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I've been eating paleo (with IF) for more than two years, high-fat paleo for almost 1.5 years, and 6 months ago I decreased exercise and protein intake and added root vegetables. I am currently suffering from a number of symptoms, which appear to have come on gradually:

  • Inexplicable food cravings which are unresolved by eating anything currently in my diet (often resulting in hyperphagia)
  • Very bloody gums upon brushing
  • Constant fatigue, sleep does not feel restful unless it's 10+ hours
  • Low sexual drive

Another friend of mine who eats a nearly identical diet has the same symptoms, plus increasing carbohydrate intolerance, poor wound healing, decreased mood and a harder time gaining weight/muscle, and he is getting worse... I also suffer from diarrhea, even while eating fully paleo, which is sometimes alleviated by digestive enzymes. Added: another friend eats a nearly identical diet without these symptoms, and the only difference we can tell is that she eats more fermented foods (especially sauerkraut).

My lab work from less than a year ago showed low vitamin B-12, normal magnesium, high-normal testosterone, low-normal TSH. Currently not supplementing with anything except vitamin D and cod liver oil.

My diet consists of: beef (often grass-fed) and rarely other meats, grass-fed beef liver, non-pastured heavy cream, hard cheeses, Fage Total yogurt, Kerrygold butter, coconut products of all kinds, dark chocolate (85%+), potatoes and sweet potatoes, a small variety of vegetable matter. Very occasionally I have fruit, nuts, a cheat with rice or legumes, alcohol, or something sugary - no gluten.

Until more recently I was not eating liver very often, and did not always eat pastured butter, so nutrient deficiency seems possible. In response to these symptoms, in the last month I have greatly increased my variety of vegetable intake (as did my friend), as well as adding substantial amounts of seafood. Thus far we have not seen any difference.

My friend tried vitamin K (edit: he tried MK-7), which seemed to partially but not fully alleviate the bleeding gums, so I have started supplementing that (edit: MK-4) as well. My friend and I both tried a vitamin C megadose regimen, 4g/day then 4g/hour until intestinal intolerance, that did not seem to help. He has now started supplementing with selenium, the results are still too early to tell.

So everyone, what do you think? Something is very clearly missing from our diet. In every other regard we seem to be quite healthy.

Hypotheses and interventions:

  • Malabsorption - this fits with my diarrhea and B-12 deficiency, and his lack of weight gain. What else are we potentially not absorbing? Can we ever repair this?
  • Vitamin B-12 - I had a known deficit, tried oral B-12, have not gotten this retested. Oral might still fall prey to malabsorption, so my next step is to try sublingual.
  • Selenium - we may know soon. I tried supplementing this a while back, and I eat brazil nuts out of nut mixes whenever I see them.
  • Magnesium - just about everyone doesn't get enough, and malabsorption can be an issue here. Blood levels were within the reference range, but hypomagnesemia is distinct from magnesium deficiency...
  • Added: Iodine - it is entirely reasonable my intake is low, due to historical lack of seafood and only sometimes adding table salt. But the symptoms don't seem to fit, and my thyroid is functioning excellently as far as I can tell from TSH levels and basal metabolic rate.
  • Added: Intestinal parasite - this could explain various nutrient deficiencies, and my friend's lack of weight gain. Never had it tested, but I don't seem to have the same weight problems my friend does.
  • Added: Dairy intolerance - if I can't process dairy products for some reason this could result in diarrhea, which alone could potentially cause malabsorption. I have never tried a full dairy elimination since switching to paleo, so this is worth considering. Lactose seems much more likely to be problematic than casein.
  • Added: Fermented foods - as noted above another friend without problems eats similarly, except for more fermented foods. But we tried Vit K MK-7, and I do eat yogurt, not sure what else is missing here.
  • Added: Bone stock - contributes mostly gelatin, plus a handful of micronutrients. Seems fairly unlikely to be the culprit - my healthy friend doesn't eat it either. May be missing minerals.
  • Added: Multiple problems - maybe the gums are just gingivitis, sleep issues due to any number of problems, the food cravings some other minor micronutrient deficiency, etc, etc. Much less parsimonious theory. Predicts we would see some symptoms clearing up but not others.

What else might be missing?

Thank you all for your help. I look forward to days without food cravings and nights of restful sleep again.

Update, May 21st: Began a sublingual B-12 regimen, 1.2 mg a few times per day. It could take a couple of weeks to significantly replenish liver stores. My friend is currently trying selenium.

Update, May 31st: Still tired and bleeding gums after B-12 supplementation, food cravings fluctuating a bit. I am going to add a multimineral supplement next, possibly liver and fermented foods. Friend still taking selenium, eating liver every other day, added magnesium, added kimchi for fermented food, no lactose except for butter - bleeding appears to be less substantial. Will try lactose-free for two weeks next.

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How are your stress levels? – Phoenix May 21 2011 at 2:46
I have literally almost no stress - and it's a wonderful way to live! My friend doesn't feel stressed most of the time, but as his mood is declining he is suffering seemingly randomly from increased anxiety. – Will May 21 2011 at 2:50
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im certainly no doctor, but if liver was only a recent addition and so was seafood, it looks like you're lacking variety in your diet. Shellfish, fin fish, lamb, bison, kidneys, pork, duck, duck fat, egg yolks (?- no mention in your post), gelatin (were you making stock?), marrow (?), herbs, all of these are delicious and have a place in a healthy diet. I personally also enjoy a variety of vegetables as well like spinach, leeks, onions, artichokes, mushrooms, and many others. I suppose I gotta ask too, do you drink any alcohol? – tartare May 21 2011 at 2:54
I very rarely but occasionally do drink alcohol. I eat eggs, although cooked and usually not free-range - I am in the process of correcting this now. I do NOT make bone stock, and have been wondering about the implications of this. – Will May 21 2011 at 3:16
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@Grok More plants and carbs is by no means taboo around here. I feel you're just trying to be antagonistic to make a point. @Will I agree with Grok. Perhaps try out some more plant-based carbs and lower fat and see how that makes you feel. Different strokes for different folks. – Phoenix May 21 2011 at 16:45
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13 Answers

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I'm surprised that nobody else has picked up on this so far, but I would stop the If-ing ASAP as this can put your body under unnecessary stress, especially if you started before achieving correct hormonal environment.

The hyperphagia is probably connected to your malabsorption problem; your body wants you to eat until it has satisified it's nutrient needs.

Equally, have you been tested for intestinal parasites? I don't mean to alarm you unnecessarily, but it seems a distinct possibility as not only do parasitic infections cause fatigue and malabsorption, but many Paleos here seem to consume raw meat/other animal products or raw dairy.

Have you been tested for pernicious anaemia? This is one of the most common causes of B12 deficiency, and it is a malabsorption/autoimmune disorder characterised by bleeding gums and fatigue.

Finally, you may well benefit from iodine supplementation, but this is a long-term project. If you decide to supplement iodine, remember that it is vital to avoid triggering reactive hypothyroidism, so start by supplementing 500mcg daily and increasing at a rate of no more than double per month, until you reach the high dose upper ceiling of 12.5mg.

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There are some really excellent ideas in here. Sharp thinking! – Rose May 21 2011 at 17:10
I should note that my pattern of fasting is highly random. I frequently eat more than one large meal per day, and I recently completed a week-long fast. I generally feel much much better while fasting than not, which may itself be a clue. – Will May 22 2011 at 0:46
The hyperphagia is almost certainly due to malabsorption! I would be surprised if I had an autoimmune disorder develop on paleo, but anything is possible, and maybe it began long ago and I depleted my B-12 reserves over time. Intestinal parasites is an excellent idea, thank you! – Will May 22 2011 at 0:48
My friend carefully checked his stool for a couple of weeks recently and found no evidence of parasites. This theory seems less likely, but I will revisit it if other interventions do not work. – Will May 23 2011 at 19:57
Good luck with everything, and be sure to keep us updated. :) – Simibee May 24 2011 at 21:39
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I'm going to go out on a huge limb here -- HUGE limb -- and suggest looking into the symptoms of scurvy:

http://en.wikipedia.org/wiki/Scurvy#Symptoms

The bleeding gums and the lethargy raise the red flag for me. In the zero carb community there have been a couple of cases lately of scurvy-like symptoms. Interestingly enough, these were with men who'd been eating low to zero carb for a long time, and in one case, who had always suffered from a chronic malabsorption/diarrhea issue.

Even though you're eating potatoes and some fruit, there's the potential issue of glucose/C competition in uptake. I know the etiology of scurvy is considered settled, but I don't think it's a closed case -- there are alternative hypotheses about the causes of scurvy that should probably be entertained.

Anyway, I'm not certain this is the right answer, but given your symptoms, I wanted to put this possibility on the table for your consideration.

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Good point Rose - which is why both my friend and I tried a vitamin C megadose regimen. Unfortunately we did not see any difference in our condition after taking a few hundred grams, up to intestinal intolerance levels. Given that vitamin C is cheap I see no reason not to continue supplementation, but this was one of our first theories too and did not pan out. :( – Will May 22 2011 at 0:38
Glad you thought of it, and sorry it didn't pan out. I hope the B12 and selenium help you and your friend. BTW, I may have missed it, but I don't see folate deficiency anywhere on this page. If you haven't, perhaps look into that. Good luck! – Rose May 24 2011 at 22:58
As I mentioned over on paleohacks.com/questions/41021#41515 , I had some scurvy-ish symptoms and vitamin C supplementation seems to help. Things to note (that I may not have made clear on my other answer): 1. It took more than a year on zero carb before I developed the symptoms, 2. It took more than a month on very high dose vit C before they started clearing up. I increased my vitamin C dosage by 500 mg a day for 30 days straight before I started decreasing it again, and my symptoms didn't start improving until I had decreased it again. – Zooko Jun 1 2011 at 15:43
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Your diet seems very solid to me; similar to my own (though I'm not low carb). You don't seem to include any fish. I don't think omega 3 deficiency is behind your symptoms but I'd include some wild salmon in that diet.

See if your symptoms resolve if you add more potatoes, fruits, and vegetables. If not, you should consider non-dietary causes, like some sort of chronic low-grade infection.

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Chronic low-grade infection is interesting... I have been experiencing occasional micro-colds associated with sleep deprivation, but a two-day fast almost always clears it up. What should I be looking for? What intervention would you suggest to cure such a thing? – Will May 21 2011 at 4:43
Sleep more; make sure you're getting sufficient mineral intake (maybe buy a multi-mineral); a mushroom (beta glucan) extact seems to work really wll for me when I have lingering sinus infections. – Jay May 21 2011 at 13:20
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casein intolerance? http://www.foodintol.com/dairy.asp

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I did notice some problems with casomorphins - constipation and sluggishness - before supplementing with digestive enzymes during dairy-containing meals. If this theory is correct it could explain the life-long diarrhea, which could itself cause malabsorption... I never tried full dairy elimination, it seems like a good experiment. – Will May 22 2011 at 0:42
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I am reading the Weston A Price book, Nourishing Traditions, and according to it you need to take good quality Cod.liver oil to get the proper balance of A, K, D, E to be able to absorb mag. It sounds like to me that your diet is unbalanced in some way. Perhaps the lack of a variety of antioxidants like quercetin and resveratrol?

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Edited to add that I do supplement with CLO, thanks for the suggestion! I'm not sure how much a variety of antioxidants matters or not. – Will May 21 2011 at 15:16
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It would appear that prior to implementing more carbs that you were fully keto adapted and you were a fat burning machine and then you introduced the carbs and your body doesn't yet know how to handle this new food that you are sending to the mitochondria.

Go back to the very successful 1.5 years of lacto paleo and all these problems will abate.

In the last 6 months the carbs have become addicting and now your body craves more and you won't quite do that because you want to be somewhat carb happy.

See the question on carb addition and evaluate.

Go back to when you were successful and never retreat to your addiction again.

The one thing I did not hear, was supplementation of Vit D3. It increases your immune system, prevents dental and gum problems, assists calcium to move into the bones, and elevates mood. 80% of the population is Vit D3 deficient because we are sunphobic. 10000IU a day for 3 months then back off to 5000IU will get your serum Vit D3 up. The Quilt on these boards wants his clients to be between 70 and 100ng/ml. Vit D Council says over 60.

Good luck and get back with an update.

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I am supplementing vitamin D. The food cravings are unabated by eating starch or sugar - and I have had distinct cravings for both in the past. I have not experienced much difference adding back starch, my friend is less fortunate. His carb intolerance is growing worse and worse, to the point he's largely stopped eating them, and is still suffering the same symptoms. – Will May 21 2011 at 4:41
I was listening to Latest in Paleo... Angelo mentions that there are 1000s of variations of Vitamin D, and that supplementation just takes care of one of them... while sun exposure to the skin causes the creation of all the ones we need naturally. Not sure if this is true, but I know that when I get plenty of sun (obviously not overly exposed) I feel on a mental high (in a great mood). – Jamie G. May 21 2011 at 13:24
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The first thing I would do is eliminate dairy. It could be irritating and partially (or completely) responsible for your diarrhea (and subsequent malabsorption of B12). I'd also consider some time of probiotic to help your gut flora repair itself.

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I never did a full dairy elimination, so that may be worth trying. I see your point about dairy --> diarrhea --> malabsorption. – Will May 22 2011 at 0:43
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Here's my guess: you are having your meat well done. That means the potassium is cooked out of it, and without fruit, you're not getting the potassium anywhere else. Add some fruit - it will help with the scurvy as well - and eat your meat rare on cuts where that is safe. If you don't like rare meat, letting it come to room temperature before cooking it will make it a lot more palatable.

Also, get rid of the potatoes; tubers are no more paleo than grains. If you want root vegetables, eat carrots and onions.

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Tubers are just as paleo as fruit, perhaps more. Not to mention, potatoes and sweet potatoes contain way more potassium than ANY fruit. – Bill May 25 2011 at 2:51
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It's not about what caveman ate. Welcome. – Ikco May 25 2011 at 8:00
Interesting idea! It seems we are likely not getting enough potassium... it doesn't fit all the symptoms, but potentially the fatigue. These issues may not all be related. – Will May 25 2011 at 8:50
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You need more carbs, more fruit, more tubers and lots of salt.

Get K2 mk4 supp/D3

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Already supplementing K2 MK-4 and D3. These problems have been getting increasingly worse during my period of increasing carb intake, so this seems fairly unlikely. – Will Jun 1 2011 at 19:39
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Which are your previous and updated TSH ?? above 2 usually indicates hypothyroidism

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Old TSH was just above 1, will get my levels checked again soon. – Will Dec 20 2011 at 1:49
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are you still drinking coffee?

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Yes. That would probably contribute to nutrient deficiency. Do you see any other role it might play? I intend to quit caffeine within the next month for other reasons, maybe it will help. – Will Dec 20 2011 at 1:45
^Just one other thing you wouldn't eat if agriculture didn't exist. I think you'll find no-caffine diet will allow you to be able to feel high without being on caffeine. It's brutal for the first two weeks, but please report back! – Henry S Dec 20 2011 at 4:13
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Guts get damaged from over consumption of wheat/corn/gluten/beans etc, not what you have been eating. Is there a fix? Yup - Glutamine in large doses, for a week. If your going to try this, just do 4-6 servings a day for a week or until the bottle is empty. Is gut damage likely? Imho it is highly unlikely.

Get on a good multivitamin, take it 2x day with meals and continue Vit D, B, C supplementation. After a week of this, it will be extremely unlikely you have a vit/mineral deficiency.

IMO I would get your doctor to order you as many labs as possible (and a full physical), full blood panel, full hormone panel, thyroid panel, lipids, cortisol, glucose, and anything else you or he/she can think of, just to be sure its not something outside of your food intake that is causing your problem (which, IMO, it most likely is).

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Glutamine is a good suggestion, I haven't tried that yet, thanks! I just got new health insurance, so I am planning to get a huge battery of tests done, probably the SpectraCell kit. – Will Dec 20 2011 at 1:42
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I say drop the dairy and add some paleo friendly variation. I had no idea I had issues with dairy until I dropped it theny did a test reintroduction. Rob W. talks at length about food variation.

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