Wednesday, October 29, 2014

Time. And Time to Bake Salmon!


Time.  Time.  Where is the time?  It slips through my fingers like water, flowing away into the distance.  My days are full, overflowing with fun activities like taking Teo swimming and going to the library and seeing friends.  And the not so fun, too, like comforting an inconsolable teething baby and cleaning the bathroom grout.  Who knew that tile grout could become so disgusting?

Among all of this I'm trying to work.  I'm writing in minutes snatched during naps and at bedtime, furiously typing and editing and tweeting and blogging.  Sometimes the planets align and I work everyday, meeting deadlines and keeping up a constant flow of social media banter.  Other weeks I get the stomach flu and Teo starts teething, then everyone in the house gets a cold and it takes all my mental energy to see us through.  The last couple of weeks have been rough.

With all the awesome parenting, I have work projects lined up into the distance, but the one that's taking most of my focus is Before Baby.  Where is it, you may ask?  It was supposed to be out September 30th, but it's no where to be found.  Well, like many big projects before it, Before Baby is held up in production.  It's so close, and we are so excited to share it with you.  I anticipate it being out in the next couple of weeks, but there are a couple of niggling issues that seem to be hydra-like: solve one problem and two more appear!  But we are soldiering on, and will have it to you before long.

With all of these demands, my cooking has become much simpler, more streamlined, less fussy.  I look for ways to get protein and veggies all in one fell swoop with minimal cleanup, and lately I've turned to roasting for quick and easy meals.  We've been drowning in rain here in Seattle.  I know, it's Seattle so I should expect rain, right?  This is the rain that comes down in sheets, overwhelming drains and flooding basements.  Typical rain here is a drizzle.  If you're a native, you go out in a windbreaker, barely remembering to put your hood up, whereas the downpours we've been having require umbrellas and goulashes and fortitude.  I've lived in Seattle for 16 years and I don't own a pair of rain boots.  And so, I turn on the oven and throw salmon and veggies on parchment paper.


Baked Salmon and Summer Squash

Preheat your oven to 400 degrees F.  Line a baking sheet with parchment paper.  Chop 1-2 summer squash into 1 inch dice and toss on the baking sheet with a splash of olive oil and salt.  Push the summer squash to the side and lay your 1-pound salmon fillet in the middle.  Brush with olive oil and salt and bake for about 20 minutes, until the salmon is cooked through.  Serve as is, or over salad or quinoa with a dressing of your choosing.


Friday, October 10, 2014

Contribute to Gluten Free Girl's Kickstarter!


Do you bake with gluten-free flours?  Do you want a whole-grain or grain-free mix but can't find one in stores?  Help Shauna James Ahern, the Gluten Free Girl, fund her Kickstarter campaign to get healthy, wholesome, gluten-free mixes to a store near you.

I like to mix my own flour because the mixes currently available, while delicious, are extremely processed, with nary a whole grain to be found.  Before Teo was born, I made up some gluten-free pancake, cookie and banana bread mixes for my mother to bake us while she was visiting because she wanted to cook for us but wasn't comfortable doing the mixing herself.  I think it would be amazing to have wholesome gluten-free flour mixes available, both for my own use and for my family to use to bake nourishing and delectable treats.

If you too would like a healthy gluten free flour option, I encourage you to pledge what you can to Shauna's Kickstarter campaign.  Let's make this happen!

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.

Enjoy!

***
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  http://www.phdcomics.com




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!