the boomerang effect of multiple antibiotic courses to treat SIBO

So you may have noticed that it's been over 6 months since I finished my ketogenic semi-elemental diet to cure SIBO, or small intestine bacterial overgrowth.  And a whole bunch of life has happened in those months health and otherwise, but for this post I will attempt to stick to the digestive issues.

The semi-elemental ketogenic diet did eradicate the bloating and abdominal distension I would get after eating, but in about 5 days of resuming my (then) normal lacto-ovo pescatarian diet, it came roaring back, just as I feared it would.  The pounds I had  lost eating 1750 calories a day of 69% fat/ 31% protein started to creep back as well.  I was pretty disheartened.  Plus I was super itchy, which is one of the most  vexing symptoms I have suffered from due to the gut dysbiosis: itching, hives, the inability to wear anything around my neck, which is awful for me because I like my neck bling.

It was not for naught, however, because I did succeed in training my body to became more efficient at burning a higher proportion of fat at a given percentage of my V02 Max,  and this had profound impacts on my training as well as on my health.  My LT went up 10 watts. (Obviously this was through training combined with diet, not merely diet)  And of course, as my body became more efficient at burning fat, I suffered through less energy dips, hunger pangs, cravings and brain fog during the day, which is helpful not just for athletes but for those of us who have to actually work as well.

My gastroenterologist, Dr.  Farzana Rashid at Penn, suggested I try different antibiotics the second time around, so she prescribed a combination of Augmentin and Flagyl.  Augmentin itself is a combination of amoxicillin/clavulanate potassium, and Flagyl is metronidazole, so as leary as I was about taking more poison  I agreed to go on this cocktail in the hopes of knocking out the colony in my small intestine, and I started them a week later.  As you can imagine I was feeling pretty desperate at this point.  I also started Amitiza to try and move things along, as it were, but it started making me feel lousy with cramping even after two weeks so I gave up on it.  I hate taking drugs and the ones bestowed upon me by gastroenterologists never work anyway.  I'm the only person who can eat half a large bottle of Mirilax and still not be prepped for a colonoscopy.  

The drug combo certainly killed off a lot of gut bacteria  (please don't ask me how I figured this out) but again 4-5 days after stopping the 2 week course I was having SIBO symptoms again.   I was still feeling as if there were a volleyball in my stomach after eating, and since I only eat fresh foods that I purchase and prepare myself, I was really feeling that despite trying to eat a super clean and healthy, vegetarian, plant-based diet, food was becoming the enemy.  So I would go on periods where I would not eat much at all.  I was not eating any fruit or added sugars, only some xylitol on the low-carb days.  I had stopped eating a 100%  ketogenic diet because of my training schedule, as I needed some carbs to get through my workout and for recovery, so instead I adopted the cyclic ketogenic diet or CKD that bodybuildiers have been using for years to get lean.  In a nutshell you eat low-carb all week, and then have 1-2 "carb-up" days where you eat primarily healthy carbohydrates.

Then at the beginning of September I had an appointment with Dr. Shiple who had been treating me for my thyroid condition known as Wilson's Syndrome.  I had had more bloodwork and we discovered my T3/reverse T3 ratio was still not optimal despite the Armour dose so he brought me up to 4 grains of Armour per day, or 240 mg , a pretty hefty dose for someone my size.  So it was good news that the reason I had gained weight is because my thyroid was on the fritz and my cortisol levels were too high.  Shiple asked me to stop the Pulmicort and cut down the adrenal support glandulars I was taking.  And most importantly, he put me on his Leaky Gut Protocol to try and correct the gut dysbiosis, although he admitted he did not have much clinical experience with SIBO and was not sure how to attack that.  The Leaky Gut Protocol was taking Augmentin daily for a month and Diflucan once weekly for 4 weeks.  Diflucan is an oral antifungal which ostensibly would keep Candida Albicans, an opportunistic fungus that can take over when other treatments or antibiotics have supressed the immune system,  in check while the Augmentin wipes out everything else.  So I filled the prescription on the way home, hopeful that perhaps the third time would be the charm?  Oh my poor microbiome.  Forgive my scorched earth policy but you know I've got to rid myself of this accursed SIBO.

day 14: keto-adaptation accomplished, but what about the SIBO?

Sunday August 19, 2012

This morning I went on another road ride, even though after the ride yesterday I only had a teaspoonful of honey in my tea for my recovery carbs.  Not much for glycogen replenishment there.  However, perhaps by sheer force of will I kicked ass on today's ride considering my only carb dose was the same mix of coconut juice, fresh-pressed watermelon juice (pulp strained out) and a splash of tart cherry juice.  I also sucked down an entire flask of raw honey.  I can tell my body has keto-adapted  because I can pull up front at sub-LT power and still be burning a much higher percentage of fat than before I started this experiment.  My metabolic efficiency has really increased.  My average power for the ride was squarely in the endurance zone so I was happy.

Later in the day however, my mood tanked, and I'm not sure why.  Mostly likely because  my body was so tired after the ride and dog walk, or it could have been my disgust that I wasted an entire Saturday afternoon and evening on a weekend when I have a ton of stuff to do with some stranger that now I have to cut loose.  I should be delighted that all of my goals for this diet have been met: I made it the entire 14 days, I'm lean, I worked out my new Paleo diet, I food shopped, I took care of my work and my animals, and I am proud of myself.  However, the original reason I went on this diet was to cure my SIBO that was resistant to Rifaximin and Neomycin, and I think I'm truly terrified to start eating normal food again.  I'm afraid to be back in the same damn place.  Well, at least I learned we all can thrive with a lot less carbohydrate in our diets.  Trust me if I can do it as an endurance athlete, you can too.

day 13: cycling in the carbs for the road ride

Saw Mill climb on ketogenic semi-elemental diet.  ouch.

Saturday August 18, 2012

So today was the final weekend of the diet and I was determined not to have to bail on my Saturday ride like the week before when I was barely keto-adapted.  The group road ride was very tough on a liquid diet, and while I did not eat carbs all week, I had to drink some on Friday to try and flush some glycogen in my muscles or I would never make it, that much I knew.  Then of course during the ride on Saturday morning I drank fresh-pressed watermelon and tart cherry juice mixed with coconut water  plus an entire flask of Hammer Gel, which meant I did have fructose, and maltodextrin actually, but it worked!  I did it: I somehow survived a 3-hour group road ride and I was up front pulling a lot as usual.  I could not believe I was 4th out of 16 up the Saw Mill climb which was incredible because my legs were just screaming in agony.   And granted I usually pull to keep the pace of the ride steady, which means, for those of you who are not cyclists, I am often the person (or persons, if the group rides 2 x 2) up at the front of the group taking the brunt of the wind and doing 30% or more work, measured in power, than those behind me who I am "pulling."  I was pretty amazed I made it to the end of the ride.  I averaged 191 watts for 5.5 minutes up the hill, which might not seem like much until you realize I did it after losing 14 pounds in 13 days and ingesting a liquid, ketogenic diet consisting of nothing but coconut oil and casein.  I was tired by the end of the ride though and most of the day afterward which is not like me, I mean really, truly spent.

A guy from Colorado who I met online showed up on my doorstep and so wanted to just spend the night here, but I was not having it.  He was back on the East Coast to visit his family and was en route from DC to Long Island so it was not terribly far out of his way, but I was too tired for an extended visit, and my exhaustion probably contributed to him getting on my nerves.  It does not take much when you have not eaten food in 2 weeks.  So I sent him on his way.

One more day.  Piece of cake.

the ketogenic semi-elemental diet day 12: chasing sheep on a low-carb diet

Santa Fe, NM 2004

Friday August 17, 2012

Well I have to say the tossing and turning at night is getting old, and I never was one to thrive on chronic poor sleep, especially as an athlete.  I am reading on the forums that is's pretty common to sleep like shit on a low-carb diet, which might be another reason I might want to reconsider continuing this long-term.   I was psyched that I am 118.4 this am; it looks like unless the carbs I will eat today and tomorrow for the 4 hour road ride interfere with fat loss (hypothetically they should not because even though I will take in extra 300 kilocalories as carbs tomorrow above the 1650 allotment for the day,  I usually burn anywhere from 1400 to 2400 on a typical Saturday ride.)  I'm going to have 56 g of carbs today, which is well above what I've been consuming in order to finally get my blood ketone levels up to where they've been the past couple of days; and I'm curious to see how that will affect the ketone meter tonight.  According to some, once you have keto-adapted you can actually creep up your carb intake a bit, although it seems most have to stay around 50g per day.  Just as a point of reference, there are around 60g of carbs in a large baked potato, and about 31 in a large banana.  So for a daily intake, 56 grams is pretty darn low.

I started this diet at 132 lbs, although I had gained 5 lbs while on the antibiotlics for the SIBO, and that was mostly water, but so far I am down 14 lbs in less than 2 weeks.  Wow.  A lot of that is water, and unfortunately a decent amount is lean mass too, and although my stomach is flat I still have a layer of fat over my midsection which has to go.  My body composition is probably around 17%; I would prefer it at 14% with me at around 115-116 ish, which is where it was a few years ago before the SIBO started.  The challenge will be to do this while eating food.  I'm going to have to count calories for a couple of weeks which I hate to do because it's obsessive, time-consuming, and completely goes against my belief that eating healthy, nutrient-dense food should be a pleasure and the shortest route to a beautiful lean, strong body.  I hate to obsess over macro-nutrient partitioning when I would rather spend my time using my creative energy  to create delicious, inventive, healthy meals that satisfy AND nourish.  But I will have to suck it up initially as this is a scientific experiment after all and the results will mean nothing without some hard data as to calories and macro-nutrients.

My plan now is to finish out through Sunday on the semi-elemental ketogenic diet, and then continue to eat keto for the week with food and keeping my carbs less than 30g per day and see if I ever get that energy spike they talk about on the bodybuilding forums.  No matter that I'm only in the gym three days a week, and my needs as an endurance athlete are very different from those of a gym rat.  I know, I know, I do lots of cardio.  I have pretty much decided through more research that as a cyclist the strict classic ketogenic diet as described by Lyle McDonald and many others is NOT for me, but I will do a version of low-carb diet.   The other option I am looking at is the cyclic ketogenic diet, where I could eat carbs on the weekends to fuel those longer efforts.  And then there is the question of whether or not I start eating meat again.  I am attracted to the paleo diet, but the problem with paleo is there is no dairy or beans, which means no homemade yogurt, kefir,  or hummus.  I mean if you're not eating wheat, beans or soy, and you're an athlete, you really have to start eating meat again I'm thinking.  I certainly tried the alternative.

the ketogenic semi-elemental diet day 11: ketoadapted enough to work but not to exercise

Thursday August 16, 2012

Holy shit imagine my surprise when the blood ketone meter read 1.5 millimolar today.  Break out the champagne....next week when I can actually have some carbs.

So according to Phinney I should be pretty keto-adapted with that reading, and although I felt better today at work than in the prior days I was not energetic, and I need that zest in order to not have to force myself to get through a workout.  I had about 20g of carbs today in the form of two teaspoons of honey and still tested at 1.5mm.  I ate the carbs in anticipation of my usual Thursday hour trail run with Madison and Chloe, but after working my leg routine yesterday without glycogen to help recovery I just could not push myself to do it.  Which sucks.

So I decided I am going to stick this stupid semi-elemental ketogenic foodless fortnight out until Sunday even though clearly the casein is not agreeing with me as I am getting a little bloating and I'm incredibly itchy and even have a runny nose.  Some might say that is a detox reaction but if you read the The China Study you discover that in fact; casein, or milk protein is a potent cancer initiator so it's hard to imagine I can be detoxing while consuming 3 scoops a day of the stuff.

I saw Dr. Mathews today, my incredible chiropractor who does ART and Graston technique and basically allows my body to withstand all the hard work I put it through.  He worked on my muscles and bones for an hour and said I was super tight.  As he was scraping that metal rod along my very sore hamstring and I was trying not to scream he remarked how skinny my legs looked. Sadistic bastard. He said they were even thinner than after the water fast, which tells me I probably lost more muscle mass that I would have liked, but welcome to hypocaloric diets.  I can gain it back as I'm in the gym 3 days a week.

Tonight I had a Match.com date with a guy from Long Island who was down in Philly on business.  He is a nice guy and we met at the outside bar at In Riva in East Falls, but after half an hour I was tired and a little bored.  I had told him about the diet, and urged him to eat even though I was not going to, but he was polite and declined.  He gave me some samples of some vitamins from a company he was representing which I thought was sweet since he had no idea if he was ever going to see me again.  The samples had fructose in them though, so I could not use them.

So I remain optimistic that I can get through this until Sunday now.  I'm in the home stretch.  I have to say it's nice to be 119 lbs again.

day 10: the switch to keto-adaptation?

what lunch used to look like

Wednesday, August 15, 2012

So I woke up almost another pound lighter, and losing a pound a day means I am losing too much muscle mass, so I bumped up my calories a bit from 1620 to 1750.   I've eaten nothing but liquid calories for 10 days now, but I'm still somehow getting a little fullness in my abdomen in the second half of the day.  I don't know if that is from the bacteria ingesting the casein, which I suppose would not have happened if I stayed on the elemental diet; that is, straight up amino acids rather than casein protein, since that way there would be nothing for them to digest.  I'm not eating fiber or anything one would think would produce any gas or create bulk.

This is the third day of zero carbs, and I am still feeling joyless.  I am really considering quitting before the 14 days are through, as it is starting to seem pointless, all except the weight loss that is.  My goal weight is around 118 and I'm just about there, but I need to be there when I have energy to fuel good workouts and everything else I accomplish in a day; plus I need to do be eating actual food.  I did do a full workout this am: 30 minutes on the  bike, an hour lifting and 20 minutes swimming laps, but it did not feel great.

My blood ketones were down to 0.8, I have no idea why.  Especially with all of the medium chain triglycerides from the coconut oil; but I guess this keto-adaption can take a month or more, as I was warned.

Anyway, I was debating all of this, then suddenly around 5 pm something shifted, and I felt almost, well, normal.  I wonder if I'm finally adapting.  So I can't quit now.  Let's see what happens tomorrow.

please, please don't EVER send me flowers like this. ever.

yes, that's a little red yorkie with devil's horns, a pitchfork, and a collar that reads, "a-dog-able."  

[excuse me while I puke]

So I was down in the kitchen today at work getting my low-carb lunch together when I man came in and asked for my co-worker, who had left for the day.  I said I would sign for the flowers, probably a little miffed that they were not for me....that is until I got a better look at them.

As I was scanning his clipboard and deciphering where to sign my name the deliveryman pointed to the flowers in a voice that was two pitches too high for his stature and said, "Check it out!  it's a little dog."

I handed him back the clipboard and looked at the little red monstrosity with one eyebrow raised suspiciously.  So it was.  A Yorkshire Terrier, perhaps my least favorite dog in the entire universe, fashioned out of carnations, which I always considered a white-trash flower.  How perfect.

I could not wait to get upstairs so I could snap a picture and blast it out to Boss #1, Boss #2, and Sock:

check out the gay flowers Gordon got today.  Yes that's a little gay dog with devils horns and a pitchfork.  I hope he gets laid tonight.

Yes, you see, the intended recipient of this horrid little floral confection was none other than a man, who happens to be a salesman for a commercial flooring company.  Construction, a totally macho industry, and he happens to have a girlfriend who enjoys sending him flowers.  Like every month.  It's bad enough that my co-worker gets more flowers than me, but perhaps the fact that that co-worker is a dude makes it easier to swallow somehow.  Maybe.  Actually the last person who sent me flowers never revealed him or her-self, so it's been a while.  And I had to lacerate my own kidney just to get those!

Of course after I texted this picture to the other office people, and some of the guys in the field, and even a customer or two, I don't think she will be sending anymore old-lady dogs sculpted out of old-lady flowers to Gordo.  He's getting a lot of grief.   And seriously, if the next floral delivery man is not bringing a bunch for yours truly, said flower-bearer might just get a black eye.  I've had it!

Here are the rules: No carnations or red roses.  I prefer orchids anyway.  And honestly if you just can't decide on the flowers I really love dark chocolate with almonds and sea salt.  70% cocoa or higher.  Just in case.