Wednesday, October 8, 2014

I've had this blog half written for weeks and then months.  I wanted to finish it.  I promised you I'd finish it.  Then life happened.  Baby Teo was in the hospital for several days and daily life stopped.  I remember this feeling from the NICU, the blinders being put on and then suddenly nothing else matters, not eating, not sleeping, just Teo.  He was a champ our little guy.  He's done hospitals before, he knows the drill but oh did he cry.  He was in pain and there wasn't anything we could do except hold him and love him and tell him it was going to be OK.  And it was.  Before you worry, Teo is fine.  He's healing well and I've started breathing again.

Weeks have turned into months and I keep forgetting to press the publish button.  What have I been doing?  Mostly parenting and finishing my book Before Baby.  When's it coming out?  Soon, very soon.  I am self-publishing and the final steps are taking just a little longer than anticipated but I am so excited to share it with you!  In the meantime, I'm giving you a follow-up on non-celiac gluten intolerance and I'm intending to be back, writing in this space.


A couple of months ago I wrote about some of the latest research bashing non-celiac gluten sensitivity (NCGS), a study which media outlets interpreted as indicating that NCGS was bunk.  In most of the articles written, journalists dug up this Biesiekierski and Gibson study from 2013 as proof that NCGS doesn't exist.  Biesiekierski and Gibson are credited with proving (if one study can prove or disprove anything) that NCGS existed back in 2011.

As I noted in my previous post, most studies investigating non-celiac gluten intolerance are done with people that have IBS and the myriad causes of IBS are innumerable.  For example, here's a review of studies that evaluated intestinal permeability as a cause of IBS.  And a review of numerous studies assessing intestinal serotonin signaling in IBS.  And this review of the role of small intestine bacterial overgrowth (SIBO) in IBS, not to mention the countless studies assessing use of probiotics and elimination diets to treat IBS.

Let's look at the 2013 Biesiekierski and Gibson study in more detail: 37 participants were placed on a low FODMAP (fermentable oligo-/di-/monosaccharides and polyols; shorthand for the less-digestible sugars that can cause bloating and discomfort) diet for two weeks, and then separated into one of three groups for 1 week.  Those groups consumed different quantities of proteins on a daily basis (16 g gluten, 2 g gluten and 14 g whey, or 16 g whey protein).  There was then a 2 week washout period, after which  22 of the participants switched treatments and were given 16 g gluten, 16 g whey, or no additional protein for 3 days.  Participants were assessed after the initial two week challenge, and again after the treatment swap period.

The results?  Participants felt better on the low FODMAP diet and worse on the gluten-containing diet.  The study determined that 8% of participants felt better on a gluten-free diet, but this was not statistically significant.

So, to recap: 37 people with IBS were put on a low FODMAP diet and then tested with high, low and no gluten intake.  Some people felt better on the low FODMAP diet, some people felt better on a gluten free diet.

I know I keep hitting the IBS issue over the head with a hammer but to me it's the biggest flaw in all these studies about NCGS because Irritable Bowel Syndrome is by definition a collection of symptoms with no known organic cause.  It's a diagnosis of exclusion, which means that all other causes (celiac, Chrohn's or colitis for example) for gas, bloating, diarrhea and/or constipation have been ruled out.  So, in performing studies to demonstrate the existence or non-existence of NCGS on participants with IBS, you are assuming that there is one cause for this syndrome when that's patently not the case.

The second issue with this study is that they chose to place participants on a low FODMAP diet prior to their gluten test.  FODMAPs were first articulated by researchers at Monash University, the same university where Biesiekierski and Gibson happen to be performing their research.  It may not be a conflict of interest but we should note it none the less.  FODMAPs are poorly absorbed by everyone, not just people with functional gastrointestinal disorders and so it seems obvious that if you remove FODMAPs from a person's diet, IBS or no, he or she will experience a decrease in gastrointestinal symptoms.

FODMAPs are made up of a collection carbohydrates and some food sources include:

Fructans: Wheat, barley, rye, onion, garlic, asparagus, beets, broccoli, brussels sprouts, cabbage, fennel and chocolate

Galactans: Beans and legumes

Polyols: Apples, apricots, blackberries, cherries, peaches, nectarines, pears, plums and watermelon

Fructose: Fruit and fruit juice, table sugar, honey, agave

Lactose: Dairy products

In practice if we suspect someone may have an issue with a FODMAP food, we eliminate all FODMAPs and then test each group individually to narrow it down and identify which FODMAP is causing the problem.  Notice the first three foods listed under fructans?  Wheat, barley and rye.  So participants in this study felt better when they eliminated FODMAPs, a collection of foods no one digests well and the foods eliminated included wheat, barley and rye, three of the five major gluten-containing grains (the others are spelt and trickle).  To me this study muddies the waters further rather than clarifying anything about FODMAPs or NCGS.

So, is the Biesiekierski and Gibson study a bad study?  No, it's has it's strengths and weaknesses just like all other research.  Can we determine anything definitive about non-celiac gluten sensitivity and FODMAPs from it?  No, it's one study among hundreds.  What the Biesiekierski and Gibson study does is add to the body of knowledge regarding functional gastrointestinal disorders and their treatment.  When it comes to treatment of a collection of gastrointestinal symptoms such as IBS, each person is going to have a different cause and therefore going to require a different treatment, eliminating gluten and/or doing a FODMAP elimination and challenge being among two of the many treatments available.

The bottom line: if you feel better when you don't eat gluten, don't eat it.

Thursday, May 22, 2014

Non-Celiac Gluten Sensitivity? Nuance Be Damned!

The debate over non-celiac gluten sensitivity (NCGS) is back (did it ever go away?), and personalities with clout are weighing in: Michael Pollan.  Shauna James Ahern.  Jimmy Kimmel.  It's a hugely complicated issue, and I almost don't know where to start because there's so much to say.  However, as a dietitian who has successfully treated her own IBS by eliminating gluten, the issue is personally important to me, so I feel that I have to try and clarify the situation a bit.

First, the majority of studies on NCGS are done on participants with gut issues, primarily irritable bowel syndrome (IBS).  To say there are a myriad of causes for gastrointestinal issues is the understatement of the century - give me 20 people with IBS, and I'll give you 20 different etiologies.  After all, it's a syndrome, a collection of symptoms rather than a specific pathological cause-and-effect relationship.  The wide spectrum of IBS causes makes it very difficult to pinpoint the clinical effects of any single intervention in a group with the syndrome, and this complicates studies that want to test for gluten intolerance (or lack thereof).

The latest round of gluten-free bashing seems to have originated from a study recently published in the journal of Nutrition in Clinical Practice, which evaluated participants with self-diagnosed gluten-intolerance.  This is the abstract:

Characterization of Adults With a Self-Diagnosis of Nonceliac Gluten Sensitivity

Background: Nonceliac gluten sensitivity (NCGS), occurring in patients without celiac disease yet whose gastrointestinal symptoms improve on a gluten-free diet (GFD), is largely a self-reported diagnosis and would appear to be very common. The aims of this study were to characterize patients who believe they have NCGS. Materials and Methods: Advertising was directed toward adults who believed they had NCGS and were willing to participate in a clinical trial. Respondents were asked to complete a questionnaire about symptoms, diet, and celiac investigation. Results: Of 248 respondents, 147 completed the survey. Mean age was 43.5 years, and 130 were women. Seventy-two percent did not meet the description of NCGS due to inadequate exclusion of celiac disease (62%), uncontrolled symptoms despite gluten restriction (24%), and not following a GFD (27%), alone or in combination. The GFD was self-initiated in 44% of respondents; in other respondents it was prescribed by alternative health professionals (21%), dietitians (19%), and general practitioners (16%). No celiac investigations had been performed in 15% of respondents. Of 75 respondents who had duodenal biopsies, 29% had no or inadequate gluten intake at the time of endoscopy. Inadequate celiac investigation was common if the GFD was initiated by self (69%), alternative health professionals (70%), general practitioners (46%), or dietitians (43%). In 40 respondents who fulfilled the criteria for NCGS, their knowledge of and adherence to the GFD were excellent, and 65% identified other food intolerances. Conclusions: Just over 1 in 4 respondents self-reporting as NCGS fulfill criteria for its diagnosis. Initiation of a GFD without adequate exclusion of celiac disease is common. In 1 of 4 respondents, symptoms are poorly controlled despite gluten avoidance.

Two big takeaways:

1. The authors found that ~3/4 of the respondents didn't meet the criteria for non-celiac gluten intolerance, but this doesn't indicate that they do not have it.  It is more meaningful to note that only 1/4 of the respondents reported that their symptoms hadn't abated on a gluten-free diet; this indicates that NCGS isn't the cause of their particular digestive issues.  Just to be clear, that's only a quarter of the respondents.  That isn't strong evidence that NCGS is bunk, as has been so widely touted.

Mostly (62%), the responses indicated that these people hadn't ruled out celiac disease.  Please, if you think you have a reaction to gluten, get tested.  Celiac causes serious long-term harm left untreated.

2.  Another 1/4 of the respondents (27%) weren't actually following a gluten-free diet, but they reported feeling better anyway!  This has also been talked up; it looks like the placebo effect, or possibly the nocebo effect, where gluten acts as the nocebo.  Keep in mind, some of these people presumably overlap with the ones whose symptoms hadn't abated, which makes any conclusion about those individuals' NCGS status impossible.

However, there's another serious interpretation problem: NCGS may have a threshold level of gluten sensitivity greater than zero, beneath which there is no harm.  Many individuals who have followed strict gluten-free diets to good effect report that they can introduce varying levels of gluten back into their diets with little or no detriment to their health.  We in the medical community are so conditioned by celiac disease to think in terms of zero tolerance (celiac sufferers have a reaction to even tiny amounts of the protein), that we may have erroneously assumed NCGS works the same way, when it does not.

Still, we have to conclude that a significant number of people who self-report NCGS are talking themselves into feeling better.  Anyone shocked that people claim benefits of a trendy but meaningless dietary change?  Raise your hand.  Anyone?

According to this study, the diagnosis and treatment of NCGS, either self-diagnosed or by a health care provider, is a red hot mess.  There is no established path to diagnosis and treatment, so people are feeling their way through, trying to come up with a solution to their health issues.  What I found terribly concerning was that 29% (22) of the 75 people who had a duodenal biopsy to rule out celiac disease had not consumed enough gluten beforehand to make the test accurate.  If a patient is going through the rigamarole of having a biopsy, the health care provider responsible for their care should make darn sure that the patient has been consuming large amounts of gluten for at least 6 weeks prior to the test!

My conclusion?  Gut issues are not cut-and-dried, and new research is coming out every single day.  Each of those studies has the potential to help, but only if we read it for what it says rather than what we want it to say.

It also looks to me like both patients and health care providers are woefully undereducated about NCGS. When a patient comes to me looking for an answer for their nausea/vomiting/diarrhea/ constipation/gas/bloating/belching, etc, I have a checklist of questions I ask myself and the patient to determine the cause.  Are they not chewing their food?  When and how much are they eating?  Do they have enough stomach acid?  Have they been evaluated for celiac disease?  Assuming NCGS is the cause of a person's digestive issues before evaluating them thoroughly is bad medicine.

And the study that everyone keeps referencing that was published in Gastroenterology in August 2013?  The small study that contradicts the other small study published by the same authors in 2011 that established the existence of non-celiac gluten sensitivity?

Yeah, I'm going to tackle that one next week.

Photo courtesy of

Friday, May 16, 2014

Introducing Baby Teo!

It's been three glorious months since Teodor Xavier was born.

"Three months?" you say.  "Where have you been?  Where are all the adorable newborn pictures of this darling child?"

As I expected, motherhood is consuming and I wanted a true maternity leave, which included time away from the computer and email and expectations of internet interaction.  I wanted quiet and time to learn about the new little being in my life.  Teo (say Tey-oh) is amazing, full of sweet smiles and giggles and snuggles.  There has also been the expected exhaustion and demanding nursing schedule, compounded by some medical issues, hospitals stays, medications and tests.  It's difficult to imagine that 3 months have passed at all.

And so, without further ado, I give you Teodor Xavier Hoverter, born 2/19/14 at 12:40 pm.  He weighed 8 pounds 5 ounces and he is the light of our life.

Friday, February 14, 2014

Happy Valentine's Day!

Spring is in the air and we even had some sun yesterday, though we appear to be back to clouds and rain today.  I'm about to pop (40 weeks!) so there's a lot of hurry up and wait happening.  I've had a cold/allergies but I'm feeling better today, though I think I'll continue to rest and recuperate.  

It's been 3 weeks since I saw my last client and the hiatus has been a strange experience.  Running FoodWise and seeing patients has been such an integral part of my life for the past several years that suddenly not doing it for an extended period of time is quite strange.  FoodWise Nutrition still exists but as  you can see, the website is down to one page.  I was joking to Ben that we should just take the website down except I need it to tell people that I don't exist!  

I'm still working on Edible Answers but as with any project it's taking much longer than anticipated to get up and running.  Isn't it like that with all first time projects?  And of course I'm having a baby right in the middle of it.  I'm not going to try and predict when we'll have it up and running but I'm hoping summer.  Wishful thinking?  Perhaps.  A girl has to have goals though!

So what are you doing for Valentine's Day?  We are staying in a making gyoza with sautéed broccoli.

Happy February!

Monday, December 16, 2013

How I Meal-Plan

Soba w/ Veggies was the new recipe this week.  See instructions on how to make it here

I know I've written several posts on this site about meal planning, but the topic comes up often, and not just in conversation with patients.  One of my friends has a 3-month old and is feeling ready to get back into cooking.  She recently asked me how I meal plan and... I wrote her a bit of a novel.  Planning meals is a big deal!  Yes, it is possible for people to eat well on a budget without meal planning, but that usually involves purchasing the same items every week with very little room for life to happen.  

Since I wrote it out, I thought I'd share exactly what I do with you all.


Here's how I meal plan, and writing it out, it sounds time-consuming, but remember, most of this happens in just a few minutes in my head.  I grocery shop on Sundays, so that's when I start my menu, and there are some days that the same thing always happens, like Friday (pizza or gyoza night).  We also eat leftovers for lunch, so I start the week with bigger meals and choose smaller meals with less leftover for the middle of the week if we are going to have enough food.  I freeze leftovers if it's obvious we aren't going to finish the food and save it for a busy night.
To start, I look at my calendar.  What's my week like?  Am I really busy with work or other obligations?  Is Ben around at all in the evening?  (If I ask, Ben will take over some of the cooking responsibilities.)  How's my energy level?  How creative am I feeling?  Do I have some recipes I want to try or should I just go with tried-and-true to keep it simple?  What's on sale at the market? What am I craving?
I look in my fridge and pantry.  Is there anything I need to use up that I can plan a recipe around?  Is it the end of the month, and therefore the end of the grocery budget?   
Even if the meal plan below doesn't name a particular veggie, I put veggies in the dish or make them as a side dish.  I usually just purchase what's on sale.

I was working 11-hour days M-Th, though I tried to be a little creative with a new recipe
on Monday night.
I can tell you the fish tacos didn't happen on Wednesday,
 and that's OK, because we had SO MUCH FOOD!
Then I start writing it out.  This is an example of how I look at my week:
Sunday:  Need something hearty with leftovers, so it's soup/stew or pasta with meat sauce and lots of veggies.  Examples include beef stew, coconut chicken soup, chili, etc.  I always double the veggies so we don't need a side, or I throw a salad together with it.  
Alternatively, I may get a bug in my bonnet to make something creative.  Lately I've been making quiche on Sundays, so I make sure that Monday's meal is filling.
Monday:  I've been working from early in the morning until after 6:00 pm, so I've been doing slow cooker this day.  I have a selection of recipes I choose from; sometimes I want to try something new, and then I pull out a new recipe while meal planning.  I always put the meal together in the slow cooker the day before, and then just throw it in the fridge to be put on to cook in the morning.
T/W/Th: These days vary by schedule and energy level.  Thursday is traditional guys' night (though it just switched to Tuesday, so I'm all confused) and I either don't cook and Ben grabs something out, or we eat leftovers.  Lately I've been cooking to save money.  T/Th were slow cooker days while I was working a contract job, but now I'm working at home on those days.  I almost always pre-make dinner during the day because I'm so exhausted by the evening.
Friday: Pizza or Gyoza, two special meals that we love, though we sometimes go out with friends. 
Saturday:  Variable.  Sometimes we go out, sometimes we eat leftovers, sometimes we have plans with friends, sometimes we pick up something to cook.  I don't plan this day.
I was working a lot this week.  I doubled or tripled the veggies in every recipe and made sure we had a lot of leftovers!
And if you want to see how I make my gyoza, click here.
I have a list of 20-minute meals or meals I can get together with barely any thought to use on days/weeks I have very little time or energy.  Ideas include: 
  • Fish tacos (20 min in the oven and I prep other ingredients while the fish cooks.  We used to have this every Monday night b/c the fish was fresh after shopping.)
  • Pesto pasta with smoked salmon (I usually have frozen pesto in the freezer... just not right now.)
  • Beef tacos
  • Tofu green curry with rice
  • Stir-fry
  • Red lentil soup
  • Chicken soup
  • Any pasta dish 
Finally, I try to get a variety of meals/proteins in during the week.  I usually have a vegetarian dish, a fish dish, a chicken dish and a beef dish.  I don't eat lamb/veal and we don't digest pork well, so I avoid those sources.  I tend toward more chicken and less beef, except pregnant Autumn LOVES beef and doesn't like fish!   
If chicken is on sale that week, we'll have more chicken.  And I'm not afraid to modify what I'm doing: meals change nights or mutate.  Squash and sausage soup turned into squash and sausage with kale hash because I didn't feel like soup.
I'm not working as much, can you tell?  I think this week shifted and I made dal on Sunday, cassoulet on Monday and quiche on Tuesday.  It all worked out in the end.
The meal plans I've shown you here aren't perfectly balanced, so it's a good example of how I work.  Unfortunately, you can't see the accompanying schedule that I planned around, but you can see that there are some repeaters.  We had a lot of gyoza filling in the freezer (bought supplies on sale and made a lot), and we both like gyoza, so we ate it and loved it!  There's also a lot of beef; I think Ben got a family pack of ground beef on sale at the beginning of November and split it into one-pound chunks, so we had that to use.   
During a couple of those weeks I was still working my contract, so you can see what an exceptionally busy week looked like (lots of slow cooker).  Also, I don't always mark it down, but if by Wednesday we have a ton of leftovers, we sometimes just have leftovers that night and I save what I was going to cook for later.  What it comes down to for me is energy, schedule, cravings and motivation.   
I love variety, so some weeks I spend 30 minutes to an hour planning out the week and making a grocery list.  I look through my cookbooks and magazines and get really creative.  Some weeks I'm exhausted/stressed/unenthusiastic, and I just plan meals around what we already have in the freezer or foods I know I can make quickly.   
The trick for me is not having a schedule I follow every week, but rather changing from week to week.  I know some people who really thrive on having a monthly meal plan, but that wouldn't work for us because my energy, time and motivations vary frequently.  You have to decide what will work best for your family and do that.  Don't be afraid to experiment and change if things aren't working.  What works one week (lots of different meals) might not work the next, so you do a pre-roasted chicken and bag salad and call it good.

I'd love to hear how you plan your meals.  What works well for your family?

Thursday, November 28, 2013

Happy Thanksgiving!

Happy Thanksgiving to you!  Today we are having Maple Bourbon Pumpkin pie in an almond buckwheat crust. I'm sure there'll be other food, but this is what I'm most excited about.  Oh, and of course, friends and family!

We are hosting a small gathering in our tiny apartment here in north Seattle and I'm so happy everyone is willing to squeeze around tables placed in the living room and bring a dish to pass. It will be tight, but there will be friends and laughter and food.  And gratitude. I am so grateful for my life and the ability to make a gorgeous meal and share it with those I love. 

There seem to be difficulties in the world as of late. Our government fighting itself, the typhoon in the Philippines. Some challenges here at home, too. In the past few days we've had issues with family, and in the midst dealing with that, our baby shower gifts were stolen. All of them. 

It was heartbreaking, but friends and family have really stepped up to make sure baby Hoverter has clothes to wear. The outpouring of love and generosity has been amazing. And so, I enter this holiday season, not with anger, but with hope and graditude. 

"Let gratitude be the pillow upon which you say your nightly prayer. And let faith be the bridge you build to overcome evil and welcome good."
                                                                          - Maya Angelou

A happy and peaceful Thanksgiving to you all!