Should You Be Gluten-Free?

I LOVE when patients ask me if they should be GLUTEN-FREE. Why? Because the gluten-free diet is inherently healthy (if you do it without searching out the elusive gluten-free twinkies) and because I have been following a GF diet for about seven years, so I have far more personal opinions and advice about this diet than your average non-GF doc.

Who NEEDS to be Gluten-Free? People with Celiac Disease. Anyone with this autoimmune disorder needs to COMPLETELY avoid gluten, which is a protein found in wheat, barley and rye. If they do eat gluten, their body basically overreacts and the inflammatory response in their gut damages the gut lining, which blocks absorption of important minerals and vitamins. Untreated celiac disease can lead to multiple complications, including anemia, a skin disorder called dermatitis herpetiformis, autoimmune disorders, neurological problems and some cancers.

Who MIGHT be helped from a gluten-free diet? People with autoimmune disorders. Gluten is pro-inflammatory, which means that it can stir up an overactive immune system by irritating the gut lining and triggering a whole body response, sort of poking the giant. With autoimmune diseases, the problem comes from too much immune response (too much inflammation) creating swollen joints, rashes, etc. The general concept is that if you remove gluten, that is one less thing to provoke your overactive system.

My most important advice about the GF diet: emphasize the natural foods that are gluten free- fruits, vegetables and protein sources (nuts, meats, fish, eggs, etc). If all you do is substitute the GF version of every bread, pasta, pizza, cookie, cake and twinkie for those things in your diet now, then yes, you will be GF but not necessarily healthy. And from the mental/emotional aspect, sometimes that's the easiest way to start GF without feeling deprived. But why not have those GF alternatives in moderation, while emphasizing the healthy wonder that is the colorful world of veggies and fruits? Your body will thank you for it.

Do I still seek out the best GF treats like pizza, calamari and brownies? You bet! Am I excited to find Udi's newest delicious GF multigrain bread? Of course! But my dietary GOAL remains focusing on more vegetables and fruits, always paired with a protein source.

BOTTOM LINE: Gluten-free diets are necessary for people with celiac disease, probably good for those with autoimmune disorders, and healthy for all of us as long as we "go natural". 

Gluten-Free Calamari: April Fools?

One of my biggest challenges of eating gluten-free (GF) can be dining out, especially at my favorite seafood or Italian restaurant. (What's Gluten? Click here.) My stomach moans and mouth waters when the waiter presents the loaded basket of heavenly scented fresh bread or crispy rings of fried calamari, and I inwardly pout (okay, perhaps I outwardly whine) as I am left to sip my water, which is often the only GF item at my place setting. This week, however, while in Boston, I had a delightful surprise on the waterfront at the famous Legal Sea Foods.

A large group had dashed over for lunch during our full conference day. I asked if they had GF labels on their dishes, and the waiter immediately swapped out my menu for one that highlighted the GF choices. To be honest, I was skeptical when I saw fried fish as part of the choices, but happily, the waiter clearly was educated about special diets, and I had my pick of numerous dishes. He took our orders, then came back with drinks and the infamous bread basket. As he set it down, however, he smiled at me and said- unsolicited- "no worries, your gluten-free rolls are in the oven and I'll be back with them in a few minutes"! I squealed with delight, much to the amusement of my new friends and colleagues, I might add...

Ultimately, I ended up eating at Legal's not once or twice but literally four times in three days (a definite first for me for ANY restaurant) and the icing on the proverbial GF cake was that last night I discovered FRIED CALAMARI on the list! This was the best calamari I have ever had, GF or "regular". Yum!

BOTTOM LINE: More and more restaurants are offering GF options- be sure to ask your waiter! AND...if you're in Boston (or anywhere there is a Legal Sea Food), you've gotta go to Legal's and have the GF Calamari!

PS. First of the month, so change those AIR FILTERS (especially here in Austin- the oak is out of control!)

Gluten-Free Diet

This week I am talking about celiac disease, which requires a life-long commitment to a gluten-free diet. So, what the heck does that involve? Well, gluten is a protein found in all forms of wheat, as well as related grains such as barley and rye. What is made with wheat? At first glance, it feels like EVERYTHING has wheat.

Most cereals, breads, cookies, muffins, cakes, dough (think pizza), buns, and pastas, etc. ALL are classically made using wheat flours. Happily, though, there are more and more foods in these categories that are made with rice, corn and potato flours- all of which are gluten-free. In almost every grocery, there is a small (and ever-expanding) section of gluten-free "bread" products and mixes. Check out my "commercial" for delicious gluten-free pancakes, for example- yum! And rice-flour cereals such as Rice Chex are still on the menu, though ones like Rice Krispies that sound gluten-free (GF) may not be (because of additives like malt.)

More importantly, though, there are tons of delicious, healthy foods that are naturally gluten-free. Practically the whole perimeter of the grocery store: every fruit and vegetable (think MORE!), dairy, nuts, and meat are all GF. Our bodies don't NEED gluten nor any of the treats/sweets/doughs that our MOUTHS or minds may crave...

I think the biggest challenge of GF eating is baking. There does not seem to be a simple recipe substitute- at least not "replace one cup of wheat flour with one cup of brown rice flour" style. Because of the TEXTURE, you need to make blends involving rice flour, potato starch and tapioca flours, for example. I have found a great baking cookbook that I would recommend: Gluten-Free Baking Classics, by Annalise Roberts- try the delicious lemon pound cake!

If you are committed to a GF diet, make an appointment with a registered dietician to really learn all the nuances of this meal plan. Here in Austin, I recommend Daniela Knight, RD, to help you with this transition.

BOTTOM LINE: Gluten-free diets are rich in fruits, veggies and protein, and can be supplemented with carefully chosen gluten-free baked goods.

Celiac Disease: Do I Have It?

This week I am talking about celiac disease, a very common problem that affects 1 in 133 Americans. With non-specific symptoms such as fatigue and abdominal bloating, how can it be diagnosed? As is often the case, it is not as clear cut as you might think.

The first caveat is that you must EAT wheat (gluten) for the whole month before you are tested to get the most accurate evaluation. Blood tests are performed that check your antibodies, including the most sensitive test (meaning it will miss the fewest cases, but may have some false positives) anti-tTG (anti-tissue transglutaminase antibody.)

The doctor must also test your IgA levels (immunoglobulin A) because if you are not making adequate IgA, you could test negative for celiac disease even though you have it. Additional blood tests include anti-endomysial antibody (EMA-IgA) and anti-deaminated gliadin peptide (DGP – IgA and IgG).

Ultimately, the diagnosis will need to be confirmed not only with a blood test, but with a small bowel biopsy which is done through endoscopy. The biopsy will look directly at the lining of the gut and determine what level of damage exists.

Alternatively, you can choose to follow a strict gluten-free diet, and if your symptoms resolve, it is likely you have celiac disease (or at least gluten-intolerance.) This is obviously less specific and accurate, but is certainly a good starting place.

BOTTOM LINE: If you are concerned you may have celiac disease, talk with your doctor about getting a simple blood test to help determine if you should go gluten-free.

Celiac Disease and GF: What is it?

You may have noticed a new section cropping up on menus in restaurants these days- the gluten-free choices. What's up with that? Celiac disease. This disease is very common in the United States, affecting 1 in 133 people. In people with this disease, eating gluten (the wheat protein) causes an auto-immune reaction that damages the small intestine, causing poor absorption of food and nutrients.

What symptoms show up? Diarrhea is the classic symptom, but it turns out there are probably more cases of celiac disease without diarrhea. The symptoms are often rather nonspecific: fatigue, irritable bowel, anemia, vitamin deficiencies, and osteoporosis. There is, though, one symptom that is 85% specific for celiac disease-a rash called dermatitis herpetiformis, DH for short. This rash has nothing to do with herpes, however (nope, no STD talk in this topic!) This rash is intensely itchy, symmetrical eruption on the face, buttocks, elbows and knees.

The good news is that celiac disease can usually be treated with dietary changes alone-no medications required! The bad news is that gluten is found in many products beyond the obvious wheat breads and cereals, so to completely avoid gluten requires significant effort and education. Stay tuned this week for more about Celiac disease diagnosis and diet.

BOTTOM LINE: Problem: Celiac disease, a very common challenge. Answer: Gluten-free diet.

To Statin, or Not to Statin- That is the Question!

Okay, in this day and age of fixing everything with pills, we are often faced with whether or not to start a patient on a cholesterol lowering drug (a statin.) How can we decide if the benefits outweigh the risks? How much improvement can we expect from a medication?

Often, simply educating the patient about a high fiber diet will do the trick, especially if it is his or her triglycerides (the smallest breakdown product of fat) that are really high. Eating a diet with more than 25g of fiber per day will often lower lipid levels to our goal range. How do we do that? At the risk of beating a dead horse, it's MORE fruits and vegetables, plus some extra sources of high fiber such as beans, nuts, more berries, or high fiber cereals such as Fiber One or Bran Buds.

What is HIGH? Total cholesterol >200, triglycerides > 150, LDL (bad cholesterol) > 130 [or >100 if other heart risk factors such as diabetes, high blood pressure or smoking], or LOW HDL (the good cholesterol that takes away plaques) which is <40 in men and <50 in women. If you have more than one number above normal, it's time to consider either serious dietary modification or perhaps medications.

Luckily, we have a tool that can help us decide whether or not to start medications. The Framingham Risk Score looks at your lipid levels and calculates your risk of an adverse cardiac event in the next decade. You can plug in "improved" numbers (that you would get with a drug like Lipitor, Zocor, or Crestor) and see how much, if any , it lowers your risk.


BOTTOM LINE: If you are deciding whether or not to start (or continue) a statin medication, consult with your doctor and discuss your Framingham risk score!

Gluten-Free Heavenly Pancakes! ( A Brief GF "Commercial")

Okay, forgive the interruption in talking about the secret stash of medicines doctors keep in their cabinets- I guess you can consider this a commercial, though I personally do not stand to profit! However, I had to break in because this morning, my kids and I devoured the most DELICIOUS GLUTEN-FREE pancakes!

Over the weekend, which teaching girl scouts about celiac disease and wheat allergies (and earning the "Let's Get Cooking" badge), the girls and I discovered a new brand of Gluten-free flours and mixes. We made chocolate chip muffins using "King Arthur's GF Muffin Mix" with soy milk (Vanilla Silk milk- because that's what was in our fridge- so these were "GFCF"-gluten free casein free) and let me tell you, they were scrumptious! And not, "wow, that's really good FOR GLUTEN-FREE", but actually delicious, in and of themselves! They had an almost sugar cookie flavor (perhaps some almond extract?) taste, and a moist, delicious, cup-cake texture. No grit!

After that success, last night I purchased a box of the pancake mix from the same maker, and voila- this morning's feast! Forget butter and syrup when you've got cool whip and fresh strawberries. We all wolfed down round one, and went back for second helpings. I showed a bit of restraint and grabbed this picture before finishing my second one...

For the record, I'm sure there are many new GF mixes and products that are delicious. We like the Betty Crocker GF Brownie mix, for example. But we've also tried a bunch that have flopped, so I wanted to share this latest success story for the ONE in ONE HUNDRED Americans who have celiac disease.

BOTTOM LINE: Gluten-free does not mean giving up all your favorite foods (especially breakfast)- try some new GF recipes, mixes, and products and share with me the ones you love!