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It’s funny, this year I will celebrate 20 years of being a registered dietitian. Yet medicine, especially in the area of gut health, is changing so rapidly that I feel almost like I’m starting over. Every week, I pour over new journal articles, blogs, and updates, realizing how much more we all still have to learn!

In the past year:

What’s with all the crazy lab testing? I don’t feel as energetic as I used to. And and I’ve had more diarrhea in the past year than you want to hear about.

Last April I had the opportunity to run the Boston Marathon. It was an amazing bucket-list adventure with my family present to cheer me on. After marathon recovery, I reduced my running, and my energy levels pretty much returned to normal. In December I began training for a local marathon this April. It soon became apparent that my gut is more unhappy than it’s been in years, and my energy levels are not what they used to be. (I’m in denial about it just being the result of getting older!) So I’m digging for nutritional causes using functional and integrative nutrition. I will let you know as soon as I figure out what is the main issue.

The more I read, listen, and study, the more I truly believe that an imbalanced microbiome is the root cause of so many illnesses, conditions, and diseases. The internet is rife with inaccurate information, but also contains some fantastic gems. Here are a couple of my favorite blogs:

uBiome blog

Gut Microbiota for Health newsletter

I have also been working on my second book on Runner’s Trots. (It’s always easier to say you are writing a book than actually writing it. I should be writing right now, but instead I’m doing a blog post!) My goal is to be finished by late August 2016. We have a Hood To Coast running team and I intend to post very large posters of my book cover on our team vans. Team #rockintheruns here we come.

 

 

I receive quite a few requests to provide nutrition counseling to people all across the US. Each state has different requirements; some allow dietitians to practice only in their state, other states allow registered dietitians to practice across state lines. It’s VERY confusing!

Needless to say, the licensure requirements in Oregon do not allow me to practice outside my home state. So, I asked my colleagues if they would like to be part of a network of Digestive Health Dietitians. I added a new tab on my website so you can find a dietitian near you!

The Issue of Perfectionism

When I was in 6th grade, the adviser for the “TAG” program pulled me into her office. After some chit chat about what I would be doing in the summer, she looked me in the eye, and said something I will never forget. “Niki, I think you are a perfectionist. And I’m concerned that this will hurt you later on in life.” After I got over the shock of her comment, I got angry. Who is she to tell me I’m a perfectionist? She didn’t even know me! (She had spent very little time with me up to this point.)

I marched home and told my parents what the counselor had said. They weren’t happy about it either, but I don’t remember anything being done about it.Strive for excellence, not perfection

Flash forward. For my high school graduation, a friend gave me the book “Life’s Little Instruction Book” by H. Jackson Brown, Jr. One of the quotes resonated with me: “Strive for excellence, not perfection.” It became a mission for me.

Through the years, I have continued to fight the urge to be the perfect wife, mom, dietitian, daughter, and friend.

How much less would I have accomplished if I was striving for perfection instead of excellence? Would I have started my business or written a book? Would I have tried to qualify for the Boston Marathon? Would parenting have been too overwhelming if I felt the need to be perfect?

I have learned to give myself a break. Doing my best is enough.

Interestingly, the more pressure I put on myself, the worse my diarrhea flares up. Coincidence? Nope. What about you? Can you fight the urge to be perfect and settle for giving your best effort?

 

Have you heard about Girls with Guts (GWG)? How about this mission statement:GWG_Logo

The mission of Girls With Guts is to empower girls and women with Inflammatory Bowel Disease (Crohn’s Disease & ulcerative colitis) and ostomies to share their stories of confidence and to promote self-esteem.

GWG is having their fall retreat in Gresham, Oregon on October 9-12, 2015. You can find more about the retreat here.

I am thrilled to be a guest speaker at the GWG retreat on Saturday, October 10. We haven’t finalized the presentation yet, but will likely include: Nutrition and Inflammatory Bowel Disease, Tips and Tricks for Eating with an Ostomy, and one of my favorite topics, Eating for a Healthy Microbiome.

Want to join us? There is only room for 86 attendees, so sign up today. I can’t wait to meet this powerful group of women. Hope to see you there. #GWG2015 is going to be awesome!

 

This is an exciting time to be a gut health practitioner. I have been busy listening to Ted Talks and webinars, reading books and websites, and sharing and learning from my patients and colleagues. If I were a better blogger I would be sharing this information weekly. It’s one of my goals…

Here are just a sampling of what I have learned recently:

Post-surgery gut rehab

The hospital is full of really sick people. I know, because I had an opportunity to work at the hospital this past week. (This is the same hospital I have worked at for over 18 years, though in recent years I am only there on-call.) Many years ago I was responsible for all the tube feeding and TPN (total parenteral nutrition) patients at this same hospital, especially in the ICU and surgical units.

This week’s workday in the hospital alerted me to the stark contrast between the desperately ill patients who require intensive care vs. the comparatively healthy outpatients I usually see.ivabx

As I stood in the ICU next to the patient’s bed and observed the multiple hanging bottles of antibiotics, it occurred to me… in the short term modern medicine is saving this person’s life from nasty bacteria. However, in the long term, multiple abdominal surgeries with several courses of antibiotics will change this patient’s gut microbiome for the rest of his/her life.

It’s good to go back and remind myself what really sick patients go through on the way to recovery. That said, what can we do after a stay in the hospital requires surgery and/or antibiotics? Good question. I say this calls for gut rehab.

What does gut rehab look like? First, meet with your physician or surgeon and tell them you want to re-establish the good bacteria in your gut. Ask them to refer you to a registered dietitian nutritionist (RDN) who specializes in intestinal diseases and disorders.

Then, work toward restoring a healthy microbiome:

  • After this patient is released from the hospital, I would begin by making sure the patient is meeting basic energy (calorie) and protein needs.
  • Take a liquid or chewable multiple vitamin for better absorption. If the patient had parts of their digestive system re-routed or removed, it may require targeted vitamin or mineral supplementation (such as extra calcium or iron if the duodenum is affected).Jarrow-Formulas-Ultra-Jarro-Dophilus-790011030263
  • Begin taking a probiotic supplement with multiple bacterial strains, such as VSL#3 or Jarro-dophilus or saccharomyces boulardii.vsl3
  • Include fermented foods in the diet, such as yogurt (with live cultures), fermented vegetables like sauerkraut or kimchi, miso soup, or beverages such as buttermilk or kefir.
  • Re-evaluate for improvement of symptoms such as diarrhea, gas, bloating, or pain.
  • Consider trial of the low FODMAP diet if symptoms continue.

I was always taught to have measurable goals. A couple of years ago, I began running longer distances. It began as a whisper in the back of my head… maybe I should train for a full marathon?  But if I run a full marathon, I need a tangible goal. I better get serious about it and try to qualify for the Boston Marathon.

So my quest began. I blogged about my history of running and my first marathon. Since I had just turned 40, my Boston qualifying time was 3hrs and 45 minutes (3:45:00). At the Eugene Marathon, my finish time was 3:46:01. I thought, I can shave a minute and a second off my time, no problem! Later that year, I trained harder (still using Runner’s World’s Run Less Run Faster program) for the Portland (Oregon) Marathon in October 2013. The good news, again I was able to run a whole marathon without any diarrhea, but bad news, I started getting nauseated at mile 19 and it slowed me down the rest of the race. My finish time? 3:45:17. Yes, I missed my cutoff time by a mere 17 seconds!

I have never been one to give up. So earlier this year, I signed up for a downhill, but Boston-qualifying marathon called Light at the End of the Tunnel Marathon on July 13, 2014. I trained in earnest, getting my workouts in while keeping **BOSTON MARATHON** in the forefront of my mind.

Week Prior to the Marathon

As I had done with previous marathons, I spent the week prior to the marathon eating very conservatively… only foods and quantities my gut would tolerate. I ate quite a bit of chicken, some dairy, eggs, a fair amount of bread (gluten and I are still friends), and actually very few veggies. As a result, my GI tract was quiet all week heading into the race. I also made sure I was well hydrated.

For dinner the night before the race, I ate the typical pre-race pasta meal (fettuccine alfredo with chicken). That evening before bed,  I took my dose of Imodium and and a Prilosec (proton pump inhibitor). Since I had experienced nausea the first two marathons about mile 19, I was curious to see if it was related to the acid in my stomach somehow. That night I had to get up and pee twice during the night, so I knew I was plenty hydrated!

IMG_7489On race morning I was so nervous I could only eat some dry Life cereal. I was able to have a normalish BM and popped two more Imodium (for some of you that may be TMI).  The day was gorgeous, but forecast for 91 degrees for a high temperature. It was already 63 degrees at the start! I headed to the porta potty first (no diarrhea–yay!). As I waited in line to pick up my bib number, I powered through 1.5 scoops of UCAN. I haven’t discussed UCAN yet on my website, but it is my new FAVORITE running fuel. I will spend an entire blog post on it in the future, but you can read more and check it out here.

[BIG SIDENOTE: What is UCAN? From their website… “Generation UCAN is powered by SuperStarch, a healthy, natural, gluten-free innovation in carbohydrate nutrition. SuperStarch is a complex carbohydrate (derived from non-GMO corn) that uniquely stabilizes blood sugar and causes virtually no reaction from the fat-storage hormone insulin. It’s backed by proven science. Finally there’s a healthier, more efficient energy source than sugars, caffeine, or high-carb meals. Originally discovered for children with life-threatening energy imbalances, SuperStarch is a revolutionary fuel being used for ENERGY, SPORTS, and FITNESS.”

I started using UCAN in March of this year for my long runs. It is now officially part of my toolkit for marathons. (Disclosure: I do not work for UCAN, I simply believe in the product and think all long distance runners should at least try it!) UCAN is easy on the tummy… no gas, bloating, or crazy runners trots when I use this product! The only two downsides to UCAN: it’s expensive, and it doesn’t taste awesome. I mix the powder into a slurry, gulp it down just before the race, and then fuel again in 1.5 hours! As of yet, I haven’t found a way I can take it in the middle of the race, so I use other fuels.]

Tunnel Marathon Info

There are several very cool things about this race. Just 1/2 mile into the race, you run into an old railroad tunnel which is pretty narrow and completely dark. You wear a headlamp because you run for over two miles in the tunnel! You can see a pin prick of light that gets bigger and bigger as you get closer to the end of the tunnel. (When you leave the tunnel, you can pass your headlamp to a volunteer who takes it to the finish line for you.)

This course is beautiful. It’s about 30 miles east of Seattle up in the mountains near Snoqualmie Ski Resort. The marathon is billed as an “all downhill course”, but there are are few uphill sections. The course itself is a gravel road; you run in the ruts ( no cars, only bikes and people walking/running). The scenery is breathtaking, and you cross four or five suspension bridges. The downside, there are no porta potties on the course, and only a few outhouses along the way.

Back to the Race

DSC_0249

Waving goodbye to my family at the start of the race. Notice my Sport Beans are about to fall out of my fuel belt?

The race gun sounded, and I waved a final goodbye to my husband and kids. About a mile into the tunnel, I had a sickening realization: all my fuel had fallen out of my pocket. It hit me… I was going to have to use the fuel they provide at the aid stations on the course. And not all fuels agree with my GI tract. UGH.

An hour and a half into the race I realized I needed fuel asap. At the next aid station I looked over the fuels (water and fuels were “self serve”) and grabbed a Roctane Blueberry Pomegranate gel. I downed the gel with a whole bunch of water (I carried 4 bottles with me on the course). I was surprised that I tolerated it well and didn’t have any tummy distress.

By the time I saw my family at mile 13, it was already hot, and I was tired. At mile 16 the dreaded nausea kicked in (I guess the Prilosec didn’t help…) I picked up another gel from the water station, and would spend the next mile literally dry heaving while trying to get it down with water. I glanced at my heartrate… 180 beats per minute. I was too hot and my heart rate wouldn’t go down…

I saw my family again at mile 21. Calves were cramping. I was hungry and tired, but I was still running, albeit slower than my goal pace. I passed a lot of people walking. It was hot and the water stations were too far apart.

IMG_7493

Sad glassy eyes. I threw up shortly after this picture was taken.

finish line

Just missed my goal.

As I ticked off the miles, and looked at my watch, I knew it was going to be tough to reach my goal time. The finish line was ahead, and I sprinted as fast as my cramping tired legs would let me… and I crossed the line in 3:45:01.6. I missed my goal by 1.6 seconds. It was 86 degrees by this time. I was cramping, dizzy, dazed, and clearly overheated. Then I vomited in front of my kids. A low point that day.

Not Giving Up

I think I was home 24 hours when my husband planted the seed: I should run another marathon soon, since I’m already fully trained. We researched possibilities… and I decided to run the exact same race, only in September (they call it Tunnel Lite, since there are fewer runners). It was challenging to both recover from the last race and simultaneously prep for the next.

I figured it was time to do something new, so I hired a coach, Nikki Rafie. We only met in person one time, she gave instructions on improving my form while I peppered her with 1000 questions. Some important tidbits from Coach Nikki:

  • When I told her how many gels (6) I had taken during the previous marathon, she asked how many calories I eat the day before a marathon. I wasn’t sure, but she told me I should be consuming “around 3000”. While I have focused on carb loading, I have never tried to come close to 3000 calories the day before a race.
  • She recommended a negative split, meaning, run the second half of the race faster than the first. (“I’ve never been able to run a negative split in a workout,” I told her.)
  • She told me if I was worrying about missing time in the first half of the race, I could intersperse several 1 minute intervals of increasing speed to almost a minute faster than my average marathon pace.

I completed a 20 mile and 18 mile run before my next race, in between two 9 day family motorhome vacations, one of them to the Grand Canyon. It was tough to get my workouts in!

Deja Vu?

September rolled around, it was time to run the same exact race I had run in July. I was ready to achieve my goal. The week before, I again ate conservatively. The day before the race, I pushed the calories to almost 3000 by snacking like crazy. The night before the race, I again took Imodium, but skipped the Prilosec this time.

IMG_8354

Brrr, 38 degrees at the start!

IMG_7590-XL

Coming out of the tunnel, ready to hand off my headlamp. (Thank you comerphotos.com!)

On race morning, I took another dose of Imodium and ate my simple breakfast of dry Life cereal. As we drove to the starting line, I watched the outdoor temperature (on my car’s thermometer) dropping. By the time we got to the start it was a very chilly 38 degrees… a far cry from the 63 degree start just 8 weeks earlier. I waited in line for the warm indoor bathrooms, and ate my UCAN. Finally, it was time to start the race!

It was chilly outside, but it warmed up a bit once we got inside the tunnel. I wasn’t sure of my actual pace because I lost GPS signal inside the tunnel. Once we left the tunnel, I noticed the mile marker chalk lines weren’t on the ground like they had been at the previous race. So my pace at that point was a bit of a mystery.

At mile 5 I admitted to myself that I had to pee badly (a side effect I have noticed with taking Imodium, I suspect it takes water out of the bowel and transfers to the bladder… though I have not confirmed the science on this). Maybe I can hold it for the rest of the race? I thought. However, I have learned from past experience that a full bladder will eventually lead to GI distress, which would be worse. I was trying to stay hydrated, but couldn’t drink anything because it made the bladder situation worse.

By mile 11, I knew I would have to stop and pee.  There were runners waaaay in front of me, and no one I could see behind me (we were running on an old railroad trail out in the woods), so I jumped off the path and pee’d in the bushes. It only took 17 seconds!

I knew from previous experience I had no extra time to spare. So I used the trick taught by my coach: over the next several miles I sped up to ~45 seconds faster than goal pace for 1 minute, then slow back down to race pace. I did this several times, especially in the downhill portions.

After emptying my thimble-sized bladder I felt like a million bucks, and was excited to see my family at the halfway point. They met me with full water bottles and extra fuel. (During the July race I needed my first fuel after 1 hr 15 of running; this time I didn’t need to fuel the first time until 1 hr 30 minutes.)

I saw the first mile marker at Mile 14 and realized I was at least 4 minutes slower than I needed to be to meet my goal time. I sped up just a bit, concerned that I would bonk before the finish if I went too fast. I was alternating Sport Beans and water with my favorite oral rehydration solution packets.

At Mile 18, my phone died, along with my race day music (bummer), so it was now just me and the gravel trail. A race marshall came up on a bike to see how I was doing. “I feel awesome,” I said, and I actually meant it! (I learned from my friend Katie at the Portland Marathon to say “I feel awesome” no matter how bad you feel. Positive thoughts!)

He told me I was running strong and to keep up the good work. I realized at this point, I did not have the nausea that had plagued me with all three of my previous marathons. I think it was because I had run the first half of the race so conservatively. I significantly picked up the pace. The air temperature was rising, but I noticed my heart rate was staying around 164, a good place for me.

At Mile 21, my family cheered me on and my friend Eileen jumped in to pace me to the finish. The final 10K I ran over a minute per mile faster than my goal pace. I was tired but energized at the same time. My gut was quiet, so I took a shot of caffeinated gel and chugged down some water with three miles to go. We pushed hard the final miles, passing people who had passed me much earlier in the race. My calves started cramping just slightly at Mile 25, but it was much more manageable than it had been during my previous marathons. My friend Eileen was SO encouraging, keeping me on pace, and supporting me all the way.

niki BQ finish

Success!

Niki & Eileen

Thank you Eileen!

I could finally see the finish banner ahead and could hear my family cheering me on. I ran as hard as I could… and crossed the finish line in a Boston Qualifying time of 3:43:45! And bonus, my calves didn’t immediately seize up and I didn’t vomit! : )IMG_8359

What was Different about this Race

  • I ran the second half of the race six minutes faster than the first half. This is the first time I’ve ever run a negative split. I think it made a huge difference in how I felt the second half. No nausea or major calf cramping.
  • Eating close to 3000 calories the day before the race allowed me to fuel less often during the race.
  • During the race, I took 1 Bluberry Roctane (caffeinated), 1 Honey Stinger, and 1-1.5 bags of Sport Beans (caffeinated). (The same race in July I consumed 6 gels during the race.)
  • Although it was still 76 degrees at the finish, my heart rate was much lower during the September race because of the cooler temps.

What I have Learned from 4 Marathons

  • Know where the aid stations are on the course and what fuel they offer at each. I didn’t pay attention before my July race because I thought I would be carrying all my fuel and water. But when I lost my fuel 1 mile into the race and needed to refill my water bottles on the course, I didn’t know where the aid stations were.
  • The importance of being hydrated BEFORE the race and STAYING HYDRATED during the race. I think this is why my gut was able to tolerate unfamiliar gels on race day. I also washed those gels down with plenty of water to offset high osmolality (a blog post for another day…)
  • Most importantly, Positive Thoughts and Never Give Up on Your Dreams!

What’s Next?

The day after the race, I applied for the Boston Marathon 2015. Ten days later I received my confirmation letter. Boston Marathon 2015 here I come!

An excerpt from my book…

How Much Fluid Do I Need Each Day?

It’s best to try to exceed the established standard for adequate intake (AI), especially if you have chronic diarrhea. Remember that all non-alcoholic, caffeinated-free fluids count toward your total, including water, ORS, juices, milk, herbal teas, decaf coffee, and soup. Even fruits and vegetables can contribute to your total fluid intake.

According to the Institute of Medicine, an adequate intake for…

  • Men is about 3 liters (about 13 cups) of total fluids per day
  • Women is 2.2 liters (about 9 cups) of total fluids per day

These guidelines do not take into account fluids lost during…

  • Excessive sweating, which occurs in hotter climates and during summer months
  • Exercise
  • Diarrhea
  • Breastfeeding

Tips for Getting Enough Fluid Each Day:

  • Drink a beverage with each meal, then between meals too.
  • Use a large water bottle labeled with ounces or liters to keep track of how much you are actually drinking. Take it everywhere you go.
  • Don’t forget to drink before, during, and after exercise.
  • If you do not like the taste of plain water, try adding slices of lemon or lime to improve the flavor. Or, try non-caloric beverages such as Crystal Light® as tolerated.
  • If you have diarrhea, room temperature water is often easier to tolerate than very cold water, which can cause cramping.
  • Monitor the color of your urine. If it is very odorous and dark yellow, you are not drinking enough!

Sometimes, when I’m in a counseling session, I look into your eyes, and it hits me… IT’S NOT ABOUT THE FOOD.

Sometimes, I am able to overcome my discomfort to come right out and say… “I know I don’t know you very well yet, but I’m going to come right out and tell you… IT’S NOT ABOUT THE FOOD.

“What is it about?” you quietly whisper.

“What other things are going on in your life? What stressors are so deep within you that it is making you physically sick?” I ask.

You look at me in surprise. Tears flow. I’ve hit the target. So we talk about life… what happened in your childhood or the status of your current relationships. And we don’t talk about carbohydrates or FODMAPs or what you put in your smoothie this morning.

Life doesn’t happen in a vacuum.  While your gut problems are certainly connected to what you ate for breakfast and the handful of medications you take, they are just as related to the stress and the pain buried deep inside. My heart breaks for you, because I know how bad it must be to be causing so many physical problems.

Ultimately though, I have hope. Because if you work through the emotional pain, the physical pain will improve too. Thank you for trusting me with your secrets.

Sometimes, IT’S NOT ABOUT THE FOOD.

I recently purchased a copy of Low-FODMAP Diet bookSue Shepherd’s “The Complete Low-FODMAP Diet” book. It was a great read. The photography is beautiful and the information is clear.

As a dietitian, I absolutely love learning new information. I was reading along and BOOM! out popped an “A-HA” moment for me. How had I missed this important tidbit in all my years of researching irritable bowel syndrome (IBS)? Under the section listing causes of IBS, number 5 caught my eye: Joint Hypermobility. The book states, “About one in five people has joint hypermobility syndrome… It has recently been found that this condition is associated with a higher chance of having IBS. It is assumed to be related to the relative laxness of the tissues in the gut– they tend to distend more.”

1986 niki beam Here is a photo from my youth. Do you think my elbows are hypermobile? (I have not been diagnosed with joint hypermobility syndrome, but I do meet some of the criteria.)

You can find more information on hypermobility syndromes here. I’m still researching the connection between hypermobility and IBS. I plan to write a longer blog post in the future.

In other FODMAP news, my friend and colleague Patsy Catsos, MS, RD, LD (author offlavor-without-fodmaps “IBS– Free at Last” recently published her FODMAP cookbook. You can read about it on her website www.ibsfree.net and purchase on Amazon here.

 

 

Another 21-day tummycolleague and friend Kate Scarlata is also a wonderful FODMAP resource, including some free downloadable handouts (I love free stuff!). You can find her blog here and her website here. By the way, Kate recently co-authored  “21-Day Tummy” with Reader’s Digest.

If you are about to embark on a Low-FODMAP diet, there are many choices. You will also need to partner with a knowledgeable registered dietitian/nutritionist to help you navigate the diet.