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.