How To Eat: Retraining Your Dietary Habits
The Organ System clock according to Classical Chinese Medicine.
You may be thinking, I know how to eat - you put food in your mouth and chew it a little then swallow! Simple, right? Actually, no. Eating is a very complex and sacred act that involves a lot more than your mouth. It involves your mind, body, and spirit. For those of us with compromised digestion, we must adhere to some important rules in order to properly digest and absorb all that we can from our foods. You were taught as a kid not to waste food, right? Well, food waste doesn't just happen when you throw your half-eaten banana in the trash; it happens when you don't properly digest and absorb what you put in your mouth. Not only that, but improperly digested food is more than wasteful, it's harmful. In Ayurdeva, the ancient Indian medical system, improperly digested food leads to the formation of a toxic, sludgy substance in the GI tract called ama. A famous American pediatrician in the early 1900's, Dr. Samuel Gee, wisely stated, "We must never forget that what the patient takes beyond his power to digest does harm" [1].
Here I will discuss what you can to digest your food better, whatever it may be. What to and what not to eat will be discussed in the next sections.
1. Food Combining
The first thing that we should know when eating is that certain combinations of foods are easier to digest than others. Developing an understanding of proper food combinations has helped me tremendously in improving my digestive health. Chinese Medicine has been studying this for thousands of years, and most traditional diets have rules as to proper food combinations. I have studied and experimented with the rules of proper food combining that come from Chinese Medicine, so I will explain them here. Proper food combining is important for all people with impaired digestion, but it is especially important for CFers who have all sorts of malabsorption issues. When I eat proper combinations I digest better, avoid G.I. problems (gas, bloating, stomach aches, heartburn, intestinal cramps, constipation, diarrhea, etc.), and since I digest quicker this way, I am able to eat more, which is very important for those of us trying to gain weight or keep it on. I think proper food combining is especially important for those dealing with gastroparesis, or delayed gastric emptying.
The basic rules are:
A. Eat protein alone or with green/non-starchy vegetables.
B. Fats can be eaten with:
1. green or non-starchy vegetables and/or starches, OR
2. fruits.
C. Starches can be eaten with green vegetables and/or fats.
The chart below is very helpful. It is from Paul Pitchford's Healing with Whole Foods [2] and is based on principles of Chinese Medicine. Please note the special combinations he outlines at the bottom. The only additions/modifications I have made to this chart is that I consider nut butters to be a fat, since most contain at least two times more fat than protein. When fat and protein are equal (as with cheddar cheese, for example) or when protein is slightly greater, I consider that a protein. I have also found that some subacid fruits like apples and berries combine perfectly well with fats like nuts or nut butter.
1. Food Combining
The first thing that we should know when eating is that certain combinations of foods are easier to digest than others. Developing an understanding of proper food combinations has helped me tremendously in improving my digestive health. Chinese Medicine has been studying this for thousands of years, and most traditional diets have rules as to proper food combinations. I have studied and experimented with the rules of proper food combining that come from Chinese Medicine, so I will explain them here. Proper food combining is important for all people with impaired digestion, but it is especially important for CFers who have all sorts of malabsorption issues. When I eat proper combinations I digest better, avoid G.I. problems (gas, bloating, stomach aches, heartburn, intestinal cramps, constipation, diarrhea, etc.), and since I digest quicker this way, I am able to eat more, which is very important for those of us trying to gain weight or keep it on. I think proper food combining is especially important for those dealing with gastroparesis, or delayed gastric emptying.
The basic rules are:
A. Eat protein alone or with green/non-starchy vegetables.
B. Fats can be eaten with:
1. green or non-starchy vegetables and/or starches, OR
2. fruits.
C. Starches can be eaten with green vegetables and/or fats.
The chart below is very helpful. It is from Paul Pitchford's Healing with Whole Foods [2] and is based on principles of Chinese Medicine. Please note the special combinations he outlines at the bottom. The only additions/modifications I have made to this chart is that I consider nut butters to be a fat, since most contain at least two times more fat than protein. When fat and protein are equal (as with cheddar cheese, for example) or when protein is slightly greater, I consider that a protein. I have also found that some subacid fruits like apples and berries combine perfectly well with fats like nuts or nut butter.
Understand that this plan for food combining is given for those of us with compromised digestion and illness. Healthy people with robust and resilient digestive tracts can be more liberal with their combinations. Paul Pitchford has a food combining chart for people without compromised digestion, but I have not included it here.
One explanation of why certain foods digest well together is that their nutrients complement eachother (eating acidic or bitter foods together with fats stimulates the release of bile from the gallbladder which is necessary to break down lipids) or that these combinations take similar amounts of time to digest and therefore minimize the risk of rot and putrefaction of foods that can happen when bad combinations slow digestion down so much that foods just sit there in your guts and are inappropriately broken down by bacteria. We want our digestive tract to move swiftly and efficiently to avoid putrefaction of proteins, rancidification of fats, and fermentation of carbs in your guts. When these three things happen in your guts, you can feel it. They can cause inflammation and bacterial overgrowth, bloating, constipation, pain, stomach aches, and heartburn.
Another explanation of why these combinations work is that they balance the yin and yang energies contained within each of the foods we eat. Yin energy is described as dark, wet, cold, female, contractive, alkaline, descending, calming, nurturing (the characteristics of the womb). Yang energy is described as bright, hot, dry, male, expansive, acidic, ascending, rushed, impulsive (the characteristics of lightning). Every plant, animal (including humans), and natural feature has a balance of both yin and yang energy, and these energies fluctuate throughout our lives and under certain circumstances. In terms of balancing the yin and yang energies of the plants and animals that we eat, it is helpful to label our foods either yin or yang depending on which energy is most dominant, although we must keep in mind that this is a simplification. If our body is overly yang we must be sure to eat more yin foods. If we are overly yin we must be sure to eat more yang foods. Our bodies need to come to an equilibrium of these two energies, or as close to equilibrium as we can get. In one meal, for example, I may combine a starch (with a yang or neutral energy, depending on the plant and how it's prepared) with a good fat (which is yin) with green/non-starchy vegetables (which are yin). That is, steamed carrots fried in lots of bacon fat or coconut oil plus a stir-fry of kale, onions, mushrooms, and garlic.
Our CF bodies are usually yin deficient because our extracellular tissues and fluids are chronically dehydrated due to our CFTR mutation. For us, yin deficiency can manifest as thick mucus, inflammation, fever, infection, high blood sugar, and lung acidity [3,4]. So in our diets we must emphasize yin foods that will calm us, thin out our mucus, rehydrate us, and cool inflammation. We also need yang foods like proteins, but they must be balanced yin foods. We must also eliminate all unnecessary yang foods and extreme foods (junk food, sodas, sugary things, low quality meats, bad fats like transfats, hydrogenated fats, and rancid polyunsaturated fats, and harmful carbohydrates).
2. Bitters Before Your Meals
For hundreds of years people have taken bitter tastants (bitter roots and herbs, which can be steeped in alcohol to make a tincture) before meals to help prepare the digestive system for proper digestion and assimilation of foods. Tasting bitterness before a meal triggers the release of the necessary elements for proper digestion, including bile from the gallbladder, pancreatic enzymes, hydrochloric acid in the stomach, pepsin (an enzyme released in the stomach that breaks down protein), and gastrin [5]. Bitter plants have been in our diets since before we became humans, and our physiology has coevolved with them to the point that we depend on their presence for proper digestion. Humans have always had the bitter flavor very present in our diets, until now. In the last 100 years of modern society bitter plants have been almost completely removed from our diets, and we can see a proliferation of digestive and inflammatory diseases as a result. The solution is to reintroduce bitters back into the diet where they belong [6]. In Europe, it is still traditional in many cultures to drink bitter herb-infused teas or alcohol before or after meals, and/or eat a salad of bitter greens like arugula before meals. These traditions have been forgotten in America, but we can reinvigorate them now. In East Asia, pickled vegetables like kimchi are often used in a similar fashion to stimulate digestive secretions before meals. Bitters can also be used after meals to prevent indigestion and post-meal heartburn. It is my firm belief that improving digestive secretions is the big missing puzzle piece to the universal CF struggle to maintain weight. Increasing the calorie content of the diet may not be effective if the ability to absorb those extra calories is compromised. In my own life I have noticed that improving my digestion has done more to improve my ability to maintain weight than increasing daily calorie intake, and bitters have played a big role in this.
Commonly used bitter herbs include burdock, dandelion, artichoke leaf, yellow dock, motherwort, gentian, and wormwood (listed from more mild to stronger) but there are hundreds of bitter herbs to choose from. Use one dropperful (1 mL) of the tincture placed directly on the tongue 10-15 minutes before eating. You need to be able to taste the bitterness in order for it stimulate digestive secretions via central nervous system enervation. Your health foods store or co-op should sell little bottles of bitters in the supplements aisle, or if not you can order them online from plenty of places. A really great company that specializes in bitters in Urban Moonshine. Also check your local farmer's market - they are all the rage right now where I live. You can even make them yourself! It's absurdly easy and dandelion grows everywhere if you hadn't noticed.
Bile Excretion and Fats
Bitter herbs and the bitter taste in foods stimulates the liver to make bile and the gallbladder to excrete it. Bile is a critical part of fat digestion, as it emulsifies fats (breaks them up into tiny globules) so that lipases have an easier time breaking them down into triglycerides for absorption. Emulsification needs to happen before enzymes can have an optimal effect on dietary fats. Some CFers may have trouble getting bile out of the gallbladder and into the intestines either because the bile duct may be clogged with mucus, or because the small intestine is inflamed and the end of the bile duct has been swollen shut. This intestinal inflammation is most often caused by eating irritating foods, but can also be caused by a gut infection (i.e. dysbiosis). If your stools are consistently gray or light colored (e.g. tan, yellow, light brown) this means that your bile production is insufficient because bile contains pigments that darken our stools. Stools can also be light colored if the diet does not contain enough bitterness in it. If I forget to take my bitters, I can see a direct affect on the color of my stools the next day. From talking to several CFers about their difficulty absorbing fats, even when they take their pancreatic enzymes as directed, it has become clear to me that bile secretion is an issue for many CFers largely caused by eating inflammatory foods and from a lack of the bitter taste in their diets. It has recently become popular for CF doctors to prescribe PPIs to make pancreatic enzymes work better (according to the theory that the CF pancreas has a hard time secreting bicarbonate which is supposed to alkalize the small intestine so that enzymes can be activated), but given the many negative side effects of using PPIs, it seems the smarter and more effective route to improving fat absorption in CFers is to encourage proper bile production and flow.
There are two special scenarios that I want to discuss in relation to bitter supplementation. The first is if there is currently a large gallstone blocking the duct that lets bile flow into the small intestine. If this is the case (and you would know it because there would be pain and you'd likely have to get an ultrasound or CT scan to see what the problem is) then your stools will be acholic (chalk-colored due to total lack of bile) and eating fats will cause you lots of pain in your right abdomen just under the ribs. In this situation, bitters should not be used because encouraging more bile flow could cause a back up of bile in the gallbladder leading to increased pressure that could rupture it. However, if you have a history of small gallstones or sludge in the gallbladder, then taking mild bitters can help keep that bile diluted and flowing regularly enough that stones can be passed and/or prevented. If your stools are gray or light colored but there is no history of gallstones and no associated pain, then it is likely that this is caused by deficient bile flow blocked by inflammation where the end of the bile duct meets the intestine, or a lack of bitters. In this case, using bitters with every meal will help. The second special scenario I want to mention is for those without a gallbladder. Surgical removal of the gallbladder is done way too often, in my opinion, (docs seem to have a policy of "if in doubt, take it out!") mostly to prevent the formation of gallstones in the those who have a history. If only those docs knew about the power of bitters! But if you don't have a gallbladder, for whatever reason, using bitters before meals is even more important than for the rest of us. In these situations, using the stronger bitters like gentian or motherwort 10-15 minutes before meals (no less) is going to be important because you are now having to rely on the liver to put out enough bile on demand, which is difficult (but possible) for it to do, so it needs a very strong stimulus.
You can work your way up to the stronger herbs as you develop a taste for it. A taste for bitter herbs is acquired the same way as for coffee or chocolate. I started with dandelion and burdock because they're the mildest and safest, but I now I find that I like the stronger bitters like gentian and motherwort.
3. Smaller, Simpler, More Frequent Meals
I have found that I am able to digest more quickly and eat much more throughout the day if I eat smaller and simpler meals more frequently throughout the day. If you have a need to gain weight, one part of your strategy could be to eat very simple, small, nutrient-dense, and high-calorie meals frequently throughout the day. In terms of macronutrients, you could have one of two choices for designing a meal: a "fat meal" or a "protein meal". Every meal should incorporate one of the these two macronutrients (but not both). I used to make my larger meals "fat meals" because fat combines with more things than proteins (as outlined in the chart above) and so I can make these meals much more calorie-rich. I used to eat protein as a snack or a smaller meal because it has half the calories per gram than fat, and digests more quickly (given adequate stomach acid). Starches/carbs are never the basis of a meal, they are only a complement, and only taken in combination with fats. I add leafy greens to almost every meal in one way or another, in a stir fry, salad, or smoothie/shake. Eating small and frequent meals is also one way of monitoring and controlling blood glucose.
4. Glycemic Load
Having an understanding of the concept of the Glycemic Index and glycemic load is very important for all CFers, because if we have a reduced ability to excrete pancreatic enzymes, then it's likely we also have impaired insulin production, as I discuss in CF 201. Using the glycemic index/load as a tool for making sure your meals won't spike your blood sugar is a very good idea. Having high blood sugar for a prolonged period of time can contribute to many of our problems including inflammation, infection, tissue degradation, hemoptysis, etc. If we can do some simple things to lower the glycemic index of our meals and prevent reactive hypoglycemia, we can alleviate a significant burden on our already overburdened bodies. With each meal we need to maximize the amount of fat, protein, or fiber so as to slow down the transit of carbs in the small intestine for a more even and steady release of sugars into the blood stream. Also choosing sources of carbohydrates with more fiber (like whole grains, root vegetables, and whole fruits) slows glucose absorption. Slowing down the release of sugar into the blood will help match our blood sugar curve with our insulin curve, to the extent that it may be possible. In addition, add certain specific foods to your meal that may decrease its glycemic load, such as cinnamon or ground flax seeds or green vegetables. However, since I've become diabetic I've noticed that adhering to a low-glycemic load diet is not enough to keep my blood sugars low. The only thing that is truly effective is eating fewer carbs, eating only certain kinds of carbs, and taking insulin when I do eat carbs. The concept of the glycemic index/load may not be useful for everyone. The more glucose intolerant I've become, the less effective eating low-glycemic load foods is for maintaining steady blood sugar. For example, eating whole-grain brown rice will send my blood sugar sky high regardless of how much insulin I take, but eating rice pasta or a rice cake (which have glycemic loads technically higher than whole brown rice) allows me to control my blood sugar much more easily. So don't rely too heavily on the concept of glycemic index - let your body tell you what foods are best for you (and test your blood sugar regularly).
5. Chew Your Food
You may think I'm silly for writing this one down, but it's not as simple as you may think. Next time you eat a meal try to notice how thoroughly you are chewing your food, especially any carbohydrates. Also, regularly inspect your stools to see what you're not digesting well. In Chinese medicine this is an extremely important thing to do, especially for those with compromised digestion. If food, specifically carbs, are not thoroughly and completely chewed and turned into a paste before moving into the stomach, it cannot be fully utilized because the particles are too big for your small intestines to absorb anything from. Carbs must be chewed and mixed thoroughly with saliva, which contains amylase, the carb-digesting enzyme. This is especially true with whole grains, leafy greens, and seeds. Undigested carbohydrates can feed pathogenic bacteria that cause dysbiosis, as we discussed earlier. Proteins also need to be thoroughly chewed so that stomach acid can work most effectively on them. Proper break down of proteins is critical to the prevention of leaky gut-mediated molecular mimicry, as I discussed in CF201. Don't wolf your food down or you'll get little nutrition from it and also cause yourself digestive upset. Eating slowly and mindfully can be a meditative practice as well, and be a necessary reprieve from a busy day. Meal time is sacred time where we give thanks for the life that we are consuming.
6. Take a walk
Taking a short, gentle walk after eating a meal, especially a big one, will help your digestive system get things moving. The digestive tract is made up of a lot of muscle and it is always moving. By taking a walk you're getting the blood circulating throughout your entire body including your internal organs. The digestive organs live right alongside the heart and lungs, and are connected to an intricate web of blood vessels. Getting our blood pumping and inflating our lungs with gentle exercise loosens the diaphragm and literally massages the digestive organs, ensuring good circulation and peristalsis (waves of intestinal muscle contraction that move the bowels). Plus, exercising muscle uptakes a lot of glucose which can prevent post-meal blood sugar spikes and resulting crashes. Exercise also increases insulin sensitivity. In addition, getting fresh air and being outside is enjoyable and good for our spiritual and mental health, and the calming effect it can have can help us move into the parasympathetic "rest and digest" mode.
7. Keep a Food/Health Journal
Keeping track of what you've eaten, when, what happened during your breathing treatments, what your sputum looks like today, what your energy is like, what meds you've taken, what your poops look like, and how much exercise you did is a very important part of being an empirical self-healer. Doing this will help you map trends and figure out what actions caused what results, and how that hurt or helped your health over a longer period of time. This tool has been invaluable to me. Also, while I am not a fan of calorie counting in general, I have at times used a free online calorie counter called Cron-o-meter to help me in my efforts to gain weight.
8. Drink More Water
It seems simple, but this one is hard for me. I am pretty much never thirsty, so I have to remind myself to drink water outside of meal time. There is a reason for this. Due to the defect in the CFTR channel, there is not enough chloride moving out of the cells into the blood and other body fluids. Your body detects whether or not it's dehydrated by the balance of electrolytes (salts) to water content in your blood. In a normal person, when they are dehydrated the blood has too much electrolytes compared to water, and so a thirst response is triggered. In CF, the blood is always slightly low in electrolytes, so even when we're dehydrated the balance of electrolytes to water does not trigger the body's thirst response. So we unfortunately can't rely on thirst to tell us when we need to drink water. Since CFers are constantly fighting infection and flushing toxins and drugs out of our systems through our kidneys, we actually need to drink a lot more than healthy people.
So drink whenever you remember to. I keep a water bottle with me at all times. Drink when sitting at your desk, when on a hike, when in the car, when on the train, when picking your nose, when on the toilet, when... just all the time. The only time it is not ideal to drink too much is during mealtime, as it may dilute digestive secretions. Your CF doc has probably told you that you should also be eating (and drinking) more salt or electrolytes. This is because we're low in salt in our blood and interstitial space for the reason I just described. Having an imbalance in water and electrolytes in our muscles can cause cramps, fatigue, and other issues. I LOVE salt, so this is not a big deal for me. I'm addicted to tamari, Red Boat Fish Sauce, salted fish, salted meats, pickles, olives, and sauerkraut. But do not - I repeat - DO NOT drink electrolyte sports drinks! These are full of sugar or high fructose corn syrup and lots of nasty chemicals and food colorings. Fruit juice and sodas are also not good for us because it can cause blood sugar spikes if we are glucose intolerant (neither are good for humans in general, by the way, especially not children). If you're sweating bullets or on a long hike, bring your water bottle and something salty to snack on (salted nuts, beef jerky, pickles, etc.) plus a fresh fruit or vegetable, which contains other electrolytes. The perfect electrolyte pick-me-up is a lactofermented pickle... salty, juicy cucumbers - can't get better than that on a hot day! Another good choice is coconut water, which is low in sugar but high in electrolytes. There are packets of sugar-free (and artificial sweetener free) electrolytes that you can add to water, like Emergen-C Electromix. A little bit of glucose is needed in times of vigorous exercise or profuse sweating, so adding a little honey or maple syrup may be a good idea.
9. Eat local, seasonal, and climate-appropriate foods
Eating local is not only good for the environment and your local economy, it is also biologically appropriate. Eating local food reduces the carbon emissions associated with transporting foods, and supports local farmers and small businesses. What grows locally in your climate-zone during its various seasons is what is needed to naturally balance the body's energies (yin and yang) and provide it with the right vitamins and minerals. For example, in a climate with four seasons, trees grow fruits in the summer that are yin, which help balance the yang of the sun's blazing heat. Another way to see it is that those fruits provide the electrolytes and carbohydrates we need for a higher level of activity and a lot more sweating during the warm, productive part of the year. Similarly, it is advised to eat warming (yang), nutrient-dense foods during the cold seasons to help the body maintain homeostasis, i.e. meats, properly prepared grains or root-vegetables, and lots of fat. So think about what the land is offering you this season and how you can eat what nature is intending you to eat so that you can become more aligned with the cycles of your ecosystem, benefiting you mentally, spiritually, and nutritionally.
10. Gratitude
Life is sacred, and that includes the life of your food. We eat animals that had mothers, fathers, siblings, and friends. We eat plants that began as tiny seeds and grew as they were filled with the energy of the sun and the nutrients of the soil. We are animals, and we must eat life in order to live. This is natural and good. But we must also give thanks for the lives of these individuals and recognize them as equals, and important parts of our local and global ecosystems. There is much more to a living being than the vitamins and minerals that make up its tissues. Every being has a consciousness and an energy that we consume, at least in part, by eating it. We must choose which energies are good for us to absorb, but we must always be grateful for what is offered and available to us. We are truly privileged to be able to eat other animals and plants. They are generous and gracious and ask nothing in return except our gratitude, recognition, and respect for their lives. So it is wise to give thanks to who you are eating by taking a silent moment before a meal and saying thank you to them. You can be more elaborate and say a prayer. You can go further and imagine these individuals when they were alive, waving their leaves in a sunny breeze, or oinking happily as they rolled in the mud. If you did not know these individuals personally (you didn't grow them in your own garden or meet them in the farm yard they were raised in) imagine what they could have been like, imagine their happiness when they were alive and their peaceful acceptance of death for the nurturing of more life. We are natural beings and part of the great circle of life and death. Being realistic about what and who your food is is a very important part of eating and being nourished.
***********************************************
[1] Breaking the Vicious Cycle: Intestinal Health Through Diet. Elaine Gottschall.
<http://www.breakingtheviciouscycle.info/p/science-behind-the-diet/>
[2] Healing with Whole Foods: Asian Traditions and Modern Nutrition. Paul Pitchford.
[3] CF and pH – Lung Acidity in Cystic Fibrosis Increases Infection. <http://www.thenakedscientists.com/HTML/news/news/2605>
[4] Reduced airway surface pH impairs bacterial killing in the porcine cystic fibrosis lung. <http://www.nature.com/nature/journal/v487/n7405/full/nature11130.html>
[5] http://chriskresser.com/paleo-diet-challenges-solutions-ii-its-all-about-the-gut
[6] The Wild Medicine Solution. Guido Mase.
One explanation of why certain foods digest well together is that their nutrients complement eachother (eating acidic or bitter foods together with fats stimulates the release of bile from the gallbladder which is necessary to break down lipids) or that these combinations take similar amounts of time to digest and therefore minimize the risk of rot and putrefaction of foods that can happen when bad combinations slow digestion down so much that foods just sit there in your guts and are inappropriately broken down by bacteria. We want our digestive tract to move swiftly and efficiently to avoid putrefaction of proteins, rancidification of fats, and fermentation of carbs in your guts. When these three things happen in your guts, you can feel it. They can cause inflammation and bacterial overgrowth, bloating, constipation, pain, stomach aches, and heartburn.
Another explanation of why these combinations work is that they balance the yin and yang energies contained within each of the foods we eat. Yin energy is described as dark, wet, cold, female, contractive, alkaline, descending, calming, nurturing (the characteristics of the womb). Yang energy is described as bright, hot, dry, male, expansive, acidic, ascending, rushed, impulsive (the characteristics of lightning). Every plant, animal (including humans), and natural feature has a balance of both yin and yang energy, and these energies fluctuate throughout our lives and under certain circumstances. In terms of balancing the yin and yang energies of the plants and animals that we eat, it is helpful to label our foods either yin or yang depending on which energy is most dominant, although we must keep in mind that this is a simplification. If our body is overly yang we must be sure to eat more yin foods. If we are overly yin we must be sure to eat more yang foods. Our bodies need to come to an equilibrium of these two energies, or as close to equilibrium as we can get. In one meal, for example, I may combine a starch (with a yang or neutral energy, depending on the plant and how it's prepared) with a good fat (which is yin) with green/non-starchy vegetables (which are yin). That is, steamed carrots fried in lots of bacon fat or coconut oil plus a stir-fry of kale, onions, mushrooms, and garlic.
Our CF bodies are usually yin deficient because our extracellular tissues and fluids are chronically dehydrated due to our CFTR mutation. For us, yin deficiency can manifest as thick mucus, inflammation, fever, infection, high blood sugar, and lung acidity [3,4]. So in our diets we must emphasize yin foods that will calm us, thin out our mucus, rehydrate us, and cool inflammation. We also need yang foods like proteins, but they must be balanced yin foods. We must also eliminate all unnecessary yang foods and extreme foods (junk food, sodas, sugary things, low quality meats, bad fats like transfats, hydrogenated fats, and rancid polyunsaturated fats, and harmful carbohydrates).
2. Bitters Before Your Meals
For hundreds of years people have taken bitter tastants (bitter roots and herbs, which can be steeped in alcohol to make a tincture) before meals to help prepare the digestive system for proper digestion and assimilation of foods. Tasting bitterness before a meal triggers the release of the necessary elements for proper digestion, including bile from the gallbladder, pancreatic enzymes, hydrochloric acid in the stomach, pepsin (an enzyme released in the stomach that breaks down protein), and gastrin [5]. Bitter plants have been in our diets since before we became humans, and our physiology has coevolved with them to the point that we depend on their presence for proper digestion. Humans have always had the bitter flavor very present in our diets, until now. In the last 100 years of modern society bitter plants have been almost completely removed from our diets, and we can see a proliferation of digestive and inflammatory diseases as a result. The solution is to reintroduce bitters back into the diet where they belong [6]. In Europe, it is still traditional in many cultures to drink bitter herb-infused teas or alcohol before or after meals, and/or eat a salad of bitter greens like arugula before meals. These traditions have been forgotten in America, but we can reinvigorate them now. In East Asia, pickled vegetables like kimchi are often used in a similar fashion to stimulate digestive secretions before meals. Bitters can also be used after meals to prevent indigestion and post-meal heartburn. It is my firm belief that improving digestive secretions is the big missing puzzle piece to the universal CF struggle to maintain weight. Increasing the calorie content of the diet may not be effective if the ability to absorb those extra calories is compromised. In my own life I have noticed that improving my digestion has done more to improve my ability to maintain weight than increasing daily calorie intake, and bitters have played a big role in this.
Commonly used bitter herbs include burdock, dandelion, artichoke leaf, yellow dock, motherwort, gentian, and wormwood (listed from more mild to stronger) but there are hundreds of bitter herbs to choose from. Use one dropperful (1 mL) of the tincture placed directly on the tongue 10-15 minutes before eating. You need to be able to taste the bitterness in order for it stimulate digestive secretions via central nervous system enervation. Your health foods store or co-op should sell little bottles of bitters in the supplements aisle, or if not you can order them online from plenty of places. A really great company that specializes in bitters in Urban Moonshine. Also check your local farmer's market - they are all the rage right now where I live. You can even make them yourself! It's absurdly easy and dandelion grows everywhere if you hadn't noticed.
Bile Excretion and Fats
Bitter herbs and the bitter taste in foods stimulates the liver to make bile and the gallbladder to excrete it. Bile is a critical part of fat digestion, as it emulsifies fats (breaks them up into tiny globules) so that lipases have an easier time breaking them down into triglycerides for absorption. Emulsification needs to happen before enzymes can have an optimal effect on dietary fats. Some CFers may have trouble getting bile out of the gallbladder and into the intestines either because the bile duct may be clogged with mucus, or because the small intestine is inflamed and the end of the bile duct has been swollen shut. This intestinal inflammation is most often caused by eating irritating foods, but can also be caused by a gut infection (i.e. dysbiosis). If your stools are consistently gray or light colored (e.g. tan, yellow, light brown) this means that your bile production is insufficient because bile contains pigments that darken our stools. Stools can also be light colored if the diet does not contain enough bitterness in it. If I forget to take my bitters, I can see a direct affect on the color of my stools the next day. From talking to several CFers about their difficulty absorbing fats, even when they take their pancreatic enzymes as directed, it has become clear to me that bile secretion is an issue for many CFers largely caused by eating inflammatory foods and from a lack of the bitter taste in their diets. It has recently become popular for CF doctors to prescribe PPIs to make pancreatic enzymes work better (according to the theory that the CF pancreas has a hard time secreting bicarbonate which is supposed to alkalize the small intestine so that enzymes can be activated), but given the many negative side effects of using PPIs, it seems the smarter and more effective route to improving fat absorption in CFers is to encourage proper bile production and flow.
There are two special scenarios that I want to discuss in relation to bitter supplementation. The first is if there is currently a large gallstone blocking the duct that lets bile flow into the small intestine. If this is the case (and you would know it because there would be pain and you'd likely have to get an ultrasound or CT scan to see what the problem is) then your stools will be acholic (chalk-colored due to total lack of bile) and eating fats will cause you lots of pain in your right abdomen just under the ribs. In this situation, bitters should not be used because encouraging more bile flow could cause a back up of bile in the gallbladder leading to increased pressure that could rupture it. However, if you have a history of small gallstones or sludge in the gallbladder, then taking mild bitters can help keep that bile diluted and flowing regularly enough that stones can be passed and/or prevented. If your stools are gray or light colored but there is no history of gallstones and no associated pain, then it is likely that this is caused by deficient bile flow blocked by inflammation where the end of the bile duct meets the intestine, or a lack of bitters. In this case, using bitters with every meal will help. The second special scenario I want to mention is for those without a gallbladder. Surgical removal of the gallbladder is done way too often, in my opinion, (docs seem to have a policy of "if in doubt, take it out!") mostly to prevent the formation of gallstones in the those who have a history. If only those docs knew about the power of bitters! But if you don't have a gallbladder, for whatever reason, using bitters before meals is even more important than for the rest of us. In these situations, using the stronger bitters like gentian or motherwort 10-15 minutes before meals (no less) is going to be important because you are now having to rely on the liver to put out enough bile on demand, which is difficult (but possible) for it to do, so it needs a very strong stimulus.
You can work your way up to the stronger herbs as you develop a taste for it. A taste for bitter herbs is acquired the same way as for coffee or chocolate. I started with dandelion and burdock because they're the mildest and safest, but I now I find that I like the stronger bitters like gentian and motherwort.
3. Smaller, Simpler, More Frequent Meals
I have found that I am able to digest more quickly and eat much more throughout the day if I eat smaller and simpler meals more frequently throughout the day. If you have a need to gain weight, one part of your strategy could be to eat very simple, small, nutrient-dense, and high-calorie meals frequently throughout the day. In terms of macronutrients, you could have one of two choices for designing a meal: a "fat meal" or a "protein meal". Every meal should incorporate one of the these two macronutrients (but not both). I used to make my larger meals "fat meals" because fat combines with more things than proteins (as outlined in the chart above) and so I can make these meals much more calorie-rich. I used to eat protein as a snack or a smaller meal because it has half the calories per gram than fat, and digests more quickly (given adequate stomach acid). Starches/carbs are never the basis of a meal, they are only a complement, and only taken in combination with fats. I add leafy greens to almost every meal in one way or another, in a stir fry, salad, or smoothie/shake. Eating small and frequent meals is also one way of monitoring and controlling blood glucose.
4. Glycemic Load
Having an understanding of the concept of the Glycemic Index and glycemic load is very important for all CFers, because if we have a reduced ability to excrete pancreatic enzymes, then it's likely we also have impaired insulin production, as I discuss in CF 201. Using the glycemic index/load as a tool for making sure your meals won't spike your blood sugar is a very good idea. Having high blood sugar for a prolonged period of time can contribute to many of our problems including inflammation, infection, tissue degradation, hemoptysis, etc. If we can do some simple things to lower the glycemic index of our meals and prevent reactive hypoglycemia, we can alleviate a significant burden on our already overburdened bodies. With each meal we need to maximize the amount of fat, protein, or fiber so as to slow down the transit of carbs in the small intestine for a more even and steady release of sugars into the blood stream. Also choosing sources of carbohydrates with more fiber (like whole grains, root vegetables, and whole fruits) slows glucose absorption. Slowing down the release of sugar into the blood will help match our blood sugar curve with our insulin curve, to the extent that it may be possible. In addition, add certain specific foods to your meal that may decrease its glycemic load, such as cinnamon or ground flax seeds or green vegetables. However, since I've become diabetic I've noticed that adhering to a low-glycemic load diet is not enough to keep my blood sugars low. The only thing that is truly effective is eating fewer carbs, eating only certain kinds of carbs, and taking insulin when I do eat carbs. The concept of the glycemic index/load may not be useful for everyone. The more glucose intolerant I've become, the less effective eating low-glycemic load foods is for maintaining steady blood sugar. For example, eating whole-grain brown rice will send my blood sugar sky high regardless of how much insulin I take, but eating rice pasta or a rice cake (which have glycemic loads technically higher than whole brown rice) allows me to control my blood sugar much more easily. So don't rely too heavily on the concept of glycemic index - let your body tell you what foods are best for you (and test your blood sugar regularly).
5. Chew Your Food
You may think I'm silly for writing this one down, but it's not as simple as you may think. Next time you eat a meal try to notice how thoroughly you are chewing your food, especially any carbohydrates. Also, regularly inspect your stools to see what you're not digesting well. In Chinese medicine this is an extremely important thing to do, especially for those with compromised digestion. If food, specifically carbs, are not thoroughly and completely chewed and turned into a paste before moving into the stomach, it cannot be fully utilized because the particles are too big for your small intestines to absorb anything from. Carbs must be chewed and mixed thoroughly with saliva, which contains amylase, the carb-digesting enzyme. This is especially true with whole grains, leafy greens, and seeds. Undigested carbohydrates can feed pathogenic bacteria that cause dysbiosis, as we discussed earlier. Proteins also need to be thoroughly chewed so that stomach acid can work most effectively on them. Proper break down of proteins is critical to the prevention of leaky gut-mediated molecular mimicry, as I discussed in CF201. Don't wolf your food down or you'll get little nutrition from it and also cause yourself digestive upset. Eating slowly and mindfully can be a meditative practice as well, and be a necessary reprieve from a busy day. Meal time is sacred time where we give thanks for the life that we are consuming.
6. Take a walk
Taking a short, gentle walk after eating a meal, especially a big one, will help your digestive system get things moving. The digestive tract is made up of a lot of muscle and it is always moving. By taking a walk you're getting the blood circulating throughout your entire body including your internal organs. The digestive organs live right alongside the heart and lungs, and are connected to an intricate web of blood vessels. Getting our blood pumping and inflating our lungs with gentle exercise loosens the diaphragm and literally massages the digestive organs, ensuring good circulation and peristalsis (waves of intestinal muscle contraction that move the bowels). Plus, exercising muscle uptakes a lot of glucose which can prevent post-meal blood sugar spikes and resulting crashes. Exercise also increases insulin sensitivity. In addition, getting fresh air and being outside is enjoyable and good for our spiritual and mental health, and the calming effect it can have can help us move into the parasympathetic "rest and digest" mode.
7. Keep a Food/Health Journal
Keeping track of what you've eaten, when, what happened during your breathing treatments, what your sputum looks like today, what your energy is like, what meds you've taken, what your poops look like, and how much exercise you did is a very important part of being an empirical self-healer. Doing this will help you map trends and figure out what actions caused what results, and how that hurt or helped your health over a longer period of time. This tool has been invaluable to me. Also, while I am not a fan of calorie counting in general, I have at times used a free online calorie counter called Cron-o-meter to help me in my efforts to gain weight.
8. Drink More Water
It seems simple, but this one is hard for me. I am pretty much never thirsty, so I have to remind myself to drink water outside of meal time. There is a reason for this. Due to the defect in the CFTR channel, there is not enough chloride moving out of the cells into the blood and other body fluids. Your body detects whether or not it's dehydrated by the balance of electrolytes (salts) to water content in your blood. In a normal person, when they are dehydrated the blood has too much electrolytes compared to water, and so a thirst response is triggered. In CF, the blood is always slightly low in electrolytes, so even when we're dehydrated the balance of electrolytes to water does not trigger the body's thirst response. So we unfortunately can't rely on thirst to tell us when we need to drink water. Since CFers are constantly fighting infection and flushing toxins and drugs out of our systems through our kidneys, we actually need to drink a lot more than healthy people.
So drink whenever you remember to. I keep a water bottle with me at all times. Drink when sitting at your desk, when on a hike, when in the car, when on the train, when picking your nose, when on the toilet, when... just all the time. The only time it is not ideal to drink too much is during mealtime, as it may dilute digestive secretions. Your CF doc has probably told you that you should also be eating (and drinking) more salt or electrolytes. This is because we're low in salt in our blood and interstitial space for the reason I just described. Having an imbalance in water and electrolytes in our muscles can cause cramps, fatigue, and other issues. I LOVE salt, so this is not a big deal for me. I'm addicted to tamari, Red Boat Fish Sauce, salted fish, salted meats, pickles, olives, and sauerkraut. But do not - I repeat - DO NOT drink electrolyte sports drinks! These are full of sugar or high fructose corn syrup and lots of nasty chemicals and food colorings. Fruit juice and sodas are also not good for us because it can cause blood sugar spikes if we are glucose intolerant (neither are good for humans in general, by the way, especially not children). If you're sweating bullets or on a long hike, bring your water bottle and something salty to snack on (salted nuts, beef jerky, pickles, etc.) plus a fresh fruit or vegetable, which contains other electrolytes. The perfect electrolyte pick-me-up is a lactofermented pickle... salty, juicy cucumbers - can't get better than that on a hot day! Another good choice is coconut water, which is low in sugar but high in electrolytes. There are packets of sugar-free (and artificial sweetener free) electrolytes that you can add to water, like Emergen-C Electromix. A little bit of glucose is needed in times of vigorous exercise or profuse sweating, so adding a little honey or maple syrup may be a good idea.
9. Eat local, seasonal, and climate-appropriate foods
Eating local is not only good for the environment and your local economy, it is also biologically appropriate. Eating local food reduces the carbon emissions associated with transporting foods, and supports local farmers and small businesses. What grows locally in your climate-zone during its various seasons is what is needed to naturally balance the body's energies (yin and yang) and provide it with the right vitamins and minerals. For example, in a climate with four seasons, trees grow fruits in the summer that are yin, which help balance the yang of the sun's blazing heat. Another way to see it is that those fruits provide the electrolytes and carbohydrates we need for a higher level of activity and a lot more sweating during the warm, productive part of the year. Similarly, it is advised to eat warming (yang), nutrient-dense foods during the cold seasons to help the body maintain homeostasis, i.e. meats, properly prepared grains or root-vegetables, and lots of fat. So think about what the land is offering you this season and how you can eat what nature is intending you to eat so that you can become more aligned with the cycles of your ecosystem, benefiting you mentally, spiritually, and nutritionally.
10. Gratitude
Life is sacred, and that includes the life of your food. We eat animals that had mothers, fathers, siblings, and friends. We eat plants that began as tiny seeds and grew as they were filled with the energy of the sun and the nutrients of the soil. We are animals, and we must eat life in order to live. This is natural and good. But we must also give thanks for the lives of these individuals and recognize them as equals, and important parts of our local and global ecosystems. There is much more to a living being than the vitamins and minerals that make up its tissues. Every being has a consciousness and an energy that we consume, at least in part, by eating it. We must choose which energies are good for us to absorb, but we must always be grateful for what is offered and available to us. We are truly privileged to be able to eat other animals and plants. They are generous and gracious and ask nothing in return except our gratitude, recognition, and respect for their lives. So it is wise to give thanks to who you are eating by taking a silent moment before a meal and saying thank you to them. You can be more elaborate and say a prayer. You can go further and imagine these individuals when they were alive, waving their leaves in a sunny breeze, or oinking happily as they rolled in the mud. If you did not know these individuals personally (you didn't grow them in your own garden or meet them in the farm yard they were raised in) imagine what they could have been like, imagine their happiness when they were alive and their peaceful acceptance of death for the nurturing of more life. We are natural beings and part of the great circle of life and death. Being realistic about what and who your food is is a very important part of eating and being nourished.
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[1] Breaking the Vicious Cycle: Intestinal Health Through Diet. Elaine Gottschall.
<http://www.breakingtheviciouscycle.info/p/science-behind-the-diet/>
[2] Healing with Whole Foods: Asian Traditions and Modern Nutrition. Paul Pitchford.
[3] CF and pH – Lung Acidity in Cystic Fibrosis Increases Infection. <http://www.thenakedscientists.com/HTML/news/news/2605>
[4] Reduced airway surface pH impairs bacterial killing in the porcine cystic fibrosis lung. <http://www.nature.com/nature/journal/v487/n7405/full/nature11130.html>
[5] http://chriskresser.com/paleo-diet-challenges-solutions-ii-its-all-about-the-gut
[6] The Wild Medicine Solution. Guido Mase.
