# General Advice for Diet Most patients with ME/CFS do best on small, frequent meals. They should be high in protein and balanced with a fat and carbohydrate source. This will keep blood sugar stable and reduce POTS exacerbations that can come with large or heavy meals. Avoid simple sugars which can make you feel better in the short term but introduce peaks and drops in blood glucose. Due to poor digestion experienced by many with ME/CFS, I recommend eating primarily cooked foods as opposed to salads and raw vegetables. Soups and stews can be nourishing and easy to make when ingredients are added to a slow cooker. An elimination diet can be a helpful way to identify and remove foods to which the patient is sensitive. I recommend the [[Fibro Food Formula]] as a practical and detailed elimination diet to follow. # Avoid Caffeine People with ME/CFS are more likely than the average person to be sensitive to caffeine. Many patients become reliant upon caffeine to function during the day. This can not only worsen PEM over time by masking symptoms and encouraging the patient to exceed the energy envelope, it can also lead to insomnia when it is finally time to go to bed. Most patients would benefit from a trial of no caffeine for a couple of weeks. At that point, you may add back in a single cup of coffee in the morning if it is important to you and it is not worsening insomnia or anxiety. # Avoid Alcohol Most people with ME/CFS are sensitive to alcohol, probably due to [[MCAS]]. It should be avoided. # Protein Recommendations I recommend eating 80-100 grams of protein per day. For many patients, eating 10-20 grams of protein every few hours all day long can help stabilize energy and reduce symptoms that can come along with larger meals. Examples of snacks that meet this criteria include: - 2 hard boiled eggs (12 g) - 3 oz meat or fish (22-28 g) - 2 tbs peanut butter (14 g) - 2 oz dry roasted nuts or seeds (10-15 g) - ½ cup lentils (9 g) - 6 oz greek yogurt (18 g).  Other high protein snack options include: - Nut butters - Jerky - Grain free granola - Lunch meat (without nitrates) - Oatmeal with nuts, nut butter, seeds, or protein powder - Protein powder smoothie ## Eat a Small, High Protein Snack before Bed A subset of patients wake up with low blood sugar in the middle of the night. They may experience palpitations, anxiety, hunger, sugar cravings, or just have trouble getting back to sleep. Something like a hard boiled egg before bed can help stabilize blood sugars and prevent nighttime awakenings. # Avoid Emulsifiers Dietary emulsifiers need to be avoided as they have been shown to increase intestinal permeability, promote inflammation and negatively alter the gut microbiome. These changes have been shown in animal models to promote obesity, metabolic syndrome and [[NASH|fat deposition in the liver]]. In human studies, they have been shown to reduce microbial diversity, reduce production of short-chain fatty acids, and allow bacteria to invade the inner mucous layer. These food additives help oil and water to combine without separating. This ability also causes them to [[Leaky Gut|break down the mucosal barrier]], allowing bacteria to come into direct contact with the cells that line the gut. Common emulsifiers include: - Lecithins - Mono- and diglycerides - Polysorbates - Carrageenans - Gums (Acacia, Arabic, Xanthan, Guar) - Carboxymethylcellulose - Propylene glycol - Maltodextrin - Agar # Fiber The gut microbiota can convert fiber (starch pectins, fructan, cellulose) into fatty acid metabolites which enhance oral tolerance to food antigens and control inflammatory immune responses in the gut. Gut bacteria live off of what you eat but do not absorb. When you do not give your gut bacteria a healthy amount of fiber to live off of, they will avoid starvation by consuming the mucosal barrier that protects your intestines. Therefore, increasing fiber intake is necessary for restoring gut health. Increasing fiber too quickly can cause GI upset so it should be done slowly. I recommend the book [Fiber Fueled](https://amzn.to/4bV1jK5) for a more detailed look at the health benefits of fiber. ## Sources 1. Aristo Vojdani, Vojdani. Food-Associated Autoimmunities: When Food Breaks Your Immune System. # Living Foods By “living” foods, I mean foods off the plant which will still be colonized with all of the microorganisms from the garden. This would include foods from a home garden or farmer’s market. It excludes preserved, pasteurized, canned, frozen and processed foods. Organic is strongly preferred. # Fermented Foods Fermented foods, such as sauerkraut or yogurt, will have a wider variety of healthy lactobacillus and other strains than a probiotic which will have much less diversity and have been shown not to colonize the gut as they pass through. # Legumes Legumes contain both protein and fiber. However, some people find they are sensitive to them and so I recommend testing out how well you tolerate legumes through an elimination diet. Test canned legumes and legumes prepared from dry separately as the histamine content will be much different. Prepare in a way to reduce lectins: - Soak overnight (48 hours is better) - Add 1/6 tsp baking soda per qt water during soaking - Change water up to 3 times per day while soaking - Rinse thoroughly before cooking - Cook low and slow (all day) - Remove foam during cooking - Pressure cook - Add kombu seaweed while cooking - Add spices like fennel, garlic, cumin, turmeric, ginger, cloves and cinnamon # Veganism The link between ME/CFS and veganism is unclear but I do have a significantly higher percentage of vegans in my practice than the average population. Many of the recommended diets, including the Low Histamine Diet, Low Nickel Diet and the Fibro Food Formula Diet are very difficult to achieve while avoiding all dietary animal products. My current recommendations for my vegan patients are as follows: - If morally acceptable to you, consider making an exception for eggs sourced from backyard hens or rescued battery hens on a temporary basis while recovering from ME/CFS. - Eat nutritional yeast regularly. Nutritional yeast provides important B vitamins that are hard to find outside of animal products including riboflavin, vitamin B6, niacin, and most notably, vitamin B12. A mere two tablespoons of nutritional yeast can offer up to a half of a gram of beta glucan, a powerful prebiotic and immune regulator. - Supplement with B12. Many people find injections with methylcobalamin to be the most effective way to supplement B12. Sublingual is another option. - Supplement with Vitamin D. - Supplement with omega-3 fatty acids. You can supplement with plant-based ALA (a precursor to EPA and DHA). Conversion rates are poor, however, so if you are OK with animal-based supplements, krill or fish oil with high EPA content is optimal. - Avoid high sources of omega-6, such as vegetable and seed oils, which can be inflammatory. - Test iron levels and supplement if necessary. - Work to get at least 525 mg of calcium in your diet (the minimum amount needed to reduce bone fracture risk). Plant sources of calcium include bok choy, kale, mustard greens, turnip greens, watercress, broccoli, chickpeas and calcium-set tofu. - Work to get at least 15 mg of zinc in your diet. The recommended daily allowance is 1.5 times the normal value for vegans due to limited absorption in high phytate diets. Foods rich in zinc include whole grains, tofu, legumes, nuts and seeds. Soaking nuts, seeds and legumes overnight may increase bioavailability. Consider taking a zinc supplement. - Make sure you are getting enough iodine in your diet. A half teaspoon of iodized salt is sufficient. Seaweed is another rich source of iodine. - Make sure you are getting a good variety of protein in your diet. Good non-legume sources of protein include: Quinoa, Amaranth, Buckwheat, seeds (hemp and chia especially) and nuts. # Recipe Ideas When you don't have someone cooking for you, you will need to find ways to make meal prep easy and quick. Sheet pan meals are my favorite for this. You can combine them with rice in a rice cooker or a boiled carb source such as potatoes or noodles. Vegetables can be bought pre-prepared and frozen to save energy on food preparation. ## Blueprint Recipe Ingredients - 3 tablespoons extra virgin olive oil - 1 1/2 pounds bone-in, skin on chicken leg quarters, thighs or breast - 8 cups of vegetables. Choose from: - broccoli florets - cherry tomatoes - cauliflower florets - zucchini, sliced - summer squash, sliced - 2 cups potatoes, sweet potatoes, or other starchy vegetable - Salt, pepper and seasoning (try lemon pepper) - Cheese (optional, try feta) Directions 1. Preheat oven to 425 F 2. Toss vegetables with 2 tablespoons of oil and 1/4 teaspoon salt and pepper to taste 3. Brush chicken with oil and season to taste 4. Place the chicken on one half of a rimmed baking sheet and roast for 10 minutes. 5. Remove from oven and add vegetables to the other side of the pan. 6. Roast another 15-18 minutes more until the chicken is cooked through 7. Sprinkle with cheese and serve topped with pan drippings ## Variations The above blueprint recipe can be made into several variations. Here is one example: Shrimp and asparagus - Season shrimp and asparagus with butter, olive oil, crushed red pepper and lime juice - Bake together at 400 F for 10-12 minutes - Serve with rice or noodles See more ideas here: [Low Carb Sheet Pan Meals](https://kalynskitchen.com/low-carb-and-keto-sheet-pan-meals-for-easy-family-dinners/) Be sure to add in a carbohydrate source to keep the meal balanced. ## Dietician Recommendations Laurie Bilyeu at [connectionnutrition.org](connectionnutrition.org) is very familiar with MCAS, POTS and hEDS, telehealth only. Can see patients in Indiana and Illinois but not Kentucky. Is able to bill some insurance plans. Nikki DeRoss at Healthier Tomorrows. She takes BCBSIL. has neurodivergence expertise. https://healthiertomorrows.com/dietitian/nikki-derosa-ms-rd/#bio Wendy's nutrition recommendations from last year: Digital nutrition counseling program: consider this program (4 module course for $99) available online to learn about what to eat to limit pain when you have EDS and GI discomfort https://nasarnutrition.com/eds-nutrition-pain-protocol/ Remote consult with an expert dietician: Laurie Bilyeu of ”Connection Nutrition” https://www.connectionnutrition.org/ Lorna Ryan https://lornaryanhealth.com/clinic Bonnie Nassar https://nasarnutrition.com/ Erin Hurst https://erinhurstwellness.net/our-team Dana Sivak https://www.myhealthfirstwellness.com/staff Ashley anderson/Rachel brown 331-213-9955 240 W River Drive, St. Charles, IL 60174 https://movefullynourished.com/ “Direct to Consumer” testing of nutrient difficiencies (aka nutrigenomics) from Root and Fruit Nutrition https://www.rootandfruitnutrition.com/about