The Roller Coaster Ride

Step right up, folks!  Only one thin change in diet to board!

Yes, the last several days have been a bit of a roller coaster.  Gut seems fine... gut explodes... gut seems fine... gut explodes...

The diarrhea episodes are generally short, and completely different than what I was experiencing after the appendectomy but before I started taking Immodium.  And I don't know if they're being caused by the switch to a meat-based diet, or by one or more of the foods that I'm eating, or by something else.

One possible culprit is spinach.  Spinach -- and leafy greens in general -- is sort of a mixed bag: lots of nutrients and fiber, but also a high quantity of oxalic acid, which binds with some of the nutrients and decreases their bioavailability. And the oxalic acid itself might be a problem.  Some people have problems with leafy greens, so, for a while, I'm going to lay off the spinach.  I may re-introduce it in a week if things have settled down to see if problems recur.

Another possible culprit seems to be water.  Yes, water.  I made a joke about it in an earlier post, but honestly, drinking a lot of water -- something that happens out here in the desert quite frequently, especially when I'm riding my bike or knocking down walls -- really seems to play havoc with my intestinal tract.  I'm feeling like I have to be just as careful with how much water I drink and when I drink it as I do with what foods I'm eating.  If the quantity of water that I'm drinking really is having a negative impact, it seems as though there are a number of different possibilities as to why, based on things I've read over the past few days.

If what I've read is accurate, 80%-90% of ingested fluids are absorbed in the small intestine.  Whatever's left is supposed to be absorbed by the colon.  Based on the results of last year's colonoscopy, I'm not inclined to believe that there's anything wrong with my colon's ability to absorb liquids in general.  So could it be that my small intestine isn't doing a good enough job of absorbing fluids, thereby sending too much to my colon, and that's causing a problem because it does fine absorbing a normal amount of fluid but it can't handle the excess volume?

Well, maybe so.  I found a celiac site where members were discussing a decreased ability of the small intestine to absorb water because the villi and microvilli in the small intestine had been damaged by celiac disease.  While I don't have celiac disease according to a blood test from a year or two ago, I do think it's likely that the villi and/or microvilli in my small intestine have been damaged by decades of SIBO.  So at this point I'm hoping that continuing on the Specific Carbohydrate Diet will allow my small intestine to heal, which will presumably decrease any symptoms I may have due to water intake.

There is another road that this search took me down that I found very interesting, though, at the moment, I'm still thinking it's an unlikely explanation for my water woes.  The other day I decided to try to limit my water intake (not to dangerous levels, just to maybe 40 or 50 ounces) to see if it would help my gut.  I was thirsty all day, yet my pee continued to be clear or near-clear.  So I Googled a bunch of different phrases related to thirst.  Most of my searches resulted in many pages discussing diabetes; this was no surprise to me, as I've known since my mother was diagnosed with Type II Diabetes Mellitus that excessive thirst is a common symptom of this disease.  I've had a glucose tolerance test and the results were completely normal, but that was some years ago, so it would probably be wise to get re-tested given genetics and all that.  Still, I'm not overly concerned about the likelihood that I have diabetes mellitus.

What I learned after browsing a few pages, however, is that that there is another type of diabetes that is virtually unrelated to diabetes mellitus: diabetes insipidus.  The main symptom?  Excessive thirst despite drinking fluids, and the excretion of excessive amounts of diluted urine.  This sounded intriguing.  So I read up on it on the Mayo Clinic's website.

As I was reading, I was thinking (and I still think) that this is a stretch.  I'm not always extremely thirsty, and it's not so much that I'm excreting a large amount of urine, it's just that it never seems to darken up much even when I'm exerting myself and not drinking much.  But then I got to the "causes" page, and got suddenly alert when I read this:

"Certain drugs, such as lithium and demeclocycline (a tetracycline antibiotic), also can cause nephrogenic diabetes insipidus."

So I looked up democlocycline and found that it's marketed as... Declomycin.

Declomycin.  That sweet, drinkable antibiotic that has become the bane of my existence.  It turned my teeth gray.  It most likely damaged my gut.  And now I find out it may have damaged my kidneys, making them unable to respond properly to anti-diuretic hormone (ADH), also known as vasopressin.

Now, I still think this is a stretch.  Given the results of my SIBO test combined with the results so far of eliminating all complex carbohydrates from my diet, I'm inclined to believe that a) I did, indeed, have SIBO, and b) a long-standing, low-grade SIBO situation damaged the structure of my small intestine, and c) that damage is what's responsible for any difficulty I may currently have absorbing water.  But given my body's slightly weird response to water -- not just lately, but for many, many years -- and given the fact that Declomycin, a drug that I took a lot of way back when, may be implicated in a disease that alters your body's ability to deal with water normally, I have to raise an eyebrow.

I'm planning on finding a family practice or internal medicine doctor here in Tucson soon, just to establish a relationship with a local doctor.  I'll probably schedule a full physical exam since I'm turning 50 this year, and I'll request a glucose tolerance test as well as one or more of the tests for diabetes insipidus.  I don't expect positive results, but it won't hurt to check.

If nothing else, I learned some interesting stuff!

As far as the diet goes, a couple of new additions today: green beans and avocado.  And in addition, I found a mustard that doesn't have any added sugar.  So mustard is back on the menu!  I found that mustard and avocado on my hamburger patty at lunch today made it about 300% better than the plain one I had last night.

Two weeks down

I've made it through two weeks of the Specific Carbohydrate Diet.  It hasn't been easy -- what I wouldn't give for a bag of chips right now -- but I think it's been helpful.

It's not all positive.  Another internal melt-down today, after several days of fairly normal activity.  It could have been due to one of the new foods I've added, or to some sort of bacteria making its way into something that was in the fridge too long, or to sunspot activity.  Who knows?

But still, it's mostly positive.

The latest vegetables are zucchini, summer squash, and spinach, and the latest fruit is apple (in the form of applesauce).  The latest meat is ground turkey, made into sausage-patty size portions for breakfast.  The guys at scdlifestyle.com have a recipe for this "turkey sausage" which calls for 4 lbs. of ground turkey and just a few pinches of spices; I halved the meat amount and doubled (at least) the spice amount, and it was still way too bland, the next time I make it I'll double the spice amount again.  Upcoming vegetable additions will be green beans and asparagus; while several fruits are allowed in phase II of the scdlifestyle.com plan, I'm probably going to hold off on adding too much in the way of fruit, because I think the sugar -- even though it's simple -- might be a problem.  I'll be adding cod to the fish list, and probably turkey (not ground) to the meat list.

One slightly surprising outcome is that I've lost some weight: I'm almost back down to the 32" waist that I had 25 years ago.  I don't think I've lost so much that it's something I need to be concerned about, but I'll be keeping an eye on it.

Generally speaking, I think I still have the same amount of energy that I had before.  I'm often feeling snoozy in the afternoon, but that's nothing new, and I think it's actually worse here in Tucson than it was in the Bay Area just because of the weather: who wants to do anything when it's 105 degrees out?

So I'm going to continue on this path for the time being.  Someone mentioned that it takes 4-6 weeks for the body to adjust to a carnivorous diet after a long time as a vegetarian, but I don't know if that's an opinion, or something based on a study, or just some random numbers they thought sounded good.  I will almost definitely give this at least a month.  Hopefully all the internal stuff will continue to improve.

Respect and Frustration

I've been on the Specific Carbohydrate Diet for 10 days now, and I'm still encouraged by the results so far.  I'm proceeding a little faster than the meal plan approach that I got from scdlifestyle.com, because the foods I've introduced so far don't seem to have been a problem, and because I'm fairly certain that none of the foods available in this phase will be a problem.

One thing that this process has done for me is give me a newfound respect for what many (maybe most) homemakers did back in the 40s and 50s.  The amount of time that I've spent in the past week prepping food and cooking food and washing dishes has surprised me, and I was expecting to have to do a lot of work.

Now I know that there are a lot of people out there who still do a lot of this.  But with the prevalence of convenience foods of all kinds, I think that cooking three meals a day from scratch is more the exception than the rule.  Pouring out a bowl of cereal doesn't take much time or thought, and neither does building a sandwich from lunchmeat out of a package.  I'm not trying to put these things down: everyone does whatever they think is best for themselves and/or family members, and if heating up a frozen meal is acceptable and all there's time for, it's not up to me to say that's good or bad.  I'm just saying that I now have a greater sense of the amount of time and effort that went into the process of cooking meals, day after day, before convenience foods became so popular.

I went to the market last night to pick up some more supplies (spinach and applesauce will be the next new menu items).  As usual, there were several sample tables with chips and salsa, and cheese, and various other goodies to try to tempt you into buying the products.  I have to admit, seeing them was pretty frustrating.  I'd usually stab a little cheese cube with a toothpick, or try whatever salsa they had out, just to see if I liked it -- and occasionally the marketing trick would work, and I'd buy the product.  But now I can't try the samples, or buy the products, or even think about any other similar products.  Unless they start setting out bowls of pureed vegetables with no added ingredients, samples are a thing of the past, at least for the time being.  It was a little disheartening.

But I know it's worth it if I can get my gut back on track, which is the direction things seem to be heading.

One Week Down

Well, I've made it through one week of the Specific Carbohydrate Diet, which, if I do say so myself, is quite an accomplishment.

Results so far are mixed, but I see them as positive overall.  I'll definitely be continuing.

I haven't advertised this blog very widely, but for the few who are reading, thanks for your support!

Something's Fishy

Today's new food:  salmon.  I used to grill halibut on my hibachi on the patio of my apartment in San Leandro 23 years ago, but I don't remember ever cooking salmon; I don't even remember eating it, but I'm pretty sure I have.  I broiled it, since that's one of the approved cooking methods at this point; thank goodness for the internet, I found step-by-step directions for broiling salmon on wikihow.com.  Jenny was on Febreze patrol after my dinner, but I didn't find the smell overpowering, and the salmon was pretty good.

So here's what's on the meat portion of the menu at this point:

• Broiled hamburgers (not a fan, I'm skipping ground beef for the time being)
• Boiled chicken (in SCD chicken soup; quite bland)
• Broiled chicken (not bad)
• Broiled pork loin (quite good)
• Broiled salmon (quite good)

I've been buying the meat at Whole Foods, and our food bill has increased substantially.  I know that I could get cheaper meat at Safeway, but without any information about where the meat came from.  If I'm going to have to do this, I'm willing to pay a premium to feel better about the purchase.  And I feel better about the purchase at Whole Foods, since they have a rating system for the conditions in which the animals were kept.  While I still think that killing, by definition, isn't humane, I'd still prefer that treatment up until that point be humane, and I think that's more likely (though not guaranteed, since I can't actually go to the companies they buy from and inspect the conditions myself) with Whole Foods meats.

And the vegetable portion of the menu:

• Carrots -- boiled (to death) and pureed
• Butternut squash -- boiled (to death) and pureed

Basically, when it comes to vegetables, I'm eating baby food: bland and extremely easy to digest.  Fortunately, salt and pepper are allowed, and at this point I can start adding other spices.  I can stop pureeing pretty soon as well: the scdlifestyle.com guys recommend 14 days, so I'll probably puree my next vegetable (zucchini), which I'll probably add this weekend or just after, and then start cooking them in other ways.

Tomorrow I'll be cooking up a batch of pearsauce, and it will be nice to have something sweet.  So far the only things that I've had that have been sweet are grape juice and apple juice, each diluted 50/50 with water -- and not much of either.  These are allowed because they only have simple sugars.  I believe the same is true with pears, and the cooking makes them easy to digest (back to the baby food idea).

So, you might ask, is this working?

Hard to say.  I've still had several episodes of diarrhea, but I've also had relatively long stretches without, and I've had far less gas.  I still think that any gut explosions may be attributable to a sudden change to a meat-centric diet, but at this point the whole die-off thing might be in play.  A friend read my two-steps-forward-one-step-back description and said that he thought it sounded more like two steps forward and one step left.  I like that way of looking at it better: the diarrhea is different than it was, so it doesn't exactly feel like a step back.  It's still frustrating, but I'm doing the best I can to stay positive and to continue to view this as a reasonable approach.

Two steps forward

After no gut activity yesterday, I got up this morning, had breakfast, and actually went to the bathroom and everything came out normal.  No big deal for most people, but for me, it's been almost two years since that's happened without the aid of Immodium (which I stopped taking a couple of days ago), so it felt pretty good.

Then my gut blew up again later in the morning (though, fortunately, it was a small explosion).  Maybe it was eating breakfast, which I haven't been doing for the past year and a half, and only started again on SCD day 2.  Maybe it was because I drank many glasses of water this morning after swinging a sledge hammer at a block wall post for half an hour; while drinking water doesn't sound like it should be a problem, with my gut, I wouldn't be surprised.  Maybe the chicken soup snack I had last night was too late, I should have had it 5 minutes earlier.  Maybe a couple of planets are misaligned.

In any case, I felt off for the rest of the day.  But I'm trying to look at it as two steps forward and one step back, instead of the other way around.

The good news is that I made today day 1 of Phase 1, instead of day 4 of the Intro Phase.  Despite this morning's setback, I decided to add one new food: butternut squash.  It's pureed, like the carrots I've been eating, but it's still pretty tasty (fortunately, salt and pepper are allowed!).  I also started adding new meats:  I went to the market today and bought some pork chops, NY steaks, and salmon along with some more chicken.  Tonight's pork chop was quite good.  I'm still not happy about eating meat, but I'm glad I don't mind the taste or texture.

How much time you need to spend in each of the five phases is variable.  The scdlifestyle.com guys recommend a four-day trial period for each new food, but that seems pretty extreme to me, it would take at least a few weeks to add the few additional foods allowed in phase 1 (mostly different kinds of squashes).  I'm hoping to step it up just a bit and spend no more than a couple of weeks in phase 1.  Phase 2 will almost definitely take longer, as there are quite a few new foods allowed.  But I'm playing it by ear, since I'm not really sure what to expect.

So... hopefully there'll be a couple more steps forward in the next few days, even if I end up taking a step back as well.

Giving thanks

Day 2 was not a good day.  My gut exploded around midday; not completely unexpected, given the lack of Immodium (stopped taking it today) and the major diet change, but not pleasant nevertheless.

I suspect that those in the alternative health profession would attribute today's experience as a symptom of "die-off," a process wherein the bad bugs in the gut die because they're being starved and then release toxins as they decompose that the body can't deal with because of the sudden large quantity. I would dispute this.  While I think the whole concept has merit, I personally think that this is too early in the process for it to be a problem:  I had complex carbohydrates and alcohol as recently as two nights ago, making it only about 36 hours before today's problem, so I'm sure that the bugs had plenty to eat.  And given the fact that these bugs supposedly have a 14-day lifespan, well, the whole die-off thing this early just seems implausible to me.

I suspect that my problem is more a matter of a radical diet change.  I went from eating a completely vegetarian diet (except for three meals during the week prior to the start) to eating a diet consisting of chicken, ground beef, eggs, and pureed carrots.  I'm sure my body was just saying, "What the hell has come over you?  Here's how I feel about this!"

But enough of that.  I thought I'd share a few thoughts I'm trying to hold onto as I make this transition to eating meat.

The first is that I'm trying to remember to be thankful in a sort of Native American kind of way.  I've always sort of appreciated the rituals -- at least as far as I've seen them portrayed in the popular media, which, admittedly, might not be all that accurate -- surrounding killing animals for food.  I realize that the whole Christian "grace" concept is similar, but I don't find a lot of deep-felt emotion there: it seems like it's more about thanking God for food, not honoring the fact that we had to kill something to get it, and that that killing is a sad thing.  I don't have any conventional religious beliefs, but I'm still thankful that I'm able to try this path to heal my gut, and at the same time I'm sorry about any animals having to suffer death in order to provide it.

Another thing that I'm keeping in mind is that sometimes, medicine is not pleasant.  It's also not always a guaranteed cure.  For me, this approach is medicine, and I don't know whether or not it's going to work.  But I'm willing to try it to find out.

Speaking of thanks, I got a phone call tonight from a wonderful friend who wanted to know how the whole thing was going, and she offered to come over and re-introduce me to cooking meat since I seem to have forgotten just about everything I ever knew.  I thought it was very sweet, and appreciate the fact that I have friends like that.

Hopefully tomorrow will be a better day.  Getting a wart on my foot frozen won't be pleasant, but at least it won't affect my gut (and hopefully my gut won't affect my ability to keep my doctor's appointment!).  The intro phase of the SCD is supposed to be 2-5 days, and, after today, I'm definitely sticking with it for at least 3 days, maybe 4 or 5.

Off and Running

Made it through day one today.  I imagine the Specific Carbohydrate Diet would be difficult for someone who's used to eating meat; for someone who just started again after over 20 years of being a vegetarian, it's pretty unnerving.

Still, the day went well.  Beef, chicken, eggs, and carrots, that's what's on the menu for the next few days.  I can certainly do this for a few days.  Then I get to add a few things to the menu.

SCD, Day Zero

So, all of what I've written so far is how I got to where I am today: giving up vegetarianism, at least temporarily, to see if I can get my gut to some version of "normal."

Today was the prep day for the intro phase of the Specific Carbohydrate Diet.  I cooked chicken soup, hamburger patties and meatballs, pureed carrots, and hard-boiled eggs.  It was not terribly pleasant for someone who hasn't cooked meat in over twenty years.  But I got through it, and I'm sure I'll get through eating it all as well.  I'm hoping that this will yield positive results, or at least some useful data.  At least the onions and celery and parsley in the chicken soup smelled good (not so much with the ground beef).

Given my history, I'm planning on going through the phases of the diet fairly slowly, but hopefully not at a glacial pace.  The guys at scdlifestyle.com have put together a program that has an intro period of 3-5 days, then five phases.  If you're super conservative and only introduce one new food item at a time, you could probably take a year to get to phase 5; I'm hoping to spend no more than two or three weeks on each phase, but I'll be playing it by ear to see how things go.

Time will tell.

Hypothesize This

As an analyst type, this whole wonky gut problem has vexed me like you can't imagine for the past two years.  It's been in the back of my mind for the past, oh, 40+ years, but since the appendectomy it's been in the forefront of my mind.

Okay, so I've always had a wonky gut.  But why on earth would it get far wonkier after having an appendectomy?  This useless, vestigial organ gets removed, and suddenly nothing works right anymore; that just doesn't make sense.  So I've come up with more than a few hypotheses, a few of which I'll share here.

I should also mention a short -- very short -- test that I gave myself a month or so after the operation.  Most people have heard of some sort of "elimination diet," where you get rid of most of the things that you eat and then add things back in slowly.  Since I often ate oatmeal for breakfast, I decided to "start from scratch" eating only oatmeal.  I was planning on eating only oatmeal, three meals a day, for a week, then start adding things back in.  But an interesting thing happened: after a day and a half, my symptoms got worse; after two days, it was clear that eating a lot of oatmeal was a Very Bad Idea.  So I stopped (I think that was the point at which I stopped eating breakfast altogether, but I'm not sure).  The important thing that I took away from that failed experiment, even if I didn't recognize it immediately, was that a diet high in a single complex carbohydrate was exactly what I didn't need.

So what's going on?  Perhaps:

• The human appendix does actually have a purpose.  In 2007, Dr. William Parker, PhD., of the Duke University Medical Center, conducted a study and came just short of concluding that the human appendix may actually be a sort of "bug warehouse" for the good bacteria that's supposed to populate the colon.  After a catastrophic event, like a bad bout of diarrhea, the appendix kicks in and repopulates the lower intestine with the good bacteria that's supposed to be there.  So, maybe, despite a compromised small intestine, my large intestine was able to compensate, and whenever things got really bad my appendix would help out by recolonizing the colon.
• The slicing and dicing involved in the operation severed nerves that my body was relying on to tell my large intestine when to work harder.  One thing I learned after all this started was that the human gut is incredibly complex, and has a highly advanced nervous system of its own.  Whenever you're cut into, nerves are severed; small ones, large ones, whatever is in the path of the knife is going to be severed.  Even a small incision on the surface of the skin can cause some numbness, and that's due to one or more nerves being cut.  So maybe one or more nerves got cut, and my body stopped understanding when it was supposed to get rid of excess fluid in the colon; I think I've always been sub-par in that area to begin with, so maybe this just made it exponentially worse.
• My body went into shock, and "normal" operations were disrupted.  One thing the surgeon mentioned was that there was a lot of adhesion in the area, which is usually caused by inflammation.  He'd done a bazillion appendectomies, and he said the average time it takes is about an hour and quarter, and mine took two hours because of all the adhesions he had to break up to get to wherever he needed to get to.  Well, maybe my body had gotten used to everything being stuck together, and got really, really pissed off at having everything separated, so much so that the normal neural pathways no longer performed their appointed tasks.  The problem I see with this hypothesis is that two years seems an awfully long time for my body to continue operating sub-optimally without figuring out how to re-hook up some neural pathways to get things working correctly.  But what the hell do I know, I'm not a neurologist.
• I'd had a SIBO situation all along, but it got exponentially worse during the operation.  The appendix is right next to the ileocecal valve, which keeps large intestine contents from working their way back into the small intestine.  When you go in for an emergency appendectomy, you don't have the luxury of the time it takes to get rid of all of the contents of your gastrointestinal tract (and I do mean ALL), like you do when you're going in for a colonoscopy.  I'm sure that there are procedures in place that limit any cross-contamination, but I wasn't watching the procedure; what if things got actively backed up into an area they weren't supposed to be in? Maybe that told a colony in my small intestine, "Hey, reinforcements coming!"
• Certain planets aligned on July 8, 2011, and I just happened to be in their crosshairs.

I honestly have no idea what happened.  Clearly, neither does my gastroenterologist, and while I'm sure he'd be happy to be able to help, I don't believe he has near as much interest in resolving the issue as I do.  At this point, my best guess is that:

1. I've had a dysbiosis (microbial imbalance) situation going on in my gut for as long as I can remember due to overuse of antibiotics;
2. That situation damaged and continued to damage the microvilli in my small intestine, making it impossible to digest complex carbohydrates completely;
3. My large intestine made up for that imbalance as best it could, helped out by my appendix, either because it repopulated depleted good bacteria populations or simply gave my large intestine more surface area to work with;
4. The appendectomy removed the help that was needed, and my colon simply can't do the job alone.

Based on that guess, getting rid of complex carbohydrates completely seems to be in order, hence my upcoming SCD trial.

I went shopping today, and I can tell you that it felt weird, really weird, to be buying chicken and ground beef.  Weird in a bad way.  But I feel like I have to give this a try.

IBS, SIBO, SCD... WTF?

So, my gastroenterologist runs all the standard tests after my appendectomy ruins my gut, and tells me I have a pretty classic presentation of Irritable Bowel Syndrome, or IBS.  This is basically a nice way for the medical community to say, "How should I know what the hell is wrong with you?"  Almost every time I'd see him he'd ask how my stress level was, if anything was making me more stressed than I used to be.  Yeah, being in the fucking bathroom for half my life, THAT'S stressing me out a bit.  Having you ask me about my stress level every time you see me, THAT'S pissing me off a bit as well.  Honestly, I think focusing on stress for gut problems is the single most misguided approach to a medical problem that I've ever encountered.

Anyway, all the tests came back negative.  Blood tests for celiac disease and other things, poop tests for parasites and bacterial infections and exocrine pancreatic insufficiency and other stuff.  As anyone who has had to do them knows, poop tests are the worst:  poop into a container, then, depending on the test, either mix some with various solutions in vials or just dump some in a container and freeze it.  Then take it back to the lab.  "Hi, here's my poop."  Nice.  We didn't bother with a colonoscopy because he said he thought it unlikely that anything would show up (and I agreed, based on everything I'd read); I ended up getting one a year or so later, and, not surprisingly, my colon looked happy and pink and unadorned with polyps or anything nastier.  Two days after the test, my gut was back to its usual tricks.

So I'm left with IBS.  IBS and all of its cousins and more distant relatives, like Inflammatory Bowel Disease (IBD), Crohn's Disease, ulcerative colitis, diverticulitis, etc., all suck on their own, but they're made worse by the fact that nobody wants to talk about them.  And you never see anything about these problems in the popular media, unless it's to make a joke; aside from Adriana La Cerva in The Sopranos, who talks about having IBS before getting whacked by Silvio, I don't remember ever seeing a character who had a gut problem -- and even Adriana is made the butt of a few jokes (pun intended).  Now, I understand this: it's not the kind of conversation that anyone wants to have.

"Hey, Bob, how's it going?"

"Not bad, Steve, although I was stuck in the bathroom for an hour this morning with diarrhea that just wouldn't quit.  Had cramps and really awful-smelling gas to go along with it.  How about you, how's your poop these days?"

"Good!  Yeah, once a day for me.  I get constipated every couple of weeks, but after a day or two I'm pretty regular again, though the first one hurts quite a bit."

Yeah, real good dinner conversation.  Funny how absolutely everyone poops, but aside from the nerdier gastroenterologists out there nobody wants to talk about it.  I mean, funny in a completely understandable way.  The problem is that that leaves those with the problems feeling pretty damned isolated.

So I read some more.  ibsgroup.org was a nice place to find a community that understood, and I learned about different diets that people try, and the latest ideas about the causes of IBS.  I ended up learning about SIBO: Small Intestinal Bacterial Overgrowth.  It's basically a situation where bacteria that are good in the large intestine but bad in the small intestine invade the small intestine and set up a little village.  The more the village thrives, the worse you feel and the more negative symptoms you have.  A lot of the symptoms sounded awfully familiar to me, so I looked into it in more detail.  When I found out there's a test for it (which is, thankfully, not a poop test), I talked to my gastroenterologist about it.  He mentioned the negative response that I had to a short trial of Rifaximin which should have had an impact, but I reminded him that it was only a 10-day trial, and at a lower-than-normal dose for this particular purpose (which was all because of the fucking insurance company denying coverage for the 30-day, higher-dose trial that would have been appropriate, which would have meant a $1,400 out-of-pocket expense), so he agreed that it would be a reasonable test.

The test for SIBO is a breath test.  The bad bacteria feed on sugars that the body can't break down, and the by-product of their consumption of this sugar is excess hydrogen, which shows up in the breath when it gets to the lungs.  So the patient fasts for 12 hours after a day of eating a very limited number of acceptable foods, then a baseline hydrogen level is taken, then the patient ingests a small amount of lactulose (a complex sugar that's undigestible by humans) solution, then readings are taken every 15 or 20 minutes for a few hours to see if the hydrogen level in the breath increases above a certain threshold.  In my case, the level did increase above that threshold -- but it increased slowly enough that my gastroenterologist considered it a negative result.  However, he was concerned enough to show the result to a colleague of his in San Francisco, who considered the result "borderline."  How typical of my body, to show a result that's in some netherworld between positive and negative; I think I inherit this from my mom.

My gastrodoc was reticent to start me on drugs, and I was pretty reticent as well, given past experience.  So I tried to "treat" the problem with diet and probiotics.  But none of the changes I made made all that much difference, and the one probiotic I found that seemed to help only helped a tiny bit.

At some point in this process, I read about a book that sounded interesting:  Breaking the Vicious Cycle by Elaine Gottschall.

It sounded interesting, and I was getting nowhere, so I bought it.

Elaine's hypothesis, based on the experience she'd had with her daughter and a bunch of scientific evidence obtained from a bunch of doctors, was that most gastrointestinal problems are caused by a small intestine that's not doing its job correctly, which leads to a bunch of bad bacteria taking up residence and damaging the small intestine, which leads to the small intestine not doing its job correctly, which leads to more bacteria, etc.  The short version of the root cause is that after some sort of initial damage to the small intestine, the microvilli of the small intestine are unable to process complex carbohydrates correctly, and a vicious cycle ensues.  The solution is to remove ALL complex carbohydrates from the diet until the gut can heal, then re-introduce them slowly.  How long this takes, and whether or not one can ever go back to a "normal" diet, depends on how damaged the small intestine is.

In my case, leaving aside the sharp uptick in symptoms after the appendectomy, a reasonable question is: what would have caused the initial damage to the small intestine?  The answer to that is easy: buckets and buckets of antibiotics when I was a kid.  I was the sickest kid in the world, and this was back in the dark ages, when antibiotics were the new wonder drug (I get really angry when I hear how often they're still prescribed for mild cold-like symptoms).  I'd have a terrible sore throat, take antibiotics, get better, and no sooner was I better than I'd get sick again.  I had my tonsils out when I was a couple of years old, much earlier than they usually did that operation even back then, and still I got sick all the time.  I took Penicillin, Erythromycin, Tetracycline, and Declomycin (gallons of the stuff, it's the only one I liked because it was cherry-flavored).  I think there were other Penicillin-family drugs as well, like Amoxycillin; I definitely took Dicloxacillin later in life for an infection after an ingrown toenail operation.  When I was a teenager I took Sumycin for acne, and I still think that was a terrible choice by the dermatologist, but again, this was back in the dark ages, and what the hell did I know, I was just a teenager.  I read someplace a year or so ago that if you take five courses of antibiotics your gut flora has been thrown out of whack; if there's even a shred of truth to that, my gut flora had no chance whatsoever, it might as well have been napalmed.  In the past decade I've taken some of the newer antibiotics, like Cipro and Zithromax; but after having antibiotics turn my teeth gray (another wonderful side effect of massive amounts of antibiotics) and probably trash my gut, unless I have a bad fever I'll go weeks now before I'm willing to take an antibiotic for something.

So, is SIBO the problem that I have?  I don't know, the test result was borderline, and therefore inconclusive; even if it is the problem, why things got so much worse when I had my appendix removed still remains a mystery.  If it is the problem, will this diet help?  I don't know; while the explanation in the book seems plausible, I don't know enough about how the gut works to know whether or not this approach should actually do any good, and even if it should, if it will in my particular case.

But I decided to give it a try.  Unfortunately, being a vegetarian made this very difficult.  Elaine provides an intro diet, and then suggestions about how to proceed after the intro phase, but all of it is very meat-intensive.  This is not surprising, given the almost complete lack of carbohydrates in the diet: all you're left with are proteins and fats, and since most vegetarian protein sources (e.g., beans) are high in complex carbohydrates as well, there's not a lot of non-meat foods available, especially in the intro phase.  So what I did instead of the intro as Elaine described it was simply eat anything on the "acceptable" list, without any intro period.  This didn't work: there was only a slight change in my symptoms, and I was hungry all the time.  I mean, it was like the jokes you hear about Chinese food: I'd eat an enormous meal of a salad and whatever, and two hours later I'd be starving.  Elaine discusses the possibility of following the diet as a vegetarian, saying, in part, "Since soy products, including tofu, are not permitted on this diet, it will be very difficult, but possible, for a strict vegetarian to obtain sufficient nutrients and calories."

Well, it wasn't possible for me.  So I bailed after only a week and a half.

And now, a couple of months later, I'm sick enough of my symptoms that I'm willing to give up my dietary choice of over 20 years to see if this will help, even without any sort of guarantee that it will.  I'll be following the intro diet and meal plans that I found at scdlifestyle.com: they go into excruciating detail about how to prepare things and how to move from one phase to another, which will be very helpful to someone who hasn't cooked meat in over 20 years.

Tomorrow is shopping day, the next day is cooking day, and the next day It Begins.

Going Vegetarian

Over the past 20-some-odd years, I've been asked why I became a vegetarian too many times to count.  For me, it's always been about the animals.

When I was living alone in my 20s I did all my cooking for myself.  And I was pretty good at it.  I'd always liked being able to make something tasty -- I went through a cake-baking phase when I was a senior in high school, I baked a cake a week, and my family enjoyed that phase as much (or more) than I did -- so I'd learned how to make things my mom used to make, and I liked trying new recipes.

One day I was at the market in the meat aisle, and I thought to myself, "This is pretty gross."  I don't remember what I was looking at at the time, probably a cut of beef.  I thought about the fact that some cow had been killed, and then someone else whacked the carcass up into pieces, and them some butcher had whacked it up some more, and here it sat, on a piece of styrofoam, wrapped in plastic.  It wasn't the first time I'd thought it was pretty gross, so I thought to myself, "You'd better either stop buying it, or stop thinking about it."  So I stopped buying it.

It basically came down to the fact that I wasn't interested in another creature getting killed just so I could have a meal.  That's really all it's ever been about for me.  The farther I went down that path, the more I learned about the potential health benefits of a plant-based diet; but I also recognized that with all things in moderation and a healthy dose of exercise, it's just as likely that someone who eats meat will live as long and healthy a life as someone who doesn't, so it's never been about the health aspects.  I've always been willing to discuss my thoughts on the subject, but, as far as I know, I've never been preachy about it.  I realized early on that if I was only going to have meals with vegetarians I was going to be eating alone a lot -- and if I got in people's faces about it, the end result would be the same.

I wasn't sure I was going to be able to make it on a vegetarian diet after eating some amount of meat at almost every meal for 20 years, so I eased into it.  I stopped buying meat at the market, but continued to order anything off the menu when I went out, and didn't mention it when someone invited me over, I'd just eat whatever was being served.  But after a short period of time I realized it really wasn't a problem, so I stopped eating meat at restaurants, and I started letting friends know.  Most restaurants have something that a vegetarian can eat, and my friends were all happy to accommodate me; at first I tried to make sure nobody went to any trouble -- "Just cook whatever you were planning on, I'll just eat everything but the meat" -- but everyone seemed happy to make a meatless main dish or extra sides, so I never had any problems.

As I mentioned before, going vegetarian didn't seem to have much, if any, of a positive impact on my wonky gut.  But it certainly didn't have a negative impact, so I was happy with my choice.  If this current attempt at correcting my gut problems works, I hope to be able to get back to a vegetarian diet.  And if it doesn't work, I'll definitely be switching back!

My Wonky Gut

As I head into this diet change, a little history might be in order for anyone following along at home.

I've had various problems with my digestive tract for as long as I can remember.  I was always the kid with the "sensitive stomach," or "nervous tummy."  I can remember getting up and eating breakfast, and then feeling like I was going to have diarrhea (or, worse, having it), and having a lot of gas, before going to school.  The family doctor prescribed Lomotil for me on several occasions; years later, I learned that Elvis had taken a lot of Lomotil, but instead of making me feel better about it, that made me feel worse: great, I'm taking opiates like celebrity drug addicts (I learned years later that I'd misunderstood what I'd heard, and that Lomotil isn't an opiate, it's that one of the main ingredients is an opiate receptor agonist).  By that time I was in my teens, and I decided not to ever take it again, I'd just deal with my "tummy troubles" as best I could without drugs.

At some point -- I think I was in junior high school -- the doctor thought maybe I was allergic to milk; this was before "lactose intolerance" was a household phrase.  He told my mom to switch me to low-fat, then non-fat milk.  Now, at this point, that seems like a silly response: the fat content wouldn't have anything to do with the amount of milk protein present (which I could be allergic to), or with the amount of milk sugar present (which I could be intolerant of).  But I'm old enough that this was in the dark ages of gastrointestinal medical knowledge, so we tried it.  Non-fat milk seemed to help a little -- or was it just the placebo effect?  Who knows.  In any case, I went along as before, having occasional problems, but, generally speaking, nothing so chronic as to cause me to have to miss school or work on a regular basis (I don't actually remember ever missing school or work because of my occasional symptoms, but I may have forgotten an incident or two).  What I did realize later was that all of this was having an impact on me, even if I didn't realize it: I would always take bathroom locations into account when I was traveling for more than an hour or two, and I'd be more cautious about what I was eating when I wasn't at home.  I probably know the locations of all of the bathrooms at Disneyland better than any other non-Disney employee.

The first time I remember getting food poisoning -- or what I believed to be food poisoning -- I was in my 20s.  I started to feel sick about 36 hours after I ate what I thought had caused the problem, had diarrhea, threw up, felt better, felt worse, threw up some more, and about 24 hours later felt dehydrated but basically back to normal.  Over the next 20 years this happened to me many times, probably a dozen or more.

When I was in my late 20s, I decided to become a vegetarian.  I'll go into that in another post, but suffice it to say I didn't do it for health reasons, although I did think that maybe it would help my wonky gut.  It didn't seem to really make any difference, at least at first.  But over the next decade or two, I did seem to have more serious problems with my gut (e.g., actual diarrhea instead of just feeling like I might get it) less and less often.  Maybe my body was just trying to give me a break, since I seemed to get food poisoning so much more often than anyone I knew.

Over the years, there were a few times when I got what I assumed was some sort of intestinal bug: no serious pain to speak of, but just about anything I ate would cause diarrhea for a week or so.  During those times I'd just eat as little as possible, and within a week I was feeling fine.  This type of thing only seemed to happen every couple of years.

One of those episodes started in early December of 2010, just as my wife, Jenny, and I were heading to New Orleans before going to southern Mississippi to visit Jenny's mom.  I didn't eat much in New Orleans, but by the second day in Mississippi I was pretty much back to normal.  On the last night of our trip, however, we went out for dinner, and within six hours I'd developed major stomach cramps and I knew I was in for it.  In the morning the sluice gates opened at both ends; it really seemed like it wasn't just me this time, because Jenny's brother was apparently up in the middle of the night throwing up.  I felt better by noon, so we made the trip to the airport, but that was a big mistake: I was just in the middle of the "feeling better" phase, and by the time we were sitting on the tarmac in Houston in our connecting flight, with precious little air coming out the vents, I was feeling much worse.  I ended up passing out in the bathroom and getting escorted off the plane by paramedics.  Since the only flight back to the Bay Area the next day was full, we ended up spending two nights at the Airport Hilton or Marriott or Something without our luggage.  Probably the worst travel nightmare of my life, courtesy of my wonky gut.

Then, three months later, it happened again: I couldn't really eat anything without it causing diarrhea.  On top of that, I was nauseous, and I had some lower abdominal pain, which was unusual.  After a couple of days the pain had decreased enough that I wasn't worried, but the episode concerned me a little. 

And then, after another three months, it hit again, and the pain was worse.  I decided I was concerned enough to see a doctor, and I was fortunate enough that the gastroenterologist I'd seen several years earlier about reflux had had a cancellation, so I was able to get in to see him in two days instead of six weeks.    By then the pain had decreased, but it was still there, and when he pressed in at McBurney's Point it made itself quite obvious.  So he sent me to the emergency room across the street, and late that night I gave birth to an unhealthy appendix.  Not ready to burst, but definitely inflamed.

Before the operation I was a bit nervous, but I was pretty excited, too: could it be that my appendix had been the cause of my problems all along?  Could it be that my tummy troubles were over for good?

Alas, no, it could not.  In fact, they got a whole lot worse.  A week after the operation I was back to bland but normal food, and I was having serious diarrhea, along with a fever.  I went to an emergency clinic, but they checked everything and said that it all seemed in order.  The fever eventually came down, but the diarrhea didn't stop, so I saw the surgeon for a follow-up appointment and he was concerned about the possibility of c. diff., so he consulted with my gastroenterologist and put me on the standard drug for that nasty pathogen, metronidazole; there was a slight improvement, but very slight, and when the course was over the slight improvement vanished.  That wasn't surprising, since the symptoms didn't really rise to what you'd expect to see from a c. diff. infection.  I started working with my gastroenterologist, who put me on probiotics, and a short course of Rifaximin, neither of which did more than a tiny amount of good.  He ran every test available for parasites and bugs and what not, all of which came back negative.  In the end, I was left with a diagnosis of Irritable Bowel Syndrome.  That made me very unhappy, since it was clear that although I'd had problems in the past, the current level of symptoms were somehow caused by the appendectomy.

So I started reading.  Well, I'd actually started reading whatever I could find on gut problems right after the operation, when I was still excited about the possibility of having eliminated mine.  But now that it was clear that just the opposite had happened, I was reading for a whole different reason: I figured I was my only hope.

In the end, the point that I got to was 1mg of loperamide (Immodium) twice a day.  That seems to keep the symptoms at bay 80% or so, and it's a very low dose: many people with Crohn's Disease or Inflammatory Bowel Disease take many times that amount every day.  But I wasn't happy about having to take a drug every day for the rest of my life for something that nobody can even explain.  So, based on that unhappiness and a test result that I'll go into later, I'm trying a different approach.

The End of an Era

NEWS FLASH: I had a chicken burrito for dinner tonight.

Now, for most people, that's a pretty boring news flash.  But for someone who's been a vegetarian for 23 years or so, it's a fairly important story.

Going back to an omnivorous diet -- and, initially, primarily a carnivorous diet -- after being an herbivore for so long was not an easy decision to make.  In fact, I've put it off for many months, hoping I wouldn't have to make it.  But at this point, I feel like I have no choice.  I'm not happy about it, but if my health improves, I'll consider it worth it.  Even if my health doesn't improve, I'll know that I tried, which is worth something.

I'll be going into more details about my vegetarianism, and my reasons for abandoning it, in the days and weeks ahead.  The short story is that my gut has been wonky since I had my appendix out almost two years ago, and I'll be starting the Specific Carbohydrate Diet in a week in an attempt to correct what I believe to be the underlying problem.  I tried this diet a few months ago as a vegetarian; it was virtually impossible to do it "correctly," and the attempt failed to change anything, so this time I'm trying it in earnest, which includes eating meat.  Time will tell if doing it "correctly" will have a more desirable outcome.

I can certainly use all the support I can get while I make this transition!