Healthy Food & Healthy Living by Dr. Ayala

The gluten-free health fad: the good and the bad-part 2

In the previous post I reflected on the rapid expansion of the gluten-free market share and the rising popularity of the gluten-free diet, and said I'm glad to see the growing awareness of celiac disease, and also happy that keeping a gluten-free diet is becoming easier.

But is there a downside of the gluten-free fad? Are we replacing lack of awareness of celiac disease with confusion?

There are now several categories of gluten-free people: Genuine celiac patients, people who suspect they may have celiac and have gone gluten-free without a doctor’s diagnosis, and gluten-free lifestyle adopters, who joined in for perceived health benefits or as treatment for ailments that are not proven to be aided by a gluten-free diet.

The first group, celiac patients, needs to adhere to a very strict gluten-free diet for life. How strict? Very! Even small amounts are forbidden. Gluten sometimes hides in unexpected places, and can cross contaminate food. Although many celiac patients will not experience discomfort after eating some gluten their bowel will feel it and there are long-term consequences to non-adherence.

The second group needs to be evaluated by a doctor, and the diagnosis of celiac confirmed or excluded. Without a clear diagnosis and treatment plan they may be doing themselves harm, or alternately, putting themselves through unnecessary restrictions.

As to the third group they may adhere to the gluten free regimen loosely or strictly, and may feel better on it--we cannot argue with success. But the different degrees of adherence to gluten avoidance is a source of much confusion as we’ll cease to identify a gluten free diet as the extremely strict--not a bread crumb to touch that food--that a celiac patient needs.

Perhaps it's time to give the diet concentrating on gluten avoidance of those without celiac a unique name, such as "low-gluten" or "reduced-gluten" diet. This way it will be clear both to those on it and those cooking for them that they don't have to be extremely strict, and on the other hand it'll be clear to the public that unlike other diets and food preferences a celiac patient's shouldn't be on just a low-gluten diet, but rather on a truly a gluten-free one.

If we don’t understand gluten-free as a medical entity, we won’t treat is with the seriousness it deserves. Gluten-free will have more than one meaning, and there will be gluten-free for celiac and for hobbyists.

Who’s making gluten-free food?

The FDA has a proposed draft that will allow the “gluten-free” claim for voluntary use on products if:

“food does not contain any of the following: An ingredient that is any species of the grains wheat, rye, barley, or a crossbred hybrid of these grains (all noted grains are collectively referred to as ”prohibited grains”); an ingredient that is derived from a prohibited grain and that has not been processed to remove gluten (e.g., wheat flour); an ingredient that is derived from a prohibited grain and that has been processed to remove gluten (e.g., wheat starch), if the use of that ingredient results in the presence of 20 parts per million (ppm) or more gluten in the food; or 20 ppm or more gluten.”

The amount of gluten accepted in a gluten-free product is minute: 20 parts per million, so you can see that contamination by even tiny amounts of wheat flour, which has about 80,000 ppm, brings a gluten-free food to unacceptable levels.

At this point it’s up to the manufacturers of gluten-free food items to guarantee such a claim.

Now it’s one thing to manufacture gluten-free packaged goods in a controlled production facility, and quite another to offer gluten-free options in a busy restaurant.

The growing gluten-free demand is encouraging many restaurants to offer gluten-free options. I believe they mean well, but could they really guarantee a meal is gluten-free? It takes much more than using special gluten-free pasta to make a meal fit for a celiac patient.

My daughter has a close friend who has celiac disease. When I cook a meal for her and her family I will usually skip any gluten-containing food for the entire meal for everyone because it makes cross contamination less likely. If I’m going to still make bread or use any other flour-based recipe, I will do so hours before making the rest of the meal, then completely clean-up the kitchen, store the flour, put my apron in the wash, and cook gluten-free.

Many parents of kids with celiac opt for a gluten-free kitchen because it’s so difficult to avoid contamination. I find it quite hard to imagine that a restaurant kitchen—with many people working under intense pressure using lots of shared equipment—can really make sure the flour from the pasta maker doesn’t touch the rice and that the spoon stirring the gluten-free soup didn’t also go into the barley soup. I think that, try as a restaurant might, it’s very hard to keep menu items truely gluten-free, and the best advice to patients with celiac is to eat at restaurants as little as possible.

Gluten-free junk

While there are a few really wonderful and innovative new gluten-free foods, there’s also a proliferation of gluten-free junk. One of the advantages celiac patients used to have was that they were somewhat protected from our fast- and junk-food environment, and ate home-made naturally gluten-free foods. Do they really need dozens of new processed foods reformulated without gluten?

The take-home message about the gluten-free label

Gluten-free should not read as “healthy” or “pure.” Gluten-free should be read like allergen information (celiac is not an allergy to gluten, but in terms of how strictly the diet needs to be kept, a serious nut allergy is a good comparison) and just like nut-free is information for those allergic to nuts, not signifying good or bad attributes, so it is with gluten: Gluten-free means it’s food that's acceptable to those with celiac; it can be nutritious or pure junk—you’ll have to read the ingredients.

If you don’t have celiac, and are ready to make a change for better health, why not spend your time, energy and money on strategies that make more sense, and reduce (not necessarily eliminate) more serious offenders, such as fast and highly processed foods, or resolve to follow the age old advice of eating more fruits and veggies?

What I hope we’ll all get from the gluten-free boom (before it busts) is greater awareness of celiac disease (along with timely diagnosis) and some great tasting gluten-free breads and pastas, which are no small feats.

What do you think of the popularization of gluten-free foods?

Dr. Ayala

The gluten-free health fad: the good and the bad - part 1

Have you noticed the gluten-free food explosion? I have the privilege of attending many food shows, and I’m stunned by the proliferation of grain based foods—prepared meals, cookies, snacks bread and crackers—developed for the benefit of those on a gluten-free diet and with “gluten-free” as a marketing proposition.

Gluten-free foods are a necessity for people with celiac disease, a disorder resulting from an immune reaction to gluten. But are these foods good for everyone else?

While the precise prevalence of celiac disease isn’t known, it’s estimated to range from about 0.4 percent to about one percent of the general population in the U.S. (up to three million Americans). The number of Americans with physician-diagnosed celiac however, although growing, is still not very large, and estimated anywhere in the range of 40,000-110,000 cases.

Not to sound cynical, but even a one percent consumer base wouldn’t drive manufacturers and retailers to the accelerated expansion of the gluten-free options we’re seeing. The reason food manufacturers have jumped in full force into this market is because gluten-free products are now favored not only by celiac patients, but by many people without the diagnosis—gluten free is indeed the latest food fad—and it’s a huge opportunity to make money. Research firm Mintel estimates that nearly 10 percent of shoppers currently seek gluten-free foods; they forecast 15- 25-percent growth in gluten-free product sales in coming years.

I’m glad to see the growing awareness of celiac, and also happy to see that keeping a gluten-free diet is becoming easier, more acceptable, and requires less sacrifice on taste.

On the other hand, the “fad” aspect of the gluten-free boom worries me quite a bit.

Is gluten bad for you?

Gluten is a protein found in wheat or related grains. It's a remarkably large molecule that’s quite central to the structure and texture of dough.

Gluten is definitely not an evil food component for those not afflicted by celiac. Gluten is part of whole-wheat flours and whole wheat, barley and rye grains—parts of a healthy diet. Although many junk foods contain gluten, gluten isn’t what makes these foods not nutritious—it’s the other ingredients or the processing of the grains that makes them so. If going gluten-free means choosing from the gluten-free menu at Wendy’s or Dairy Queen, or replacing wheat based snacks with corn based ones, you haven’t done yourself much good.

What’s a gluten-free diet good for?

There are only two established medical reasons to avoid gluten: celiac disease and dermatitis herpetiformis, a very itchy chronic skin rash of bumps and blisters, frequently linked to celiac. In celiac disease, complete removal of gluten from the diet is necessary for life, and results in complete resolution of symptoms. Non-adherence to a gluten-free diet can have dire consequences (even if the person is asymptomatic), including poor growth, infertility, osteoporosis, anemia, bowel narrowing and bowel cancer.

A gluten free diet is now touted for many other conditions, from autism to attention-deficit disorder, irritated bowel syndrome, multiple sclerosis and now even weight loss.

Although there are anecdotal stories about gluten-free diets making a difference for these conditions, there's really no good evidence to support such advice.

Autism

The gluten-free casein (milk protein)-free diet is a very common treatment attempt for autism.

A Cochrane review did an extensive literature search to identify randomized controlled studies of gluten-free or casein-free diets as an intervention in autistic features. They found only two small randomized controlled studies, with a total of 35 patients between them. The results of one of these studies indicated that a combined gluten- and casein-free diet reduced autistic behavior, but the second study showed no significant difference in outcome measures between the diet group and the control group.

The researchers concluded (emphasis is mine):

“Research has shown of high rates of use of complementary and alternative therapies (CAM) for children with autism including gluten and/or casein exclusion diets. Current evidence for efficacy of these diets is poor. Large scale, good quality randomised controlled trials are needed.”

Weight loss

There's no logical reason why adopting a gluten-free regimen should result in weight loss. Unless you have a strategy of reducing caloric intake on what just happens to be a gluten-free regimen, I can’t see how gluten-free for weight reduction makes any sense.

In fact, patients with celiac often gain weight once they start a gluten-free regimen. The reason is that while they’re eating gluten, many suffer abdominal pain, malabsorption and other symptoms that lead to reduced consumption or utilization of food. Once they’re on the gluten-free diet they thrive, eat well and gain weight.

Perhaps paying more attention to food—no matter what the regimen—can anecdotally lead to weight loss, but there’s nothing inherently low calorie or healthy about a gluten-free diet.

I learned from nutritionist Janet Helm about Elisabeth Hasselbeck’s book “The G free diet,” which Janet criticizes for inaccuracies, and also for “glorifying gluten-free and making it appear to be the best thing since, um, sliced bread.”

In the introduction to her book, Hasselbeck (who has celiac disease, and therefore greatly benefited from going gluten-free) writes:

“But a gluten-free lifestyle can help countless others as well. People suffering from a wide range of diseases—from autism to osteoporosis, from diabetes to rheumatoid arthritis—can often benefit from this change in diet. Even people with no health issues have a great deal to gain by giving up gluten. The G-free diet can help with weight management. It can elevate your energy levels, improve your attention span, and speed up your digestion.”

To which all I have to say is: Show us the proof! I searched Medline (the online computer database for biomedical journals) and couldn't find it.

But is there a downside to giving gluten-free a try? I'll get to that on the next post, in the meantime, your comments as always are welcome.

Dr. Ayala

Social trends study shows how we compare in healthy living

A press release caught my eye this week. It stated that the French excel at two leisure activities: They spend more time at the table and in bed than any other country surveyed.

The news came from OECD (Orginasation for Economic Co-operation and Development), reputed to be the world's largest and most reliable source of comparable statistics on economic and social data. The organization collects data, looks at trends and analyzes many aspects of life, including economic development, social changes, trade, environment, agriculture, technology, taxation and health. Its Society at a Glance reports give a snapshot of how society changes, and most interestingly, how we compare to other countries.

There are 30 member countries in OECD (Australia, Austria, Belgium, Canada, Czech Republic, Denmark, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Japan, Korea, Luxembourg, Mexico, the Netherlands, New Zealand, Norway, Poland, Portugal, Slovak Republic, Spain, Sweden, Switzerland, Turkey, United Kingdom and United States), and data are compiled using representative samples from each country.

Leisure time around the world

One chapter of the Society at a Glance latest edition is devoted to leisure time, and compares 18 countries’ leisure habits. Leisure is loosely defined as what people do when they’re not working.

Sleep

Most of leisure time is spent sleeping. I used to moan this “waste,” but I now recognize sleep as the cornerstone of health and sanity. The French sleep the most of any people in the report—almost 9 hours a night—but the U.S. comes in second, at more than 8 and a half hours a night. Korea and Japan are at the low end of sleep-time.

Waking leisure

The French spend the most time eating and drinking—more than 2 hours a day. The U.S. is close to the bottom end of the chart, joined by Mexico and Canada, with an average of a little over an hour spent on these activities.

A pity, really, since when people were asked what leisure activities they enjoy most, eating was near the top, right up there with relaxing and socializing. By this measure we have half the fun a Frenchman does.

A big chunk of leisure time is spent watching TV. TV takes up almost half of the leisure time in Mexico and Japan, but we in the U.S. come in third in time spent in front of the TV screen.

Visiting or entertaining friends takes up 34 percent of a typical Turk’s time, and about 16 percent of the typical Americans’ (we’re somewhere in the middle for that, and above the OECD average), and very little time is spent participating in sports—5 percent of time in the U.S., below OECD average.

Men have more fun. They have more leisure time than women, with the greatest disparity in Italy, where men have 80 minutes more a day of disposable time, while women are apparently doing housework. In the U.S., men have about 40 extra minutes of leisure a day compared to women. I wouldn’t get up in arms over this data, as it’s not clear at all how much of our leisure time is spent on “personal care,” and it very well may be that much of the disparity is because (relatively speaking) women spend so much time tending to hair and other personal grooming and maintenance. I keep telling my dear husband how lucky he is to be bald—being bald frees up enough time to pick up another serious hobby.

Health and wellness

Since we didn’t come out on top anywhere in the leisure chapter, nor did we excel in student performance or in equity indicators, I went on to the “Heath Indicators” section of the report, and there, sure enough, we’re leaders.

Although there are high obesity rates (obesity defined as having BMI—Body Mass Index— of greater than 30, and not mere overweight, defined as BMI in the 25-30 range) in many OECD countries, the U.S. is still at the top, with 34.3 percent. Our neighbor to the south is a close contender, with Mexico rating 30 percent (is obesity contagious?), while the U.K. has 24 percent and Greece comes in at 22 percent. What happened to Greece, birthplace of the healthy Mediterranean diet? The traditional ways of eating have been replaced by fast and highly processed foods, and obesity, diabetes and hypertension have skyrocketed at the same time (see here).

The least amount of obesity is seen in Korea (3.5 percent), Japan (3.9 percent), Switzerland (7.7 percent) and Norway (9 percent), with Italy and France about tied at around 10 percent.

The world is fat, but at least there’s equality among the sexes. Overall women are no more or less obese than men.

Other interesting facts about our general health, that fall in line with what advocates of a major overhaul of healthcare often cite: Life expectancy in the U.S. is 24th of the 30 OECD countries (men typically live for 75.2 years, while women live 80.4 years), and below the OECD average, yet the U.S. spends more on healthcare per capita than any other nation. Much more.

I’ll end with a few encouraging statistics:

• Cigarette smoking among teens has gone down dramatically in the U.S.; both boys and girls in the U.S. have the lowest teen smoking and repeated drunkenness rates among the countries reported in the study.

• The percentage of people aged 15 years and over reporting perceived good health in the US is very high—89 percent.

• Life satisfaction in the U.S. is above average.

• Although divorce rates are generally going up in OECD countries, they’re going down in the U.S.

We may not be doing that great in a factual sense compared to our global neighbors (especially in overall life expectancy), but we do seem quite happy with ourselves (and our spouses). And while feeling great is an important step toward being great, taking a glimpse at how people in other nations approach their lives could give us a few good ideas.

Dr. Ayala

Eating green for our planet – Vegans and vegetarian diets part 3

“Nothing will benefit human health and increase chances for survival of life on Earth as much as the evolution to a vegetarian diet.”

This quote is attributed to Albert Einstein, who—according to his writings—supported a vegetarian diet, but didn’t strictly adhere to it. In fact he admitted, "I have always eaten animal flesh with a somewhat guilty conscience."

After discussing the health impact of vegan and vegetarian lifestyle on personal health, I’ll be devoting this third chapter to the important subject of the environmental impact of meat production, and how eating meat (especially lots of it) affects the health of the planet.

A shocking report published in 2006 by the United Nations Food and Agriculture Organization, showed that the livestock sector generates more greenhouse gas emissions (as measured in CO2 equivalents)—18 percent of all greenhouse gas emissions—than transportation, and is also a major source of land and water degradation. Livestock production uses about a third of the world’s arable land, and as land becomes scarce, expansion of livestock production encroaches into forest land and is causing mass deforestation.

Given the livestock sector’s enormous environmental impact, the report calls for it to become a focus of environmental policy, and says such changes will have a huge potential payoff.

The American Journal of Clinical Nutrition’s May supplement on vegetarian, vegan and plant-based diets and their effects on health included two studies that examined how our eating choices affect the planet.

In the first of these studies, a review paper looking at the greenhouse gas contribution of different foods gives number values to our food choices.

Which greenhouse gases are the by-products of food production? There’s widespread conversation about carbon dioxide, and its contribution to climate change, and fossil fuels are used in agriculture for fertilizers, transportation and other energy requirements.

But two other gasses produced mainly by agriculture have an even larger green-house effect: methane and nitrous oxide. Methane is produced by ruminant livestock (such as cattle, sheep and goats) and stored manures, but also from rice grown under flooded conditions. Nitrous oxide is generated through feed-production processes and is an animal waste by-product.

Comparing emissions

A study of 22 food items sold in Sweden shows that the greenhouse gas emissions associated with foods differ greatly. For this study, carbon dioxide, methane and nitrous oxide were assessed for the farm-to-table production cycle, so storage, transportation, preparation and processing all factored into this calculation.

Here are the findings:

• The lowest emissions are produced by domestic vegetables, cereals and legumes (excluding rice).

• The highest emissions are produced by domestic beef, which produces about 70 times more greenhouse gasses per kilogram (about 2.2 pounds) of food than fresh domestic veggies fruit and grain.

• All animal products have higher greenhouse gas emissions than plant-based products, with the highest emissions produced by beef, cheese and pork, in that order.

• Fowl meat and eggs are relatively climate-friendly compared to beef; a kilogram of chicken produces about a sixth of the greenhouse gasses generated by a kilogram of beef.

• Tropical fruit, flown by plane, had emissions that were similar to animal foods.

• Fruit and grain shipped by boat had about double the amount of emissions compared to domestic fruits and grains, but their emissions were still 1/40 of domestic beef.

• Rice has greater emissions—about three times more—than other grains.

• Fish may cause high emissions due to high use of fossil fuels for fishing. Many fish are on the verge or under a severe threat of extinction, and the article sees the fish option as environmentally unsound for the most part.

To put these emissions in perspective, the researchers compare food emissions to those of the average European car: Consumption of one kilogram of domestic beef equals driving for about 100 miles in green-house gas measures.

Looking at the findings above, you may argue that comparing a kilogram of carrots to a kilogram of beef is misleading, as beef provides lots of protein, and therefore a bigger emission footprint might be justified. The paper therefore provides a table that shows how many grams of protein different foods make per kilogram greenhouse gas emissions.

The best-for-the-planet winner is domestic whole wheat, but even vegetables such as green beans and carrots, which contain very little protein, are more climate-efficient than beef in producing protein.

How green is your dinner?

The authors then analyzed the green-house gas effect of three meals, each containing a vegetable, a fruit, cereal, and a protein source, and all with similar nutritional value (i.e., the same amount of calories and protein).

• Meal A contained domestic carrots, domestic whole wheat, soybean from overseas by boat, and an orange from overseas by boat.

• Meal B contained green beans, potatoes, pork meat, and an orange from overseas by boat.

• Meal C contained frozen vegetables, rice from overseas by boat, domestic beef, and tropical fruit from overseas by plane.

The emissions of meal C are about 11 times those of meal A, while those of meal B are three times the emissions of meal A. (I daresay that besides the tropical fruit flown by plane, meal C is a pretty typical American meal). By this analysis, meal A is the “greenest.”

The authors conclude:

"The analysis shows that changes toward a more plant-based diet could help substantially in mitigating emissions of GHG (green house gasses)."

Comparing diets

The second American Journal of Clinical Nutrition study compared the environmental impact of vegetarian and non-vegetarian diets. The researchers looked at the data from the Seventh Day Adventist cohort, which includes 34,000 Adventists, 50 percent of whom are vegetarian, and found 11 food groups that vegetarian and non-vegetarians consume in significantly different amounts, such as animal foods (vegetarians consume less), and fruits, nuts and beans (vegetarians consume more). The researchers then looked at water consumption, energy use, pesticides and fertilizers applied to produce these foods using federal, state and industry data.

The non-vegetarian diet required 2.9 times more water, 2.5 more energy, 13 times more fertilizer and 1.4 times more pesticides than the vegetarian one.

These results are not surprising at all, considering the fact slaughter animals raised in factory farms are usually fed plant food (grains, such as corn and soy), which they convert very inefficiently to the animal meat that we eat. It’s of course much more efficient for us to eat the grain directly.

I’ve touched upon the animal rights and welfare argument very briefly in a previous post, and indeed, I think the morality and ethics of food and eating are an unscientific subject rooted in personal values on which many people may not easily find common ground.

However, the health argument for moderating meat intake, especially red meat intake, is quite compelling and supported by plenty of evidence. I’d buy into that.

Clearly the environmental impact of the expanding meat industry is huge, and evidence shows that if we just reduced our meat intake we’d see substantial environmental gains for our planet.

Unfortunately, the demand for meat is still growing as developing countries aspire toward a typical Western diet. The current global average daily consumption of meat is about 100 grams or 3.5 ounces per person, but there’s great disparity: The US intake is about half a pound a day, and Africa’s is about an ounce a day.

It’s clear that meat production even at current levels is unsustainable. If we want to combat global warming, land and water degradation and all of the other ills caused by industrial meat production, we need to reduce meat consumption. And the major reduction needs to occur where meat intake is high—half a pound a day is seriously way too much from a health point of view even if it were beneficial for the planet.

Current public policies are very friendly to the meat industry. For example, the grain animals are fed is subsidized, and meat and poultry producers aren’t forced to treat the mountains of waste an industrial farm generates. This ensures relatively inexpensive meat, which encourages us to eat more animal products.

No matter what your reason, I believe if you eat lots of meat, reducing meat intake is a significant personal action you can take to help reduce greenhouse gasses and improve your health.

What do you think?
Dr. Ayala