The Food Is Terrible. And Such Small Portions. (Confessions Of A Fresser)

Relying on the Borscht Belt humor to provide a gateway into my subject matter, I want to mainly reflect on my experience with a low FODMAP diet, both the immediate sensations during it all, today begins the sixth and final week, and as a gateway into my troubled relationship with eating too much, having done so over a good chunk of my life.  There must be a zillion other essays written by overeaters about their experiences and possible lessons learned.  The bit of novelty I can add with mine is incorporating some knowledge of behavioral economics/decision theory into the narrative, which might help to explain my approach, and possibly be of use to others.

I wrote the above yesterday.  I will try to finish off the post today, aiming to conclude with a sketch of my daily diet as of late. 

Let me begin with the symptoms I had (and still have, though to a lesser extent) that got me to seek help.  A few of these were probably there for some time already before I knew I had a problem - a growling stomach, excessive gas/flatulence, and more recently a feeling of being full after eating only a little bit of food. I'll get back to that last one as it relates to the overeating issues.  I got a mild  case of Covid during the return from our Christmas vacation to visit my younger son in Seattle, and the feeling full thing happened during that.  The Covid manifest as a bad head cold for a couple of days - there never was a fever - and then a lot of congestion after that that lingered for perhaps 10 days or so.  Almost immediately after that concluded I started to experience stomach pains, rather intense, and for me debilitating, which means I was unable to concentrate enough to write a blog post like this one.   Also, the stomach growling and gas/flatulence seemingly intensified.  The former would sometimes happen at night and keep me from going back to sleep.  The latter would sometimes produce chest pains that I was quite convinced were not related to heart issues.  

I had my semi-annual appointment with my oncologist near the end of January.  (I had been treated for prostate cancer in 2018 and this was part of the routine follow up.)  These visits sometimes would wander over a variety of topics - my writing, for example - and not just be contained to my health issues, narrowly conceived.   At this one I complained about the stomach pain, even though I thought it was outside of his jurisdiction.  He said otherwise and got me a referral to a digestive health specialist.  Scheduling healthcare appointments for non-life-threatening illness being what it is these days, it took not quite three weeks before the appointment actually happened.  

At the appointment we discussed my symptoms, a modest physical exam was performed so she could feel and listen to my abdomen while I breathed deeply, and then a variety of tests were prescribed as was the low FODMAP diet.  The first test, done a few days later was a breath test, which confirmed that I have SIBO and led to the prescription of a rather strong antibiotic, Xifaxan.  I had to wait another week for the second test, providing the lab with a stool sample, because I had been taking Prilosec and she wanted me to stop taking it for a week to not confound the test results.  I did that and have not resumed the Prilosec since.  That test turned out negative for H. Pylori, which I take it means I don't have ulcers.  The third test, really two different tests on the same day, is an endoscopy and a colonoscopy.  We agreed to schedule this, as the lag for getting an endoscopy is quite long, but would cancel it if the symptoms were gone.  At present the symptoms are still there.  The procedures are scheduled for April 13.  I hope there is improvement between now and then, but for the time being I'm expecting to still have the symptoms.  After these procedures I hope to have a better sense of the cause(s) for my digestive health issues.

Now let me drill down into the diet and how I tried to manage it.  At the time my wife was on her own self-imposed regime, a no-alcohol February and an Atkins diet.  The no alcohol part overlapped with my agenda. The Atkins diet part meant that apart from a protein at dinner time (typically chicken breast or fish) we were eating separate foods.  So I needed to plan what I would eat and when during the day I would eat it.

The low FODMAP diet is somewhat daunting, particularly at first.  The big deal is no lactose (originally I took this to mean no dairy products, but I learned that certain aged cheeses, cheddar is one of them, lose most of their lactose over time so are okay on the diet) and no wheat (so no bread nor the Bran Buds cereal that I favored as part of my breakfast).  Basic microeconomics assumes that more choices are better, but when there is so much uncertainty about what makes sense to do, developing a routine is really the thing to do.  Having a routine reduces the uncertainty and thereby lessens the chance of making decisions that ultimately go astray.  So, some of my immediate goals were centered around finding a routine for my eating.  

I want to consider this relative to the food culture that many of my peers participate in.  There are many posts in Facebook from friends which feature interesting foods, either prepared by the author or purchased at some restaurant.  In some sense these photos are substitutes for photos of their cats (or their grandchildren).  The photos send an indirect message.  Eating should be an engaging activity, with the variety and the quality of food preparation part of what engages.  As a fresser, I confess that quite frequently I've found volume of eating more important than the quality of what was eaten, though the two are really complements not substitutes.  

But now, with the stomach pain and the feeling full happening early in the meal, I needed a plan for eating less.  Having the meals be okay but boring, in the sense that it's the same as what was eaten yesterday, became part of the plan.  Boring is good in this context.  I also learned that sometimes I had to walk away from the meal halfway through, to return sometime later to finish it.  With that I basically did away with seconds at the same sitting. I'd eat what was prepared and when I was done that was it.

Let me get to some other issues one has to grapple with in following a diet like this.  One is how much of a stickler one should be in following all the rules.  Here is one example.  I learned that the canned tuna packed in water for brands we are familiar with (I'm a Charlie the Tuna guy) are actually packed in vegetable broth.  So I searched online and found another company, Wild Planet, that really does pack its tuna in water.  I ordered some of that.  It tastes a little different than StarKist.  But does it really matter for staying on a low FODMAP diet?  When I ordered it, I thought it might.  Now I'm less sure.  I found a recipe online for low FODMAP ratatouille and had my wife make a batch.  (It has since become my go to way of having the same vegetable dish from one day to the next.)  The first time around, the color was a bit weird and my wife complained about the fresh tomatoes being out of season.  The next time, on her own initiative, she used canned tomatoes and has been doing that ever since.

Another issue is how much to experiment with foods specifically designed for a low FODMAP diet.  In the days prior to these health issues I would like to start the morning with a treat to go along with my coffee.  A blueberry fritter from Schucks is one of my favorites.  A chocolate chip cookie from the Art Mart is even better.  So I found some vegan, probiotic alternatives and ordered a couple of them as alternative.  One I didn't like much.  I stuck with treats from Belli Welli and now get both their chocolate chip cookie and their blueberry muffin, alternating days with each. It's pricey compared to a doughnut, but under the circumstances seems to make sense. I'll explain how it fits in with breakfast in a bit.

Another experiment, one that I tried a bit before this diet, was to have non-dairy yogurt.  I've settled on Silk Vanilla Unsweetened, made with almond milk (partly because I prefer the large containers to the ones for individual servings), and in the course of doing this tried other yogurt made with cashew milk and once oat milk.  I definitely want to go back to dairy asap.  And a couple of times I've had my cereal and fruit without any yogurt at all, which wasn't too bad.  I've finally concluded to have a more modest amount of yogurt than I would if it were dairy.  I won't advocate for this solution, but I can live with it for the rest of the diet.

Then there is the matter of portion size, for individual foods and for entire meals.  In my not entirely thorough reading of what is allowable under a low FODMAP diet, certain foods make the list if they are eaten in modest quantities.  I found this less than satisfactory because the unit seems to be per meal, rather than per day or per week. That didn't make sense to me. There is then the issue of how many meals per day.  I'll get to my answer in a bit.  On the portion size thing, I'm one who'd rather eyeball the answer than to measure out each thing exactly.  (The one exception is the amount of water to add to the oatmeal before putting it in the microwave.)   So for foods like sweet potatoes and garbanzo beans, I'm aware of the recommendation and try to follow it, but only with an eyeball approach.  

Now let's consider factors that make it easier to stick with the diet and then other factors that make it much harder.  I've lost about 10 pounds since starting with the low FODMAP diet and it turns out (not surprisingly to my friends, I'm sure) that I'm quite compulsive about weight loss, as an end in itself and because of improved appearance (manifest in the ability to wear clothes that I had stopped wearing 30 years ago).  So, that sticking with the diet is associated with weight loss makes it easier for me. 

Indeed I had a period of my life, from summer 1976 through summer 1992 where I was almost normal in my weight, after having gone on a crash diet and losing about 45 pounds and then finding a reasonable balance between my food and drink excesses and the amount of exercise I would get.  My weight then was about 210 pounds for much of the year.  It might get as high as 220 during the winter, when I wouldn't get as much exercise, but then come back down again.    I'm now within ten pounds of that earlier norm and reattaining that weight or possibly getting even lower than that seems within reach.  That's quite a motivator.  One wonders why it wasn't as strong a motivator over other portions of my life.  Here's a bit of background about why weight gain returned for me.

In August of 1992 our first son was born.  Parenthood was great, but the lack of of sleep that goes with it somewhat crippled my defenses to sweets, other junk food, and alcohol.  I became a campus administrator for ed tech in summer 1996 and the increased stress from that was substantial and almost immediate.  The weight drifted up a little more accordingly.  A breaking point was reached for me right around 9/11.  Jogging had been my go to exercise after tennis and golf became somewhat untenable.  But my knees couldn't take it and I had to stop.  Foolishly, I didn't find walking as an alternative for quite some time.  And the job stress mounted more after my little ed tech unit merged with the big campus IT organization, ultimately taking much of the pleasure out of the work I was doing.  My weight really ballooned after that until September 2006, when I had a serious fall that ended severing all the ligaments between my left thigh and knee.  I didn't immediately find the light after that, but found a little and did more so in retirement. where health stress rather than work stress became the driver.  

Now let me mention some good news, which I didn't anticipate in prospect but is evident now, regarding the health benefits from losing weight.  My blood pressure is much more under control now, sure, but I don't associate high blood pressure with physical pain.  What I'm referring to is pain in my right hip and lower back.  I had been x-rayed some years back and learned I was a candidate for a hip replacement. I ultimately decided to delay that for fear of developing an infection. 

The idea that food (and drink) might serve as an escapist way for dealing with stress is certainly not new.  Here I want to point out that it should be considered a bad habit rather than a rational response to stress, which is obvious yet I think it is worth considering for two reasons.  One, the habit likely develops well in advance of the evident stress, so it is "available" when the stress occurs.  For me, this happened as a teenager with overeating, particularly with regard to various issues I had with my mother, where nominally she had authority over me yet I felt no real basis for that.  I discussed this at some length in my post The (Not So) Mystical Mom.  The other reason is that once the stress is manifest, you look for easy outs rather than try to develop rational responses then and there.  So, unless a rational response was anticipated in advance to address the situation, it likely won't be forthcoming at all.  And then there is a negative feedback loop between the source of stress and the bad habit to make the situation seem even worse.

Returning to the hip and lower back pain, I found it limited me in how much walking I could do.  Eventually, I took up walking on the treadmill instead, because there I could use my arms to take hold of the handrails, bearing some of my weight that way and thus taking pressure off my back, so being able to walk longer as a result.  But I continued to try walking outside as an alternative.  As I lost weight, I found I could go a longer distance without needing to sit to take the pressure off my back.  (Recently, I've been able to go about a mile and a half before needing to take a break.) With that discovery, I'm wondering whether I'm still a candidate for a hip replacement or if I can just go on as is, which would be my preference, as long as I can do the long walks. 

Another such discovery happened quite recently, during the low FODMAP diet.  I have been having issues with constipation, which the diet seems to have exacerbated.  I read somewhere that taking muscle relaxants might make constipation more severe.  I had been taking them for quite some time to deal with issues related to a compressed disc in my neck.  I would get spasms in my left arm and then the area above the wrist would seem to cramp up, which was quite painful.  But I deemed the constipation as the more immediate concern, so I stopped taking the muscle relaxants, under the proviso that if the issues returned I'd resume with them.  So far, those issues haven't returned.  Could losing weight be the reason?  I really don't have a clue as to the answer.  But it's nice to imagine that it is.  

Alas, some other health issues don't seem to be related to my weight.  I've had a rather large cyst on my left shoulder for at least the past 5 years (and maybe a good deal longer).  Recently, it got infected and looked like a big bright red bump.  It was painful.  After a week or so I decided it wasn't going to go away on its own, so I went to Convenient Care.  The doctor prescribed an antibiotic, Bactrim.  For two days I took that and the Xifaxan and had to make sure they were sufficiently separated by ingest time to not interfere with each other.  Then the Xifaxan prescription expired.  I worried that the Bactrim would interfere with the digestive health issues, but I subsequently learned that sometimes it is prescribed to treat SIBO. So my gut may have gotten an unplanned boost from that.  Perhaps 5 days later the abscess started to ooze on its own accord.  It was even more painful then.  Indeed, I would say that pain was more severe than the stomach pain, so it became difficult to determine whether I was making progress with the latter or not.  

A couple of days later I went back to Convenient Care, this time seeing some nurses.  They ended up squeezing out a good bit of the infection from the wound.  It was very painful while they did it.  And the entire experience was quite stressful for me because I like to prepare myself mentally some before a procedure such as this is done.  In this case they told me one thing, that I'd get an injection to numb the area and then they'd cut open the abscess, but ended up doing another, no injection and no cutting, just manual pressure to get the gunk out of me.  I was unnerved for the rest of the day as a consequence.  I should report that after that there was much less pain.  And tomorrow I have a consult with a general surgeon to see whether something more needs to be done to get all the infection out.   That there is a lingering infection definitely is a worry.  

The other main physical pain is in my feet, where there is chronic puffiness, some of which is surely arthritic, and perhaps some other cause as well, gout perhaps.  The right foot is worse than the left.  I had a stress fracture in the right foot back in 2018 and I thought that perhaps I had done it again last summer.  The Podiatrist said no.  I looked at the x-ray.  Instead of individual bones for each toe, it seem to show one big blob, as if the bones fused in some way.  I don't know.  This stuff is beyond me.  I can say that is hurts simply to push on the brake pedal when I'm driving.  This issue, I take it, will be with me for the rest of my life.  So I've got to deal with it, one way or the other.  

The last health issue I will mention here is what I call old-man disease - having to go to the can at night multiple times.  Whether this was caused by the prostate cancer or not is moot, from my perspective.  I do take Flomax to regulate the problem.  The real issue is not having to get up to go to the john.  It is whether I can get back to sleep in a reasonable amount of time afterwards.  If I can get back to sleep each time, the night is a success.  If I can't, I'm worn out the next day and lacking in energy (though perhaps surprisingly I seem to get better at doing the NY Times Spelling Bee,  Some things maybe are better done on autopilot.)  This too is a an issue I'll deal with for the rest of my life.

There are, of course, non-health sources of stress.  I'll mention two serious ones and one other that many will find ridiculous.  The first is our national politics, no surprise there.  The second is related to the volunteer work I do, for a human rights organization in Uganda.  There is inherent stress in this but what is happening Uganda now regarding the Anti-Homosexuality Bill and related consequences is truly horrible.  Then, there is being a fan of Illini basketball.  Even though I no longer go to games I do invest myself in watching them on TV and wear the orange garb while doing so.  

This is a good lead-in to the behavioral economics approach in managing how to deal with stress, particularly the excess eating and drinking.  First there is the idea called hyperbolic discounting - meaning that what is "optimal" to do will seem different at 7 AM in the morning over the first cup of coffee from how it looks at 6 PM at night, where the temptation to have a drink or a highly caloric snack is more immediate.  Non-economists will talk about impulse control, much the same way as others talk about deferred gratification.  But behavioral economists take a different approach - nudges.  (See the book by Sunstein and Thaler.)  A nudge is a change in the economic environment made beforehand to raise the cost of unhealthy behavior and thereby promote the healthy alternative.  When I was single, one of the nudges I relied on (though then I hadn't yet heard the term nudge) was to never keep ice cream in the apartment.  I could have ice cream with colleagues when we took our afternoon walk to Baskin-Robbins, but not at nighttime.  Nowadays, my big nudge is to go to sleep early.  (The move to Daylight Savings Time has changed when this is on the clock.  Think of it as just around sunset or 7 PM, whichever is later.)  My urge to have a drink or an unhealthy snack is much greater at night.  Further, if I already know that I will go to sleep early, I can more readily show some discipline in the evening.  It seems then that I don't have to hold on for so long.

Here's how this nudge has worked in practice as of late.  If the day is ordinary from a stress point of view, I won't drink and I will stay on the diet.  In contrast, if the day has an unusually high amount of stress, then I'll have a drink.  After this, my willpower will be less.  I likely will have another drink.  I may then go off the diet portion-wise (eating more of what is most attractive or having another breakfast treat).  The ordinary days string together, maybe for a week.  The high stress days are typically one and done.  I already mentioned the return visit to Convenient Care and the stress that ensued.  I drank that night.  A week later  I drank when Illinois stunk it up against Arkansas. (Even though Arkansas subsequently beat Kansas, the number 1 seed in the region, that was small consolation only.  It should have been Illinois that beat Kansas.)  A couple of nights later I didn't sleep well at all.  I drank the following evening.  I'm hoping the sleepless nights are few and far between, but it is a real concern. 

The effect of this behavior on weight loss is something like two steps forward and one step back.  Also, it must be that though drinking is said to dehydrate you, I retain water in some way when I'm drinking.  Not drinking for the next day or two seems to produce larger weight loss than usual the following morning. That has to be due to water loss. I'd like somebody who understands this stuff to explain what's going on here.  For me, it's a bit of a puzzle.

Let me get to the diet itself.  In the ideal, I drink one glass of water for each of the first two or three cups of coffee and then continue drinking water for the rest of the day. For the first glass of water, since I need to take my morning pills, it is pretty much a no-brainer.  Thereafter, it's more of a struggle and some days I do this better than others.  Once I've had my fill of caffeine I'll switch to decaf, though recently I've taken the second cup to be decaf and have more caffeine later.  Someone needs to fill me in on whether water and decaf are reasonable substitutes or not. I hope they are.

Somewhere in the middle of the first real cup of coffee I'll have the Belli Welli breakfast treat.  (This is usually after doing the Wordle but still in the middle of the Spelling Bee.) About an hour later I will have the real breakfast - now half a banana sliced up, maybe some blueberries or strawberries added, some non-wheat cereal and the delightful yogurt.  Most days I use a round bowl which holds a fair amount of the stuff.  Some days I use a flat bowl which holds less.  It is one bowl and done.  Then nothing to eat till lunch.  Every third day or so I change the routine by having oatmeal instead of yogurt.  Some salt is added but it is otherwise not doctored with sweetener, milk, or butter.  I do put sliced banana into the oatmeal.  Then a few blueberries or strawberries will be served on the side.  Compared to what I was eating before the low FODMAP diet, there was a full banana sliced into the yogurt with Bran Buds, and I would frequently raid the refrigerator a couple of hours later.  I don't do that now.  Truthfully, I'm rarely tempted to do so, but maybe this is the digestive health issue rather than any discipline in sticking to the diet.  

Lunch is typically a salad.  I used to favor salad kits that featured some version of Caesar Salad.  But now the croutons and Caesar dressing are out of bounds.  So I get a bag of greens, some cherry tomatoes, a protein source (either from dinner the night before or canned tuna) and then some other fixings that vary - possibly a bit of sweet potato, possibly a few garbanzo beans, once or twice it has been white rice, and maybe some bits of cheddar cheese.  I will mix this all up in a big bowl and use Balsamic Vinaigrette dressing.  I'll eat half the day I make it and the rest the following day.  I use a small flat bow for serving the salad, so that even with half of the big bowl, it takes two servings in the small bowl to make a meal, the only time I allow myself to have seconds.  Every once in a a while I will have something else instead of  salad.  I will microwave some green beans (for 3:45 on high power).  I serve those without seasoning or dressing.  I actually like the taste of the green beans themselves.  I'll have that with some protein and maybe a starch as well.  The rice I get is in one-serving containers that can be microwaved.  That or a bit of sweet potato would be the starch.  

An afternoon snack is planned roughly 2/3 of the way between lunch and dinner.  My go to food during the diet has been cantaloupe.  I will go back to apples eventually, and then have cantaloupe as part of lunch.  But apples are not low FODMAP.   Somewhere in the afternoon I will also have a cup of chicken broth made from Wyler's powder.  Its a diversion from the decaf.  I don't know if it has any other nutritional value than that.  

There is then a regime of pills and eye-drops, that lasts about 90 minutes in total.  (There is a lot of downtime between the various steps in this regime.)  After it is over dinner is served.  Some nights there will be a protein made by wife.  Tuesday and Thursday there is fresh fish at the market.  We get either salmon or cod.  Chicken breasts, cut up into smaller pieces, are also a mainstay.  Last week we got smoked turkey from Indian River Smokehouse, which I thought quite good eaten plain, without gravy and without any side dishes.  Ratatouille is the main vegetable dish.  My wife will make bok choy every once in a while.  And then there is a starch of some sort.

My attitude about eating starch as part of the diet has changed as a consequence of recent experience.  The portion size question, when it is not the low FODMAP diet itself which determines that, is still something I'm trying to master.  Smaller portions overall would seem to indicate more rapid weight loss.  But depriving yourself too much, even if currently overweight, may be counterproductive.  I found that around week three of the diet I would sometimes have rather intense headaches in the morning.  I wondered whether dreaming itself might produce that or if it was something else, possibly dehydration or low blood sugar, or the two in combination.  I found that the headaches would be gone after the morning pills, the first cup of coffee, and the breakfast treat.  So one wonders whether the headaches can be avoided by eating a bit more starch the night before.  Likewise, sometimes I feel little oomph during the day, even if my sleep was not bad the night before.  Might a bit more starch help with that too?  Getting the magnitudes right seems more art than science at this point.  But I'm convinced that for diet to achieve weight loss, slow and steady wins the race.  That's the goal.

The question, entirely open now, one I will pursue seriously if the stomach pain goes away for real, is whether this approach to diet with a meal plan of this sort can still work for me.  I'm thinking that maybe it can.

Then again, the Illini better have a good basketball team next year.