Tuesday, January 6, 2015

Gluten Freedom: my thoughts on the book

I just finished reading Dr. Alessio Fasano's book, Gluten Freedom, and it is amazing!  Definitely a must-read for any clinician who works with patients suffering from digestive, dermatological, neurological conditions or for anyone who is a patient and thinks they might have a gluten-related condition.  It is especially helpful for anyone whose doctor has ever said "it's all in your head"!


The leading expert in gluten-related disorders, Dr. Fasano tells the history of celiac disease, explains the improvements in diagnostic methods throughout the years, and also covers the spectrum of non-celiac, gluten-related disorders, including wheat allergy (think hives and difficulty breathing) and the more recently accepted non-celiac gluten sensitivity (NCGS) - which is a real condition!  He uses friendly analogies to explain scientific concepts and includes multiple real-patient stories to help illustrate key points, both of which make the book fun and easy to read.

I read the book Wheat Belly last fall and, although I enjoyed the facts Dr. William Davis provided, I didn't agree with his point of view that everyone should avoid high-yield, semidwarf wheat.  Indeed, there are scientist who believe that gluten is toxic for humankind and everyone should follow a gluten-free diet. While there is some evidence to support this -- for example, it is true that no one is able to completely digest the protein gluten and that that fragments of undigested gluten peptides can make the intestines leak, attract immune cells into the intestines causing inflammation, or kill cells -- it doesn't make sense that a food that humans have been eating for thousands of years is the root of all disease.

Zonulin and Its Regulation of Intestinal Barrier Function:
The Biological Door to Inflammation, Autoimmunity, and Cancer

Read the study here

Although Dr. Fasano has contributed to the above discoveries about gluten, he does not share the same position.  Instead, he writes that "we engage daily in a ware with many dangerous bacteria but rarely do we lose this battle, which is an event that leads to infection.  We are also engaged in daily confrontation with gluten, but only a minority of us will lose this battle.  These are the genetically susceptible individuals who will develop gluten-related disorders."

My own beliefs align more closely with those of Dr. Fasano, that only genetically susceptible individuals need to follow a gluten-free diet.  Instead of silver bullets and one-size-fits-all approaches, it is my opinion that practicing personalized medicine is the best way to help clients achieve health.  How do you know if you need to follow a gluten-free diet?  Learn more here!

Perhaps my favorite part of the book is near the end when Dr. Fasano gives an overview of the human genome project ("genomics") - how many scientists thought that cracking the code would help us better understand and eradicate human disease...until we realized that humans actually have way fewer genes than originally expected...so we focused on "proteomics," which also failed to answer our complex questions about health.... so we eventually turned to "microbiomics."

Ultimately, he hypothesizes that humankind is made up of two genomes - the human genome and our individual microbiome, which is expressed by the trillion of bacteria that live on and in us.  He advocates for vaginal birth (the best way to inoculate baby with a healthy dose of probiotics) and concludes by saying "In my opinion, the result of this interplay between the human genome and the human microbiome ultimately holds the key to the answer of how to maintain the yin and yang between health and disease."

Check out this NPR story - Finally, a map of all the microbes on your body
It is obvious that Dr. Fasano has spent his life dedicated to "increasing the awareness of celiac disease in order to provide better care, better quality of life, and more adequate support for the celiac disease community," -- the paramount goal of the Center for Celiac Research, which he founded in 1996.  When treating his first patients, Dr. Fasano asked them to write down their top three wishes in regard to celiac disease.  Here are the "Aladdin's lamp" wishes:
  1. A treatment alternative to the gluten-free diet
  2. Improving their quality of life by educating physicians about celiac disease and by providing more palatable gluten-free food
  3. A way to avoid the cumbersome intestinal biopsy as a necessary step to diagnose celiac disease, especial for children.
Nearly 20 years later, almost all three wishes have been granted.

This book inspires me to finally choose ONE thing to focus on and become an expert at something, just as Dr. Fasano has become an expert on celiac disease and gluten-related disorders.  It also reminds me how much I love the mystery of the gut - this black box where food goes in one end, waste comes out the other, and exactly what happens in between is largely unknown.  If I had to bet, I would bet that the next big discovery in health and medicine has to do with the microbiome.  I just hope that I can be a part of it!

Should I follow a Gluten Free diet?

There is currently a lot of confusion around gluten.  Due to increasing availability of gluten-free products as well as coverage in the media, more and more people are choosing to follow a "gluten-free" diet.  What amazes (and worries) me is that some folks adopt this diet without even knowing what gluten is!


What is gluten?
Gluten is the general name for proteins, gliadin and glutenin, found in the cereal grains wheat, rye, barley and triticale that makes bread dough elastic enough to rise, giving it that light and fluffy texture (read more here).

This picture came from grist.org (follow link above)

Who should avoid gluten? 
People who have celiac disease, an autoimmune disorder that affects approximately 1 in 100 people, must avoid gluten because ingestion of gluten leads to damage in the small intestine.  Left untreated, celiac disease can cause serious health problems such as vitamin and mineral deficiencies (including anemia), early onset osteoporosis, infertility, and gastrointestinal cancers (read more about celiac disease at The Celiac Disease Foundation).  Until new treatments are approved (e.g. Lazarotide acetate), people diagnosed with celiac disease must follow a gluten-free diet to remain healthy.

What about the other 99%?
Although many people claim to feel better when they follow a gluten-free diet, the scientific community is still conflicted as to whether individuals without celiac disease might benefit from a gluten free diet.

Some scientists, like Dr. William Davis, believe that gluten is toxic for humankind and everyone should follow a gluten-free diet.  There is some evidence to support this.  For example, it is true that no one is able to completely digest gluten.  It is also true that fragments of undigested gluten peptides can make the intestines leak, attract immune cells into the intestine causing inflammation, or kill cells.

Zonulin and Its Regulation of Intestinal Barrier Function:
The Biological Door to Inflammation, Autoimmunity, and Cancer

Read the study here

However, according to Dr. Alessio Fasano, the leading expert in gluten-related disorders, "we engage daily in a war with many dangerous bacteria but rarely do we lose this battle, which is an event that leads to infection.  We are also engaged in daily confrontation with gluten, but only a minority of us will lose this battle.  These are the genetically susceptible individuals who will develop gluten-related disorders."

Who are these genetically susceptible individuals?
In addition to celiac disease, there exist spectrum of non-celiac, gluten-related disorders, including well-known wheat allergy (think hives and difficulty breathing) and the more recently accepted non-celiac gluten sensitivity (NCGS) - which is a real condition!

How do I know if I have gluten sensitivity?
While there are several diagnostic tests for celiac disease -- including elevated levels of tissue transglutaminase (tTG), the presence of genetic markers HLA-DQ2 or -DQ8 and, of course, the "gold standard" intestinal biopsy -- a biomarker for gluten sensitivity has not yet been found.  However, researchers at the Center for Celiac Research are working hard to identify one!  I am excited for this!  Once a biological marker is discovered, we will be able to measure levels in the body, making it much easier to figure out whether or not insidious symptoms like gas, bloating, muscle aches and brain fog are being caused by gluten!

What the heck are FODMAPS?
The tricky thing is that sometimes gastrointestinal (GI) distress is caused by the ingestion of Fermentable Oligosaccharadies, Disaccharides, Monosaccharides, Polyols and Sugars (FODMAPS) - all which draw water into the intestines (diarrhea) and feed colonic baceteria (gas and bloating).  While gluten-containing products are on the list of FODMAPS, there are many other foods that may be contributing to GI discomfort if you have a FODMAPS intolerance.  This is a new area of research, but I do my best to explain it here (link coming soon!).

Which condition do I have?
The best way to determine if a gluten-free diet is appropriate for you is to see your doctor or dietitian nutritionist.  Before you change your diet, it is imperative to get tested to rule out celiac disease.  Once you stop eating gluten, your body no longer produces the biomarkers (i.e. tTG, villous atrophy) needed to diagnose the disease.  If your doctor is not up-to-date on the latest gluten-related research, recommend that he or she read the book Gluten Freedom by Dr. Alessio Fasano and/or the book released by The Mayo Clinic this past November called Mayo Clinic Going Gluten Free, which provides the checklist* for diagnosing non-celiac gluten sensitivity.
*checklist available in New York Times article, here

My own beliefs align more closely with those of Dr. Fasano, that only genetically susceptible individuals need to follow a gluten-free diet.  Instead of silver bullets and one-size-fits-all approaches, it is my opinion that practicing personalized medicine - which considered genetics (fixed), microbiomics (modifiable) and environmental factors (culture) - is the best way to help clients achieve health.


I just finished reading Dr. Fasano's book, Gluten Freedom, and it is amazing!  Read my review here.

Saturday, December 20, 2014

Everyone (secretly) loves healthy food...because the body (intuitively) craves it

I went to Girl's Night this week.  The instruction was to bring something festive (wine, cheese, or a delicious baked good) that started with the letter of your first name.  As people began to reply with sweet and indulgent holiday treats, I started to worry.  At that time of the day (7pm), I knew that I would be hungry for food, not (just) candy and desserts.  So I opted to bring an Arugula Salad (A for Adair!), for balance.

I had planned to do something homemade but ran out of time, having packed my schedule a little too tight.  So I stopped by Trader Joe's and found everything I needed to assemble a delectable salad.


Ingredients

  • 1 bag wild arugula
  • 1/2 package pre-cooked lentils
  • 1 package pre-cooked baby beets, sliced
  • 4oz feta cheese, crumbled (I buy the 8oz block of feta because it costs less per oz than the 6oz container of pre-crumbled feta)
  • 1 cup walnuts
  • Balsamic vinaigrette dressing, to taste
Instructions
  1. Combine arugula, lentils, beets, feta and walnuts to large bowl.
  2. Add dressing, to taste.  I like to start with a small amount of dressing, toss the salad, taste the salad, and then add more as needed.  This way, I never end up with an over-dressed salad.


Back to Girl's Night.  As expected, the table was spread with caramel corn, peanut brittle, chocolate cookies, gluten-free rice crackers with apple-glazed goat cheese and other carbohydrate-loaded sweets.  When I added my healthy salad to the collection of goodies on the table, not only did it look delicious, but it disappeared within 10 minutes!

My conclusion: even though we talk about indulging in (and may fantasize about) eating sweets and candy, everyone intuitively craves healthy food!

Wednesday, December 10, 2014

Theranos: get labwork done quicker, cheaper, and without needles!

How do you feel about getting blood drawn?  Do you faint at the sight of needles?  Does the cost of laboratory tests make you gasp in disbelief?  Are you a fellow dietitian-nutritionist who is unable to order bloodwork and must wait, instead, for clients to visit their doctors to obtain nutrition-related diagnostic tests (e.g. vitamin D, B12, ferritin)?  What if I told you that a faster, cheaper and less painful lab test is available?

Allow me to introduce you to Theranos,  Theranos is a privately held company that is revolutionizing the way we do blood tests in America.  They take only a small amount of blood, the quantity obtained from a finger prick, and use it to run multiple tests for a cost 50-90% less than the cost of medicare reimbursement rates*.  All of this is done within a couple of hours at your local Walgreens!

*Vitamin D: Theranos $20.35 vs. Medicare $40.70

from: http://www.theranos.com/our-technology
The traditional method of laboratory testing is to have a nurse stick a needle in your arm and take several vials of blood, usually one for each test, which are then sent off to a laboratory to be tested.  Patients do not usually get the results until a week later.

Theranos was started by Elizabeth Holmes in the fall of 2003 when she was a 19 year old sophomore at Stanford University.  I love this quote from Fortune Magazine's article "This CEO is out for blood."  When her professor asked her why she wanted to start a blood analytics company she replied "Because systems like this could completely revolutionize how effective health care is delivered.  And this is what I want to do.  I don't want to make incremental change in some technology in my life.  I want to create a whole new technology, and one that is aimed at helping humanity at all levels regardless of geography or ethnicity or age or gender."  Elizabeth Holmes is like the Steve Jobs of the health care field.  She is also the youngest self-made woman billionaire on the Forbes 400 list.

But the money isn't what I am most impressed by.  What I appreciate most is Elizabeth Holmes's vision for the future - where patients can purchase lab tests whenever they need them and gain access to actionable health information in a timely manner.  She states in her TedMed talk that "Laboratory information drives 70-80% of medical decisions," but that "disease begins before signs and symptoms appear."  There are many Americans who have pre-diabetes but don't even know it!  When patients are able to engage with information about themselves, it can motivate them to make the diet and lifestyle changes needed to improve health.  I su increased understanding and adherence.  This is what personalized medicine is all about!  Theranos may actually redefine the paradigm of diagnosis.

Unfortunately, Theranos Wellness Centers are currently only located in Palo Alto, CA and Pheonix, AZ according to the searchable map, but they claim that Theranos Wellness Centers will soon be located within Walgreens stores nationwide.  I just sent an email to Theranos asking when they will reach the Washington, DC metro area.  I will provide an update once I receive a reply.

Thursday, December 4, 2014

Should I get my Vitamin D level tested?

This week I attended a Conference on vitamin D hosted by the National Institutes of Health.

While I did not see President Obama (who was on campus Tuesday 12/2 to praise the NIH for its vaccine and treatment research on Ebola), I did see all the big names in vitamin D research, including Micahel Holick and Robert Heaney (speaker bios here).

My expectation going into the conference was to learn the BLACK and WHITE facts to share with clients and colleagues.  What I actually learned is that the science of vitamin D is a lot GREYER than I originally thought!  The conclusion of the conference was "we don't know."

Seriously.

This topic is important, yet the experts seem unable to come to consensus about when, who, and how much to treat.

In the U.S. Preventive Service Task Force (USPSTF) statement published last month, they wrote that "No consensus exists on the definition of vitamin D deficiency or the optimal level of total serum 25-hydroxyvitamin D [25-(OH)-D] (the major form of vitamin D that circulates in the body).  Depending on which cut point is used (usually less than 20 ng/mL or 30 ng/mL) some studies have shown that lower levels of vitamin D are associated with increased risk for fractures, functional limitations, cancer, diabetes, cardiovascular disease, depression and death."

First of all, the definition of deficiency is controversial.
  • The U.S. Institute of Medicine (IOM) report from 2010 stated that "almost all individuals get sufficient vitamin D when their blood levels are at or above 20 ng/mL."
  • One year later, The Endocrine Society released clinical guidelines, defining vitamin D deficiency as less than 20 ng/mL and insufficiency as 21-29 ng/mL.
  • At the conference, I heard Michael Holick say that less than 30 ng/mL is deficient, 40-60 ng/mL is preffered and that up to 100 ng/mL is safe.  This is echoed in his book The Vitamin D Solution.
In addition to varied expert opinion, there exist many uncertainties which confound the investigative process.

Labwork - depending on the detection method used, the measured value of total serum 25-(OH)-D between laboratories vary by up to 15 ng/mL - which can mean the difference between sufficiency vs. treatment!

Individual requirements - vary according to genetic polymorphisms, usually fall within a bell-shaped Gaussian distribution

Effective dosage - studies may not use a high enough supplemental dose to impact initial vitamin D status.

Initial vitamin D status - most benefit is seen when deficiency is corrected (moving from deficient to sufficient).  Without knowing what constitutes "deficient," studies working with populations who already have "sufficient" vitamin D status may not show any experimental impact and vice versa.  There is a big difference between making sick people healthy and making healthy people healthier.

Validated Intermediate endpoint - does not exist (yet?) for vitamin D

There have been 247 new studies on Vitamin D in the last five years, but none of them change the recommendations for chronic disease.  The strongest evidence in support of vitamin D supplementation is in bone health and fracture prevention, yet many family doctors are prescribing vitamin D for depression.  This is partly due to vitamin D coverage in the media, where journalists claim that vitamin D may help with a whole host of diseases.

The USPSTF's Final Recommendation Statement is that "The evidence is insufficient to assess the balance of benefits and harms of screening for vitamin D deficiency in asymptomatic adults." In other words, they do not (yet?) recommend screening the general population for vitamin D deficiency.

In the U.S. Preventive Service Task Force (USPSTF) statement published last month, they wrote that "No consensus exists on the definition of vitamin D deficiency or the optimal level of total serum 25-hydroxyvitamin D [25-(OH)-D] (the major form of vitamin D that circulates in the body).  Depending on which cut point is used (usually less than 20 ng/mL or 30 ng/mL) some studies have shown that lower levels of vitamin D are associated with increased risk for fractures, functional limitations, cancer, diabetes, cardiovascular disease, depression and death."

But that won't keep me from encouraging my clients to get their vitamin D levels tested.  Especially if they live above the 40th parallel (for reference, Washington, DC is at 38.9° N, Boston 42.3° N, Seattle 47.6° N), have darkly pigmented skin, shield their skin from the sun with sunscreen and/or clothing, spend most of their time indoors, if their diet lacks dairy products and other vitamin D-fortified foods (orange juice, energy drinks, etc), or if they are obese.

You can get vitamin D from the sun!  Your skin makes it!
One FACT I did learn is that obese individuals need to consume 2.5 to 3 times more vitamin D (through food, supplement, or sun exposure) to increase serum vitamin D levels compared to lean individuals.

As a dietitian, I can help people manage current disease but I prefer to prevent disease in the first place.  In addition to disease prevention, I also support optimum cellular function (i.e. helping you go from "good" to "great!").  That being said, here is my recommendation:

Get tested (insurance willing).  If your vitamin D is less than 30 ng/mL (75 nmol/L), you should probably try to increase your level - through food, supplementation, or sun exposure - until your vitamin D falls between 30 ng/dL and 100 ng/dL.

Updated (12/10/2014): if you visit a Theranos Wellness Center, the cost of a vitamin D test is only 20.35.  Read more here.