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Wellness Wednesday for August 9, 2023

The Wednesday Wellness threads are meant to encourage users to ask for and provide advice and motivation to improve their lives. It isn't intended as a 'containment thread' and any content which could go here could instead be posted in its own thread. You could post:

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I have a very annoying medical mystery that I would appreciate some help with. I've had acne since my adolescence, not just whiteheads but the uncomfortable hard ball underneath the skin, and my nose would get very red and inflamed. I had no idea how to get rid of it and tried lots of dermatological interventions that did not do much. A couple years ago I was experimenting with ways to improve my athletic performance and tried a carnivore diet (only beef). I was surprised to discover that the acne and redness completely went away almost immediately.

Since then I have eaten a diet of mostly beef and a few other very simple things (a starchy carb like potatoes, some basic green vegetables, even some dairy now and then). When I'm on this diet, my skin is pretty much clear. When I try to introduce other things, even very basic ones, it tends to lead to a big problem. I tested some salmon last Friday and am currently dealing with another one of those hard balls that I otherwise never get.

Based on the testing I've done over the past 2 years or so, I am completely confident that this is related to food. It only occurs when I deviate from the basic diet that I have confirmed works for me. The difference is visible and dramatic.

I need to find a better solution than just eating beef for the rest of my life. It's expensive, a hassle, makes traveling and socialization difficult, and I'm not sure how healthy it is for me in the long term. But I have not been able to find any medical or scientific knowledge related to this phenomenon. It seems like I'm dealing with some kind of highly idiosyncratic intolerance to vast groups of food and nobody knows what might have caused this or how to help with it. Is there any medical specialty or institute that might be able to help me get to the bottom of this?

Is there any medical specialty or institute that might be able to help me get to the bottom of this?

afaik (not being a medical professional myself) there really isn't. You're doing the thing that's done here -- elimination and reintroduction. There are just conceptual categories that can guide that process to potentially make it more precise and efficient.

Some proposed classes of problems that could lead to having a problem with a wide array of foods include

  • true food "allergies" -- allergies to a large number of different foods sometimes, but not always, involves characteristic patterns of cross-reactivity between specific foods or specific foods and specific environmental substances. For instance, people who are allergic to birch pollen in the air are also often allergic to certain fruits and vegetables that share some similar-looking protein domain. An allergist would know about these patterns, but their tools for diagnosing food allergies are limited -- the gold standard of diagnostics is still 'try it and see if you feel bad' (unlike blood testing for environmental allergies, blood testing for food allergies is so prone to false positives it's basically useless) -- and the treatment is still 'then don't eat it' (or, if dealing with a single severe allergy, perhaps a targeted regimen of gradual desensitization that has to be maintained by eating small amounts of the offending substance indefinitely, but this may as well be voodoo magic for as well as it's really understood).

  • food 'intolerances' that aren't true allergies but are clearly about some particular food -- lactose intolerance and celiac disease being the best known. An allergist would know about these and a couple of the most common intolerances might even sort of have non-challenge-based tests, but when you get into the possibility of having a large number of specific intolerances, medicine seems to lose the thread in terms of a parsimonious explanation.

  • problems with FODMAPs as already suggested -- the research base on this is poor, the lists people compile on the Internet of what foods have higher or lower FODMAP content are poorly sourced and often inconsistent (charitably, because FODMAP contents of foods are actually highly variable within even, say, the growth stage of a given plant), but it's a real thing. However, FODMAPs are plant sugars that aren't present in animal tissues, so if your problem includes salmon, it's definitely not (only) this. Also, you should expect this to present with definite gastrointestinal distress, don't know about connections to skin issues.

  • histamine intolerance -- some people have difficulty degrading histamine that's already present in foods -- most notably highest in aged/fermented foods, or mishandled seafood -- and get a sort of inconsistent-looking pseudo-allergy to a wide variety of foods as a result. It's hard to pin down because often the 'same' foods provoke different levels of reaction depending on how the specific batch was stored or prepared prior to consumption -- for instance, salmon that was immediately frozen after catch and stayed frozen until cooking might be ok, but the same salmon that was only refrigerated for a couple days anywhere in the storage chain might not be. Like with FODMAPs problems, the research base sucks, the lists of potentially problematic foods are somewhat inconsistent, and medicine doesn't generally have much to say about it, but it seems like a real thing with repeatable effects and a plausible biological mechanism.
    I might expect beef to not be good for you if this were your problem, since almost all beef is aged somewhat before sale. Also would be a poor explanation for any problems provoked by, say, fresh vegetables.

  • other issues that, like histamine intolerance and FODMAPs problems, relate to a failure to adequately metabolize some common component that's found in many foods but in different amounts. Gout -- the pathological accumulation of urate, a metabolic end product of purines, is a classic example. Purines are in all unprocessed foods and are also produced endogenously, but the variation in purine content among foods is high enough that diet is an important factor in managing the disease.
    Relevant to acne, maybe something to do with PUFAs? Beef fat is pretty highly saturated and maybe that's helpful for you. Polyunsaturated fats found in fish, pork, seeds, nuts, oils, etc can be relevant to inflammatory disease. How do you do with a predominantly monounsaturated oil like avocado oil vs. a more polyunsaturated oil like peanut oil?

  • issues related to macronutrient composition, rates of absorption, problems with energy storage and retrieval -- diabetes, glycemic index, etc. If you can eat lots of potatoes without issue, it's not a 'carbs are too fast' sort of problem, nor a 'need to maintain ketosis for metabolic signaling reasons' problem, and if you can eat all beef for extended period, it's probably not an issue with the the utilization of fats, amino acid, or ketones. This sort of thing -- especially glycemic index sort of stuff -- seems to have gotten some research attention relating to acne, but I don't know if the results are very promising. This stuff is also going to involve the quantities and timing and ratio composition of meals, beyond just the identity of the components.
    If it already seems like you have a good deal of flexibility on that front among your 'known good' foods, this is probably a waste of time, but it may still be worth challenging with something like a large amount of pure sugar (or better, pure dextrose) which really shouldn't be a problem under any other framework.

Past these categories, venturing well out beyond the scope of 'real medicine', there's a very long tail of increasingly rare, obscure, or dubious possibilities (idiosyncratic metabolic polymorphisms, 'antinutrients', 'mold toxins', etc) where some paradigm might suggest a potential underlying pattern to your problem, but without ultimately providing any shortcuts around the empirical challenge testing you've already been undertaking.

You've probably already considered (and experimentally excluded) flipping the framing to 'is there something I happen to need a lot of from beef that I'm not getting if I cut back the beef?' Maybe you really just need a lot of cholesterol or carnitine or something? Obviously if you get messed up by adding other foods without cutting back the beef, it's not like this, but I mention it for the sake of completeness (somebody will still tell me something I missed, hopefully).

Wow, I haven't absorbed all of this yet but I first wanted to say thanks for writing it up and taking my problem seriously, it's very comprehensive. I've actually been wondering prior to this discussion about the different-fat-types explanation because it seems to fit with dairy being largely OK and non-beef proteins not. It also fits with the fact that this was a permanent fixture of my life until I tried a radical diet because of the high prevalence of soybean oil and other similar oils in American food. Even then, though, I have noticed other triggers, like adding flour to the beef roasts I make as a thickener, so I think gluten may be a problem too, but I may have to try again to confirm since that was a while ago.

I fear there may be no solution though, even if it's possible to ultimately identify what is causing the problem, which would leave me in the possession of a permanently broken digestive system requiring the long-term consumption of a dubiously healthy diet if I don't want to look terrible all the time, and that scares me a lot...

I second the suggestion below to ask a dermatologist if this is actually rosacea rather than acne. Rosacea is much better known to respond to dietary triggers, including a class I forgot to mention, 'spicy' stuff -- substances that hit the TRP channels (which can include stuff that's not so obviously spicy -- even broccoli contains some AITC, which hits the TRPA1 channel, for instance -- AITC : wasabi :: capsaicin : chili peppers, and AITC : TRPA1 :: capsaicin : TRPV1).

Also rosacea may be related to the 'niacin flush', which different people have different thresholds for experiencing, and salmon is notably high in niacin. If you can get some niacin -- not niacinamide, which doesn't produce the flush -- you might be able to see if your threshold for this is unusually low.