1. Watch your fat intake.
I recently saw video footage of a low-carb proponent saying, "On a very-low-carb diet, the more fat you eat, the more fat you lose." If only that were true! Sadly, for many people -- particularly women of a certain age -- this isn't the case. Although a very-low-carb diet is by definition high in fat (contributing more than 50% of calories), it's the restriction of carbohydrates, reduction in overall energy intake, and low levels of insulin that promote weight loss -- not dietary fat. There's nothing wrong with eating fatty meats and other high-fat foods, but adding butter to entrees already sufficiently high in fat (i.e., ribeye steak with sautéed mushrooms) will only make weight loss more difficult. 

2. Make the best choice available when dining out.
Admittedly, going out to dinner isn't as easy as fixing food at home where you have control of the ingredients. It can be particularly challenging when others in your party pick the restaurant. But over the past four years, I can honestly say that I've always been able to find an entree on the menu -- or modify one as needed -- that allows me to stay low carb. This goes for both fast food and fine dining establishments. Sometimes my clients report not seeing anything appropriate on the menu and instead just choosing something that sounds good. I actually tell them that they can call or text me if they're at a restaurant and feeling uncertain what's best to order (I do this for my husband too), but no one has taken me up on it thus far...

Here are a few things I recommend: 

In restaurants, request that any sandwich be made as a salad, ask for extra vegetables in place of high-carb side dishes, and let your server know that you're avoiding sauces that contain sugar and flour (this is particularly important for Asian cuisine). 

At fast food places, order a bunless burger, chicken, or other protein source with your choice of condiments and a side salad. Guacamole and sour cream are ideal toppings, but mayo is fine too.

Feel free to let me know in the comments section if there are any restaurants or types of cuisine that you find particularly problematic, and I'd be happy to make a few suggestions.
 
3. Plan ahead so that being sick doesn't throw you off track.
Many people tend to go off their low-carb diet when they get a cold. Chicken noodle soup, hot cereal, sorbet, and cherry cough drops top the list of comfort foods and remedies. My article Low-Carbohydrate Foods and Beverages to Consume When You're Sick provides several alternatives, but it's important to stock up on these items before you actually come down with a cold or mild flu. I'm not a big fan of flavored cough drops or throat lozenges; the regular ones are loaded with sugar, and even the sugar-free ones have up to 2 grams of carbohydrate per drop, which can add up quickly. Taking a few of these isn't a problem, but warm beverages can also soothe your throat, as well as provide needed hydration.

4. Find low-carb substitutions that work for you.
One of the most common reasons I hear for going off track is craving a favorite food, whether it's bread, cereal, pasta, pizza, or sweets. I'm not a foodie; I like just about everything and could easily eat the same three meals every day without ever getting bored. I don't crave any of the foods listed above, but if you do, there are low-carb alternatives for each of them. Do they taste exactly the same as the original version? In most cases, no. But they're still  delicious and only a Google search away.  Here are a few to start:

Bread: Ultimate Keto Buns (KetoDiet App)
Cereal: Cinnamon Crunch Cereal (All Day I Dream About Food)
Pasta: Chicken with Shirataki Noodles (Just a Pinch Recipes)
Pizza:  Cauliflower Pizza Crust with Roasted Vegetables and Goat Cheese (Domesticate Me)
Dessert: Raspberry Cheesecake Bars (I Breathe...I'm Hungry)

There are so many great low-carb recipe sites out there that it would be impossible to list them all, and it seems like new ones are cropping up all the time. Pinterest boards are great for finding new recipes and organizing them according to type so they're easily accessible.

5. Realize that sustainable weight loss takes time.
This is really important to keep in mind. For the first few weeks of any diet, especially a carbohydrate-restricted one, weight loss is often rapid. However, it usually slows down a lot after that, and once again, women seem to experience this to a greater degree than men do. As a somewhat impatient person, I completely understand being frustrated at not seeing progress on the scale, in the mirror, or feeling as though your clothes are getting looser. But it will happen eventually, even if it's months down the road. That's just the way it is with weight loss. Even when doing everything perfectly, there are no guarantees of losing a certain amount of weight within a specific time frame.

For this reason, it's vital that you genuinely enjoy eating low carb. If you don't, it'll be all but impossible to stay motivated to stick to it for the weeks (or months) that you don't lose anything. And remember, once you're done losing, you'll be eating in a very similar way for maintenance. The statistics on people who have successfully maintained are discouraging, but it can absolutely be done. It does take discipline and perseverance, though. I say this from personal experience (although I didn't lose via low carb), as well as that of several others I know who have maintained losses far greater than mine (most of whom did lose it all with carb restriction).

I truly wish you every possible success in achieving your weight loss and health-related goals and will leave you with a great quote that I strongly agree with:

"Losing weight is hard. Maintaining weight is hard. Staying fat is hard. Choose your hard."

Over the past few months, several women have contacted me  expressing frustration at being unable to lose weight despite strictly following a LCHF diet. When I ask whether they're including high-fiber plants like brussels sprouts, berries, nuts, and dark chocolate, the response is typically, "I avoid those because they're so high in carbs. I limit my carbs to less than 20 grams total." This is the trend I've noticed lately in the low-carb community: the belief that limiting vegetables and other high-fiber plants in an attempt to keep carbohydrate intake at an absolute minimum (sometimes as low as 10 grams of total carbohydrates per day) long term is the key to losing weight.

Soluble Fiber's Role in Improving Blood Glucose Regulation

A few weeks ago, Martina from the KetoDiet App website wrote an excellent blog post about counting net carbs vs. total carbs for those following a carbohydrate-restricted lifestyle. In the article, she correctly states that insoluble fiber passes through your system without being absorbed, so it should be subtracted from the total carbohydrate count. In addition, Martina explains that, unlike insoluble fiber, soluble fiber does not pass through the colon but rather is fermented into short-chain fatty acids (SCFAs) by our gut bacteria. 

The principal SCFAs are acetate, butyrate, and propionate. Of these, propionate is the only one that can be converted into glucose via gluconeogenesis (1). But would this have any significant effect on postmeal blood glucose given that most fiber is insoluble and only 15-40% of any soluble fiber will be converted to propionate (2)? Take brussels sprouts, for instance, one of the few foods that contains more soluble than insoluble fiber. A 1-cup serving has about 4 grams of soluble fiber. Less than 2 grams will be converted into propionate, and the amount of glucose produced from it via hepatic gluconeogenesis would be quite small, so serum blood glucose levels wouldn't be affected much.

More importantly, as Martina pointed out, De Vadder, et al, recently reported the results of a study on mice suggesting that SCFAs promote intestinal gluconeogenesis (IGN), with propionate acting as substrate and butyrate promoting the expression of genes necessary to induce this process. Compared with control mice fed their normal diet, mice who were fed diets enriched with SCFAs and fructo-oligosaccharides (FOS) experienced lower fasting serum blood glucose levels, improved glucose tolerance, and a significant reduction in the enzyme responsible for hepatic gluconeogenesis (3). Essentially, propionate is converted to glucose and used within the intestine, decreasing the amount of glucose produced by the liver, resulting in the above-mentioned benefits. Yes, this was an animal study, but it provides an intriguing explanation for the improvement in blood glucose levels seen in human studies examining the role of dietary fiber (4, 5).

Blood glucose response to fiber-rich food may differ among some people with Type 1 diabetes, whose blood glucose levels can reportedly rise as a result of higher food volume in the stomach or other stimuli, regardless of digestible carbohydrate intake. Dr. Bernstein and others with T1 have suggested such a response (what he calls The Chinese restaurant effect), but I know of no studies confirming this and would appreciate references if anyone has them.

Health Benefits of Fiber and SCFAs

We've known about the benefits of fiber on colon health for decades. Although it's believed these are due in part to insoluble fiber's ability to reduce intestinal transit time so potentially carcinogenic substances in our food spend as little time as possible in our GI tract, more recent research suggests that fiber's chemoprotective effects may be due primarily to the effects of one of the SCFAs, butyrate (6,7), which provides energy and nourishment for the cells of the colon.

In addition, higher fiber intakes may reduce levels of C-reactive protein (CRP) and other inflammatory markers, improve our immune response, and protect the gut from harmful microorganisms that can make us ill (8). In essence, fiber's fermentation to SCFAs helps keep our gut well nourished and working the way it should. 

Increasing High-Fiber Carbohydrate Intake May Be Helpful for Weight Loss

Let's go back to restricting intake to less than 20 grams of total carbohydrates in order to lose weight. When carbohydrate intake is this low, there's a limited number of foods that can be eaten: meat, cheese, fish, eggs, butter, cream, coconut oil, olive oil, and small amounts of greens and other very-low-carb vegetables. Yes, carbohydrate intake may be well below 20 grams of total carbs daily, but depending on portions consumed, calorie/energy intake  may be too high to promote weight loss. A serving of bullet-proof coffee contains 440 calories, zero carbs, zero protein, and zero fiber.

Aside from fiber's beneficial effects on overall health outlined above, consuming at least a moderate amount of fiber can facilitate weight loss, and both insoluble and soluble fiber can be helpful in this regard.

Insoluble fiber passes through the body without being absorbed. It adds volume to meals, but zero calories and zero carbohydrates. In fact, you could almost say that insoluble fiber provides negative calories, in that it may lower the amount of energy derived from fat and protein when all three are consumed at a meal (9).  Most foods are higher in insoluble than soluble fiber, with a few exceptions (Please refer to Martina's fiber chart in the blog post linked to above).

Soluble fiber does contribute calories/energy to the body, but no carbohydrates. The chief benefits provided by soluble fiber are due to its fermentation to the SCFAs acetate, butyrate, and propionate, which have been shown to promote satiety, reduce intake, and and decrease body fat (3,10-11).

Carbohydrate and Fiber: What's Optimal?  

Like carbohydrates, fiber is another substance where across-the-board recommendations can't be made, but I think it's best to aim for at least 20 grams daily, with 1/3 or more from soluble fiber. If you're limiting yourself to less than 20 grams of total carbohydrate, the maximum amount of fiber you can possibly get is 18 grams, and that's only if the carbs come from foods that are more than 90% fiber, such as chia seeds, flaxseed, or avocado. Generally speaking, those who consume diets containing less than 20 grams of total carbohydrate end up with 10 or fewer grams of fiber. Some people reportedly consume less than 5 grams on a consistent basis.

The goal of carbohydrate restriction is to keep blood glucose and insulin levels low, and this can be accomplished without reducing carbs to near-zero levels. I consume around 30-45 grams of fiber daily, and my net carb intake is around 35-50 grams, so my fiber to nonfiber carb ratio is roughly 1:1. This works well for me, but some people do better with 20-30 grams of fiber and slightly lower net carb intake. People with certain GI disorders* may require restriction of certain types and amount of fiber.

How do you get to 30 grams of fiber yet still maintain net carb intake of less than 40 grams? Here's one of the sample menus with recipes that will be included in my upcoming book, The Low Carb Dietitian's Guide to Health and Beauty. 

Sample Low-Carb, High-Fiber Menu

Breakfast:
Cinnamon Flaxseed Pudding*
1 cup blackberries 
Coffee or tea with 2 Tbsp half and half

Lunch:
Insalate Caprese*
1/2 oz dark chocolate (at least 85% cocoa)
Water, tea, or other sugar-free beverage

Snack:
3 celery stalks with 1 Tbsp almond butter

Dinner:
Chicken Curry*
Chocolate Avocado Pudding*
Water, tea, or other sugar-free beverage

Daily totals:
Calories: 1575
Protein: 88 grams 
Total Carbohydrates: 68 grams
Fiber: 31 grams
Insoluble Fiber: 20 grams
Soluble Fiber: 11 grams
Net Carbohydrates: 37 grams
Fat: 108 grams 

Recipes:

Cinnamon Flaxseed Pudding
Number of Servings: 1

Ingredients:
½ cup cottage cheese
2 Tbsp ground flaxseed
½ tsp cinnamon
3 Tbsp chopped toasted pecans
Stevia or other sweetener, if desired

Directions:
Combine all ingredients in small bowl.

Insalate Caprese
Number of Servings: 1

Ingredients:
4 oz fresh mozzarella cheese, sliced into ¼-inch rounds
1 large vine-ripened tomatoes, sliced ¼-inch thick
1/2 cup fresh basil leaves
Coarse sea salt, to taste
2 Tbsp cup extra-virgin olive oil

Directions:
On a plate, alternate mozzarella slice, then tomato slice, followed by basil leaf, and repeat sequence, overlapping each item slightly. Sprinkle salt and drizzle olive oil over top. 

Chicken Curry
Number of Servings: 4

Ingredients:
2 Tbsp coconut oil
1 cup chopped onion
2 tsp sea salt
2 tsp chopped garlic
2 tsp ground ginger
2 tsp coriander
1 tsp turmeric
1 tsp chili powder
4 cups broccoli florets
2 cups snow peas
2 cups mushrooms
½ cup coconut milk
1 lb chicken breast, cut into bite-sized pieces

Directions:
Heat oil in a wok or large saucepan over medium-high heat. Add the onion, then cook and stir until browned. Mix in garlic and spices. Add broccoli, pea pods, and mushrooms. Cook and stir for 1-2 minutes.
Add coconut milk and chicken. Reduce heat to medium and cook for 7 to 8 minutes, until chicken is no longer pink. Stir and remove from heat. Serve immediately.

Chocolate Avocado Pudding
Number of servings: 4

Ingredients:
2 medium very ripe avocados
½ cup unsweetened coconut milk
½ cup unsweetened cocoa powder
1 cup erythritol or other granulated sugar substitute equivalent to sweetness of ¾ cup sugar
2 tsp vanilla extract

Directions:
Cut avocado in half, remove pit, and scrape flesh into food processor or blender. Add coconut milk, cocoa powder, sweetener, and vanilla extract. Process until ingredients are well combined and there are no lumps of avocado. Divide into four dishes and refrigerate at least 30 minutes or until ready to serve.

                                                             
Roasted Brussels Sprouts Recipe

And for anyone who was hoping for a brussels sprouts recipe after seeing the photo and reading about their high soluble fiber content, please check out this delicious side dish, Roasted Brussels Sprouts with Pecans, from Kalyn's Kitchen.
                                                         
A Balanced Low Carb Diet: Eat Plenty of Plants and Animals


If you're consuming less than 20 grams of carbohydrate daily and achieving your weight loss goals, I'm very happy for you. But I would consider adding at least a few grams of high-fiber carbohydrates -- such as vegetables, berries nuts, and dark chocolate -- to optimize overall health and increase your likelihood of long-term success. And if your weight loss has stalled, I definitely recommend increasing your intake of these foods and perhaps decreasing fat and increasing protein intake, depending what you're doing currently. A  sustainable low-carb lifestyle consists of a balance of nutritious animal and plant foods, based on personal tolerance, preferences, and goals. 

                                                                                 * * *
*For those with small-intestinal bacterial overgrowth (SIBO) or other conditions requiring a low-reside diet, such as acute diverticulitis or other inflammatory bowl conditions, the recommendations for fiber intake provided in this article may be contraindicated. Consult your healthcare provider, who can provide guidance or refer you to a dietitian for recommendations.


References

1.Mithieux G, et al. Intestinal glucose metabolism revisited. Diabetes Res Clin Pract. 2014 Sep;105(3):295-301
2. Bergman EN, et al. Energy contributions of volatile fatty acids from the gastrointestinal tract in various species. Physiol Rev. 1990 Apr;70(2):567-90
3. De Vadder F, et al. Microbiota-generated metabolites promote metabolic benefits via gut-brain neural circuits. Cell. 2014 Jan 16;156(1-2):84-96
4. Post, RE, et al. Dietary Fiber for the Treatment of Type 2 Diabetes Mellitus. J Am Board Fam Med Jan-Feb; 25:16-23, 2012 
5. Aller R, et al. Effect of soluble fiber on lipid and glucose intake in healthy subjects: a randomized clinical trial. Diabetes Res Clin Pract. 2004; 65(1): 7-11
6. Cho Y, et al. Colon cancer cell apoptosis is induced by combined exposure to the n-3 fatty acid docosahexaenoic acid and butyrate through promoter methylation. Exp Biol Med (Maywood) 2014;239(3):302-310
7. Fung KY, et al. A review of the potential mechanisms for the lowering of colorectal oncogenesis by butyrate. Br J Nutr. 2012 Sep; 108(5):820-31
8. Levison ME, et al. Effect of Colon Flora and Short-Chain Fatty Acids on Growth In Vitro of Pseudomonas aeruginosa and Enterobacteriaceae. Infect Immun. Jul 1973; 8(1): 30–35
9. Baer DJ et al. Dietary fiber decreases the metabolizable energy content and nutrient digestibility of mixed diets fed to humans. J Nutr. 1997 Apr;127(4):579-86
10.Darzi J, et al. Do SCFA have a role in appetite regulation? Proc Nutr Soc. 2011 Feb;70(1):119-28
11. Lin HV, et al. Butyrate and propionate protect against diet-induced obesity and regulate gut hormones via free fatty acid receptor 3-independent mechanisms. PLoS One. 2012;7(4):e35240

The Artificial Sweetener Study

I'm sure that by now most of you have heard about the recent study about artificial sweeteners purportedly increasing the risk of diabetes and obesity due to changes in gut bacteria. Bill Lagakos wrote a fantastic blog post about the study, including the questionable way some of the results were reported. I definitely recommend reading Bill's article (as well as his book and blog, if you're not already doing so). But as a brief synopsis, the paper discusses the adverse metabolic effects experienced by mice, and potentially some humans, in response to changes in their intestinal microbiome after consuming saccharin (and by inference other artificial sweeteners). The human study looked at saccharin's effects on 7 people who didn't regularly consume artificial sweeteners. Just over half of these subjects exhibited changes in their gut microbiota and apparently declines in glucose tolerance, according to daily glucose tolerance tests (GTTs), although this is an area where the data was oddly reported. However, the initial bacterial composition of the "responders" likely differed from the 3 participants whose bacteria and GTT results did not change.

Sugar Substitutes: Yes or No?

The use of sugar substitutes -- particularly artificial sweeteners -- is one of the more controversial issues within the low-carb, whole-foods community. From what I've read online, as well as having talked to people about this quite a bit, intake seems to range from drinking several Diet Cokes and using Splenda in multiple cups of coffee every day to only using "natural" sweeteners like stevia in small amounts or avoiding sweeteners altogether. Since the study above came out and was widely circulated on social media, I've seen many arguments about the risks vs. benefits of using sugar substitutes, and some of them have gotten pretty heated. I can relate to the first line of Bill's post: "I didn't want to blog about the artificial sweetener study." The truth is that I'm ambivalent about the use of sugar substitutes and can understand the points being made by both sides.

I have a long history of artificial sweetener use, beginning at around age 12, when I started using them in an attempt to prevent further weight gain after putting on several pounds following puberty. I'm turning 48 next week, and although I can't quantify with any degree of accuracy how much artificial sweetener I've consumed over the course of the past 36 years, I'm fairly sure it was a lot more than the average person. I started with saccharin-sweetened Shasta and Tab, progressed to Equal (aspartame) once it became available, then Splenda, acesulfame potassium, sugar alcohols, and stevia within the past few years. A couple of times I took a brief break  (including the few months I went "full Paleo" about 3 years ago) but always went back to using them. My weight stayed the same, and I didn't notice any difference in my appetite or intake whether I consumed them or not. However, research and anecdotal reports suggest that some people have a different experience.

Looking at Both Sides of the Argument

Obviously, I can't say whether changes occurred in my own microbiota as a result of fairly heavy long-term sugar substitute use, but I do know that in my own case, they haven't caused weight gain and, if anything, have likely helped me remain thin for the past 30+ years. Consuming sugar-free beverages and desserts allows me to treat myself to something sweet (an innate preference in humans) without ingesting empty calories or experiencing unstable blood sugar levels. I think they can play a supportive role in weight loss and diabetes for the many people who tolerate them. In terms of which to use, every sweetener has its advantages and drawbacks, including "natural" ones (which are often highly processed, just like artificial sweeteners), so it's up to each person to make a choice from among the growing list of available products. I just finished trying out some of the newer sugar substitutes (monk fruit and Just Like Sugar, which is inulin based) so I can include my own thoughts in the "Sugar Substitutes" section of the book I'm currently writing. They aren't bad, although not nearly as sweet as saccharin tablets, which is still my favorite after all these years, particularly in hot cocoa tea. (It's very simple and quick: Pour boiling water over a rooibos or other herbal tea bag, steep a few minutes, then add 1 Tbsp cocoa powder, 1 Tbsp cream or half-and-half, and sugar substitute to taste. Voila -- delicious hot cocoa tea with antioxidants galore!)

On the other hand, some people have legitimate adverse reactions to certain sugar substitutes, find that their sweet taste triggers cravings for sugar and other high-carbohydrate foods, or have trouble losing weight when consuming them. Others may simply not want to eat anything sweet other than fruit. In these cases, it makes sense to avoid them. But trying to discourage everyone else from using sugar substitutes doesn't sit well with me. Since the studies on them aren't definitive in terms of risk and we know that high sugar intake does increase the likelihood of developing  diabetes and obesity, I'll go on record as saying that sugar substitutes are the better choice for many. Should they be considered a health food? No, and I certainly don't recommend overdoing them; this is one of the many nutrition areas where I believe the term "in moderation" applies. But if they can help overweight people or those with diabetes maintain low intakes of sugar without feeling deprived -- and experience better health as a consequence -- I think their use can be justified.

Could Bitter Be Better?

Now, after my defense of artificial sweeteners, I'm going to share something that may surprise you. As of this past weekend, I've taken another break from them. I decided to do this after one of my colleagues made a point about Americans disliking the taste of many bitter vegetables prized for their health benefits by practitioners of Ayurveda. Instead of indulging in bitter foods like coffee and chocolate in their natural state, we add sweeteners to mask the flavor. I thought about this, realized how true it is., and did a little research into bitter and astringent foods. I'm one of those rare people who actually enjoys eating unsweetened chocolate (I keep bars of 100% cocoa Ghiradelli chocolate and unsweetened Bakers chocolate in my pantry at all times), and although I typically sweeten my coffee, I also like it with just cream or half-and-half. So I'm interested to see how embracing bitter, unsweetened foods and beverages goes. This is an experiment, and I may go back to using sugar substitutes (given my past history, I'd say that's pretty likely). But I don't think the use or avoidance of them will have much of an impact on my health given that I eat a very healthy, balanced low-carb diet, exercise regularly, get enough sleep, etc. And by the way, unsweetened hot cocoa tea is a lot better than I thought it would be.

References:

1. Suez J, et al. Artificial sweeteners induce glucose tolerance by altering the gut microbiota. Nature 2014 Oct 9;514(7521): 181-6 
2. Lavin JH. Lavin JH. The effect of sucrose- and aspartame-sweetened drinks on energy intake, hunger and food choice of female, moderately restrained eaters. Int J Obes 1997 Jan;21(1):37-4
3. Saha P, et al. Highlighting the anti-carcinogenic potential of an ayurvedic medicinal plant, Swertia Chirata Asian Pac J Cancer Prev. 2010;11(6):1445-9.

Caveat: This is one of those posts geared toward "women of a certain age" (roughly 40 and over) who are dealing with mid-life hormonal changes. But guys, you're welcome to read on as well, of course! 





Sick to My Stomach, But Not Truly Sick

I'm what's known as a morning person. I wake up every day around 4:00-4:30 am without an alarm clock and generally eat breakfast right away. It's one of my favorite times of day, as well as my most productive. However, occasionally over the past year or so, I've woken up with a pounding headache and felt queasy for an hour or two, so I've stayed in bed and avoided eating until it passed. At 47, I always figured it was related to the way I slept or possibly hormone-related, but because the symptoms weren't terribly severe and quickly resolved, I didn't give it much thought.

That all changed yesterday. I awoke with a severe, pounding headache accompanied by nausea and decided it was strong enough to warrant taking ibuprofen. (I try to avoid taking pain relievers unless the pain is unbearable). Unfortunately, the glass of water I drank with the tablet didn't stay down. I tried to go back to sleep, but the headache made it impossible. About an hour later, I made some weak tea, thinking the caffeine might help the headache, but I vomited that up as well. Thinking I probably had the flu (even though I was having normal BMs and only throwing up liquid), I returned to bed. I started trying to mentally inventory the contents of my refrigerator and pantry to make sure I had the appropriate supplies for when I felt up to reintroducing liquids.

But in just a few hours, I began feeling pretty normal. The headache was gone, I was no longer nauseated, and I could keep water down, then tea, and then food. In fact, I was hungry! I ate a normal-sized lunch and felt great. It was as though the events of the morning had never happened. And when I woke up today, I hopped out of bed and went down to the kitchen to fix breakfast, feeling perfectly normal. What was going on? I described my experience to a few friends, each of whom said, "That sounds like a migraine."

Migraines During Perimenopause

The decline in estrogen levels during perimenopause, the 5-20 year period leading up to menopause, can have many effects. Although the most common symptoms of estrogen fluctuations are night sweats, hot flashes, and irritability, there are many others that can occur during this transitional period. One of them is an increase in the frequency of migraines or even their onset at perimenopause in women who never had them prior.

What's the difference between a migraine headache and a regular tension headache? It's my understanding that there's no test to distinguish between the two, and diagnosis is based on symptoms. While a migraine typically occurs on one side of the head, this isn't always the case. If a headache is severe enough to cause nausea and vomiting, it's usually considered a migraine. The symptoms experienced by some perimenopausal women are very similar to morning sickness.  Just as there are some ladies who have intense nausea and vomiting during their first trimester of pregnancy while others have only mild indigestion or none at all, the same spectrum of symptoms seems to occur during the perimenopausal transition -- and for some, the problems continue into menopause. 

Treating Perimenopausal Symptoms with Nutrition and Lifestyle Changes

Whether what happened to me yesterday was a migraine or simply a response to hormonal changes, I decided right away that I needed to figure out how to control it or at least lessen the severity of the symptoms. Losing half a day to nausea and vomiting once every few months might be tolerable but what if it started happening much more frequently, as I've read stories about online?  As usual, when something goes wrong -- blood glucose, cholesterol, etc. -- I always try to see if I can remedy it with lifestyle changes prior to looking at medications or hormones.

I did an online search for conventional strategies for morning sickness and found the following:

1. Eat 5-6 small meals daily
2. Have small amount of plain foods like crackers for snacks
3. Avoid fatty foods
4. Try soy isoflavones

None of those sounded appealing or doable, particularly items 2-4.

I found a list of the Top 10 migraine triggers and was disappointed to see that it included some of my staple foods: chocolate, dairy, and nuts. However, I ate all of those yesterday after the episode and again this morning with no problem. So perhaps it's a matter of personal tolerance, as with most nutrition-related issues. 

Looking further into tactics to improve nausea and vomiting associated with migraine or pregnancy, it started to get better. 

Alpha-linolenic acid (ALA) and gamma-linolenic acid (GLA): These polyunsaturated fatty acids (PUFAs) have anti-inflammatory effects that may decrease the frequency and severity of migraine episodes.

ALA sources:  chia seed, flaxseed, walnuts, and ALA supplements
GLA Sources:  evening primrose oil and borage oil supplements

Ginger: Ginger has long been considered one of the most effective herbs to control nausea, and there is considerable evidence supporting its use for this purpose.

Sources: fresh ginger, ginger tea, ground ginger, diet ginger ale (I like Hansen's)

Ketogenic diet: Last year, Italian researchers published a study in which twin sisters of perimenopausal age (47 years) experienced a fringe benefit of the cyclical ketogenic diet they were prescribed for weight loss: Their migraines disappeared during the ketogenic portion of the diet. And mild ketosis appears to be sufficient, as the women were prescribed diets containing 1 gram of carbohydrate per kilogram based on their body weights of 73 kilograms and 79 kilograms. 

Acupressure: Acupressure may be modestly effective for reducing nausea and migraine symptoms. There's even a sea-band designed specifically for morning sickness, although in reading the reviews on Amazon you'll see there are many people it worked incredibly well for and others whom it didn't help at all.

Sources: traditional acupressure, sea-band for morning sickness, instructional handout

Yoga: Besides being one of the best forms of exercise for flexibility, strength, and stress reduction, yoga has also been shown to provide relief from migraine symptoms. 

Sources: classes, DVDs, TV, podcasts


Final Thoughts

I wrote this post because I know many of my readers are around my age and might be experiencing similar hormonal issues. The above recommendations may or may not be helpful based on your own unique biochemistry. I saw my doctor a couple of weeks ago, and according to all my lab work and her physical exam, I'm very healthy but definitely well into perimenopause. I'm not sure what I had yesterday was a migraine, but I don't see the harm in making the assumption that it was and trying a few of the interventions above to see if they're effective, as well as continuing the things I've been doing with respect to diet and activity. And if you've discovered other effective ways to manage these symptoms without medications or hormones, I'd very much appreciate if you'd share them in the comments section. Thank you!

* Prior to taking making dietary changes or taking any supplements listed above, please  speak with your provider, particularly if you are taking medications, herbs, or other supplements.

7/31 Update : After going over my My Fitness Pal food diary Monday trying to figure out if I ate too much dairy, nuts, or chocolate yet seeing nothing out of the ordinary, I realized what the trigger for the migraine might have been. I don't record beverages since the ones I consume are calorie- and carb-free, but I now remember drinking a couple of glasses of water flavored with a generic flavor-enhancer sweetened with sucralose Monday evening. I don't use sucralose/Splenda regularly and I've never had a problem with it or any other artificial sweetener in the past, but perhaps I've developed a sensitivity which may be heightened by hormonal changes. I'm not against artificial sweeteners -- I use saccharin tablets to sweeten hot beverages every day -- but I've always told people that if they develop headaches or other symptoms as a result of AS use, they should discontinue them and/or find a replacement that doesn't cause the problem. A brief online search on potential sucralose side effects suggests it may indeed trigger migraines in some people but not others. Personally, I plan to avoid it from now on, as it seems to be the most likely explanation in my case.


8/1  Update: Although I'd pretty much settled on sucralose as the culprit, I had to investigate further, since I'd used Dasani drops a few weeks prior with no problem. What I purchased on Monday was the Kroger brand, which I assumed had the same ingredients. However, the Kroger brand contains both maltodextrin (source of MSG) and propylene glycol, both of which can be migraine triggers. There's also a lot of other questionable ingredients in both of these drops.
 
I kept thinking back to how I developed headache and nausea (although no vomiting) the morning after eating at a Chinese restaurant a few months ago, and I'm really thinking it's the MSG that I'm sensitive to, coupled with hormonal issues. I read a few more online accounts of migraines related to sucralose, and most people who have problems seem to experience this only with Splenda (yellow packets), which contains maltodextrin, but can tolerate liquid sucralose, which does not.

Just to be safe, I'm going to try to avoid all three potential triggers: sucralose, maltodexrin/MSG, and propylene glycol. In any event, I feel that saccharin, stevia, and erythritol -- consumed in moderation -- are the best sugar substitutes available.


References

1. Hodson J, et al. Headache at menopause and in hormone replacement therapy users. Climacteric 2000 Jun;3(2):119-24
2. Chai NC, et al. Migraine and estrogen. Curr Opin Neurol. 2014 Jun;27(3):315-24
3.Wagner W, et al. Prophylactic treatment of migraine with gamma-linolenic and alpha-linolenic acids.
Cephalalgia 1997 Apr;17(2):127-30
4. Ben Arye E, et al. Herbal medicine in women's life cycle. Harefuah. 2006 Oct;145(10):738-42, 782
5. Thomson M, et al. Effects of ginger for nausea and vomiting in early pregnancy: a meta-analysis. J Am Board Fam Med. 2014 Jan-Feb;27(1):115-22 
6. Di Lorenzo C, et al.  Diet transiently improves migraine in two twin sisters: possible role of ketogenesis?
Funct Neurol. 2013 Oct-Dec;28(4):305-8
7. Allais G, et al. Acupressure in the control of migraine-associated nausea. Neurol Sci. 2012 May;33 Suppl 1:S207-10
8. John, PJ, et al. Effectiveness of yoga therapy in the treatment of migraine without aura: a randomized controlled trial. Headache 2007 May; 47(5):654-61

A couple of days ago I received an email from the makers of a soy-based protein bar that began:

"Scientific research continues to show that a plant-based diet is a healthy dietary pattern. In fact, previous versions of the Dietary Guidelines for Americans have emphasized plant-based diets, and the 2015 Dietary Guidelines Advisory Committee appears to be supporting these previous conclusions."

I'd heard this before, after the US Dietary Guidelines Advisory Committee (DGAC) held their third public meeting on the subject this past May. The fourth meeting is scheduled to be held on the 17th and 18th of July, and there's an opportunity to participate online, if you're interested.

It does seem that plant-based diets -- which are usually, although not always, synonymous with vegetarian or vegan diets -- are gaining favor in terms of public perception of their health benefits and sustainability.  While I value the contribution vegetables, fruits, and nuts make to our diet, I disagree that most people would benefit from adopting a diet consisting solely of plant foods and have written about this before. And I'm disappointed that low-carbohydrate diets aren't being presented as an alternative at this point, particularly for the many groups of people who would benefit from them.

However, I dislike the confrontational and accusatory messages I've seen from many advocates on both sides in blog posts, comments,  and social media sites. I'm passionate about carbohydrate restriction (apparently I'm not supposed to use this phrase to describe myself, but I think it fits), and I get upset when people criticize it and make claims about the superiority of plant-based diets too. But in my opinion, being respectful of the other side -- who are often equally committed to their way of eating -- while letting the evidence in favor of low-carbohydrate diets speak for itself, is the best way to go. 

You may have already seen the debate between Dr. Eric Westman and Dr. T Colin Campbell held at the University of Alabama held in the spring of 2013. Both of these men have put many years into researching the effect of diet on various aspects of health. Each strongly believes that his way is the healthiest and most sustainable even though they are quite different. Dr. Campbell's view is that a plant-based, low-protein, low-fat, high-carbohydrate diet provides optimal nutrition, while Dr. Westman favors an eating plan that is very low in carbohydrate, moderate in protein, and high in fat. I encourage you to watch the video if you haven't already, or even if you have. Notice how Dr. Westman seeks to find common ground with statements like "There's more than one way to achieve excellent health," and then goes on to present the large body of evidence --including randomized clinical trials -- supporting carbohydrate restriction for diabetes, metabolic syndrome, and obesity, with early but promising research on ketogenic diets for cancer and neurological disease. I strongly agree with this approach and feel it's what will ultimately allow for more flexibility in the Dietary Guidelines -- specifically, including low-carbohydrate diets as an option.

I'm a firm believer in keeping track of the foods you eat and the nutrition they provide. Many times people believe they're doing everything right but find that their weight, ketones, and blood glucose levels tell a different story. Online tracking apps like My Fitness Pal are helpful, but they weren't designed for people following a low-carbohydrate or ketogenic diet. However, there is an app created specifically for us: KetoDiet App. Some of you may be familiar with Martina's KetoDiet App website, including the blog, which contains fantastic recipes and useful information about healthy, low-carb living.

I love the look and functionality of this app. First of all, it's highly customizable based on your goals for carb intake and weight loss. There are currently over 100 recipes that are beautifully photographed through every step of preparation, and the instructions are very easy to follow. An RSS feed automatically adds new recipes that Martina posts to the website. The app allows you to easily enter your own foods, recipes, and restaurant items,  in addition to the KetoDiet recipes. As you add items for the day, the energy (calories), protein, fat, fiber, and electrolytes are tabulated, along with net carbs, which are highlighted in green at the right edge. If you go over your personalized net carb goal (i.e., 30 grams), the color changes from green to red, instantly alerting you. Although the app is called KetoDiet App, you don't necessarily have to be on a ketogenic diet to use it, since you can program in whatever level of carb intake you like.

In my opinion, just about everyone on a low-carb diet would enjoy using this app because of its innovative design, ease of use, reliability, and comprehensive list of mouth-watering recipes. Those of you who read my blog regularly know that I like to be balanced and consider both the positive and negative aspect of everything, but in all honesty, I can't find anything negative to say about this app. I think it's fantastic and, along with the KetoDietApp for iPhone and KetoDietApp book, an excellent value. (Note: The iPhone app is a basic version which does not include the planner and tracker.)

If you haven't already, I highly recommend checking out the KetoDiet App blog and trying out some of the recipes, such as Paleo Greek Meatballs (Soutzoukakia), Cajun Chicken Tacos, and Low Carb Strawberry and Rhubarb Panna Cotta.

Disclosure: Martina provided me with a free copy of KetoDiet App for iPad, but I have received no monetary or other compensation for this review.