DrDesChat : Naturopath Burnaby & Virtual BC

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Gluten revealed. Deciphering the confusion.

Co-authored with Dr Kate Whimster, ND

Gluten awareness has greatly increased in the last decade.  This has come with great progress for individuals who must live gluten-free.  The number of individuals going gluten free has increased.  Not all of them who have chosen to go gluten-free are celiac, so what’s the rational?  There are more reactions to gluten then that of the most known celiac diagnosis.  An emphasis on celiac and the symptoms associated with it as well as different types of gluten reaction will be explored.

In a past article, we discussed the difference between food sensitivity, allergy and intolerance.  I highly recommend you review that article prior to reading this one.  Despite my best effort to avoid technical terms.  Some of the concepts of this article build on that article.

What do anemia, diarrhea, constipation, hypothyroidism, osteoporosis and a type 1 diabetes trigger have in common?  They can all be signs or symptoms of some type of reaction to gluten.  Over 100 symptoms have been to varying degrees associated with gluten.  This is why this topic is vast and confusing.

What is gluten?

Gluten is a protein found in all types of barley, rye, wheat and spelt.  An acronym to help you remember is B.R.O.W.S: Barley, Rye, Oats (debatable), Wheat and Spelt.  Oatmeal is sometimes included due to risk of contamination.  It is often farmed, transported and/or package in factories that also have gluten containing grains.  A recent study suggest most individuals with celiac can tolerate uncontaminated oats well (Kemppainen et al, 2007).  Extra precaution can be taken by purchasing Gluten-Free Oats which means careful attention to potential contamination has been considered. An example of this is Bob’s Red Mill Gluten-Free Oats.

3 types of Gluten reactions.

Celiac Disease is an autoimmune condition against the cells of the small intestine triggered by the ingestion of gluten containing grains.  Celiac disease is the best understood gluten reaction.

One in every 133 healthy people have celiac disease.  In individuals with typical celiac symptoms 1 in 56 people have celiac disease.  In people with a family history of celiac disease 1 in 22-39 have celiac disease. Sixty percent of children and 41% of adults diagnosed during the study had no symptoms (Fasano et al., 2003).

The average length of time it takes for a symptomatic person to be diagnosed with celiac disease in the US is four years; this type of delay dramatically increases an individual’s risk of developing autoimmune disorders, neurological problems, osteoporosis and even cancer (Green et al., 2005).

Celiac disease is associated with greater risk of additional autoimmune conditions.  The more delayed the diagnosis the greater the risk.  Those diagnosed with celiac disease between 2-4 years of age had a 10.5% chance of developing an autoimmune disorder. This incrementally increased by age of diagnosis.  Those diagnosed at the age of 20 years or older had a 34% chance of developing an autoimmune disorder.  Additional findings show that the later one is diagnosed, the more likely he or she is to develop an autoimmune condition (Ventura, 1999).

The difficulty with celiac is that symptoms can greatly vary from typical GI symptoms to an atypical form that presents with no gastrointestinal symptoms (Sanders, 2005).

Individuals diagnosed with Celiac’s must follow a strict gluten-free diet to avoid the autoimmune destruction of there small intestine and the consequential immune and metabolic consequences. The first step to celiac diagnosis involves an in office blood test.  If positive a colonoscopy of the small intestine may be performed to visualize the current damage.

 

Wheat Allergy is an IgE antibody mediated immune response to gluten.

These are your typical food allergy type reactions.  They can vary from mild itchy skin, swollen eyes to potentially life threatening difficulty breathing.  What is intriguing about this food allergy is that in some individuals with a wheat allergy, consuming wheat prior to exercise can induce anaphylaxis reaction.  Following a gluten-free diet is required.

Gluten Sensitivity is defined as every other reaction to gluten.

The definition of gluten sensitivity is broader than the definition described in my article food sensitivity, allergy and intolerance.   The simplest definition is all reactions triggered by gluten exposure and alleviated by gluten withdrawal.  The difficulty with the research on gluten sensitivity is that the symptoms are not very predictable.  Some, individuals with gluten sensitivity can experience mild to severe digestive complaints to no digestive symptoms at all. Others experience fatigue, migraines and the list goes on.  If it doesn’t always look the same how can you diagnose it?  It is a diagnosis of exclusion.  When celiac and Wheat allergy have been ruled out and an evident reaction to gluten is seen, it is labeled gluten sensitivity.  Despite it not being associated with the same risks of a celiac diagnosis, symptoms can be quite severe and debilitating.

What is it about gluten that it can be so ruinous for so many people?

“Possibly, the introduction of gluten-containing grains, which occurred about 10,000 years ago with the advent of agriculture, represented a “mistake of evolution” that created the conditions for human diseases related to gluten exposure…. a number of in vitro studies have confirmed the cytotoxicity of gluten’s main antigen, gliadin (Sapone, 2011).”

The truth is we don’t really know.  We are simply realizing that many individuals are adversely affected by gluten in different ways.  It’s really hard to know why our body seems to react to this protein differently… it just seems that in a great proportion of us it does.

What’s the bottom line?

  • If you suspect you may be having a negative reaction to gluten in your diet never eliminate it until you have had a proper work up.  I can perform a quick in office celiac test that will indicate if you have some of the blood markers for celiac.  If you eliminate gluten from your diet the test is no longer valid.
  • Once you have ruled out celiac, a strategic elimination and challenge diet can help assess the influence it has on your health.
  • Do you tolerate gluten well?  There may be no need to go gluten free although I still recommend exploring non-gluten containing grains to increase variety in your diet.
  • For more details visit the 4R GI restoration program.  Strategically and carefully understanding if foods may or may not be contributing to your symptoms is essential to the path of optimizing your health.
  • Here is a gluten free resource guide.

Do you have a story to share relating to gluten?  Please comment below.

 

References:

Fasano et al. Prevalence of celiac disease in at-risk and not-at-risk groups in the United States: a large multicenter study. Arch Intern Med (2003) vol. 163 (3) pp. 286-92

Feighery. Fortnightly review: coeliac disease. BMJ (1999) vol. 319 (7204) pp. 236-9

Green et al. Mechanisms underlying celiac disease and its neurologic manifestations. Cell Mol Life Sci (2005) vol. 62 (7-8) pp. 791-9

Green PHR et al. Characteristics of adult celiac disease in the USA: results of a national survey. Am J Gastroenterol (2001) vol. 96 (1) pp. 126-31

Hadjivassiliou et al. Gluten sensitivity: from gut to brain. Lancet Neurol (2010) vol. 9 (3) pp. 318-30

Kemppainen et al. No observed local immunological response at cell level after five years of oats in adult coeliac disease. Scand J Gastroenterol (2007) vol. 42 (1) pp. 54-9

PubMed Health. Celiac Disease- Sprue. (2010).

Sanders et al. Antibody negative coeliac disease presenting in elderly people–an easily missed diagnosis. BMJ (2005) vol. 330 (7494) pp. 775-6

Sapone et al. Divergence of gut permeability and mucosal immune gene expression in two gluten-associated conditions: celiac disease and gluten sensitivity. BMC Med (2011) vol. 9 pp. 23

Ventura et al. Duration of exposure to gluten and risk for autoimmune disorders in patients with celiac disease. SIGEP Study Group for Autoimmune Disorders in Celiac Disease. Gastroenterology (1999) vol. 117 (2) pp. 297-303

Image Credit: Henry Gavamaro

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Food sensitivity, food allergy or food intolerance? Is it making you sick?

Food sensitivity, food allergy and food intolerance are often used interchangeably.  Should they be?  I’d like to suggest that they are very distinct and deserve to be addressed as such.  In addition, once you realize the simplicity of their differences you’ll have a significantly better understanding of the processes that are affecting you.  In order to clarify these differences let’s first review some  basic definitions used to describe some of the functions of the immune and digestive system.

Antibodies: It is a large Y-shaped protein produced by the immune system.  Its job is to recognize foreign protein and then neutralize it.  It’s what happens when you get a cold, the bacteria or virus is recognized and then neutralized by antibodies.

Enzymes:  In simple terms enzymes help breakdown things.  The important thing to note is that enzymes are very specific for what they break down. Therefore, your body has thousands of different enzymes in your body to efficiently break down very specific compounds.  Without the enzyme the process may not occur at all or at a very reduced rate. In the digestive system, enzymes help break down food into smaller units.

Both food allergy and food sensitivity are antibody mediated reactions against food.  The antibody recognizes a food protein as harmful and tries to neutralize it.  If this is similar then what is different?

We have different types of antibodies in our body.  Different types of antibodies react differently to neutralize the foreign invader.

Food allergy

Food allergy is mediated by an antibody called IgE.  When this type of antibody reacts with a foreign protein it immediately elicits some of of the following typical reactions.  Food allergy reactions can vary from uncomfortable to life threatening.  Skin irritation, redness, swelling are often seen.  Difficulty breathing can be ominous and represents tightening of the air passageway.  Other symptoms such as hoarseness of voice, stuffy and runny nose, itchy and red eyes as well as nausea and vomiting can been seen with food allergies.

Food sensitivity

Food sensitivity is mediated by an antibody called IgG.  IgG antibodies react very differently from IgE.  In food sensitivities, when IgG antibody react with a foreign protein, it elicits a milder, slower and non typical reaction.  The reactions vary from migraines, to increased behavioural difficulties in children with ADHD, to chronic digestive concerns, decreases in energy and other vague symptoms.  Here’s the killer news.  Unlike a food allergy, food sensitivities are very hard to diagnose.  This is because their impacts can be seen 24 to 48 hours after the ingestion of the offending food.  There are two ways that can help identify food sensitivities one is a strategic hypoallergenic diet.  The other is an IgG food sensitivity blood test.  This tests how reactive your IgG antibodies are against various foods.  The higher the reactivity the higher likelihood a food sensitivity might be present.  This test isn’t perfect but can really be a good starting point in assessing potential food sensitivity.

Food allergy & Food sensitivity:  How they react differently.  

Here’s a diagram to simplify their difference.  Imagine the pink line represents the symptom threshold- when you cross this line you have symptoms.  The star represents the ingestion of the allergic food item.

Food allergy and IgE

With a food allergy, as soon as the offending food is ingested the IgE levels rise and react quickly.  The allergic symptom threshold is always reached. Avoidance of this offending food is necessary as it can be life threatening.  The levels of IgE will also drop relatively quickly and within  5-7 days you typically no longer have any symptoms.

Food sensitivity and IgG 

With food sensitivity, the offending food is ingested and the IgG antibody levels rise slowly and linger around for up to 3 weeks.  This is what makes a food sensitivity so hard to diagnose.  You first ingest the offending food sensitivity and you are symptom free.  This is because you are still far from your symptomatic threshold.  In a few days, you ingest this same food item and again no symptoms.  What you don’t know is that your IgG antibody levels have accumulated with those of your last exposure.  Third time is a charm,  you ingest the food sensitivity and this time you get “fill in the symptom blank”: a migraine, constipation, weight gain, water retention, dermatological outbreak, general fatigue etc.  Please note in this example I used 3 days but this is for illustrative purposes and is not literal.   It’s confusing.   The symptoms don’t appear immediately, it is hard to link exposure to symptoms and you are left non strategically removing and adding foods hoping something will change.  This can be a frustrating way to figure things out.  Unlike an IgE food allergy were every single exposure is followed by symptoms, IgG food sensitivities depends on frequency and dose of the exposure.

Food intolerance

Food intolerance represent an enzyme deficiency.  Our body can’t break it down and it typically causes digestive concerns.  The most infamous example is that of a lactase enzyme deficiency.  This enzyme is important in breaking down lactose found in dairy products.  The lack of this enzymes results in gas, diarrhea and discomfort.

I work with many individuals strategically to figure out potential food sensitivity reactions.  The goal isn’t to eliminate a food for the rest of your life although significant avoidance for a period of time is sometimes necessary.  Following the 4R GI restoration program we can in most cases improve the integrity of the gut lining so that you can once again tolerate the offending food.  The reality is when you figure out what’s bugging you and you understand the symptoms it generously provides it makes avoiding it much easier.

PS:  If you learned a thing or two please share this article via facebook, retweet, or google+ it. If you would like future articles delivered into your email box sign up for email updates on your right.

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What you need to know when choosing your sunscreen

What we know for sure about sunscreen

  • It is really good at preventing the dreaded sunburn when applied adequately.
  • Decreases the appearance of sun spots also known as solar keratosis.

What we think we know

What confuses the heck out of us

  • Some studies report higher incidence while other studies report a lower incidence of the deadliest form of skin cancer, malignant melanoma, among frequent users of sunscreen.  This is likely due to increasing exposure to UVA despite adequate UVB sunscreen protection.
  • It’s easy to be confused when the experts contradict each other.

The American Medical Association recommends 10 minutes of unprotected daily sun exposure for vitamin D production.

The American Academy of Dermatology states “there is no scientifically validated, safe threshold level of UV exposure from the sun that allows for maximal vitamin D synthesis without increasing skin cancer risk”

 

What you can do about it

The best protection is physical protection such as protective clothing, hats and sunglasses which protect you from the harmful impact of ultraviolet-A rays on your skin without any harmful chemicals. Staying out of the sun during peak times and looking for a shady environment is also key to your safest defense. Sunscreen should only be considered when doing the previous is unavoidable. The environmental working group recommends mineral cream based sunscreens containing zinc or  titanium dioxide as they have very little skin penetration.  If mineral based sunscreen cannot be used avobenzone or mexoryl Sx seem like the next safest bet.

Sunscreens to avoid

  • Oxybenzone:  Found in 60% of sunscreens.  It is known to penetrate the skin, it is really absorbent and a potential hormone disruptor.
  • Vitamin A (retinyl palmitate): Preliminary but replicable research has shown it to be photocarcinogenic- carcinogenic once exposed to ultraviolet light. Vitamin A is found in over 41% of all sunscreens on the market despite these findings.
  • Sprays and powders should be avoided due to a concern of lung inflammation when inhaled.

Check out how your sunscreen measures up at the environmental working group sunscreen database, an iphone app is also available.

 

Image Credit: Bernhard Aichinger

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The best weight loss: A Head to head diet dissection

There are numerous diet plans out there, all touting to be the best.   Some are better than others but how do you decipher this information?  Lists that rank and discuss pros and cons of the most common commercial diets are available and always subject to the authors’ biases.  Beyond all the marketing of slender figures there are some less sexy, black and white documents found in the databases of PubMed that have looked at this clinical question objectively.

Background 101: How to dissect a commercial diet for weight loss.

  1. By the ratio of fat, protein and carbohydrate.  Let’s call this Macronutrient proportions.
  2. By the amount of caloric restriction.
  3. By its impact on health risk factors.

In order to dissect a diet plan you need to assess it for these 3 main characteristics.  First, understanding the recommended proportions of macronutrients, is it low carb, low fat/high carb or some other perfect mix.  Secondly, understand the caloric restriction expected.  What was this number based upon; will exercise be encouraged or discouraged?  Thirdly, what are the beneficial or detrimental side effects this diet will so generously provide.  One must also understand the importance of visiting clinics like Sarasota Weight Loss Clinic for the desired results. Finally, ask yourself, is weight loss the bottom-line or are things like life expectancy worth taking a look at too?

Numéro un: Macronutrient proportions head to head

  • Low carb diet: The low-carbohydrate, non–restricted-calorie diet was based on the Atkin’s Diet
  • High carb/low fat diet: The low-fat, restricted-calorie diet was based on the American Heart Association guidelines.
  • Mediterranean diet: The moderate-fat, restricted-calorie, Mediterranean diet is rich in vegetables and low in red meat, with poultry and fish replacing beef and lamb.

The major difference in most diets are the way in which they may emphasize or de-emphasizes certain macronutrient groups.  To analyze the diet you want to embark on you must understand their rational, if any, for they’re magical weight loss secret.

When these 3 diets were put head to head in a controlled study setting here were the results.  The fastest amount of weight loss occurred in the first six months of this 2-year trial for all diet types.  At six months the low-carb diet (Atkin’s) showed the most significant weight loss.  At the end of the trial, 2 years later, the Mediterranean diet and the Atkin’s diet demonstrated equal average weight loss of 4.4kg and 4.5kg respectively.  These results highlighting that despite Atkin’s initial greater weight loss at 6 months these were not sustained and greater regain was found within the 2 years.  The low fat-diet demonstrated inferior weight loss throughout the 2-year period with an average 2.9kg of weight loss (Trichopoulou et al., 2007).

Another well-designed 2-year study echoed similar results:

“Reduced-calorie diets result in clinically meaningful weight loss regardless of which macronutrients they emphasize (Sacks et al., 2009).”

Bottom line:  Short-term Atkin’s does appear to have greater weight loss success that is quickly overshadowed by a faster regain in the following months.  In the long-term, the Mediterranean and the Atkin’s diet seem equivocal as far as weight loss is concerned.

Numéro deux: Caloric restriction head to head

  • Very low cal diet: <800 kcal/day ie. HCG Diet, fasting, liquid diets
  • Low cal diet: 800-1350 kcal/day ie. Dr Bernstein, weight watcher’s

Do you want the quickest way to weight loss?  You may have found it. At less than 800 calories a day you might as well call it a prolonged fast.  At the end of 6 months the very low calorie diet lost 16.1 % of their body weight in comparison to 9.7% for the low calorie diet groups (Tsai and Wadden, 2006).

Yes, there it is.  If you are looking for a quick short-term solution this may be your best bet.  If you are looking for long-term success, not so much.  The individuals in the very low calorie diet were the quickest to regain the weight and no difference in weight was seen between the low cal diet and the very low cal diet at 1 year.

At the end of the day it appears compliance and caloric restriction are greater determinants to long-term weight loss than macronutrient composition of the diet.

Feel free to check out the references here.

Unimpressed with the study results so far?  I know the results are far from exciting and definitely less interesting than the models plastered in the diet advertisements.  My next article will discuss numéro trois, selecting a diet based on its impact on health risk factors among other things.

What has your experience been on commercial diet?  Care to share some pros and cons?

Image credit: Rob Owen-Wahl

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What does choosing a dog and choosing a probiotic have in common?

In the last few decades, research on probiotics has grown exponentially. Our understanding of how they can influence our gut health as well as how they influence seemingly unrelated systems such as the immune system has been greatly refined. Unfortunately, as research creates buzz, so does the marketing world and our shelves are popping up with probiotic labels everywhere. Now, we have a dilemma- how to decide which probiotics give you the bang for your buck. This current article builds on my last article explaining some of the research and the benefits of probiotics. If you haven’t read it you can check it out here.
Are all probiotics created equal?

Saying I take probiotics is as vague as saying I take vitamins. Just as different vitamins play differing roles in the body, we also know that different probiotics with different genus, species and strains do not have the same effects.
If you currently take probiotics take a look at the label now.

What do you see? Can you find the Genus, species and strain of the probiotic?

Some of the lower quality probiotics only specify the genus and species and not the strain. This is because identifying strains take an additional level of evaluation. This step however is proving to be extremely important as we are learning that probiotics with the same genus and species but different strain can play different roles in your health and do not all confer the same benefits.

To conceptualize, consider that all dogs have the same genus and species- Canis lupus. Within this genus and species we have various types of dog breeds. Visually it is evident that different breeds have very different characteristics. For example, some are great hunter dogs others are better sled dogs while some are hypoallergenic dogs. Having a probiotic that doesn’t specify strain is like looking for a hunting dog but blindly buying a dog without knowing the breed.

If you own a dog you very likely chose a specific breed of dog to suit your lifestyle. In the same way, there may be a specific probiotic strain that is indicated for the outcome you are looking for.

Take home message: Top 5 things to know before choosing your probiotic

1. Know your probiotic strain

Look for a known probiotic strain that has been tested in humans and known to confer the specific outcome you are looking for.

2. Know the colony forming unit (CFU)

CFU indicates the amount of live microbes in the supplement. Recommending a dose is very difficult as it depends on the probiotic strain and the outcome you are looking for. Doses range from 50 million to 1 trillion CFU a day.

3. Know the probiotic strain’s tolerability to digestion.

Digestion provides a rough journey for some of these living microbes. Some strains are tough naturally and others aren’t. Has the strain you are taking been studied to assess its tolerability to the gastric acid of your stomach, the bile salts of your gallbladder and the digestives enzymes of your pancreas? Some strains are tolerant; some are not. The ones that aren’t need to be formulated in capsule that will only dissolve in the lower gastrointestinal track.

4. Know your manufacturer: 3 questions to ask.

Does this manufacturer ensure that strain-identification has been done, a process that ensures you have the strain of probiotic you are looking for?  Is the manufacturer diligent about the entire process ensuring that if a probiotic needs to be refrigerated it is from the moment it leaves their hands, through shipment and until the time it gets to your home?  Have they studied the probiotic to ensure it has a stable shelf life until expiry?

5. Are you having a double rainbow “what does it mean” moment?

I know, I’m sorry but it was a bit of the point of this article. I see so many patients taking probiotics but they have no idea what strain or for what outcome. Next time you see the word probiotic I hope you can see through some of the hype of what might be good marketing versus some of the benefits the best of science has to offer today. For overall intestinal and systemic health, the most basic recommendation in adults would be the periodic use of 15-30 billion of Lactobacillus acidophilus NCFM® (talk to your primary care giver). This strain was first isolated from the human gut and has been well researched. It is known to have digestive tolerability and been shown to adhere to the human intestinal wall. It is one of the most common probiotics in the gut and one with a very good safety record. There are over 6o studies on this specific strain demonstrating various beneficial outcomes for certain conditions.
Are you looking for specific outcomes, do you have irritable bowel syndrome or disease? If so, talking to someone who is well versed in the different strains of probiotics can get you inline with the research ensuring it has the best chance at improving the outcomes you are looking for.
If you would like more info, the International Scientific Association for Probiotics and Prebiotics (ISAPP) has been created to demystify some of complexities of this ever growing and expanding body of research. Hope you’ll have a more critical eye next time you see the word probiotic.

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