Find the Good

This year, as we celebrate another Thanksgiving, I have to remind myself that I have a lot to be thankful for.  They say it’s human nature to focus on the negative.  After all, back in the caveman days, it was the bad, scary stuff we had to pay attention to in order to stay alive.  Enjoying the pretty flowers without being aware of possible dangers would have gotten us killed.

In this day and age, I have to remind myself to focus on the positives rather than the negatives.  A while back, I came across an exercise called Find the Good in this New York Times article:

It involves writing down 3 things that went well that day.  You do so right before bedtime, and also write why each good thing happened.  Per the article, it helps train your mind to focus on the positives.

I happened to go to a conference on physician wellness last month, and one of the speakers was someone who is involved in research with this exercise.  He said the reason to do it before going to sleep is that it helps solidify the thoughts.  In a similar fashion, he said it’s good to study important things before going to bed, if say you have a test the next day.

By doing this exercise nightly for just 2 weeks, he says it improves people’s moods better than an antidepressant like Prozac.  And even when they stop doing the exercise, there are lasting improvements.

For me personally, I’d done the exercise nightly for much longer than 2 weeks, but I was still under so much stress from work that I still felt burnt out.  So I eventually stopped doing it, and haven’t been doing it lately.  With that said, I think there is still value in this exercise and it’s worthwhile to spend the time doing it.  The time commitment is minimal and the possible rewards are significant.

Since I’ve gotten away from the daily exercise, I need to remind myself to focus on the good things in my life.  Especially since it’s Thanksgiving weekend.  I have an amazing husband, who has been unbelievably supportive this year as I have struggled with the stresses of work, and infertility.  He takes care of much of the things around the house, cooks dinner on his off days, and foots more of the child care responsibilities than I do.  Oh yes, and he still works full-time.

We have a healthy, happy son who is thriving in his new preschool 2 days per week as we’ve transitioned away from the in-home nanny.  He is an active kid, learning new words rapidly, and is full of laughter and fun.  Well, you know, except when he’s tired and cranky.  In other words, he’s a normal toddler, and I am very grateful for that.

The rest of my family is healthy as well.  I am grateful for parents who are able to take care of WZW one day per week now that we no longer have our nanny.  My brother and his wife have twins who are now 16 months old, and it’s a joy to see all 3 of the cousins interacting as toddlers.  My mother-in-law is helping pick up WZW from preschool, and it’s really helpful to be able to ask my husband’s side of the family for help with him as well.

Despite the stresses of my job, I still enjoy what I do and feel rewarded by taking care of my patients.  It is a stable job that provides financial security.  With the recent fires in the North Bay, as well as the other natural disasters that have occurred this year, I feel grateful to have a stable home.

My tendency is often to focus on the negative- so far I’ve tried one cycle of IUI unsuccessfully and will continue to try.  It is a challenge, but I have to keep reminding myself that there are others in much more difficult situations in terms of their fertility struggles.  One of my friends recently told me she is on her 8th frozen embryo cycle of IVF.  She already has one child like me, so even then we both know we are lucky to already have one child.

So I have to keep actively reminding myself of all of the above, rather than letting my mind focus on all of the challenges I’m going through.  It’s fine to acknowledge that there are various things that are stressful and difficult.  And some days are going to be harder than others.  With that said, even writing what I just did about all that I am grateful for makes me feel better, and helps put things into perspective.

Here is our little guy with his new haircut.  Mommy wanted a break from WZW’s hair care for a while, so for Halloween we chopped all of his curls off.  Don’t worry, we’ll let it grow back.

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Unexplained Infertility

It took us a while to get into see the fertility specialist, or REI doc as I call them (they are OB/Gyn physicians who did an additional fellowship training in Reproductive Endocrinology & Infertility).  I was curious to get his thoughts on stress and acupuncture, but we spent most of the time discussing the plan and the reasons behind the options.

He confirmed that we have “unexplained infertility,” which means no explanation based on the usual tests.  Many couples fall into the categories of ovulatory dysfunction (not ovulating regularly, such as with PCOS patients), diminished ovarian reserve (age-related decline in fertility), or male factor infertility.

For many of us, there is no obvious reason.  We’ve had a child before, somewhat recently, so obviously things seem to be in working order.  There is a chance that I have developed hydrosalpinx, which is when you have a dilation and fluid filling of the fallopian tube.  A study called a hysterosalpingogram (HSG) can be used to assess for this, as well as to confirm that the tubes are open.  Given that it doesn’t seem super likely that this is what I have, I decided to hold off on the study unless we don’t conceive after several attempts.

In terms of the available options, we can use hCG (the same pregnancy hormone used in pregnancy tests), as an injection to help time ovulation more predictably.  From there, we could do timed intercourse vs. artificial insemination, aka IUI (intrauterine insemination).  IUI involves sperm washing- the semen is processed and spun down into a sperm concentrate, if you will.  Then it is injected directly into the uterus at the time ovulation is expected.  That way, you get way more sperm vying for the egg compared to the usual way.  Normally, the sperm have to make their way from the vagina and into the cervix, into the uterine cavity.  Only a fraction usually make it that far.  And then they have to make their way to the correct fallopian tube where the egg is waiting.  So IUI helps aid that process.

My labs confirmed that I am ovulating on my own.  If they hadn’t, then there is the option of a medication to help with ovulation.  He typically uses letrozole, though Clomid is another one many people are familiar with.  And then if all of that doesn’t work, then IVF would be the next step.

We decided to give the IUI a try to see if that gives us the extra boost needed to conceive.  So we’ll see how that goes with my upcoming cycle.  I still wonder, though about the contribution of stress.  He didn’t say too much on the subject, which I asked about in combination with acupuncture.  It seemed like he wasn’t super familiar with acupuncture for fertility, and reacted the way most of us doctors approach alternative medicines/therapies.  It’s probably safe, but he’s not aware of how helpful it is, and if it helps with stress, that’s not a bad thing.  He did caution using the herbs, as they can often contain ingredients that aren’t recommended to take in pregnancy.  One of the acupuncturists did recommend herbs, to take from the beginning of the cycle until ovulation.  So I suppose any effects on the fetus would be less likely given the timing, but nevertheless I’m skeptical on how helpful they’d be, so I’ve decided against taking them.

The biggest change I made this month is starting a part-time schedule.  For a long time, I’ve been struggling to keep up with the workload.  Even though I’m not ecstatic about cutting my salary, it was a necessary decision for my sanity, which also affects my husband.  So I will now have one day off a week.

I recently attended a fascinating conference on physician health and wellness, the American Conference on Physician Health.  The conference sold out, and was attended by physicians from all over the country, and even a handful from other countries.  It’s disturbing how prevalent physician burnout is.  According to Medscape polls, about half of all U.S. physicians have at least one sign of burnout, with the highest rates in emergency medicine and obstetrics & gynecology.

Traditionally, the culture in medicine has been that of toughness- that we’re able to, and expected to handle the difficulties of medicine.  It’s like a badge of honor- not sleeping for X hours, seeing X number of patients, working so much that we don’t have time to eat or pee.  Now, it’s becoming evident that physician burnout is costly to healthcare, which is why CEOs are finally starting to take notice.

This overworked, disgruntled workforce not surprisingly tends to have less satisfied patients, with more patient complaints.  Unhappy physicians are more likely to take more sick leave, and leave the practice or sometimes medicine altogether.  On the more serious side, physician burnout is linked to increased liability- meaning that they have more medical errors and more lawsuits.  Worst of all, the rates of physician suicide are much higher than that of the average American, and higher in women physicians.

There are many factors that contribute to physician burnout, such as insurance companies dictating care and reimbursement.  Excessive time spent on administrative duties is another huge factor.  I was fascinated to learn in a talk by Robert Wachter, MD that in any industry, there is a paradoxical delay in productivity increase when there is a change from paper to computers.  Even though you’d think the switch to computers would automatically increase productivity, it usually takes 10 years for that to occur.  That’s because the change from paper to computers isn’t enough to increase productivity.  The industry needs to figure out how to use technology effectively to increase productivity.

Well, in the case of medicine, given the additional rules and regulations, and patient privacy concerns, change is even slower.  So he estimates it will probably take 15-20 years.  Over the last 10 years, there has been the switch from just a few practices having electronic health records to the vast majority going electronic.  So that means we have at least 5-10 years before we actually develop the electronic health record into a system that is truly user-friendly and efficient.

I’m optimistic that the healthcare organization that I work for is recognizing that physician burnout is such a significant issue and is a priority to address.  With that said, I can’t wait several years for things to change gradually.  I am burnt out right now, and I made the decision to go part-time for the sake of my well-being.  Working one day less is not going to erase the fact that I’ll still be overworked on the other 4 days of the week, but hopefully will make life more manageable.

I do suspect that this burnout has been contributing to not getting pregnant.  Even though the data is inconsistent regarding stress and its effect on fertility, I can’t help but feel like that’s a contributing factor in my case.  Maybe that doesn’t happen for every woman, but it makes sense that my body is saying- you are not at a place in your life where it’s a good idea to put yourself in a situation that is going to require more of your body’s resources.  After all, a fetus is a little parasite that is going to make me nauseous and even more exhausted.

While it may not happen right away, I’m hoping that this combination of working less, doing acupuncture, and trying IUI will help us finally conceive.

 

Why Do I Want Another Child?

Now that we’ve been trying so hard to get pregnant with #2, I’ve been thinking a lot about why it is that I want another child so badly.  After all, many people are perfectly happy with one child.  Some people never planned to have children, but then it happens, and they are content with the one child.  In other cases, some always planned on one child.  And then there are those who struggled to conceive, and ran the gamut of fertility treatments, IVF, and/or adoption.  For those, they are grateful for even having their one child.

I don’t have time these days to keep up with all of the Lenny newsletters (compiled by Lena Dunham and crew), but this recent one did pique my interest.  The author, Garance Doré, gives a vivid account of her struggles with IVF, and how it sucked her soul and made her into a miserable version of the person she used to be.  She talks about the enormous pressure on women to be mothers; this concept of needing a child to be complete.  In the end, she came to terms with being happy just as she is:

http://www.lennyletter.com/health/a956/garance-dore-failing-ivf/

I feel selfish wanting more, when I already have a beautiful, healthy child.  Not to mention, it’s been a struggle adjusting to life as a working mom.  I think it’s hard for me to accept that everything is a struggle once you have a child.  Going to a restaurant these days is exhausting, since WZW is so active and often defiant at this age.  Maybe some toddlers have the kind of temperament where they’re a little more open to following directions, but my son certainly isn’t.  Regardless of personality, a toddler is a toddler, and they can only sit still for so long.  So I can never fully enjoy my meal or get into great conversations because I’m constantly having to make sure WZW isn’t going to cause a colossal mess or break something.

At home, I’ve struggled to come to terms with the lack of alone time.  Since I’m introverted, I need the quiet time alone, whether it’s to take care of things on the computer like bills, or just doing frivolous things like plucking my eyebrows.  I feel like I never have enough time to feel settled and restored.  Especially given how stressful work has been, I crave more of this time.  Once he’s down for his nap, there is a flurry of things I need to get done.  And then once he’s awake, forget doing much.

As it is, I tend to have a hard time multitasking.  I need to focus on one task at a time.  Of course, with a toddler, there is a lot of time spent focusing on his needs- getting him fed, battling him for poopy diaper changes, and playing with him.  During the times he’s able to play on his own, that is great.  But I can never do too much, because I have to make sure he stays out of trouble.  Plus, if I try to do things on my own, he’ll want my attention.  So my own attention is always divided, and as all parents know, productivity is diminished.

I also think just based on my personality, I’m unfortunately not that flexible in going with the flow.  I tend to get frustrated with the lack of focus and productivity.  I miss him during the workweek since I barely get to spend any time with him.  But once I do have a chance to spend more time with him, I honestly find myself exhausted after a short time of toddler defiance and tantrums, and wish I could be alone and do the things I need to and want to do.  I sincerely appreciate that my husband is aware of my needs, and will do what he can to have WZW stay with him while he’s doing things around the house, or take him along to Costco.  Even if that means dealing with a fussy kid and the crowds.

Given all of the above, why would I want to add yet another child to the mix, which will only make things more difficult?  I have wondered that- whether I can handle it.  Ultimately, the decision to have a second child is in part wanting the best for WZW.  I want him to have the inevitable social interactions that come from having another child in the home.  It’s one thing for us to tell him to stop being selfish.  It’s another to be living with another little human who is just as attention-seeking and needy.  Having a sibling would take the pressure off of him, vs if we had all of our eggs in one basket, so to speak.  Even though I tell myself now that I don’t care about WZW getting into the best colleges, or being an elite athlete, I am a high achiever myself (and my husband is, too).  So I don’t know if I’d be able to avoid inadvertently putting pressure on my son.  Hopefully having a sibling would help disperse that a bit.

When we get older, I want him to have a sibling to share in the responsibilities, rather than having no choice but to shoulder them alone.  And then there is my biggest fear- what if something happened to him?  One of my colleagues lost her 3 yo daughter in a car accident.  It hits close to home, reminding me that nothing is promised.  I realize that I could have 5 children, and losing one would still be unthinkable.  But on some level, I tell myself that losing my only child seems even more painful.

By no means is there anything wrong with having an only child.  Ultimately it’s each family’s decision.  After thinking about it a lot, I feel this overwhelming sense that our family would be incomplete without another child.  It’s something that’s always been important to me and my husband.  Despite the challenges of parenting, our son brings us such immense joy.  The tantrums may be a pain, but his laughter is so pure, and thankfully abundant.  It’s rewarding seeing how he’s learning constantly (even if it’s how to unlock doors and sneak outside).  These days, he’s all about “choo choos,” cars, trucks, etc.  His presence brings a sense of fun and play that was missing before he showed up.  A woman with adult children once mentioned to me how despite her children being grown now, she never lost the sense of perspective her kids gave her.  She looks at the world through different eyes now.

I have patients who already have children who are older, then decide they want another, but have struggles with infertility.  It’s common for them to have a new partner this time.  Sometimes I’d think to myself, “But you already have 2 children.  There are so many people out there with no children.  Do you really need to have another?”  Now I understand better.  Everyone has different goals and desires in life.  I do remind myself to be grateful of what I already have.  But I don’t think it’s unreasonable to still want another child.

I won’t lie- it’s been difficult so far, and I haven’t even done any fertility treatments.  Much of it has to do with the stress of my job, and physician burnout is a whole other topic that I won’t get into.  I have chronic fatigue syndrome secondary to motherhood.*  There are so many shoulds- I should be eating better, I should exercise more, I should meditate more, I should be less stressed.  It’s a lot of pressure I’m putting on myself, and it doesn’t help that the acupuncturist is reinforcing the clean eating and decreased stress.  It’s a balance of doing what I can, but also being kind to myself and accepting that I am only human.  I often feel like I’m failing miserably to find that balance, but I’m still willing to continue to try for #2.  Sometimes life doesn’t work out as planned, and if I went through the struggles that Garance Doré did, then I’d come to peace with where I am.  But thus far I seem to have time on my side.

Here’s our almost 2 year-old, looking very pleased as he breaks up his Swiss cheese.  Oh yes, and he just “cut the cheese” as well.  Apparently one learns early in life that farts are funny.

*Not an actual diagnosis, just one made up by me and shared by parents everywhere. 🙂

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Pulling Out All the Stops

Since WZW was born, I never went back to being strictly on the Paleo diet.  Initially the sleep-deprivation made a huge impact, but even as that improved (thank goodness!), other factors continued to affect my lifestyle.  Time is the biggest factor- no longer could I leisurely exercise after work and come home at 8 pm.  Nor do I have the energy to prioritize meal prepping.

Instead, I’m spent after my work days, and feel like everything else goes towards dealing with a nonstop toddler.  I’ve grown accustomed to eating lunches made by Trader Joe’s, or eating what’s offered at work.  On Mondays, which are the busiest for me and my husband, we get dinner delivered by Munchery.  While we can choose options that aren’t totally carb-laden like pasta, the meals usually involve a starchy side.

A lot of it was my mindset as well- with the stress of work, and dealing with a toddler, I just felt like prioritizing eating was something I didn’t have the capability of doing.  So I got used to comfort eating, and not trying so hard.

But I started realizing that it’s expensive to be half-assing the Paleo lifestyle.  We spend extra money getting things like Paleo crackers and gluten-free bagels from Whole Foods.  It would be one thing if I was really following the diet, but since I haven’t totally been, it’s kind of a waste of money.  It’s like buying organic produce, and then eating Hot Cheetos.

A workplace “Biggest Loser” competition has also motivated me to focus more on my eating habits again.  One of the ladies at work decided to start a Biggest Loser challenge for those who are interested.  Her intent is to promote healthy living, so although there is a cash prize for the winners who lose the most weight, the contest will last 6 months, and among other rules, no fad dieting or other unhealthy methods of weight loss are allowed.

I decided to participate, not with the intention to win (because hopefully I’ll get pregnant during the 6 months), but as a motivator to eat better and also exercise more when I can.  I also wanted to help motivate and educate our staff participating.  So far we’re one month in, and I have been better about avoiding dessert, and being less lax about the carbs.  My husband has been monumental in doing the bulk of the cooking.  The exercising is more difficult due to time constraints, but I’m doing what I can.  Sadly, at the one month weigh-in, my weight still hadn’t budged, but I’m trying not to let that get me down.  I need to focus on the fact that I’m taking better care of my health by eating better.

In addition to the lifestyle improvements, I also decided to get referred to the fertility docs, the REIs as we call them (reproductive endocrinology and infertility).  After 6 months of trying, given that my age is over 35, I qualified for referral.  At that point, I asked my doctor/colleague to check my labs.  We checked my cycle day 3 FSH, which if elevated would indicate age-related infertility.  I was concerned that’s what the issue was, especially since my mom went into menopause on the earlier side.  The FSH was in the normal range.

So that’s a relief, but then what’s the issue?  It’s hard for me not to blame myself for not eating better/being at a healthier weight, and for being under too much stress.  Ultimately, I’m doing the best I can with the situation I have, and logically I tell myself not to get down.  But it’s hard not to beat myself up.

After another 2 months passed for a total of 8 months of trying, I decided I shouldn’t waste too much time and went ahead with the referral.  I have yet to meet with the REI doc- we have to complete our labs, and then schedule the consultation.  In the meantime, I decided to look into another modality to help me with fertility- acupuncture.

My first exposure to the concept was the episode of Sex and the City where Charlotte gets acupuncture to try to help herself get pregnant.  I don’t know much about it, and hadn’t thought about it recently until one of my patients mentioned using it to get pregnant.  That reminded me that one of my OB/Gyn friends had said she used it while doing IVF, at the recommendation of her REI doc.  She wasn’t sure if it helped, but at the very least it helped her destress.

Once I started asking colleagues and friends about it, there were all these mentions of, “Oh yeah, so-and-so was having a hard time, and finally got pregnant after doing acupuncture.”  Of course, it doesn’t work for everyone, and one of my colleagues said it didn’t work for her (she later succeeded with IVF).

Given that my insurance has coverage of acupuncture, I figured I didn’t have much to lose.  I still don’t know the data regarding acupuncture and fertility.  And I’m not sure how best to find a trustworthy practitioner.  But so far, I completed my first session.

I filled out a health questionnaire with some different inquiries than you’d find on a Western medicine form- things like the color and consistency of my menstrual flow.  The practitioner checked my pulses (done for a different purpose than in your usual medical office), and my tongue.  Then she proceeded to do the needles and left me for 30 minutes, during which I started to drift off.  It was similar to what people probably experience during a massage or savasana at the end of yoga.

Though I didn’t think I fell completely asleep, I did end the session feeling more energetic.  I’d also been feeling more anxious from my general stress, and that feeling improved as well, which was a pleasant surprise.

Interestingly, she said that she recommends eating in line with the Paleo diet more or less.  Her list of foods allows quinoa and buckwheat, but mostly everything else goes with Paleo.  She recommended eating lots of eggs.

One big difference is that based on the Chinese medicine recommendations, she advocates eating only cooked foods- that means no salads, no yogurt for breakfast.  That is going to be hard- especially avoiding raw fruit.  Now, these recommendations probably aren’t for everyone trying to conceive.  It’s based on my particular constellation of issues.

In my limited understanding of Chinese medicine, I know that there are various organs that are different from the same organs in Western medicine.  My acupuncturist said my “liver” is too strong, and the “spleen” is weak, which is the reason for the dietary recommendations.  My friend said that they generally work on the “kidney” system for fertility issues.

So we’ll see how it goes.  Hopefully between the healthier eating, acupuncture, and eventually seeing the REI doc, we will finally get pregnant.

 

Ovulation Kits and Period Tracking Apps

Medical training is a lifelong process.  During my residency in Obstetrics & Gynecology, we learned the essentials of management on Labor & Delivery, hospitalized patients, surgeries, and office practice.  During residency, the focus is generally on the critical elements- in other words, trying to prevent the really bad stuff from happening.  So things like management of preeclampsia and postoperative infections got top priority.

Which means that more day-to-day concerns in office practice, like common discomforts of pregnancy, were inevitably less of a priority.  So now that I’ve been in practice, I have continued to learn more about the issues that aren’t life or death problems, but are important concerns for my patients.

Ovulation predictor kits are one of those things I recently learned more about, because I finally used them myself.  I did my residency at a county hospital with low income and uninsured patients.  What I recall being told was that the kits aren’t always reliable, so having regular intercourse should result in pregnancy, and they were a waste of money for these patients.

So I brought that mentality with me after residency.  For my working class patients, it seemed like spending their hard-earned money on ovulation kits was probably unnecessary.  Plus I just didn’t know that much about them.

Then one of my colleagues, who had been at another practice for many years before coming to ours, told me that she generally tells her patients who are trying to conceive to use them.  She figures that even if one has regular periods and is timing intercourse, if ovulation isn’t occurring on the date predicted by the period tracker apps, you might be missing it.

I then talked to another colleague, who said that she doesn’t recommend them for everyone trying to conceive because some will conceive quickly on their own.  But for those who don’t conceive after a little bit, they can consider checking for a few months to get a sense of when they ovulate, because maybe they don’t follow the textbook pattern (14 days prior to the next menstrual cycle).  And then if there’s a predictable pattern, they can continue to time their intercourse.  And definitely for the patients with irregular periods, it’s helpful to know when they’re ovulating.

Before I get to the ovulation kits, I should mention that I downloaded a couple of period tracker apps.  There was a study that looked at free iPhone menstrual tracking apps for accuracy, features, and functionality:

https://www.ncbi.nlm.nih.gov/pubmed/27159760

It was a bit disheartening to learn that very few of the apps used medical professionals when designing the app.  So the accuracy of the tracking and information provided is questionable, and that means many women out there are using these free apps that aren’t necessarily reliable.  Now, this study was published in June 2016, so based on when they started the study, they used apps that were available in January 2015.  So by now there are a lot more apps that have been created.  Based on their ratings of the 20 apps they reviewed for the study, two seemed the most reliable to me: Clue and Glow.

So I downloaded both and have been using them to track my periods and predicted ovulation dates.  Both are easy enough to use.  I like Clue’s calendar view which also puts a star on the predicted ovulation date.  Glow’s benefit is that there’s more of the social media community and articles, in case you are interested in that.  Glow puts a percentage on each date, so for example it will say you have a 25% chance of pregnancy if you have intercourse on the ovulation day.

I just track my periods to predict ovulation, so I haven’t used the other features of both apps to know how good they are.  But they do have options to track a number of other things, like mood, sex drive, heaviness of menstrual flow, etc.  Both apps can be used by women trying to conceive, as well as those who just want to track their menstrual cycles.

I’ve only used the ovulation kits for two months, but it was interesting that Clue predicted the date accurately on the first month, while Glow was a little off.  The second month, both apps were off by a day (the day before) compared to the ovulation kit.  I have regular periods, but they do vary a bit from month to month.

On to the ovulation predictor kits.  The basic kits work by detecting the LH surge via urine test.  So you pee on a stick like with the home pregnancy tests, except instead of hCG, it’s looking for LH.  The LH surge occurs about 24-36 hours before ovulation, so typically once you see the positive test, you want to have intercourse the following day.

Clearblue also makes a fancier test that they call the Advanced Digital Ovulation Test.  In addition to checking for the LH surge, they also look for the rise in estrogen that occurs prior to the LH surge.  Their claim is that it identifies more fertile days.

Hormones Evolution Graph

This image is from their website, and they explain more about their product here:

http://www.clearblueeasy.com/advanced-digital-ovulation-test.php

I decided to compare this product to a basic LH ovulation test.  I just went on Amazon to see what was inexpensive and got decent reviews, and ended up with the Wondfo brand, though there are many other similar ones.

First, the price difference.  On Amazon, the Clearblue Advanced Digital Ovulation Test, which came with 10 strips (1-month supply), cost $28.  The Wondfo 25 strip pack cost $12.50.

The Clearblue Advanced Digital Ovulation Test

The Clearblue kit came with the digital reader and 10 strips.  They advise to start testing on day 8 of the cycle if you have a 28 day cycle, presumably because the test needs to get your baseline prior to the estrogen rise.  They have a chart of when to start testing based on your shortest cycle.

It’s easy to use- you push the test stick into the device, and dip it into your urine.  They recommend using the first morning urine.  I think it’s much easier to dip the stick in a cup rather than trying to pee on the stick.  Then after 5 minutes, it gives you a result: 1) empty circle for low fertility day, 2) flashing smiley face for high fertility day when estrogen is rising but LH peak hasn’t occurred yet, or 3) static smiley face for peak fertility day when LH peak has occurred.

Once the peak fertility day occurs, the smiley face stays lit for 48 hours and you can’t use the test again until the next cycle.  From a quick online search, I didn’t see an option to buy just the test strip refills.  Looks like you’d have to buy another kit with the reader with another 10 or 20 test strips.

The Wondfo ovulation tests

As for the Wondfo strips, they are very basic.  Each tiny strip comes in an individual packet.  You dip the strip in your urine, wait 5 minutes, and look for the lines.  Like the Clearblue, they recommend using your first morning urine.  There should always be one line that shows up which is the control line.  The second line will show up with the LH surge.  If you have a 28-day cycle, they instruct you to start testing on day 12, so that’s less strips used per month compared to the Clearblue.

IMG_4526

So how did they fare?  Well, I did both tests for one cycle.  They both worked, and both showed the LH peak on the same day.  I did not have any technical difficulties with the Clearblue test, but there was one Wondfo strip that didn’t work.  Meaning no control line came up, so the test was invalid.  So I’d recommend that you keep your urine in the cup until you make sure you have a result before dumping it, just in case you need to do another test.

The picture above was when I saw the two lines indicating the LH surge.  It was very clear compared to the other days when only one line was visible.  I saw some women write online that they’d check morning and afternoon, so I was curious and did so with the Wondfo strips, knowing that the LH surge was coming based on the Clearblue test.  Well, I only got the two lines with the morning urine that day.  So based on my experience of using the test for a month, there doesn’t seem to be a benefit in testing more than once per day.

The Clearblue test gives you more advanced notice of when ovulation will occur.  Is that helpful and necessary?  I think that if you have regular periods, then you generally know from the app when ovulation should occur, so you can just have intercourse around that time.  If you don’t have regular periods, it might be helpful to get a little advance notice.  But that also means you’re going to need to buy more strips, which can get pricey very quickly.

So for me, based on this comparison, I think that it’s a questionable benefit to use the Clearblue Advanced Digital Test.  Given the price difference, and the fact that the Wondfo strips do in fact work, that’s the better bang for the buck.  Especially if you’re having irregular periods and or end up needing it for many months, it’s much more cost-effective.

So far no positive hCG test yet for me, but hopefully these ovulation kits will help!

 

Mother Dirt Product Review

I think I first learned about this product on Mark’s Daily Apple:

http://motherdirt.com/

AO+ Mist

In any case, it’s a novel product.  I’ve talked about the microbiome previously (https://paleoob.wordpress.com/2016/09/24/more-on-allergies/) and this is like a probiotic for the skin.

This AO+ Mist contains live ammonia-oxidizing bacteria.  The premise is that with our too clean modern lives, we have washed away the naturally-occurring bacteria that we are supposed to have on our skin.  That imbalance leads to things like body odor and acne.

What this product does is restore the good bacteria that we are supposed to have on our bodies.  As a result, it is supposed to eliminate (or reduce) the need for deodorant and other skin products.

Since I do believe in the importance of a healthy microbiome, I decided to give the product a try.  In addition to the AO+ Mist that contains the live bacteria, there is also a shampoo and body wash that are designed to be used with it, which won’t wash off the healthy bacteria.  I got the bundle with all three.  They also have a moisturizer which I didn’t try.

I’m lucky that body odor has never been much of an issue- my husband jokes that I have no detectable scent.  For a while now, I’ve switched to the “natural” deodorants without the aluminum salts.  Brands like Tom’s and Lavanila have worked fine, though they don’t reduce perspiration so you can still get the wet spots on the underarms.

Also, since I was a teenager, Clearasil (benzoyl peroxide) was all I needed to keep acne at bay.  Now that I’m in my 30s, the time I spent in the sun as a youngster is catching up to me, and age spots have appeared.  But Mother Dirt can’t help me with that.

I mainly wanted to try it out of curiosity and to see if it would help my dandruff.  I’ve tried different dandruff shampoos, but the pyrithione zinc (in Head & Shoulders) has worked the best.  But even then, I’d need to wash my hair every other day and by the second day, the dandruff would start to appear again.  I did find that when I was strict Paleo, the dandruff improved, but these days I haven’t been able to keep up with that.  Come to think of it, my skin was clearer when I was eating strict Paleo as well.

I went ahead and purchased the bundle.  They shipped it with an ice pack to keep it temperature-controlled for the live bacteria.  Apparently you don’t want the bacteria to freeze, either, so they do something different for very cold climates.

The instructions say to spray the mist on more sweat-prone areas like the scalp, face, underarms, genitals, and feet.  You spray morning and night, particularly after showering.  And of course in the shower, you want to use the Mother Dirt body wash and shampoo.  The mist is best used after other products like facial moisturizer, sunscreen, etc. have been applied and absorbed into the skin.

So here are my reviews on the products.  And as a reminder, any products I mention on my blog are simply because I think the info might help others.  I’m not a Kardashian, and certainly don’t receive any compensation for mentioning products on social media.  Don’t I wish.

AO+ Mist

My main goal was to see if it would help my dandruff.  The good news is that it did- I had minimal flakes after using the mist regularly.  The problem, though, is that by the second day, my hair would start getting greasy so I’d still need to shampoo every other day.  I suppose if I really wanted to, I could use a dry shampoo to last longer, but that’s not ideal.  For many people, using the mist is supposed to mean using less products overall.

For me, if I could wash my hair every 3 days instead of every other day, it might be worthwhile.  The effort spent drying my hair is significant, so if I could reduce that, it would save me a lot of cumulative time.  But unfortunately the mist didn’t do that for me.  A lot of people don’t need conditioner, but since I have thicker hair I still needed it, and would just apply towards the ends.

I noticed that my face got less oily by the afternoon, so that was nice- less of a need for oil-blotting sheets.  I also noticed that my feet didn’t smell.  Definitely all good things!

So the issue with the live bacteria is that once you start using the mist bottle, it only lasts for 4 weeks.  The instructions said to use 5-7 sprays throughout the body each morning and night.  So I followed those instructions, not wanting to use up the product too quickly.  Well, as I got to the last week, I realized that I had a ton left.  So I started using the spray more freely, spraying more throughout my scalp.  But it still didn’t improve the greasiness on day 2.

Because I had extra at the end, I decided to try it for a couple of days on my son’s butt since he’d been having redness (presumably from the poopy diaper moisture, despite our best efforts to change right away).  It did seem to clear it up, but I didn’t use the spray on him for very long.  They do say it’s safe for babies and kids, but it’s just not practical given how frequently he has diaper changes and therefore gets wiped down.

It’s frustrating that I still had a bunch left after the 4 weeks.  I kept using it, hoping there might be some residual effect of the bacteria.  Seemed to work into week 5, perhaps since I was also still using the Mother Dirt shampoo.

Cleanser

The cleanser can be used on the face and body.  It comes in a small pump that foams, and has a pleasant rose scent.  Unlike the AO+ Mist, it can last two months.  The downside is that with regular use daily in the shower with a loofah and once daily on my face, I started to run low well before one month.  So toward the end of the month, I reverted to using my regular body wash and saved the cleanser to use only on my face.  The cleanser otherwise was like any other body wash/soap.  It lathers up and has the look and feel of a traditional cleanser.  If you wear a lot of makeup, then you’d probably also need something like the MakeUp Eraser cloth to help remove it.

Shampoo

I did this with my dandruff shampoo as well, but given how greasy my hair would get by day 2, I’d end up lathering twice with the shampoo.  The second time, I’d need less pumps since it would suds up more, but I’d probably use 6 pumps total.  So for me, using 6 pumps every 2 days lasted me over a month.  Like the cleanser, it works like any other regular shampoo would, and has a pleasant scent.  Those with thicker hair will probably need to continue using conditioner.

The Pricetag

The good news is that the stuff does work.  The biggest downside is that it is ridiculously expensive.  For your first order, they give you 20% off and free shipping.  But the mist alone normally costs $49, and you need to get one per month.  For someone like me, I could get by with just the AO+ Mist and shampoo, which costs $15.  But if you get the bundle with the mist, shampoo, and cleanser, that’s $69.  If you add the moisturizer, that’s $99 for all 4 products.

Most of that you’d need to purchase each month.  Again, I didn’t try the moisturizer so I don’t know how long that would last.  But based on my experience, you’d need to purchase the cleanser monthly.  And regardless the shampoo and cleanser don’t work longer than two months.  The expiration for the products start once you open them, so you could purchase more bottles in one shipment.  But still, bottom line is that it is very pricey.

I understand that making a product with live bacteria that needs to have temperature-controlled shipping is going to be more expensive than your regular products.  But it is unfortunate that this stuff is prohibitively expensive for the average person.  I mean I make a comfortable salary, and I admit that I like purchasing fancy skin care products from Sephora.  But I still think Mother Dirt is too expensive.

I wish I could recommend a revolutionary product like this to my patients, who often complain of acne and sometimes body odor (after all, the genital area has sweat glands like the underarms).  I read a completely separate medical blurb that mentioned that they now think that finding the right balance of bacteria on the skin rather than just wiping it all out is probably what’s needed to treat acne.  Currently, many of the treatments are antibiotics that kill the bacteria on the skin.  So for people with significant skin and body odor issues, Mother Dirt can be a lifesaver.

But because of the prices, it would not be practical to mention this product to my average patient.  It would only be for patients that had tried everything, that I’d tell them, “Well, there is a product, but it’s VERY expensive…” and then leave it to them to decide if it’s something worth budgeting for.

Mother Dirt has been mentioned in various magazines and the like, so maybe if it becomes more popular, or if competitor brands come out, it could drive the prices down.  For now, the benefits for me weren’t quite impressive enough to keep using the product.

 

The Ripple Effect

Yesterday, I started my morning with a very angry email from a patient’s son.  I won’t go into the details due to patient privacy, but they don’t matter.  He had a reason to be upset, but the reality is that I hadn’t truly done anything out of the norm of standard patient care to warrant that type of reaction.

When I read it, and starting telling my colleague about it, I lost it.  I start crying.  We were just starting our morning, and our first patients were getting roomed.  But my colleague knew I was not in a good state to see patients, so she called over our lead (our mini-chief in our location), and they redistributed my patients for part of the morning to other doctors’ schedules.

For that part of the morning, and honestly all day, I was extra emotional.  As I would start to talk about what happened to other colleagues who were concerned, I would start crying again.

On a logical level, I know this email wasn’t something I should have gotten this upset over.  My reaction to it was a reflection of my state of mind.  I’ve been chronically overworked, and when I feel like I’ve been working so hard, sincerely doing the best I can for my patients, and then the thanks I get is this angry email?  It’s completely demoralizing.  I was already mentally and physically tired.  And that’s why it broke me.

The chief of my department happened to be at my office location in the afternoon and came to speak with me.  I appreciate that she’s aware that our current workload for those of us in the office only full-time is not sustainable.  She is trying to make changes within her power.  But she’s limited by the fact that we’ve been short doctors for the last several years, and it’s not that easy to hire good quality doctors that quickly.  She’s also limited by the powers that be- those above her making decisions that affect what we’re all mandated to do, such as how many patients we see per day.

I told her about this article I came across recently in the New York Times:

It was written several years ago, but they recently re-posted it in their daily email.  It’s still just as relevant today.  It talks about what employees need to feel happy and engaged at work.  Value- feeling cared for by your supervisor.  Focus- being able to focus on one task at a time.  Purpose- deriving meaning and significance from one’s work.  Renewal- taking a break every 90 minutes.  When these needs are met- surprise, surprise- employees are happier and more productive.

I found the renewal part interesting because I definitely don’t get breaks every 90 minutes.  What tends to happen is that I keep working throughout the day.  Even during the lunch hour, if we don’t have a meeting, I’m eating and catching up on results and emails from patients.  Apparently in the end, the constant working makes me less efficient than if I completely stopped working to take a break.

So what I really need during my office day is a forced meditation break in the middle of my morning and again in the afternoon of seeing patients.  It’s kind of like when I used to get breast milk pumping time.  Except I usually spent that time concurrently typing and doing work.  It would take a significant cultural shift, and probably a monetary incentive, to not only give us the time to spend 10 minutes on a meditation app or the like, but to get us to actually do it.  It’s a hard habit to break, when we’re used to continuing to work, work, work to get the job done.

The main reason I wanted to write about the nasty email I received is that there is more I wish I could say to the patient’s son who sent me that email.  I did write him back to courteously respond to his concerns and explain things from my perspective.  What I really wanted to say to him was:

Dear [Patient’s Son],

I understand that you are upset about what happened with your mother, resulting in the email you sent me.  I want you to know what happened after that email was sent.  I read the email, and I started crying.  I was so upset that I could not see the patients I was scheduled to see that morning.  Other doctors had those patients added to their already busy schedules.  My husband was very worried about me after I texted him that I had a breakdown at work.

It’s natural to lash out with angry words and call me negligent when you feel the way you do.  I’ve felt that way, too.  Next time, I hope you take a step back to think about how those words might affect others.  Those words affected not only the intended recipient, but also her patients, her colleagues, and her family.  This same effect can occur whether you are speaking to a doctor or a telemarketer.

A more productive way to communicate would have been to explain why you were upset, and then to ask more.  “Doctor, why did you respond the way you did?  What was your thought process?”  Yes, doctors make mistakes and sometimes they are big ones.  But most likely, there is more to the story.  Finding out more before lashing out fosters learning on both ends, rather than angering and distancing both sides.  I hope you keep this in mind the next time you feel this way.

Sincerely,

Me

 

The Journey to #2

I came across this article recently, and I can definitely relate:

Our Heartbreaking Journey to Baby Number Two

This woman writes about how difficult it’s been for her trying for baby #2.  People ask all the time about it, and she has her various responses to them.  But the reality is that they’ve been trying hard, and it’s devastating for her every month when she finds out she’s not pregnant.

I can’t say I would use the word heartbreaking to describe how I feel going through the process.  People ask me a lot about Baby #2, and it honestly doesn’t bother me.  It’s a common question that’s natural for a lot of people to ask.  When it comes to these things, maybe because it’s part of my job, or because it’s just easier for me to be honest, I’m pretty open.

I’m not going to respond by saying, “Yes, we’re trying and in fact just had timed intercourse last night!”  But if it came to needing to see the fertility specialists, or if I had a miscarriage, I don’t think I’d be super secretive about it.  Tell the whole office? No.  But tell those closer to me?  Sure.  We unfortunately see miscarriages fairly frequently.  I realize that is very difficult for my patients to experience.  And who knows how I’ll feel if I go through it myself.  But being on the other side, I also know that the vast majority of my patients who have a miscarriage go on to have healthy pregnancies later on.

So the logical part of me says that it’s normal to take a while to conceive.  We wait till a couple has tried for a year or more unsuccessfully before offering referral to the fertility specialists.  For women 35 and older, it’s 6 months.  The reason behind that is that if there are age-related fertility issues, we don’t want to lose out on precious time, during which fertility can further decline.

Despite knowing full well how long it takes for a normal couple to conceive, because it happened so quickly the first time, it has been disappointing to get my period each month.  So I do relate to the author of the above article.  I can’t help but feel upset that it hasn’t happened yet, and various thoughts and emotions go through my head.

Even though I tell myself logically that it hasn’t been 6 months, it’s not a big deal, I still can’t help but cry.  Being such an overachiever, I can’t help but feel a sense of failure.  Am I failing myself by not being strict Paleo?  Is my stressful job affecting my fertility?  Or are my ovaries just getting old and pooping out?

It’s apparent from the responses the author got to her original post that many women out there relate.  So I appreciate her honesty and vulnerability.  And although I’m not bothered by people asking about Baby #2, she does make a good point that we have to be careful about asking those questions.  For example, there is a couple across the street about the same age as us, who purchased their home around the same time we bought ours.  She happens to be a doctor as well.  I’m curious, but I have to make it a point not to ask them if they plan to have children.  Unless they bring it up, it’s a loaded question- maybe they desperately want kids and have been having difficulty.  You never know.

In any case, for now I am grateful for my beautiful little trouble maker.  The other day, I came home from work and he was at the upstairs window.  It always makes me happy when he waves at me as I get home.

I got out of the car, and noticed a bunch of items on the driveway.  That’s when I realized this guy was not just waving at me.  He was happily tossing items out of the window through a hole in the screen (my husband was in the kitchen cooking dinner).

Ah, life with a toddler.

IMG_4314

Paleo vs. the Plant-Based Diet

I recently went to a conference focusing on obesity prevention and food as medicine.  One of the speakers discussed the benefits of a plant-based diet.  A plant-based diet is, from what I understand, the same as being vegan- no meat, no dairy, no eggs.  I think the difference in name comes from the focus on plant-based whole foods.  In other words, you can call yourself vegan, but eat tons of French fries and sugar.  The plant-based diet recommends healthy grains like quinoa and whole grains, and avoiding sugar and excess fat.

As a physician, it was interesting to hear all of the research supporting the plant-based diet.  There is compelling evidence to show sustained weight loss, improvement in diabetes, and reduced cardiovascular disease (ie reversing or preventing clogged arteries).

I always thought I’d be hungry all the time if I were on that type of diet.  Apparently, because of the high fiber content, people feel full faster, and because of the lack of fat, their overall calorie intake is decreased.  And therefore they lose weight and keep it off.

The speaker talked about how in Okinawa, people live among the longest and healthiest in the world- many make it to 100.  Okinawa is an island of Japan, way south of the main islands.  Think Karate Kid 2.  Their traditional diet is heavy in sweet potatoes, and they also eat white and brown rice regularly, tofu, seaweed, fish and some meat.  But the meat is more limited.  This article has a nice breakdown in chart form:

http://www.huffingtonpost.com/dan-buettner/okinawa-blue-zone_b_7012042.html

While the Okinawans don’t maintain a fully plant-based diet, their consumption of animal products is low.

So what about the evidence on the Paleo diet?  Mark Sisson has previously posted on that topic:

http://www.marksdailyapple.com/is-the-paleo-diet-supported-by-scientific-research/

http://www.marksdailyapple.com/is-the-paleo-diet-supported-by-scientific-research-part-2/

There does appear to be research supporting the benefits of the Paleo diet.  And surely more underway.  I find it interesting that the healthcare organization that I work for has been promoting the plant-based diet, but there is no promotion of the Paleo diet.  For whatever reason, it still hasn’t gained respect in the medical community as far as I am aware.

As a physician who has been trained to practice medicine based on the available evidence, which is ever evolving, I’m left wondering what to believe.  There is apparently clear data on the benefits of the plant-based diet.  But based on personal experience backed by data, there are also benefits of a Paleo diet.

There is a lot of common ground- both diets stress eating whole foods, and avoiding processed foods and sugar.  Both diets focus on eating plenty of vegetables and fruit.  And the traditional Paleo diet advises avoidance of dairy, though with the Primal Blueprint version, some is ok.  Where they differ are regards to grains, legumes, and of course meat/eggs.

That’s where I start to wonder.  According to Mark Sisson, grains and legumes, even seemingly healthy ones like quinoa and soy, have inflammatory properties and therefore are best to be avoided.  The plant-based diet proponents talk about how dairy contains hormones, and both dairy and meat, particularly cheese, is high in saturated fat.

So what am I supposed to do?  The main thing that makes me suspicious of the plant-based diet is that it requires vitamin B12 supplementation.  If a diet is supposed to be complete, and what humans are meant to eat, then why would it cause a significant nutritional deficiency without the supplement?  On the other hand, since it’s impossible to eat all meat that is from grass-fed happy cows and the like, I do wonder about the effect of hormones and antibiotics from eating too much meat and dairy products.

And if dairy is so bad, I wonder about the effects on my son.  Now that he’s past the age of breastfeeding and formula, he drinks cow’s milk with every meal.  He has about a gallon a week.  We do get the pricier organic stuff, which shouldn’t have the antibiotics and such, but still.  If dairy is such a concern, could there be long-term effects of him drinking so much?  For now, we’ll keep giving him the milk per the pediatrics recommendations.  Maybe as he gets older, we can switch him to almond milk and such.

As for me, I love cheese, so the thought of giving that up is tough.  As for legumes- eating tofu seems like it shouldn’t be that bad on the spectrum of cheating on the Paleo diet.  I’ve been seeing a lot of pastas made from legumes lately.  One from Trader Joe’s made of black beans is ok.  The one I like better is from Costco, and it’s a spaghetti made from edamame (soybeans).  If I eat that stuff instead of the regular pasta, it can’t be that bad, right?

Now is there a happy medium?  I mean those Okinawan centenarians weren’t fully plant-based nor Paleo.  Well, turns out there’s a doctor out there who coined the term peganism, or Paleo-Vegan.  Dr. Hyman explains it well here:

http://drhyman.com/blog/2014/11/07/pegan-paleo-vegan/

He recommends eating mostly plants, avoiding gluten and eating other grains sparingly.  Avoid dairy.  Eat beans sparingly, and eat meat as a side dish, not a main dish.  And if you do eat meat, get the grass-fed/sustainably raised stuff.  Given what I know now about the plant-based diet and Paleo, maybe this pegan thing is worth a try.

The hard part, of course, regardless of what diet is best, is sticking to it.  Long workdays, stress eating, grabbing what’s convenient- the challenge is getting past those hurdles.

Raising a Less Picky Eater

Finally, an article that supports homemade baby food over packaged baby food.  This was from a blurb in my American Medical Association daily email updates:

Reuters (2/23, Rapaport) reports that, according to a study published in the International Journal of Obesity, “babies who get homemade food may learn to like a wider variety of food types and be leaner than infants who eat store-bought products.” For the study, “researchers examined dietary data on 65 infants and assessments of body fat from exams when infants were 6, 9, 12 and 36 months old.” Reuters says that “when researchers scored babies’ diets based on how many of seven different food groups they consumed, the infants getting only homemade food achieved scores almost a full point higher than babies getting only store-bought foods.” Meanwhile, “at one year of age, babies who ate only homemade food had a lower percentage of body fat than the other infants in the study.”

I previously referred to an article that claimed the opposite:

https://paleoob.wordpress.com/2016/07/24/sugar-content-in-baby-food/

I think it makes sense that feeding your kid ONLY pre-packaged baby food is probably not the healthiest.

WZW is 18 months old today!  It’s hard to believe it’s already been a year since he started solid foods.  He eats mostly regular food, but for convenience we do still have baby food as well.  The pouches are nice for bringing on-the-go, since they don’t need to be refrigerated and can be easily kept in a diaper bag.  But they are more expensive.

Even though he eats most of what we eat, it’s still a lot of effort to figure out what to feed him multiple times a day, so we still give some baby food even when we’re at home.  We still like the Earth’s Best brand, because they have the glass jars that are way cheaper than the pouches, and come in 6 oz jars (rather than the 4 oz pouches).  So we’ll put them into the reusable pouches.  They also have flavors that aren’t sweet, which is hard to find when you look at the varieties of pouches in the stores or online.

We’re lucky that WZW has never been a picky eater.  Even from when he first started solids, there were only a few foods that he didn’t like.  He mostly eats everything, and since we eat a variety of ethnic foods as a family, he has tried a variety of flavors.  He doesn’t seem to be bothered by spice as well- he can handle it better than my parents can!  If anything, I worry about him eating too much, as he’s starting to need 2 yo sized clothes, thanks to his big belly.  I guess the pediatrician will tell us at his upcoming 18-month appointment if he’s getting too heavy on his growth curve.

I think for most families, doing all homemade food can be difficult.  But given the varieties of mostly sweet foods in the packaged baby foods, I think it’s good for parents to be aware so that they can feed their babies savory foods and add variety with homemade foods.  Otherwise the babies would get used to foods they like, such as apples and sweet potatoes that are often added to make the baby food more palatable to babies.

We definitely did what we could to encourage WZW to eat a variety of foods.  Supposedly different flavors and spice get secreted in breast milk, so I ate a variety of foods during his first 6 months when that’s all he was getting.  And since then we’ve given him a variety of foods, homemade (and restaurant made) and baby food.  But I think it’s also probably just him.  Many babies, when given new foods for the first time, don’t accept them until multiple attempts have been made.  Whereas for WZW, most foods weren’t a problem the first time.

For me and my husband, we’ve been using Cook Smarts more, so we’ve been eating more Paleo than before.  Thanks to my husband who has been cooking us meals during his off days, I have been eating less carbs than what had become my usual.  I’m still not quite there in terms of being completely Paleo- it’s still convenient to eat what’s available at work on days when lunch is provided.  While before, I would definitely pick a sandwich over a salad given the choice, I’ve been trying to go for the salads more often.

The problem is that the salads leave me hungry a couple of hours later.  I had forgotten about that- when I first went full Paleo, I was eating A LOT.  And then, as I got used to it, I found that I needed less food to feel satisfied longer.  Right now, while I’m still not full Paleo, I have to deal with the low carb meals (usually pre-packaged salads) often not keeping me full as long.  But I’m proud of myself for making some progress.  I’m still usually pretty exhausted from work and WZW to put any more effort into it, so any little bit helps.

In any case, last night we were eating a Cook Smarts dish, which was tamarind chicken with bok choy on cauliflower rice.  WZW was eating it all without a fuss, and even practicing his fork skills!  Made Mom and Dad proud to see their little guy enjoying his Paleo dinner.