Prednisone Mania II: Public Transit & Stripetti Squash

For those who were apprehensively awaiting the report on my wearing a face mask during each of the five flights taken on the California adventure, the venture was successful.  I was quick to smother this small victory, however.  No sooner did I get back to riding public transit to/from work every day than did the urgency to protect myself become inchoate... for whatever reason -- likely familiarity of the daily ebb and flo.  Because the person sitting next to you on the bus when you are at your most vulnerable is always the singular person coughing, and because I got my flu shot last week, I now have a Cold.

This means three things:

1) despite the hypomania of the prednisone I am becoming utterly burnt out by 10-12 hour work days,

2) my concern over catching the flu is exacerbating the hypomania which I am otherwise trying to combat, and

3) I am going to have to push back my third Remicade infusion because it, as an immune system smasher, can't be administered while ill (go figure).

These three things mean three more things:

1) anxiety over maintaining my momentum to see this work week through; the tissue processing, the number crunching, the mice prep for next week's experiments, the drug prep for next week's experiments, the behavioral training for next week's experiments, and the poster that needs to be printed on Friday... they're all very time-dependent and have crucial deadlines which I can't meet unless I continue to work 10-12hr days.

2) anxiety over having to wear a mask on the bus versus nabbing a spot by the back window where I can let airflow through even in the cold/damp without disturbing anyone else, and over not being able to avoid the mask at all in the mornings when the bus is most crowded, and over lacking the chutzpah to ask H.B. to drive me to work every day until I bypass this thing. Yes, you may laugh at the asinine superfluity of this one; I blame the drugs for obstructing my usual paths of logic.  The mask on the airplane is one thing, but on the bus to work?  With the same people I see every day of my life??...

3) and, last but not least, anxiety over interrupting my Remicade schedule at the third infusion (3-5 are the critical stages in terms of crossing a threshold into having an actual effect).  The sooner the Remicade starts to stand on its own, the sooner I can taper off of prednisone, the sooner I can taper off of Purinethol.  One immune system smasher is better than three.

Stripetti hash browns with cayenne pepper and paprika.

Anxiety + Hypomania = Less Than Exalted Nattie.  I am upholding aplomb with vitamin C  and stripetti squash hash browns!  No echinacea, because it specifically induces synthesis of TNF-alpha mRNA (Raduner et al 2006; Gertsch et al 2004).  And possibly with the scrapping of late-night work tonight, to be replaced with some much-needed Battlestar Gallactica.

Prednisone Mania

Awake at 4am (again), and not mildly interested in trying to remain in bed, I got up to do some work on my Society for Neuroscience poster (which will be presented in Chicago next week... without me) and to do a bit of side research into the legitimacy of my unprecedented episodes of ENERGY!!!!!

Corticosteroids, like our dear friend, Prednisone, work on your hypothalamic-pituitary-adrenal axis.  Otherwise known as taking over and suppressing your adrenal horomones which messes with one's mood.  Surprisingly -- or, perhaps, not surprisingly -- there are a lot of medical studies out there that address the drug-symptom correlation, and quite a few animal studies about corticosteroid-inflicted hormone dysregulation.

The actual surprise is that none of them get together and say, "Hey now, I think it's pretty safe to say that we can write a review with all of this isolated information and make some suggestions about why these particular symptoms occur with these particular doses of Prednisone"... etc.  So I'm haphazardly covering for their neglect.

There's a nice paper by Brown and Chandler (a Phd/MD and MD, respectively) laconically highlighting some dose-reponse clusters in patients on various regimens of Prednisone.  They focus on prevalence and type of psychiatric changes that occur during corticosteroid therapy.  Mania seems to be the prevailing cognitive symptom across low (<20mg/d) and acute (>40mg/d) regimens... which is of interest to yours truly because THAT IS WHAT I HAVE EPISODES OF EVERY NIGHT AND EVERY MORNING.

"Khan et al. found statistically significant increases in scores on the Young Mania Rating Scale but not on the Hamilton Rating Scale for Depression in asthma patients (N = 32) receiving 1- to 2-week courses of prednisone at approximately 40 mg/day (1999)."

"Similarly, Wada et al, in a retrospective examination of 9 patients with more than one episode of steroid-induced mood changes, found that 85% of the episodes were primarily manic in nature. The findings again seem to support a preponderance of manic symptoms with these medications (2000)."

Of course, this is not to say that there is no propensity for depression, various degrees of irritability, anxiety, faulty memory or psychosis -- this is all in the Brown & Chandler article which I highly recommend that you give a look, as it does well to cover the spread of mood versus corticosteroids.

What I want to know is how mania in particular gets such an erratic boost from Prednisone.

Brown et al did a sweet little study in 2004 that looked at -- among other, but less exciting things -- changes in volume, N-acetyl aspartate, creatine and choline in the hippocampus.  The hippocampus, everyone's favorite mood and memory relay-consolidation modulator, was the brain region of interest in this study because it is historically very susceptible to corticosteroid exposure.  It also provides negative feedback to the hypothalamic-pituitary-adreanal axis, where our friend Prednisone plays.

What Brown et al suggest is that hippocampal volume was decreased in patients who had a history of mood disorder with chronic prednisone, but not significantly so.  Similarly, ratios of N-acetyl aspartate to creatine and/or choline (NAA's metabolites) decreased, indicative of slowed metabolism in the hippocampus.

What this suggests -- and what the paper does not address because research papers written by MD's are typically lacking in such expatiation -- is that prednisone shows a trend of suppressing metabolism in the hippocampus specifically.  Not shocking for a corticosteroid.  Suppressed metabolism correlates with decreased volume of cortical tissue, and is also not shocking as NAA is a precursor for lipid and myelin synthesis as well as the peptide N-acetylaspartylglutamate.

The behavioral tests carried out to correlate psychiatric symptoms with hippocampal changes were many, but they did not suggest any psychotic features in prednisone-treated patients relative to healthy test subjects.  The Brown group concluded that the between-group differences on several of the memory tests were due to depression and anxiety, and not the manic effect of the prednisone:

"We did not find significant relationships between duration of therapy and volumetric, spectroscopic, cognitive, or mood findings, although a trend toward a relationship between corticosteroid dose and right, but not left, hippocampal volume was observed. Some (Sheline et al., 1996 and MacQueen et al., 2003) but not other (Bremner, J.D., Narayan, M., Anderson, E.R., Staib, L.H., Miller, H.L. and Charney, D.S., 2000. Hippocampal volume reduction in major depression. Am J Psychiatry 157, pp. 115–118.Bremner et al., 2000 and Frodl et al., 2002) reports in patients with MDD have found a negative relationship between time depressed or number of depressive episodes and hippocampal volume, although these relationships have sometimes been nonlinear and lateralized to one hippocampus. Several explanations for the lack of relationship between amount of corticosteroid exposure and neuroimaging findings were considered. First, the small sample size could limit our statistical power. Second, patient-reported corticosteroid duration data may be inaccurate, although we attempted to confirm their estimates through medical record review or discussion with treating physicians. Third, changes in hippocampal volume during corticosteroid exposure may be, at least partly, related to individual vulnerability rather than simply dose, duration, or treatment."

Alright.  So we've got some mostly behavioral correlations.  Sweet.  How about a mechanism? <drools over the idea of a glutamatergic mechanism involved in prednisone-induced hypomania>  The best way to go about finding a mechanism in literature is to hunt down the pharmaceutical trials.  This next one is also from the Brown group, with a different selection of co-authors in 2005 testing intervention with phenytoin, an anti-convulsant and glutamate release inhibitor (glutamate is the primary excitatory neurotransmitter throughout the brain):

"Our findings suggest that phenytoin also prevents manic or hypomanic symptoms associated with corticosteroid therapy. The mechanism by which phenytoin might exert this antimanic effect is not clear. Inhibition of glutamate release has been suggested as the mechanism behind
the neuroprotective effect of phenytoin in animal models of stress (Magarinos et al 1996). The blockade of voltage-gated sodium channels, however, has been suggested for the efficacy of phenytoin in mania secondary to bipolar disorder (Mishory et al 2000)."

Booyah!  Glutamate wins! So now we can postulate -- although, sadly, again, this paper doesn't -- that prednisone-induced hypomania results when suppression of the hypothalamic-pituitary-adrenal axis dis-inhibits glutamate release in the hippcampus, where phenytoin acts to suppress this over-activity to calm the hypomania.  Maybe.  So until I learn otherwise, that's what I'm going to assume is going on.

As a scientist, I must point out the limitations of this experiment; including whatever concomitant medications were being taken by the test subjects, secondary effects of prednisone that could just as well have been responsible for the observed effects and between-group differences in prednisone metabolism.  In other news, the Brown group used a 40mg/d regimen for a period of 7.4 days; this is an acute dose, and happens to be the one I have been on for 6 weeks, which means the outcome of the study is particularly applicable to the condition my condition is in.  Which is cacophonous.


Sidenote:  Glycyrrhizin was found to reduce the clearance of prednisolone in healthy individuals (Chen et al 1991).  I suppose I wont be taking any licorice until I am done with this beast.  And you may not want to either.

one step back

Alright.  Alright alright, alright, okay.  I get it.  No more chicken broth.

Yesterday I took H.B. down 23rd to star gaze and ogle at all the Trend that is NW Portland.  This journey entailed, by necessity, a meal at Kornblatt's where I humbly indulged in a cup of Matzoh ball soup while he had his first salamicornbeefroastbeef sandwich.  A cup, by the by, which was 80% matzoh ball and 20% soup.  Perfectly proportioned for my second attempt at re-introducing non-dehydrated chicken broth, no?  Clearly, no, for the rumble came four hours later - right on schedule, to my astonishment - and just in time to interrupt Grill Night with the Family.  Fortunately, it was an IBS assault and not Crohn's, so lasted only a half hour or so (also an indication that the prednisone is doing its duty).

Alright.  You win, relentlessly truculent tummeh.  I will continue to eat only wheat-free bread, butternut squash, egg, avocado, dry chicken breast and the occasional spread of refried beans.  Six (solid) dietary staples; one for each week I've been on Prednisone!  How coy.

Needless to say, I am less curmudgeony about Applications having spent a day in Powell's.  

Food of the Day: Avocado

Why it has taken me so long to sing the paean of the avocado, I couldn't say.

We have a history, this fruit and I.  My very first flare - and this dates me to the tune of over a decade, now - sent me to Ensure and crackers for six months straight.  When I slowly emerged from the malaise of infirmity, the first food I ate was avocado.  At the time, I wasn't quite so sensitive and could spread it on a tortilla to consume without inflaming my mouth and constricting air flow.  It inspired the creation of my favorite First Meal: tortilla heavily smeared with avocado and rolled lightly with refried beans. 

There was a CCFA NW Chapter picnic happily convening several days after I discovered my ability to move this marvelous concoction through my system with minimal damage.  Like a proud mother, I brought my Meal to the potluck where I expected everyone else to also present a panache of the most mild of culinary conceptions.  No.  Other people made salads and lasagnas.  Meals oozing with acidy, creamy, fibrous danger.  My little avocado-bean rolls were consumed widely and voraciously, nonetheless :)  But I digress...

Soluble fiber and easily digested raw fats are the best friends a Crohnie can have - particularly during a time of high carbohydrate consumption - and the avocado exudes these.  The reason it is always one of the first solid foods I reintroduce after a flare is a widely known secret my pediatric nutritionist shared with me: vitamin A.  Vitamin A plays an essential role in cell proliferation and turnover.  Of importance in Crohn's and the digestive tract, it protects your immune cells from damage (Bendich 1988), and keeps intestinal epithelial cells able to produce the mucosal lining that is so important to absorption of nutrients and other vitamins (Larsson et al 2007).

In order to absorb vitamins, you need fats in your diet.  Vitamins A, D, E and K in particular are fat soluble, which means they absorb best in the presence of the same enzymes your body uses to digest raw fats.  Avocados, endowed with their own supply of raw fats, are perfectly equipped to provide this resource. 

For those of us with severe obstruction, fiber is the enemy.  At its worst, it means stringy vegetables that just can't get anywhere; at its more benign, the bloat-tastic bulwarks of wheat and grains.  The water-soluble fiber in avocado (blah) is our redemption.  Probably the most helpful food following a flare.  Water-soluble fiber is the most easy on the digestive system.  Like other fiber, it does not digest/absorb.  However, it does transform in a fermentation process that gelatinizes (or slime-a-fies), which alleviates a great deal of the roughage of moving through battered intestines (Rose et al 2007).

When you have 2 months of nothing but starchy carbohydrates festering in your tummeh, as I do, soluble fiber is the most welcome gift of the gustatory realm.  I'm all about moving things along.

Avocado on dark rye (with a pinch of pepper because I like to taunt death).

Sidenote:  My mouth and throat swell whenever I eat non-boiled fruits and veggies.  Oral Allergy Syndrome is what some call it, and it is the most likely culprit considering the autoimmune nature of Crohn's.  Avocado in particular has become more harsh with time.  God help me if I ever get to a point where I can't eat it at all...

Heartburn

I felt it was noteworthy that even as prednisone has begun to conquer the intestinal turbulence, the inevitable heartburn reigns again.  Having come to expect and even celebrate its arrival as one might welcome the Inquisition, I made it a point this evening to make my guest feel at home in the aberrancy of my esophagus.

After a month of broth and starches, the assault of fiber and protein on my esophageal epithelials has, once again,  won out over denial.  Come chamomile; come Tums; come egg, avocado and sweet potato.

UCLA + the wrap

Good morning, Santa Monica, you seamless plain of city, sand and salty sunshine. I awoke, once again, before sunrise and disappointed at the disjointing of exhaustion and slumber by steroid-induced starvation.

We appeased my broken chakra with a stroll on the surfer-peppered beach, packed, and finally introduced a pumpernickel bagel with dry egg to my poor, neglected gut. Lord, how I have missed pumpernickel bagels.  Let it be known that it took me the course of an hour to eat this, and I had to discard of the last 1/4 egg.

UCLA, as my boss promised, was gorgeous, open and pleasantly devoid of the rapids of students who will arrive next week. My moment of swooning peaked before even setting eyes on the Health Sciences sector of the campus, which, although naïve and totally unwarranted by the dilapidated babblings of the “graduate tour” guide, may have been intuitively accurate.  The Semel Institute was excellent.

The meeting itself with Dr. L meandered sinusoidally between mildly encouraging and unnecessarily pessimistic – all on his part, of course. I remained enthusiastic the whole time, prying him for a spark of any sort.  I did, in fact, provoke three (booyah!). I was forewarned of his no-nonsense manner, but proceeded under the pretense that my own excitement would expose some vivacity in him. All in all, it was made clear to me that the logistics of applying to the UCLA program demand that you are accepted by the admissions committee – note; not composed of the program faculty - before the faculty are at all interested in you. Fair enough. I must commend Dr. L for putting his time into speaking to me when he knew very well that I may not even get an interview in the spring. UCSF works this way, as well. Contrarily, the weight of faculty sponsorship or even recognition at Stanford and USC gives a prospective student weight in the direction of acceptance.

The final rank: USC, UCLA, Stanford, UCSF.

“What’s your safety school?” Dr. L asks…

Uh… safety? I don’t do safety. I live dangerously. Dancing wildly onto the precarious glacier of a future whose apex is probably out of my league is my preferred approach. What’s my safety school… Here’s the plan: if none of these top-ranking institutions want me next year, one of their PI’s will hire me as a technician and I will blow their minds from the propinquity of beneath their snotty noses for another year until they realize the mistake of side-stepping me. Then I will proceed to make history in the atmosphere of Academia’s profusely apologetic compunction.

I do not have a safety school for two reasons: 1) I’m not choosing the school based on the reputation of the program, I’m choosing it for research opportunities that can be taken advantage of during my time there. Ultimately, PhDs are not hired for the name of their graduate institution but for their technical skills and the incites of their productivity. 2) Heroic Boyfriend cannot stay in Oregon, where I am an unquestionable shoe-in with at least seven PhD projects in the works that are all at my instigation, a guaranteed adviser, a new technique to be mastered and an excellent program in Behavioral Neuroscience. Oregon is a much smaller program and puts constraints on opportunity that I am not ready to endure for safety’s sake. Therefore, a “safety” school is a waste of $45.00.

My glorious parents met us at the airport and treated us to Rosh Hashana sushi (what I would not give to have had my mother's brisket). I got my avocado roll and udon noodle soup. Tomorrow… tomorrow will be for recuperation and preparing for the overload of excitement that will be returning to work on Monday. [No, I’m not being sarcastic, I’m more than ready to be back at work with all the amazing projects that must develop in October]

Side notes: VERY VERY AWAKE AT 3AM (thank you, prednisone and uncouth enthusiasm for life) AND VERY VERY HUNGRY ALL THE TIME (thank you, prednisone).

USC

Ah… to awaken with 4am hunger pangs.  Technically, my body has put in its eight hours of rest and consolidation, and I should be home free to interrupt this stream of consciousness that is so convinced that it is famished.

Galileo on the porch steps of dimly lit Culver City in the midst of early morning traffic, it is.

[later...]

Well then.  My mind is blown.  I had high expectations of this program, and its discreet strength as a translational medium of research... but I did not anticipate being this impressed.

Admittedly, wasn't too elated with the University Park Campus.  Also admittedly, that was more than likely because I was disappointed with the utter lack of bike rack space!  Otherwise, it was a pleasant place.  The Health Sciences Campus in north east, on the other hand, was fantastic (facility-wise... not ghetto-neighborhood-wise).  The people I met were fantastic.  The enthusiasm was tremendous.  The PIs were astoundingly invested in the translation of the program.  And, last but certainly not of least importance, they liked me.  Score.

Tonight, I lay exhausted, agitated by steroid-induced starvation and by excitement for tomorrow's adventures as I listen to the light breeze of the ocean outside my hostess's high-rise in Santa Monica, and Heroic Boyfriend sleeps soundly beside me.  Yet another for the books.

Stanford

One down, two to go.  I was thoroughly impressed with the design of the Medical side of the Stanford campus today - although my mediocre documentation does it no justice - and with the insider's perspective on the strength of the program in general.  I believe it is a good sign that the PI emailed to thank me for the visit complete with extol of my strengths, and the hope that I will bring them to the program.  Hot.  Thoroughly encouraged by my first awkwardly-fumbled-but-apparently-impressive meeting, I press onward to the interviews on which a heavier piece of my ambition supervenes.  The bar has been set for USC and UCLA to follow in the upcoming days, and I hope they are all that I'm making them out to be.

To celebrate the end of a wonderful day, through which Heroic Boyfriend chauffeured and explored with me, there was Dollar Sushi Tuesday at the Golden Roll in Marin.  And I had avocado and sweet potato rolls... and perhaps a bit of tuna.  Never before have the simplest of sushi rolls been so alluring, so decadent and so satisfying.  Definitely goes into the logbook as a notable Best Day Ever.


An aside: Prednisone has sunken in.  I'm fully adorned with acne, water weight, and best of all I am insatiably hungry.  All the time.

camping

When all is said and done, I can't say that I appreciate the rain following me down here from Oregon with such persistence, but it did serve the purpose of chasing me home from a deluge-esque, and health-threatening frolic in the woods of the Gualala Coast.

I had never seen this part of the 101 before; between Sonoma and Gualala is indisputably the most gorgeous strip of crashing waves, sea rocks and fielded cliffs I've ever beheld.  Seventy miles of curves right on the edge of the water.  Cows included.  Epic.

Yesterday was gorgeous - cool, but sunny and without wind - and the mile hike from the campsite to the ocean was (cue trill) also epic.  Having never been camping during a flare before, I noticed it was particularly difficult to watch everyone else devour sausages, chilli, smores and several nefarious fluids without partaking... I did finally give in and stuff a roasted marshmallow into my mouth.

For whatever reason - and I think I may have somewhat identified it now - my body decided to conduct Round III of the prolonged attacks of this flare.  On the camp ground.  Awesome.  Thank god for individually isolated restrooms.  Fortunately, I pre-funked with hyoscyamine, promethazine and oxycodone which, if they didn't serve to alleviate any pain - and they didn't - at least put me in such a state of mental turbidity that the agony of the first two episodes was diluted.  I stumbled back to my tent and collapsed straight into sweet drug-induced slumber.

And this morning, the rain came.  So we drove home.

Conclusions:  A nutritionist is officially necessary.  Why gastroenterologists have no idea what actually occurs during digestion is beyond me.  However, since I have identified a pattern between Rounds I-III of this flare, I can conclude that a nutritionist may be helpful in usurping its redundancy.  Without going into too much detail, it has become apparent that a week's worth of complex carbohydrates are simply sitting in my gut doing nothing more than nurturing unwelcome flora, and when I finally eat something that has the strength to push its way through - i.e. the tiniest bit of butter or fiber - everything comes out together, including that which has not yet been digested.  A veritable parade of the Untouchables of the gustatory world.  Huzzah.  I need a balance of complex carbs and other nutrients that wont destroy me on contact that will work together to go through me in a paced and "healthy" fashion.

two steps forward, one giant leap back

I was doing so well, I thought. Refried beans seemed to be fine in small amounts. The poached egg I tried two days ago had no negative ramifications. Even the small sampling of dry catfish I indulged in yesterday seemed to go smoothly enough; it did not stay in me for long. Last night I took it a step further and tried some chicken broth. Real chicken broth. From a carcass. Why did I think this was a good idea? Because after straining out what I considered to be all but the most benign coagulation of fats, broth seemed quite safe.

To my chagrin, a single cup of soup took less than 45 minutes to assault me with the most violent nausea I've had since beginning prednisone (3 weeks ago). Of course, we had guests over for dinner, so I was given the opportunity to demonstrate just how good of an actress I am. Apparently, I pulled it off.

This was not the usual nausea that began in May and for which I have been taking promethazine since. I think I'm recognizing a culprit, now. What happened last night was a very prominent type of heartburn. The type that sits too lightly in the stomach and wafts upward to petrify the esophagus. The kind that means hours of bile and dry heaving.

My suspicion is that the fats in the chicken broth were the final straw; my body had put up with beans, an egg and a bit of fish this week, and this was my portent.

I held out for three hours chatting and playing board games, trying to calm the frozen fire in my throat and bubbling bile in my stomach with hot tea. Not more than four seconds after people dispersed for the evening, I retreated to the bed to attempt to calm the swell with breathing, dark and quiet. I have never needed to take more than one dose of promethazine per episode, but last night begged it. This is one drug, however, that you do not fuss with; there is a reason the dose is rationed to one every 3-4 hours, and for fear of further upsetting my insides I settled with one pill... but god, how I wanted something to knock me out cold.

Today, it's back to rice noodles.

This is the longest that prednisone has ever taken to work its magic. I'm tired, I'm moon-faced and I have three important interviews next week.

Food of the Day: Egg

Ladies and gentlemen; after a thoroughly embarrassing evening of nibbling on sweet potato while the rest of the Family inhaled this delicious smelling Italian sausage spaghetti that Charlie's mom made, I officially hate this disease.

It is one thing to have to insult your immediate family by not partaking in scrumptious meals - in fact, mine has always been particularly patient- and quite another when the family is your boyfriend's. This is the second time they have met me. During our first trip down here in March, I was also ill. I was eating solid food, but very carefully. Charlie's papa made some amazing beef stew our first night here and I was mortified to have to refuse it. Mortified. Last night, this feeling was revisited.

This agitation never occurs among my friends, my immediate family, but the plaguing fear of Charlie's family resenting me for weighing on his life and requiring special treatment destroys me. These are particularly kind people, bear in mind, and my abashment is probably quite unfounded. Nevertheless, I am a guest in their house making demands for accommodation, unable to enjoy their food and likely being less than thrilling company in the meantime (I was so distracted by embarrassment last night that I hardly spoke during supper).

In honor of this profound motivation to begin adding to my dietary melange (potatoes, rice noodles, rice cakes, refried beans), our Food of the Day is the EGG.

In 1939, Tiselius and Eriksson-Quensel published an in vitro digestion of egg albumin in crystalline pepsin. Their results suggested that egg whites digest in an "all or none" fashion, unlike the usual graduate process of digesting most foods. If a Crohn's gut were anything like a petri dish, this would successfully dissuade me from attempting to ingest it tomorrow. I also learned that this anti-digestive factor in raw egg white is destroyed during heating. Score!

Eggs stimulate less secretion of gastric juice than meats, and also leave the body sooner; doubly enticing for a Crohnie. Soft-boiled, poached eggs and shirred eggs are the easiest forms of digestion, while scrambling slows down the process [Anthony Basser, Diseases of the stomach and upper alimentary tract]. Basically, the longer the eggs are cooked, the harder the albumin (anti-digestive factor in whites) protein becomes and the more tedious is digestion. It follows that adding butter or oil to the preparation process also markedly slows digestion.

Tomorrow, I will be ingesting a poached egg.

Food of the Day: Spaghetti Squash

Since I know you're all so anxious to hear how my contumacious tummeh dealt with spaghetti squash soup... no trouble! I can't emphasize enough how exciting it is to be able to eat something that is neither broth nor pure carbohydrate after two months. This is so thrilling, in fact, that I have resolved to make some of these tantalizing spaghetti squash hash browns when I get down to California (although I will have to substitute the onions and butter).

Our Food of the Day - you may have guessed - is spaghetti squash. It is a staple food in the SCD because it is fairly low in carbs and sugar. Additionally; low in saturated fat and cholesterol, excellent source of vitamin B6, vitamin C and folic acid. Most of the carbohydrate ratio comes from the sugar content, but these are simple vegetable sugars - the good kind of bad sugar. Spaghetti squash is also a good source of choline (also mentioned in the BEETS Food of the Day post). Although it is slightly inflammatory due to the fiber content, it seems to be a good introductory food for me (to be consumed moderately, of course).

For those who have asked, I believe that easing back into solid food with the Specific Carbohydrate and gluten-free diets is going to be ideal for this particular flare. I will not be holding steadfast to the guidelines of both, mind you, but combining the most helpful parameters of each (id est, absolutely no nuts/seeds and no meat/dairy for quite some time to come). The SCD is geared toward Crohnies and Coeliacs who have trouble gaining weight, and I have NEVER had trouble getting back to my normal weight. Therefore, I will be slowly tapering off the simple carbohydrate intake (grains, potatoes, rice) and easing into foods that result in less "residual throughput" breeding ground for unwanted flora, and that do not gibe inflammation. Complex carbohydrates (apples, plums, blueberries, fresh orange juice with no pulp) are supposed to be specifically IBD protective. Simple sugars (watermelon, dried fruit, pineapple, grapes), however, contribute to inflammation and so will be avoided. [Griel et al 2006, Art Thromb Vasc Biol; Gastrich et al 2008, Top Clin Nut]

Carbohydrate and sugar complexity is tough to negotiate because most foods have both simple and complex varieties. Low glycemic index is really going to be my best friend on this one.

--

Remicade Part Deux went well this morning, and I have finally been given permission to start up vitamin C and D (but no multivitamin yet, for a reason that I do not fully comprehend [yes, as a scientist I do not get this one... something about chelation that shouldn't actually be happening]).

And now I must sleep, for I have an early flight.

in which i embark on a most trying adventure

Tonight, I'm taking a giant leap. I'm making spaghetti squash. Because I figure... I'm due for my second Remicade infusion tomorrow morning, I have percocet available to get me through the night (if need be), and they will pump me full of chemical goodness to accommodate all ailments in the morning anyway.

Is it a bad sign that I'm having a mini-attack and major throughput in reaction to the two rice cakes and the Ensure I've ingested today? Yes, yes it is.

Don't worry, my logic is never this flawed in my scientific endeavors.

Tomorrow morning I get my second Remicade infusion, followed by an afternoon of packing, cleaning and assembling my prescription battery. The following day, I don a face mask and board an airplane bound for the Bay Area, and kick everyone's ass who looks at me funny, with the exception of small children.

The next two weeks will be exclusively devoted to visiting campuses, trying to impress potential mentors and spending some time with Charlie's family. The trick, here, is going to be to find a pace that will enable my mission without jeopardizing my severely immuno-compromised health. Because this is H1N1 season, and because college bodies (who will be the last to get access to the vaccine) are the most susceptible to this strain which hasn't surfaced since 1977, and because the vaccine isn't available until November, and because I probably wont get the vaccine because it is live and Remicade + live vaccine = bad news (2; H1N1 shot is made of an attenuated but not killed virus)... there will be much face-maskage, much hand sanitizer use and zero eating out (as if I could even if I wanted to). Also, there will be minimal stressing and anxiety; this is my Goliath.

And without further ado...

1/2 spaghetti squash, nuked and simmered in 2 cans of low-sodium chicken broth, 2tbsp tumeric, 1tbsp basil, 1tbsp coriander and 2 garlic cloves.

on weight and rebuilding muscle mass

Today I weighed myself at work (in the employee restroom of our lab on the hospital side of the building... I've always thought this was peculiar). I have officially lost 20 lbs this month due to this flare. Precipitous weight loss like this always makes me a little depressed when I finally realize it has occurred. The two reasons are these:

1. I honestly don't mind being this size and it is going to be frustrating when I gain weight again from prednisone and eating real food (whenever this day comes).
   
2. Building back my muscle mass is a very slow process, and it is always difficult for me to accept the immoderately slow pace at which I have to proceed in order for my body to respond positively.

Because I know these are popular symptoms following flares, and because I need to remind myself of their importance, I am about to discuss - at length - the logic behind their successful alleviation.

1. When we burn fat, what happens is that the amount of fat stored in each cell decreases, and the cells themselves shrink. This is why weight loss through consistent exercise works. What accompanies a dramatic weight loss due to a flare (or an eating disorder), however, is that your fat cells try to compensate for being malnourished. They do store less fat in them, but they do not shrink. They become concerned for their survival, and therefore gluttonous. When you begin to reintroduce food after starving your body, your fat cells will fight harder to retain what you provide in effort to build stores for whenever the next assault ensues [Buccholz 2008, Nature; Spalding et al 2007, Nature].

This protective mechanism is encouraged by obligatory sedation following a flare. Recovering from a flare often requires a very mild re-introduction of physical activity. Often, it is most energy efficient to begin reintroducing foods with the right supportive nutrients, and then to increase physical activity, giving your body the opportunity to utilize food calories instead of stored calories. During this slow reintroduction, your fat cells are more likely to hoard than when you are regularly active.

In other words, easing your body back into regular activity (walking, running, biking, weights, whatever sports are your fancy) is a slow process. You will probably gain more weight than you'd like to in the process, courtesy of prednisone, gluttonous fat cells and - let's be honest - the allure of suddenly-pain-free foods that were missed during the flare. The good news is that your weight is almost always able to return to normal once you have recalibrated your body to whatever combination of diet and exercise is most sustainable. Depending on your individual sensitivities, vitamins and supplements can be of great help during this re-equilibration period... but this is where you consult your gastro and your gut for specific direction.

You may gain a little more weight than you'd prefer in the process of commandeering your health. Allowing yourself to distress about weight will exacerbate it [Colles et al 2007; Rigaud et al, 1994; review]. So keep in mind that re-training your body is a process, and a slow one, but the most sustainable benefits come from responding to your body's needs and not pushing beyond its tolerance.

2. I am an ex-gymnast. The prospect of losing muscle mass is always depressing to me. Therefore, I typically have fits of neurotic ambition following Crohn's flares during which I lose a great deal of muscle mass... I am convinced that I'm going to get all of my muscle back. Immediately. And yes, as an athlete, I do understand how manic this is. This time, I have resolved to go about it differently.

Even in remission, Crohnies are prone to various nutrient deficiencies [Fillipi et al 2006, Inflam Bowel Dis]. These can make the reconstituting of lost muscle mass even more tenuous. I cannot stress enough how helpful Yoga, Pilates and Tai Chi have been for me during the transition from sedentary malnourished-mode to healthy active-mode. These remain the best ways I have encountered to combat weakened muscles after a major flare. In time, my bike will see me again.

Food of the Day: Beet

Inspired by a post from Food Loves Writing, I am resigned to write about BEETS!... which I so covet and crave.

I am reminded of the benefits of beets in Crohn's disease, and any gastrointestinal difficulty, for that matter. Among other things, beets are rich in folic acid. Folic acid is part of the B vitamin family. B9, to be exact. B vitamins are very important to cell metabolism, and folic acid/B9 plays a crucial role in cell division.

Cell division is important in Crohn's disease because the epithelial cells that constitute the lining of your digestive tract need to be renewed or replaced every 4-5 days. The tumult of drastic pH change and absorption dynamics makes it necessary for cells to regenerate in order to function optimally. In the case of Crohn's disease, this turnover does not occur normally, due, in part, to a deficiency of folic acid.

Epithelial lining not only replaces itself regularly, it is also tagged with immune system markers (TLR4 receptors). TLR4 is one of several genetic components of Crohn's disease. It is a gene that codes for lipopolysaccharide signaling (LPS), bacterial recognition and subsequent immune response. The increased expression of TLR4 in the intestinal epithelium of Crohn's patients disrupts the LPS signaling pathway, which contributes to inciting the immune system to destroy its own tissue [Franchimont et al 2004, Brit Med J]. TLR4 is also known as TNFα, the factor that Remicade and other biologics work to suppress.

What does this have to do with beets, you ask?! Beets are a solid source of folic acid, the B vitamin that helps your cells divide and replenish despite an excess of inflammatory TLR4 activity.

An additional benefit of beets is betaine (and choline, if we're being particular). Betaine is an amino acid that cells use to retain water, which protects them from high temperature and high salinity. This pleasantly laconic article by Slow, Elmslie and Lever is an excellent description of betaine's contributions against inflammation of the intestine [2008, Am Soc Nut].

If you are able to eat beets - aka, if you are not swimming in the maelstrom of a flare - eat them! Roasted beets, shed of their fibrous skins, are delicious and so good for intestines that need to build up a defensive. When I'm well, I eat them like apples... although a beet a day is probably not advisable.