado, cherries, grapefruit, longon, lychee, pomegranate, rambutan, coconut, in limited quantities at a time. Also, no canned fruit permitted
Vegetables All except for starchy vegetables (white and sweet potatoes, yams, parsnips, yucca, taro, jicama, corn), seaweed and seaweed products, canned vegetables, artichokes, bean sprouts, okra, chicory, cucumber All types of leafy greens (kale, spinach, lettuce), red bell peppers, bok choy, cucumbers, eggplant, green beans, cabbage, parsnips, pumpkin, all types of potatoes, radishes, seaweed, winter and summer squash (butternut, zucchini, yellow squash, spaghetti squash, etc.), tomatoes, turnips, water chestnuts, carrots,  bamboo shoots, canned artichoke hearts, asparagus, beet, broccoli, brussels sprouts, celery, peas, snow peas, corn, all in limited quantities at a time
Legumes No legumes permitted, except for peanuts and properly soaked lentils, navy beans, adzuki beans, peas, and lima beans No legumes permitted, except for peanuts
Nuts and Seeds All, depending on form (flour, whole, milk) and stage of diet, in limited quantity All except for cashews and pistachios, in any form, in limited quantity
Nutritive Sweeteners Honey, aspartame, and saccharine (occasionally) Sugar (white, brown, cane, etc.), maple syrup, glucose, stevia, regular corn syrup (but NOT HFCS), brown rice syrup, all in limited quantity
Cooking Oils All except for soybean All
Herbs, Spices, and Seasonings All except for mucilaginous herbs and vegetables (aloe vera, marshmallow, slippery elm, etc.), spice blends, balsamic vinegar, and various additives All salsas, jams, chutneys, pickles, sauces, etc. made with permitted fruits and vegetables, mustard, mayonnaise, green onion (green part only), soy sauce, vinegar, most spices and herbs, homemade broth, butter
Beverages Most fruit and vegetable juices, weak coffee, weak tea made with permitted foods, dry wine, spirits, nut milks Juices and smoothies made with permitted fruits and vegetables, coffee, tea, beer, wine, nut milks, all in limited quantities

The hardest thing for me, for sure, will be cutting out garlic and onion (even for 2-6 weeks, assuming the reintroduction goes well!). If you’ve ever looked at any of my recipes, you can see they all start with cutting up lots of garlic and onion! On the other hand, it feels like such a huge relief to have permission to eat some gluten-free grains here and there that it might make up for it. Not that I plan on going nuts–I still fully believe that eating unprocessed foods and focusing on eating fruits, vegetables, and protein rather than filling up on grains is healthier for almost everybody–but it’s nice to have a little bit more flexibility. To me, this diet seems much more manageable in the long term. And, while I won’t go into any gory details, in the 6 days or so that have passed since my doctor’s appointment, as I’ve tried reducing my overall FODMAPs load without yet jumping in on the elimination part, I’ve experienced more symptomatic relief than I ever did on the SCD. 

So, yeah, I think I’m going to give this a shot. Before I try the elimination part, I think I have a bit more research to do. I’m also not going to try the elimination phase until after I’m (mostly) recovered from my next surgery, since it seems like a lot to ask others to manage when I am unable to help at all with cooking or shopping. In the meantime, I might take a bit of a break from writing as well while I scope out this new territory, but I will be back, hopefully armed with a whole new set of recipes!

The Fat Conundrum

I was inspired to do this post because a very dear friend and former roommate recently visited me, and we had several conversations about how strange it was that back when I lived with her I just found it impossible to lose weight, in spite of the “healthy” lifestyle I was living. She saw me exercising regularly, trying to follow a relatively low-fat, heart-healthy, mostly vegetarian diet–the kind of diet doctors often recommend to the overweight and obese–and still gaining weight. Now she witnessed me shoveling nuts and mayonnaise in my mouth every day and still dropping pounds.

Here are pictures of me from about four years apart.  The picture of me on the right, in the blue dress, was taken just this week. The picture on the left, in the black dress and red belt, is from about four years ago. Today I want to talk about the idea that dietary fat is what makes you fat, present some evidence that this is misguided, and do a little compare and contrast with my diet, lifestyle, and weight four years ago and now.

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Mimi 2010

BMI: 34.2 (obese, nearly 60 pounds overweight)

Exercise: nearly daily, at least 1 hour. This picture was taken not long after running a 10k for which I trained religiously. I also regularly did yoga, went on walks, took spinning and zumba classes, swam laps, and worked out on gym equipment.

Dietary Staples: whole-wheat bagels, whole-grain cereal, skim lactose-free milk, vanilla soymilk, nonfat fruit-flavored yogurts, tofu and soy meat substitutes, all kinds of fruits and vegetables, salads with store-bought light vinaigrette, peanut butter, whole-wheat sandwich bread, whole-wheat flour and corn tortillas, sweet potatoes, occasional (less than once a week) fish or chicken, pasta with homemade sauces or store-bought pesto, brown rice, homemade fruit smoothies, ice cream, frozen diet dinners, olive oil, vegan butter substitute, egg whites, soft cheeses, diet soda, coffee, beer, wine, cocktails.

Mimi 2014

BMI: 27.6 (about 15 pounds above ideal weight for my height) yes, that means I’ve lost 45ish pounds, which I think gives me a right to talk about some of this stuff. I’m still hoping to lose these last 15 pounds, but I want to make sure that it’s because I’m trying to lose it, not because I’m sick and my body isn’t absorbing nutrients.

Exercise: basically none. This is not by choice, but I’ve only recently been able to start walking (2 miles at a time, a few times per week). I hope to increase walking and start yoga again soon as well.

Dietary Staples: full-fat plain kefir and yogurt, all kinds of peeled fruits and cooked vegetables, lots of nuts and nut butters and flours, homemade almond and coconut milk, hard cheeses, poultry, fish and shellfish, beef, lamb, bacon, eggs, butter, coconut oil, olive oil, homemade mayonnaise, honey, lentils, homemade fruit smoothies, tea, coffee, coconut water, occasional glass of wine or cocktail, very occasional (typically less than once a week) serving of white or wild rice, oatmeal, or white bread or tortillas, dark chocolate.

It is important to note that even though we eat dairy and/or meat at most meals, we usually: a) choose grass-fed, organic meat and dairy when possible because it has a better fat profile b) limit the serving size of animal products and incorporate plenty of veggies, fruits, and nuts (we also try to have one or two vegetarian meals most weeks) and c) choose seafood, eggs, and poultry more often than beef, lamb, and pork. That is to say, we are not following an Atkins-style eat all the bacon diet. I’m also not eating coconut oil by the spoonful, btw.

Conclusions and Caveats

I am unable to say how much of the weight loss I have experienced is due to diet, how much is due to a suppressed appetite, and how much is due to my body just not absorbing nutrients as well. But, my husband is sort of the control in this experiment, and he has pretty much stayed at the same weight since starting SCD in spite of rather more frequent indulgences and generally larger portions. And, as I mentioned before, prior to being diagnosed with Crohn’s or showing any symptoms my husband and I both did lose a significant amount of weight when on the paleo diet, which is very similar to SCD.

In addition to losing weight, other indicators of my health have improved. While I was still mostly vegetarian, some bloodwork showed that I was anemic; very recent bloodwork has shown that I am not anemic anymore, even though it is a very common problem with IBD. My cholesterol is currently slightly lower than it was while a mostly vegetarian.

I’m not suggesting my weight loss can be explained by diet alone; in fact, I’m not even recommending SCD as a weight loss diet because that’s not what it is meant for. Still, the question remains, why is it that I am the thinnest I’ve been in my adult life while on a high-fat diet, and the heaviest I’ve ever been while on a low-fat, low-calorie, “heart healthy” diet? Here are my thoughts.

  • Processed food is a thing of the past. SCD-legal processed food does not exist, so by default you have to make pretty much everything you will consume from scratch. Say goodbye to giving in to a frozen pizza after a hard day at work, or accidentally eating half a box of Annie’s white cheddar bunnies snack crackers because you were bored!
  • A corollary to the first point: you can’t just pick something up. My husband and I do go out to eat occasionally or eat at other people’s homes, and in these situations, I try to make decent decisions based on what’s available, and enjoy my food. But, on a day-in, day-out basis, I know picking up a meal or a snack is a very bad idea for me, so I just don’t do it. Ever. This takes a whole lot of temptations out of the picture altogether.
  • Food with fat in it tastes better. To make “low fat” food palatable, fat is often replaced with all kinds of sugar, sodium, and other questionable artificial flavors that are likely more harmful than the fat they are meant to replace. Just eat real food, people, even if it has butter in it.
  • Fat makes meals more satiating and reduces cravings. My husband and I were both struck by the fact that, when we eat paleo or SCD style, the food we eat leaves us feeling so satisfied but not bloated. We do much better at recognizing “full” signals earlier, and when we do stop eating we feel good, not stuffed and miserable. Since the smaller amounts of carbohydrates and sugars don’t cause major spikes and crashes in blood sugar, we have fewer cravings and we feel satisfied for much longer.
  • Eating real food changes your tastes. Food that I know I would have enjoyed previously now tastes a little too sweet, or a little too salty, or just plain “off.” It might not seem like it at first but you will eventually reach a point where fresh, simple, whole food tastes the best, and it is more enjoyable because you know it will make you feel good, too.
  • Even WebMD, that stalwart of conventional medical advice, agrees that combining fat with other foods helps our bodies absorb nutrients better. Mostly eliminating grains and replacing them with veggies, fruits, and healthy fats from sources like fish, nuts, and plant oils means that you are getting more of the nutrients your body needs, period. And when your body is struggling with a chronic condition and not absorbing nutrients properly, this is really important. Being kind and supportive to your body means that it can do all of its jobs–including metabolizing food and putting it to good use–better.
  • Your microbiome matters. Check out this article for a really good and accessible summary of the amazing scientific advances being made in the link between gut health and overall health. In short, highly processed junk food containing starches and sugars, antibiotics, and stress (among other things) can cause an overgrowth of bad bacteria and die-off of good bacteria, which is associated with inflammation in general, metabolic syndrome, weight gain, IBD, and numerous other health problems. Eating probiotic foods like fermented dairy and cultured vegetables, as well as food containing prebiotics (some whole grains, vegetables, fruits, and nuts are good sources) can actually rapidly change the microbiome in your gut by colonizing it with more diverse, good bugs. So, this is yet another argument for eating whole, real, unprocessed food if weight loss and healing is a goal.

The bottom line, is that the whole is more than the sum of its parts. I’m not advocating giving up bananas for sausage if you want to lose weight. I’m not suggesting you can cure IBD with enough kefir. And I’m not even close to saying I’ll never eat another greasy cheeseburger in my life. My point is just that I think counting calories, and especially restricting healthy fats, is not the whole answer to losing weight. Eat traditional, real, nutrient-dense foods you make you from scratch in your own kitchen 90% of the time, stop eating when you are satisfied, get plenty of rest, and exercise if you are able. I trust that more than any fad diet you can throw at me!