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Overcoming Medical Dogma Series: Eczema

The recurring series “Overcoming Medical Dogma” is a collaborative effort between The Paleo Mom Sarah Ballantyne, PhD, scientist turned stay-at-home-mom, and Paleolithic MD Dr. Ernie Garcia, MD, Internal Medicine and Sleep Medicine specialist.  The goal of these co-written posts is to go beyond the typical physician-patient interaction where the patient describes symptoms, the physician diagnoses and prescribes medication and/or dispenses diet and lifestyle advice. In each post, we will discuss a common medical condition, the typical treatments that your doctor may recommend, and what you should know about these conditions that your doctor may not tell you. We will reference relevant research and present our recommendations for addressing this condition.  Lastly, we will address the benefits of pharmaceuticals (prescription and OTC) as well as home/natural remedies which may help.

What is Eczema?  Eczema is a general term used to describe a collection of skin conditions (the most common being atopic dermatitis) in which the skin is inflamed and irritated.  The inflammation in these skin conditions is in the epidermis, or outer layer of the skin, and this is the main distinction between eczema and other skin conditions.  The presentation varies and can include any of the following symptoms:  redness, skin edema (swelling), itching, dryness, crusting, flaking, blistering, cracking, oozing, or bleeding.  It can affect any area of the body and areas can range in size from quite small to very large.  Eczema affects about 10% to 20% of infants and about 3% of adults and children in the U.S.

It was once thought that eczema was a primary immune system disorder, where an overactive immune system, led by a type of white blood cell called T-Cells, responded to environmental factors by initiating an inflammatory response.  This idea made sense because not only would inflammation produce the red, irritated skin characteristic of eczema, but this dysfunctional immune response also provided an explanation for the observed incidence of atopic dermatitis in conjunction with asthma, hay fever, and other allergies.  However, the most up-to-date research does not support this explanation.

The most current research points to a different origin of eczema.  It is now thought that eczema results from structural defects in the epidermis resulting in “impaired barrier function”.  Essentially, abnormalities in the skin make it more permeable to toxins and antigens, which then causes an exaggerated immune response 1 You could think of this as “leaky skin”, where the skin no longer is able to fulfil its primary role as the first line of defence between the body and the outside world.  Once the barrier function of the skin is disrupted, various substances (like toxins, allergens, antigens; basically anything that the immune system views as a foreign invader) can “leak” in from the outside and this is what activates the immune response.  This model is supported by recent isolation of specific mutations in the gene for filaggrin, a structural protein in the epithelial cells of the skin.  This defective gene (and perhaps other similar gene mutations) may lead to a dysfunctional epidermal barrier and is likely the primary cause of eczema.

What is your doctor likely to tell you about it?  Your doctor will likely tell you that the exact cause of eczema is unknown, but it’s thought to be linked to an overactive response by the body’s immune system to an irritant.  He or she may not be aware of the newest research on eczema, but that will not affect decisions on treatment.  It’s fairly common and not life threatening.

What is your doctor likely to prescribe?  Treatment of any skin condition should always start with proper care of your skin.  In the case of eczema, you should avoid triggers such as heat, perspiration, and low humidity, and keep the skin well hydrated at all times. The standard pharmaceutical treatment is the application of topical corticosteroid creams, which can be purchased in your local pharmacy or prescribed in stronger strengths by your doctor.  If allergies are suspected, a daily antihistamine such as loratidine (Claritin) may be suggested.  In severe cases, your doctor may prescribe an oral corticosteroid, such as prednisone.

Now if you have your thinking hats on (and we’re sure you do), you are asking “If eczema is no longer considered a primary immune disorder, why is the standard of treatment aimed at stopping inflammation and controlling the immune response?” The answer is that the symptoms of eczema are indeed caused by an immune response, but it is a response from environmental triggers entering the body through “leaky” skin as opposed to an immune system run wild and attacking itself. 

What should you know that your doctor may not tell you? As discussed above, the most current belief is that those with eczema carry a genetic predisposition to “disrupted epidermal barrier function” 1.  This could be thought of as “leaky skin” and is a very analogous to a “leaky gut”.  In fact, because of the similar roles of the skin and the gut to act as a barrier, it is no surprise that eczema is also associated with increased intestinal permeability 2, i.e., a leaky gut.  It is still unknown whether a leaky gut contributes to the development of eczema, however.

Eczema is also often seen in conjunction with a multitude of autoimmune diseases.  For example, eczema occurs about three times more frequently in celiac disease patients and about two times more frequently in relatives of celiac patients, potentially indicating a genetic link between the two conditions.  For this reason, gluten sensitivity is suspected as a possible root cause for eczema, but that is still unconfirmed.  Anecdotally, many people find that their eczema goes away when they adopt a gluten-free diet.  Other people find elimination of additional foods, such as eggs, are required to see improvement.  There also appears to be a strong link between eczema and immune hypersensitivity 3.  For example, more than 50% of children with atopic dermatitis go on to develop asthma and allergies.  This may be related to the association with increased intestinal permeability or may reflect an as yet unknown common causal mechanism (such as a gene mutation or environmental factors).   

Although progress had been made toward understanding this complex condition and how it relates to other health issues, the cause of eczema remains unknown. We are certain the coming years will bring more information and we will try to update everyone as it is available.

A Comprehensive Approach to Treatment:  We believe that a paleo diet is an excellent initial approach to dealing with eczema.  This is because a paleo diet reduces inflammation and heals the gut.  Including glycine-rich foods like homemade bone broth and organ meat can help speed the healing of both the gut and the skin (glycine is an essential component of connective tissue and the extracellular matrix that acts as a scaffold for cells).  Sun exposure and eating vitamin D-rich foods such as fish and organ meat can be very helpful in speeding healing (you might also consider a Vitamin D3 supplement, but check with your doctor first).  Consuming plenty of oily cold-water fish (at least three times per week) as well as eating grass-fed and pastured meat will also help because the high omega-3 content of these foods (and low omega-6 content) could help resolve inflammation.

Anecdotally, most people report alleviation of their symptoms with adoption of a paleo diet.  In extreme cases, or in individuals who do not see alleviation of their symptoms with out-of-the-box paleo, it may be worth trying a more restricted implementation of the paleo diet, such as the Autoimmune Protocol, a paleo version of the GAPS diet, or even something as simple as completing the Whole 30 Challenge from Whole 9 Life.

Over the counter topical corticosteroid creams may still provide some alleviation of symptoms (most notably the itching) and might be required initially.  Other moisturizers which may help heal the skin faster and relieve itching include extra virgin coconut oil and lotions containing calamine, aloe vera, arnica montana, Vitamin D and/or Vitamin E.  Diane Sanfilippo provides herbal supplement recommendations in her new book Practical Paleo (herbal supplement recommendations are generally beyond both of our backgrounds and we recommend that you consult with someone with specific training in these supplements such as a Naturopathic Physician).  If your attempts to control symptoms with diet and supplements alone do not produce adequate relief, we suggest visiting your doctor for advice on more specific pharmaceutical intervention in the form of stronger topical steroids or short courses of oral steroids in extreme cases.

 

1 Elias PM and Steinhoff M  “Outside-to-Inside” (and Now Back to “Outside”) Pathogenic Mechanisms in Atopic Dermatitis. J Invest Dermatol. 2008 May; 128(5): 1067–1070.

2 Pike MG et. al. Increased intestinal permeability in atopic eczema. J Invest Dermatol. 1986 Feb;86(2):101-4.

3 Boguniewicz M.  Atopic dermatitis: beyond the itch that rashes. Immunol Allergy Clin North Am. 2005 May;25(2):333-51.

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Posted by on July 28, 2012 in Overcoming Medical Doma

 

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Review of Nutrition Guide Created by Whole 9 Life for My Clinic

I’m at my office and on my desk if a nice crisp and spiral bound copy of our new Nutrition guide that was created by Dallas and Melissa Hartwig and Whole 9 Life for my clinic the Freedman Clinic of Internal Medicine.  Here is the Cover…

Many of you may know Whole 9 as an online community for a Paleo based diet and the source of an amazing amount of easy to understand information about the science of Paleo.  You are correct of course, but they are also a tremendous partner for offices like mine as Nutritional Consultants.  For a very reasonable fee you can partner with them to create a COMPLETE guide to paleo centered nutritional recommendations for your clients or patients.  I feel like a kid in a candy store now that I finally have it, and I’m handing them out like hot cakes.

I agree with the Hartwigs that concentrating on a “paleo” diet is not optimal, and instead we emphasize picking foods that are simply healthy for us regardless of whether a caveman actually had it!  As in their book It Starts With Food we pick foods that:

1) Produce a Healthy Hormonal Response

2) Produce a Healthy Psychological Response

3) Maintain GI Integrity

4) Limit Systemic Inflammatory Response

As many of you know, taking a Paleo naive patient and explaining to them in detail what we eat, what we don’t eat, and most importantly why, is very difficult to do in the restraints of a typical 15 minute appointment.  With this guide I am able to introduce the key concepts, explain to them why I feel it is so important, and give them a product to take home that will be a complete introductary guide to how and what to eat, as well as explaining to them WHY!  The guide is able to do so in 10 pages or so and is very easy for a layperson to understand.  It also includes further vital information for a newbie such as a grocery guide, meal planning guide, a comprehensive FAQ section answering most common questions I can think of, and a good set of recipes to start.  As a bonus, it also includes a custom personal guide to the Whole 30 program for each patient if they are so inclined.  Like I said, this is a extremely well put together and laid out collection of information for a very reasonable price.  Here is a look at the Table of Contents!

If you are in the business of helping people improve their health, and you are looking for a comprehensive guide to helping people adapt to a Paleo based lifestyle, I highly recommend partnering with Whole 9 Life and having them customize a Nutritional Guide for your business.  I have no financial relationship with Whole 9, and get nothing if you work with them, I just feel this kind of product can help you as much as it has helped me and my partners.  I can finally concentrate simply on pointing patients in the right direction, and letting our Nutrition Guide educate them and fill in the details.

Interested in how I approach patients about adapting to a Paleo lifestyle, check THIS out.

-E

 
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Posted by on July 26, 2012 in Book Reviews

 

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The Road to Fitness: Exciting Application of Paleo to Weight Loss Surgery Patients

Wanted to share a very interesting and exciting program I will be getting started with tomorrow.  Our local bariatric surgeon Dr. Sam Bledsoe has teamed up with myself and William Albritton, a first class trainer from our local Alexandria Crossfit, to put together an 8 week “The Road to Fitness” class.  Sam and William came up with the idea and asked me to come on board, but William is truly the work behind the program. Dr. Bledsoe has recruited 8 patients who have all had successful weight loss surgery and have lost over 50% of their pre-surgery body weight, but have reached a plateau and are unable to reach their ultimate goals.  They will go through the following program.

-Tomorrow night we kick it off with an Introduction covering the program overview, an introduction to crossfit, and a nutrition review discussing Paleo concepts (Will be encouraged to follow Whole 30 guidelines for first month)

-Over 8 weeks they will be scheduled for a series of physical activities including introductary low level crossfit WODs which will be adaptable to their current abilities and individual/group exercise away from the box

-They will maintain daily food logs which will be reviewed weekly by the coaches

-We will also have several get togethers to exchange Paleo recipes and food

Weight Loss Surgery patients are like any other patient, and the concepts of the Paleo lifestyle are a great way to kickstart their weight loss again, help them reach their goals, and further limit their exposure to chronic disease long term.  We will also be getting a group of people to utilize CrossFit who normally would be very intimidated to even show up for an introduction class.

Win-win all around!

Hope all have a great day, and please wish all our participants luck!

-E

 
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Posted by on June 21, 2012 in General Paleo Discussion

 

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PaleolithicMD “It Starts With Food” Book Giveaway!

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Ok everyone, time for an exciting giveaway!

Weeks ago I pre-ordered my copy of Dallas and Mellisa Hartwig’s new book “It Starts With Food” from Amazon.com. I then began the patient wait for the release date to come.

Much to my surprise when I got back from vacation I received an advance copy of the book from the Hartwig’s to read. I’m so grateful for their generosity and our growing relationship!

That said, what to do with my pre-ordered book? Sure, I could cancel it because it has not shipped yet, but I figured why not give it away to a lucky reader as a giveaway! It’s a pretty simple giveaway and will include two items…It Starts With Food and a SURPRISE!

To enter for the giveaway all you need to do is:

1) Like my PaleolithicMD Facebook Page
2) Follow me on twitter @PaleolithicMD and RT my Giveaway Tweet
3) Enter one comment on this post telling me you have done both Please include your twitter handle on the post so I can contact you in case you win! IF you don’t have both types of accounts do what you can and I’ll still throw you in the mix!

Come on, that’s pretty easy isn’t it!

I will take entries until Friday June 15th and will randomly select a winner. I’ll contact the winner via twitter and ship out the book and surprise pronto!

Good luck everyone out there, you don’t want to miss out on your opportunity to read this amazing book for free!

-E

 
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Posted by on June 9, 2012 in General Paleo Discussion

 

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A Physician’s Whole 30 Experience: What I Learned

30 days ago I began a journey that has taken me farther into myself then I knew I could go. Today it ends, and I would like to take you inside my journey and share with you how it has changed my diet, my health, and my spirit.

The Process: Around 9 months ago I decided to change my diet to one based on a Paleo framework. I spent years looking at different diets and my paleo adventure has finally landed me on solid ground. I “gave up” so many foods that I felt I was doing about as much as I could for my health. Despite that, I still had a few strongholds; the biggest of which was Diet Dr. Pepper.

For months I have been recommending a dietary challenge to patients that were interested based on Dallas and Melissa Hartwig’s Whole 30. I would normally feel somewhat strict to recommend the entire plan, and would often tell patients to follow it completely except for the artificial sweetener rule. I did this to give my patients a break, but also because I could not give that up myself. I try hard to live by the rules I preach, so this seemed easiest to me! The more I traveled into my Paleo journey, the more I felt the real calling to participate in the Whole 30 myself. I knew it would be hard, but I just felt it was the right thing for me. My diet has been pretty strict from the beginning, and essentially converting to the Whole 30 meant eliminating artificial sweetener, the small amount of heavy cream I drink with my coffee daily, and nitrates in preserved food. Otherwise, no real change! How hard could that be right?

30 Days ago I started the challenge with confidence and concern. I knew dropping the caffeine in soda would be hard, but I had no idea how bad it would be initially. The first day of the challenge was the worst I have felt in YEARS. I had a terrible headache the entire day, and felt almost in a fog. As the day progressed seeing patients in my clinic became harder and harder, and I almost gave in and drank a soda. What stopped me was the realization of just how bad things were! I felt terrible, all because I drink too many sodas. I pushed through, and made the determination not to drink any caffeine at all until I felt better. That night when I got home I was absolutely cranky (my wife will concur I am certain!) I did the best I could and went to bed as quickly as I could. As I lay in bed, head pounding, I wondered how long I could take it. It was literally incapacitating, and I feared how well I could work another day like that.

I slept off the headache, and awoke to a new day…headache free! I stuck to my guns and chose water over coffee every day for the next 10 days. I have not had another headache since that first day, and I am amazed at just how bad I felt. I felt sick, there is no other way to describe it. After 10 days I started drinking some coffee again, simply because I love coffee, not because I NEEDED it. It was a very freeing experience.

Despite the headache disappearing, I still craved diet soda. After much thought I realized that I drank it mainly to kill my need for something sweet. I had eliminated so many strongholds in my diet, but this one had become my primary one. I can say honestly that this craving for diet soda lasted a good two weeks before I FINALLY got over it. It sucked!

As far as food goes, the Whole 30 was not terrible for me. I eat a pretty clean diet to start with, and my main adjustment was bringing lunch with me from home as not to chance any illegal items when we order out often from the clinic. I can imagine that the shock to the system from a non-Paleo diet to a Whole 30 would be tremendous, and I am glad I did not have to face that!

Due to poor planning on my part, the end of my Whole 30 coincided with a week long family vacation to the Great Smoky Mountains. This was hard, by far the hardest part of the plan. By the time we left though I was over 20 days in, and there was NO WAY I was going to kill it. I sucked it up, and did all I could to stay on track. I ordered as detailed as I could when out to eat, and stuck to safe foods when none were available. Of note, when I do another Whole 30, I will make sure I’m not on vacation during any of it!

So how did the Whole 30 help my health? Here are a few observations:

Acne: I don’t have terrible acne at all, but I do still suffer with an occasional pimple. For three weeks I have not had a single pimple. Pretty amazing stuff.

Energy: I thought Paleo had given me all the energy I needed, but I was wrong that it was all I could have! Although subtle, the increase in energy on a day to day basis I experienced by taking the next step to the Whole 30 was encouraging. I never really got tired, even on the long drives during our vacation which in the past would have sent me shopping for caffeine in one form or another.

Cravings: Again, although I felt my food cravings were gone once I went Paleo, the Whole 30 taught me that my major remaining craving, diet soda, was as strong as ever. It took a good while to get rid of this one, but it was well worth it. Diet soda turned out to be the one little thing I kept for myself, and I had no idea the pull it had on me. I don’t think that drinking diet soda made me feel tremendously bad per se, but I was drinking it for the WRONG reasons. That was enough to concern me and push through the 30 days. Will I ever drink diet soda again? I would be a bold faced liar if I said I would not, but my intake will be cut by 80-90% long term. That is something I can live with, and be very proud of.

Weight Loss: After changing to a Paleo diet I lost 25 pounds without really trying at all. During my Whole 30 I lost 5 more pounds, so that is 30 pounds overall…not too shabby!. My BMI has dropped from 30.6 to 26.3. I still have some way to go, but I’m very pleased with the overall drop so far.

Mood: I have noticed a definite improvement in my mood during the Whole 30. I’m generally a pretty positive guy, and I really like what I do. Still, everyone has times when stress or anxiety get to them. This would happen to me typically when the work day would zoom out of control, or the kids would act up. I think two things led to the improvement in my mood:

—Knowledge of Health – Just knowing that I was doing something very important for my health was so invigorating. Diet, weight, and emotion are intertwined to the point they are indistinguishable. Negative emotions can be crippling, but positive emotions can fuel you to the max. I knew I was getting healthier every day, and that made me feel awesome.

—Feeling of Health – Besides knowing I was healthier, I FELT healthier! For all the reasons above, as well as sleeping well, I just had a general glow of health to me. Other’s noticed and made comments, and that will help anyone feel better! I don’t think I can really explain this, you just gotta try it to find out!

Must Have Foods: Many people are looking for the foods that are key to a successful Whole 30, and I will give my humble opinion. Here is what I couldn’t live without.

-Avocados – There is no better snack alone, or added to a protein than one.

-Coconut Milk – Such a great milk substitute for any occasion.

-Dried Fruit – Watch this as it can be a sugar substitute for you, but in moderation; often saves me

-Eggs – What else can you say about the totally versatile egg?

Homemade Beef Jerky Sometimes you just need beef!

Big picture: So what is the big picture benefit to me from my Whole 30? There are several things I would like to point out. First, it truly allowed me to put the focus back on using food as nourishment for my body, and not as a pleasure per se. Now look, I love food, and that will never change. But it’s so hard to separate sometimes the difference between what you eat to fill a “void” or “craving” in your life, versus what you eat to adequately fuel your body. You can easily fuel your body with wonderful, real, and delicious food which means you don’t have to turn to food for anything other than that. As I say, Real Food for Real Health.

Limiting my diet to this real food also brought back something else that I feel we often lose; the real taste of food. We are inundated with flavors that we quite frankly were not ever supposed to experience! As you will all (if you are smart!) soon read in the Hartwig’s book It Starts With Food the food industry has created foods that are fattier, saltier, and sweeter than anything nature can provide. This kind of numbs our taste buds to real food. Take for example marinating a steak such as in a sugary Teriyaki sauce. If you have a wonderful cut of beef, why take away from the flavor at all with anything more than a little salt and pepper? Why not taste the meat for what it is, and the glorious fat for all it can be? Are “smoked” almonds really better than raw almonds? Is a maraschino cherry better than a super ripe fresh cherry? Is a tub of store bought greenish faux-guacamole better than home made, or just a freshly sliced ripe avocado? If you really taste things, the answer is no for all these.

The reason that the food industry has designed foods to be fattier, saltier, and sweeter than nature intended is that they are taking tasteless and inedible food and creating a “food” for you to eat, and for them to make money off of. By design the Whole 30 takes all that away. What you are left with it food as God intended it to be. The Whole 30 gave me my taste buds back!

Lastly, the Whole 30 taught me that once again, even when I think I’m doing my best, I am not! It’s not good enough to do Paleo and hang on to dietary strongholds. The effort to bring about even more change in your life can produce serious dividends. I learned that and am so glad that I did.

So, you only have two things left to do. First, commit to doing your own Whole 30 right NOW! And second, pre-order the Hartwig’s book and soak it up as soon as you can. I will be doing a full review of the book once I am finished, but I am taking my time to really gain everything I can from it. I am not a paid spokesman, and I gain nothing from you getting their book. To the contrary, it is you that has everything to gain from reading it.

Please consider doing the Whole 30 challenge yourself. Ask yourself these questions…is what you are doing right now working? Are you happy with how you feel? Could you use more energy? Are you sleeping soundly? Are you worried about chronic disease? Are you sick and tired of being CONTROLLED by food? It’s just 30 days…

JUST….DO….IT!!!

-E

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Posted by on June 6, 2012 in General Paleo Discussion

 

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Whole 30: Day 30 (It is Finished!) #Whole30

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Alright everyone, my 30 day challenge is officially over! I am currently working on a complete wrap up of my experience that I will publish in the morning, but tonight I will continue with a normal post about my day.

Tuesdays are awesome, cause they are my day off! That said, I rounded at the hospital this morning because my brother is out of town and we have too many people for my other partner to see on his own. For breakfast I had some eggs and the last of my Whole 30 friendly bacon.

After the hospital I came home and did some work around the house and in the yard. My wife is teaching Vacation Bible School, and both my kids are attending. After they got out we met for lunch at a local joint and I had some baked chicken wings…they are awesome.

Dinner started two days ago when I got this awesome grass fed shoulder roast and seasoned it up. The dry rub consisted of:

Kid Friendly Dry Rub

1 T Salt
1/4 t Pepper
1 t Paprika
1 t Onion Powder
1 t Garlic Powder
1 t Dried Thyme
A Dash of Chili Powder (Kids don’t like the spice)

Dry off the roast well and liberally season with the dry rub. Afterwards vacuum seal to get ready for the Sous Vide.

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I set the roast in the Sous Vide set at 130 F for 48 hours. This afternoon I whipped up a Whole 30 friendly pesto. In a food processor add:

Paleo Walnut Pesto:

Large Handful of Fresh Basil
Large Handful of Walnuts
3 Garlic Cloves
1/2 t Salt
1/4 t Pepper
Process until roughly chopped

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Next drizzle in olive oil while the processor is running until the pesto just comes together. Next I chopped up some cauliflower into florets. My daughter went with me to the grocery, thus the colorful cauliflower!

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I Roasted the cauliflower at 375 F Convection for around 20 minutes, mixed it with a splash of water and the pesto, and it was ready.

My daughter loves mushrooms, as do I, so I make them often. Tonight I had two packs of enoki mushrooms, one white and one brown, along with some shitake mushrooms. I sauteed them simply with olive oil, salt and pepper. Not on Whole 30? Add a splash of very dry sherry or Madeira wine at the last minute and heaven awaits!

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Lastly I heated up the cast iron skillet full blast and put a little coconut oil in. I browned off the roast in the pan after thoroughly drying it. Dry it well or it won’t get that wonderful crust you are looking for. Here was my dinner plate, and what a way to end off the Whole 30! My daughter set the table, thus the awesome place card waiting for me 🙂

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So that’s the end. What a 30 days! Please stay tuned tomorrow morning for my complete Whole 30 breakdown!

-E

 

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Whole 30: Day 29

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Well, it is the penultimate day of my Whole 30, and I was treated with my advance copy of Dallas and Melissa Hartwig’s new book It Starts With Food. The masterminds of my torture (kidding of course) have created what looks like a real winner in this book. I’m dying to start reading it, so tonight will be short and sweet!

Breakfast started with left over crispy sous vide chicken. Today was absolutely crazy as expected at the office. For lunch I had some prosciutto and cantaloupe. Found prosciutto with a wonderful ingredient list: Pork and Salt :). Got home and went to the parent’s house for dinner. Ribeye, asparagus, salad = Yum. Great day, busy day

Off to start reading. After all, it all starts with food!

-E

 
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Posted by on June 4, 2012 in General Paleo Discussion

 

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