Celiac Disease, Gluten Free, and Digestive Health Advice
In order to support celiac disease research and advocacy the Celiac Disease Foundation is holding a virtual Turkey Trot 5K Run/Walk. On the weekend of November 14/15, get active and make a goal to walk 3.1 miles for Celiac Disease. Register for the event online for a t-shirt, bandana, gluten-free coupons, and a chance at prizes. I plan on participating to support my family and my patients.
https://donate4celiac.salsalabs.org/2020cdfturkeytrot/index.html
The current issues with the coronavirus pandemic have understandably created some questions and stress for many patients. Mixed messages from health authorities and the media can certainly create problems with confusion.
Many patients on immunosuppressant drugs are already aware that they are at higher risk of getting viral and bacterial infections due to the medications they take. This is why there are recommendations for patients on immunosuppressant drugs for digestive health conditions such as inflammatory bowel disease to practice good handwashing, to notify their physician if they are having cold or flu symptoms, and to make sure they are up-to-date on vaccinations.
The risks of doing things (taking medication) need to be weighed in the risks of doing nothing (not taking medication and having a disease flareup).
The American Gastroenterological Association he has issued guidance for patients on immunosuppressant drugs with underlying digestive problems. (Link)
The Crohn’s and Colitis Foundation is also a rational source of information. (Link)
“Patients on immunosuppressive drugs for IBD and autoimmune hepatitis should continue taking their medications. The risk of disease flare outweighs the chance of contracting coronavirus. These patients should also follow CDC guidelines for at-risk groups by avoiding crowds and limiting travel.”
In summary it is advisable to continue medication for underlying inflammatory bowel disease. The risk of having a flare-up which can cause problems such as diarrhea, bowel obstruction, GI bleeding is of greater health risk to a patient than the risk of getting an infection. If immunosuppressant medications are keeping Crohn’s and colitis under control, this decreases the odds of needing to utilize emergency rooms, urgent cares, and hospitals for patient. Avoiding these locations can help a patient decrease their odds of contracting an infection. Therefore good disease control along with the universal precautions being advised by the CDC remained the best defense for patients with inflammatory bowel disease.
I hope all of my patients stay well at this difficult time.
It’s Halloween! Costumes, Trick or Treat, and parties. As with most holidays there are natural anxieties that surround eating felt by anybody who deals with celiac disease, gluten intolerance, or food allergies. Wanting to participate in the festivities without worry is a very understandable feeling that most of my patients struggle with.
As a gastroenterologist it is very hard for me to endorse the excessive consumption of candy. (Yes, stealing my kids’ dark chocolate even gives me reflux). However during celabratory times of the year being able to enjoy some candy in moderation is not the worst health habit. My father is a dentist. Growing up on Halloween, if we gave out candy people would accuse him of “drumming up business”. Dad therefore would typically handout chips or pencils. He always made note that as long as you did not chew on Jolly ranchers and brush your teeth, your dental health would be okay on Halloween.
I wonder if I should be handing out Metamucil instead of candy for trick or treat. Maybe not the best call as this may be an invitation for Halloween “tricks” on the house. We will stick to candy.
Fortunately, the Celiac Disease Foundation has a guide on gluten free candy options. A few take home points after my review:
– Here is the link to the Gluten Free Candy List
– They make note of the importance of reading food labels. Fortunately most major manufactures are following food label guidelines.
-During busy times of the year such as Halloween, Christmas, and Easter, candy manufactures often need to increase their production. Due to this, they may use additional factories. Some of these factories result in some candies that typically are being gluten free not being gluten-free due to cross-contamination on the assembly line. For example, regular York Peppermint Patties and Reese’s Peanut Butter cups are gluten free; however the “shapes” and “minis” made around Halloween are not. This is outlined on the labels. Thus illustrating the importance of the food labeling.
Hope you all enjoy the festivities and Trick or Treat.
Currently the only known treatment for celiac disease is a gluten free diet. While the diet is highly effective, many patients with celiac disease will still experience symptoms while following a gluten free diet. Some of these issues may relate to cross contamination events; some may relate to incomplete healing of the intestine causing irritable bowel like symptoms.
Larazotide is a medication currently being researched for the treatment of persistent symptoms in the setting of celiac disease in patients following a gluten free diet. It is felt to limit the inflammation from gluten exposure by tightening the junctions between the cells that line the small intestines.
I am excited about the promise of a new therapy for celiac disease and the potential to offer options other than a gluten free diet. I am also excited that Allegiance Research Specialists has partnered with us at GI Associates to be a study site for the medication.
Details on the study may be found at www.celiac-study.com.
Allegiance can be contacted at 414-727-8131 or through their website.
As anyone diagnosed with celiac disease knows well, a gluten-free diet can present a challenges when having to avoid food with wheat, barley, and rye. Many other people without celiac may also choose to a eat gluten free diet for a variety of other health concerns. Whatever the reasons for adopting a gluten-free diet, the diet itself can present some nutritional challenges such as getting adequate dietary fiber. Because many gluten free breads and baked goods use substitute flours that have a higher than usual starch content and less dietary fiber than traditional multigrain breads or pastas, this can create issues with constipation.
Diet therapy is a very important element of managing all types of digestive diseases. Patients often ask me for dietary management options for issues such as constipation as an alternative to using medications. What I often counsel patients is to focus on choosing foods that are already naturally gluten free such as fruits and vegetables, which also happen to provide additional dietary fiber. In fact, I counsel all my patients – even those not on a gluten free diet – to eat a diet filled with fruits and vegetables. An easy way to remember is to “eat from the perimeter of the grocery store” as a general rule of thumb.
But what fruits and vegetables are the best to get additional fiber in your diet? While the usual suspects of broccoli, lentils, beets and apples are all great options, more exotic fruits can actually provide just as much fiber and digestive benefits when added into daily diet. In fact, some recent studies on constipation and irritable bowel syndrome have shown that Kiwifruit may be a natural remedy.
In 2 studies presented at the 2018 Digestive Disease Week, researchers in Italy and New Zealand, which perhaps non-coincidentally are the top two exporting countries of kiwi in the world) found that incorporation of kiwifruit into the diet could replace the use of daily medication for the management of digestive distress. In the studies, patients with irritable bowel syndrome, constipation, and healthy volunteers were given either 2 kiwi per day, or psyllium (fiber supplement) for 4 weeks. The results showed that the group ate kiwi had better results, with the researchers proposing that kiwis are comparable if not more effective than psyllium fiber supplements for constipation and irritable bowel syndrome.
So how can you incorporate more (or any) kiwi into your diet? While some people like to eat kiwis with the skin on (myself included) and it does add some additional fiber the fuzzy skin can be peeled and still have the same effect according to Prof. Giovanni Barbara, M.D., the author of one of the studies. In addition to finding them in the produce section of your favorite grocery store, many warehouse clubs such as Costco or Sam’s Club sell kiwi in bulk. Kiwis are a great addition to any fruit salad, are delicious when incorporated in a morning smoothie (try this kid-friendly kiwi, banana, avocado and spinach green smoothie), and are even great in baked goods (try this kiwi tart, but substitute the flour in the pastry recipe for your favorite gluten-free mix such as Cup for Cup or Bob’s Red Mill). And while I doubt that there would be any dietary fiber benefits of this white kiwi sangria recipe, it looks like it would be a fun addition to any party (make kid-friendly by swapping orange juice for the orange liquor and sparkling white grape juice for the wine)!
Sources
“Kiwi Fruit” by Sandra Cox, source: https://fineartamerica.com/featured/1-kiwi-fruit-sandra-cox.html
Cesare Cremon, Juliet Ansell, Isabella Pagano, Barbara Kuhn-Sherlock, Lynley Drummond, M. Raffaella Barbaro, Eleonora Capelli, Lara Bellacosa, and others. A Randomized, Controlled, Single-Blind, Cross-Over Study Assessing the Effect of Green Kiwifruit on Digestive Functions and Microbiota in Constipated Patients. Gastroenterology, Vol. 154, Issue 6, S-565–S-566 https://www.gastrojournal.org/article/S0016-5085(18)32081-X/fulltext
Giovanni Barbara, Shin Fukudo, Lynley Drummond, Barbara Kuhn-Sherlock, Juliet Ansell, Richard Gearry. Green Kiwifruit Compared to Psyllium for the Relief of Constipation and Improving Digestive Comfort in Patients with Functional Constipation and Constipation Predominant Irritable Bowel Syndrome — Analysis of Three International Trial Centres. Gastroenterology, Vol. 154, Issue 6, S-979–S-980 https://www.gastrojournal.org/article/S0016-5085(18)33288-8/fulltext
Whether you’re avoiding gluten because of celiac disease or for other reasons, here are a few tried and true tips or easy swaps to making your holiday celebrations easier and allow you to enjoy the day with family and friends
Food is an integral part of American culture and a major way how we socialize with friends and loved ones; so having a dietary restriction can add an extra layer of stress to social gatherings. Now that the holiday season is in full swing with parties and gatherings seemingly every night through the New Year, maintaining a gluten-free diet can become especially challenging. Holiday potlucks with family or at the office can especially become a minefield when you have less control of the menu or don’t know what is being served.
Whether you’re avoiding gluten because of celiac disease or for other reasons, here are a few tried and true tips or easy swaps to making your holiday celebrations easier and allow you to enjoy the day with family and friends:
Just because you’re following a gluten-free diet, doesn’t mean you can’t enjoy some holiday sweets and traditions. Many easily found store-brand hot cocoa mixes are gluten-free; Hershey’s Cocoa in the Cocoa, Special Dutch flavors are all gluten free, as are all Swiss Miss varieties. Make a mug of cocoa extra festive with a topping of whipped cream or gluten-free marshmallows (Kraft Jet-Puffed marshmallows are GF!).
And with three young kids, baking Christmas cookies are always a favorite in our house during the holiday season. My wife Katie has always been an awesome baker, and has used her skills to be an awesome gluten free baker. While Gluten free baking can be a bit challenging to adapt for family recipes, all-purpose alternative flour blends do not always translate well into those that were made for wheat based flours. In our house we enjoy the Land o Lake flour blend (see below) which we make ourselves to make Christmas cookies and treats every year; our family loves to make snickerdoodles and vanilla pound cake.
So as you see, gluten-free holiday parties can be just as merry and festive as any other! Enjoy your time with your family, and check out our favorite recipes below to help ease your way through the holiday season and into the New Year!
Have a Merry Christmas and a Happy New Year.
Bacon-Wrapped Blue Cheese Stuffed Dates
Martha Stewart Pecan-topped Baked Brie
McCormick Gluten Free 7-layer Mexican Dip
Land O Lakes Gluten Free Baking Blend
Land O Lakes Gluten Free Vanilla Poundcake Recipe
Land O Lakes Gluten Free Snickerdoodles Recipe
Sammys Homemade Gluten-Free Crackers
Preheat your over to 375 degrees. In a bowl, combine the almond flour and flax meal, salt and pepper and your chosen herbs (Italian seasoning, dill, garlic, ground black truffles all work well depending on what you want to pair the crackers with) mix well and add the water. Let this mixture sit until all of the water is absorbed. When all of the water has been absorbed, roll out little balls approximately the size of a large marble. Place these on a greased cookie sheet and cover with a piece of saran wrap. Using the bottom of a glass, press the balls down into a flat circular shape. Bake at 375 for 15 minutes or until slightly golden. Allow to cool on the sheet and place in an airtight container will keep for up to two weeks.
As a gastroenterologist I spend a lot of time performing colonoscopies. As a result, I spend a lot of time talking with patients after the procedures about things I find inside their colon. Common findings on colonoscopies include colon polyps, hemorrhoids, and diverticulosis. Multiple times a day I find myself discussing diverticulosis and trying to dispel common misconceptions about it. There is a lot of confusion about diverticulosis. “You mean I can’t eat popcorn anymore?” is something patients ask me. This is not true (see below). As somebody who loves popcorn, I would never want to deny somebody the chance to eat popcorn. Let’s discuss.
What is Diverticulosis? Diverticulosis is the presence of pockets in the colon. This is due to a weakness in the wall of the colon. This is seen in over half colonoscopies (50%) and increases with age. Estimates are that 50% of people over 50 have diverticulosis; 60%of people over 60 have diverticulosis; and 70% of people over 70 have diverticulosis. Many people with these pockets do not have symptoms or GI concerns.
What is Diverticulitis:? Diverticulitis is when 1 of the pockets becomes inflamed and infected. Only 4% of patients with diverticulosis will get diverticulitis. Even though this number is rather low, if you think about it, if half of people have diverticulosis, and 4% of people with diverticulosis eventually get diverticulitis, this means that about 2% of people will have an episode of diverticulitis sometime during their lifetime. This is why everyone seems to know at least one person who has had issues with diverticulitis. Not all attacks of diverticulitis are severe. While some may require surgery most resolve with antibiotics. (Clin Gastroenterol Hepatol. 2013;11)
Therefore:
– OSIS: Presence of the pockets. Does not mean a problem.
– ITIS: Means inflammation or infection of the pockets.
Diverticulitis typically resolves with a bland diet and antibiotics. Severe cases that result in uncontrollable abdominal pain, inability to eat, inability to pass gas or stool, or development of an abscess can require surgery and hospitalization.
There is reported higher risk of colon cancer in patients who have had diverticulitis, therefore a colonoscopy is typically advised 6–8 weeks after having an episode of diverticulitis if the patient has not had a colonoscopy in over a year. (Ann Surg. 2017;265(5):954.) It is unclear as to why this is the case. Sometimes colon cancers and diverticulitis can look similar on a CT scan.
What is symptomatic diverticular disease.? When the patient has symptoms from the narrowing caused by diverticulosis and there is no evidence of inflammation. Often causes issues with constipation and abdominal cramps. Very similar to irritable bowel syndrome.
Many patients ask: “How can I prevent problems from the pockets?”.
For patients without any symptoms, nothing really needs to be done. Healthy lifestyle advice in regards to diet, exercise, and maintaining a healthy body weight is always suggested. I often say, “If I find diverticulosis, I tell you to eat more fruits and vegetables. If I don’t find diverticulosis, I tell you to eat more fruits and vegetables.”
Smoking, obesity, lack of dietary fiber, and lack of physical activity are all associated with problems from diverticulosis.
Nuts and seeds? Everyone seems to have an elederly relative who would not eat berries or popcorn. This is based on old misconceptions and medical myth. A large medical research study showed that nuts and seeds do not cause episodes of diverticulitis. (JAMA. 2008;300(8):907) .In fact, high-fiber diets have been shown to be preventative of diverticular disease. There may be a subset of patients who have trouble with high residue foods. I typically advise patients that see a direct correlation to things like nuts and popcorn and attacks of diverticulitis to avoid these foods. If these foods are generally not a bother, there should be no restriction on the consumption of high amounts of roughage, seeds, nuts.
Eating the jumbo bucket of movie popcorn and getting sick does not mean you have diverticulitis. It means you ate way to much popcorn. Moderation in all things is best.
Fiber? Increasing dietary fiber or fiber supplementation is typically advised for patients with symptomatic diverticulosis. This is based on the fact that there is an inverse correlation between fiber intake and complications from the diverticula.
Probiotics? There is some medical evidence, albeit week evidence that probiotic supplementation may also help with symptoms from diverticular disease. (Therap Adv Gastroenterol. 2013 May; 6(3): 205–213.) If a patient has symptoms from diverticular disease I do advise trying probiotics. If a trial of probiotics for 2–4 weeks tends to help with the symptoms I advise continuing them. If the trial of probiotics does not help with the symptoms I typically advise stopping them as the evidence is not strong. Lactobacillus probiotics have been studied the most for this.
Hopefully this helps explain those pesky pockets in the colon.
Eating out with any sort of dietary restriction can be tough. We eat out for the experience of eating different foods and for the camaraderie of being with others. Not being able to relax when out in a social setting and needing to worry about diet restrictions is stressful and can be upsetting.
Many restaurants now have gluten free menus. As gluten free diets have become trendy as people use them for weight loss and some other health conditions, there is a demand for more gluten free dining options. Things like gluten free bread and gluten free pasta are becoming more common. Many restaurants offer items that are already naturally gluten free like meat, potatoes, and rice.
There can be some pitfalls to these menus; while the items on the menus often are gluten free ,a common concern is cross contamination. Many of my patients have this correct concern when eating out. Cross contamination is when food containing gluten gets mixed into the gluten free food. Cross contamination often occurs when eating out when bread products are placed on the grill in the kitchen, when fryers are used for products that contain breading, or when wheat flour is used to thicken sauces. For example, french fries fried in oil are gluten free, until the breaded chicken strips are fried in the same fryer. In order to avoid cross contamination, it is important to be able to ask a few questions when ordering food:
I often get asked about cross contamination. “How much gluten is safe?” This is a great question. We typically advise celiac patients to be 100% gluten free, as cheating on the diet has been associated with health and nutrition problems. Small medical research studies have suggested that less than 50 mg of gluten per day does not causes changes in the small intestine on biopsies. The FDA regulation of 20 parts per million (PPM) for a food to be considered gluten free means 20 mg of gluten per 1000 mg of the food. This suggests that very small accidental exposures may be tolerated by the intestine, but intentional exposure should still be avoided. This is an evolving question for medical research to answer.
There are a lot of questions now about the class of acid reflux medications called proton pump inhibitors (PPIs). PPIs include Prilosec (omeprazole), Nexium (esomeprazole), Prevacid (lansoprazole), and Protonix (pantoprazole). As acid reflux and stomach ulcers are common health conditions, many people take these medications. There have been several news stories raising concerns about these medications and many patients coming to see me in the office ask me about these drugs,
Why do people take PPI medications? Common reasons to take PPI medications include:
Acid reflux – Medication reduces stomach acid, and hence helps the symptoms of burning and discomfort.
Stomach ulcers- By reducing stomach acid, the PPI helps ulcers heal. Can also prevent recurrent ulcer bleeding in people that need to take blood thinners and medications like aspirin or ibuprofen (NSAIDs)
Upper abdominal pain (also known as dyspepsia)- medication for a short duration can relieve discomfort in the upper gut.
Barrett’s esophagus– reduced acid helps eliminate damage to esophagus tissue.
There are some clear health benefits to a PPI medication. Acid reflux can be associated with a condition call Barrett’s esophagus which can lead to esophagus cancer. Severe issues with acid reflux can cause pain, sleep disturbance, and poor quality of life. Stomach ulcers can cause internal bleeding.
So what are the risks?
A study in the journal JAMA Neurology (JAMA Neurol. 2016;73(4):410-416. doi:10.1001/jamaneurol.2015.4791) raised concerns that PPI use may be associated with dementia. The researchers obtained data on patients in a German health insurance plan and compared the rates of dementia on patients that took PPI to patients that did not take PPI. They did find that there was a weak statistical association with higher rates of dementia in patients on PPI medications. The issue with this study is that the patient’s on PPI medications in the study also had higher rates of stroke, heart disease, and use of multiple medications which can also cause dementia. These sort of research studies need to be interpreted with caution. A correlation does not equal a cause. You can ask my children to tell you about this. If you wear the green Packer jersey and they win this week, it does not mean that the Packers will win again next week if you wear the same jersey. Correlation does not equal cause. (Reference: 2016 NFC Championship game)
What should you do if you are on a PPI?
The most important thing to do would be to talk with the doctor prescribing the medication. If you are taking over the counter PPI medications, you should consider discussing your symptoms with a doctor. Even though I do not think the study on dementia was well designed and valid, I do like that the study has opened many discussions and has encouraged patient’s to ask questions. “Why am I taking this medication, doc?” is a question you need to know the answer for every pill bottle in your medicine cabinet.
For patients with GERD, I typically advise them to try and go off PPI medication and see how they feel. I advise this more for cost and simplicity; not due to concerns about dementia. If frequent issues with reflux return, then resuming the PPI for 2-4 weeks at a time for treatment tends to control the symptoms. This works for most patients. For patients that have issues with symptoms multiple times a week whenever they are off PPI, long term use may be indicated.
For patient’s with Barrett’s, it is advisable to stay on the medication as Barrett’s can cause cancer.
For patient’s that take blood thinners and have had issues the stomach ulcers in the past, there is a clear benefit to remaining on the medication.
What is rebound reflux?
Sometimes stopping PPI medication abruptly can cause what is called a rebound reflux. After long term PPI use, patients can have a temporary increase in reflux symptoms. This will typically resolve with time. Sometimes weaning the dose of the medication or changing to every other day dosing first can help with rebound. Using milder over the counter antacids can also help with this while coming off PPI.
My advice is in line with the American College of Gastroenterology’s recommendations. For more information:
http://acgblog.org/wp-content/uploads/2016/05/Loren-Laine-Long-Term-PPIs-AJG-04262016.pdf
There are a variety of tests available for celiac disease. Confirming a diagnosis of celiac disease is important, as there can be some implications of a confirmed diagnosis of celiac disease versus “gluten intolerance”. Patients with celiac disease are at risk for certain types of cancers, nutritional problems, and diminished bone density. Knowing for sure is very important as patients with a confirmed diagnosis of celiac disease require monitoring by a physician. Patients with celiac disease also need to be 100% gluten-free in regards to diet.
“Gluten intolerance”, also known as “non celiac wheat sensitivity”, causes people health issues or digestive distress when they are exposed to gluten. People with gluten intolerance do not have a confirmed diagnosis of celiac disease. Patients with gluten intolerance do not always need to be 100% gluten-free. Patients with gluten intolerance do not require the same level of monitoring that a patient with celiac disease would require. Both conditions can make people feel rather sick. The symptoms of gluten intolerance can mimic other serious health issues, hence it is important to seek a formal opinion from a doctor.
Simply feeling better on a gluten-free diet does not constitute a diagnosis of celiac disease.
This has been shown in medical research. (Am J Gastroenterol 2011;106:508–514; Scand J Gastroenterol 2008;43:1311–1314.) Other health conditions including irritable bowel syndrome can improve on gluten-free diets.
Given these factors, formal testing is important. There are 2 types of tests for celiac disease. It is important to know that both are measuring the body’s response to gluten. In order for proper testing and confirmation of a diagnosis of celiac disease, the patient must be exposed to gluten.
1. Labs. A tissue transglutaminase antibody is most sensitive lab test for celiac disease. There are older antibody tests that are still available. We typically only use these older antibodies in certain clinical situations.
2. Biopsies of the small intestine. A biopsy of the small intestine enables the doctor to see how the small intestine is reacting to gluten. Biopsies of the small intestine are the most accurate test. The endoscopy will show breakdown of the intestine lining and the biopsy will show inflammation as well as breakdown of the intestine cells. An adequate number of biopsies is required to make a proper diagnosis. Typically this is 6 specimens. Biopsies are taken during an upper endoscopy procedure.
I typically advise patients not to start a gluten-free diet until they have at least considered laboratory testing for celiac disease. If somebody is already on a gluten-free diet the standard labs and biopsies are rendered inaccurate. There is a genetic test we can do for celiac disease but this only rules out celiac disease it does not rule it in. Establishing a diagnosis of celiac in a patient already on a gluten-free diet requires the patient to ingest at least one serving of gluten per day for at least 4 weeks in order to measure the body’s response to gluten.
The bottom line is to consult with a physician on testing for celiac prior to starting a gluten free diet.
Video of me discussing these tests can be found here.
