Healthy Food & Healthy Living by Dr. Ayala

Is sourdough bread really better for you?

 

My sourdough starter is part of my home. Like a pet, it needs attention – a morning and evening feed. It's all the pet I want as it has asks for so very little, yet like a pet, it gives back so much more than it receives. 

Feeding my starter has been part of my daily routine in the past few months, as has been the baking of the daily loaf. When I have too many I give them away, sometimes with an offer of a jar of the starter – or leaven – that’s the magic behind the sourdough.

My starter is indeed some kind of reflection on my home, as it contains the unique microorganisms collected in it. No two starters are alike, even if they started from the same batch, or came from your favorite bakery, and today’s starter is different from the one you’ll have next month. It took me around two weeks to get from whole wheat flour and water to a reliable starter, but now my baby’s strong, resilient, and as long as it’s fed, it will make delicious, nourishing bread.

A sourdough bread is made out of four ingredients: flour, water, salt and the starter. Seemingly simple ingredients, except the starter – many bakers name theirs and speak of them in terms of endearment – is no ordinary ingredient. 

The starter is a complex microbial ecosystem, consisting mostly of lactic acid bacteria and yeast. These microbes ferment the dough, give it its unique flavor characteristics, and change the bread’s nutritional profile.

In the beginning

Fermentation must have started as a happy accident thousands of years ago.

In order to digest dry cereal ancient people had to process it: grind the hard grain, and mix it with water. At some point they must have noticed the pleasant sour aroma from the left-on-its-own porridge, and the accompanying airy quality it took, and when they heated this puffed up sponge it rose even more, like magic, emitting the most magnificent scent.

The rest is history. Sourdough was already part of the European diet 5000 years ago; murals of baking leavened dough in Egypt date from 1500 BC. Sourdough was how bread was leavened up until the 19th century, when it was largely replaced by baker’s yeast, Saccharomyces cerevisiae, a monoculture of yeast that gives predictable results. Nowadays, sourdough starter is used mainly in artisan breads.

What’s in that starter?

Each starter is unique, and because it’s a living culture of organisms, which produce their next generation several times an hour, it also evolves constantly. The dominant bacteria are Lactobacillus species, bacteria that produce lactic acid, which vary from region to region, as the typical San Francisco environment has native inhabitants that are distinct from those in Rome. Lactobacillus sanfranciscensis, a common species of lactic acid producing bacteria is named after San Francisco, where it was first identified in this city’s famous sourdough, but it’s by no means endemic to the Bay area. Yeasts are less abundant, there are generally 100 bacteria to each yeast. There are many different kinds of yeast typically in sourdough starter, and those, too, depend on variables such as where the leaven originated, the type of grain used, humidity, and temperature. The yeast and the bacteria are everywhere, in the air and in flour; by nurturing your starter you’re giving them an opportunity to form a colony and collaborate in bread making.

No wonder homemade sourdough bread holds so many surprises.

Professional bakeries go to great lengths to get a consistent loaf, but for the home baker the endless mystery of the sourdough experiment may be part of the appeal – you can nurture your starter, but total control isn’t possible, and serendipity is part of the game.

During the sourdough’s long fermentation, typically 12-24 hours, the microorganisms extract energy from the carbs in the dough, and develop flavor molecules – mainly organic acids, alcohols, esters, and carbonyls – through that process. The yeast in the starter is responsible for most of the rise of the bread, and this negative space, created by the gasses that the microorganisms emit, is as important as its substance. A perfect sourdough inner texture will have holes both big and small, alveoli in baker speak.

Is sourdough healthier?

Sourdough’s flavor and mouthfeel are its main selling points – devotees swear it’s the best bread with no parallels – and it’s a more natural and traditional loaf.

But is it nutritionally superior to other breads? 

The long fermentation process is one in which the microbial culture changes and digests the dough, hydrolysing proteins, using up sugars, and chemically transforming an amorphous blob into a plump crusted loaf. 

During fermentation, sourdough bacteria and yeast produce bioactive peptides, which are fragments of protein made of 3-20 amino acids with antioxidant and anti-inflammatory activity, at least in the test tube. These peptides remain active after baking, and may promote health. Lunasin, for instance, is a strong anti-tumoral peptide that's produced during sourdough fermentation.

Sourdough, as the name suggests, is sour, acidic. The bacteria’s produce lactic acid, as well as bacteriocins and antifungals, which act as biopreservatives, protecting the bread from spoilage microbes, that’s why sourdough keeps so well despite having no added preservatives.

Phytic acid, or phytate, which is part of cereal grains, is considered anti-nutritional: it interferes with absorption of grain’s minerals such as iron, magnesium, potassium and zinc. The enzyme,, phytase, present in flour, breaks down phytic acid, making these minerals bioavailable, but this enzyme is usually quite inactive. The acidity of sourdough, as well as the phytase made by the culture, degrade phytate significantly, therefore increasing the bioavailability of the hidden micronutrients.

Sourdough may be better tolerated by people with gluten sensitivity. Sourdough fermentation results in some breakdown of gluten, especially the gliadin component of gluten, and wheat flour sourdough may be better tolerated by people sensitive to gluten. Wheat sourdough isn’t gluten free, though, and people with celiac should avoid it.

Sourdough typically has a lower glycemic index than regular bread – 54, which puts it in the low GI food category – and may elicit lower spikes in blood sugar and insulin, making it more suitable for people with diabetes and insulin resistance (regular breads have a glycemic index in the 70s).

The friendly bacteria in sourdough don’t survive the high temperatures of the oven, therefore sourdough is not a probiotic. It’s a prebiotic though – the fiber and absence of additives may benefit a healthy microbiome.

Each sourdough bread is of course different, sourdough can be made with whole or refined flour, with wheat and with rye and many other grains, and the more whole grains in the dough, the healthier the bread.

Outsourced

A sourdough routine has been somewhat popular in these crazy Covid-19 times for many reasons. Once you look at a sourdough recipe you’ll realize the time and space commitments and that sourdough bread making is more logically outsourced. Even in old times bread was at least baked in a central location – I kind of feel bad about heating my oven to 500 °F daily for just one or two loaves. It’s more hobby than practicality. 

I strongly believe in healthy homemade meals – those needn't be complicated, or terribly time consuming, and they’re key to taking charge of your health and wellbeing. 

Look at sourdough as metaphor. When you do through the exercise of telling this bread apart from factory-made fast loaves, you see the nutritional sacrifice on the one hand, and the time saving on the other. Bread making is perhaps best left to the specialists; not so with something like a salad, which you can make in minutes, with incredible results.

Dr. Ayala

An end to the gluten-free fad?

 

May is Celiac Awareness Month. Celiac disease can have very subtle manifestations, and its relatively non-specific and sometimes almost invisible symptoms make awareness of it critical. Awareness should make patients and physicians consider the possibility, and then diagnose it; or rule it out.

It doesn’t mean that everyone should avoid gluten, just in case.

It’s estimated that up to 1 percent of the American population has celiac, most of these people don’t yet know they have it. Others may have gluten sensitivity, a less clearly defined clinical entity. But there is now a widespread belief that gluten is just bad for your health, and the rise in gluten-free food adoption has been meteoric. A survey shows a third of Americans are trying to avoid gluten.

The anti-gluten movement has been greatly beneficial for the people whose health depends on gluten-free food – at last there are breads, grains flours and even restaurants that cater to their needs.

But the belief that gluten-free foods are better for the general population has many downsides.

The downside of the gluten-free fad

One of the obvious ones is that pointing at the wrong target makes you miss more important, more proven-to-harm ones.

Another downside is that by avoiding gluten you might actually be eating worse.

A new study just published in BMJ, that included about 6500 people who were followed up for more than 20 years, found that avoiding gluten not only didn’t improve heart hearth, it may have also increased their risk, as it led to reduced consumption of beneficial whole grains, known to reduce the odds of coronary artery disease.

Eating more gluten was associated with a lower risk of type 2 diabetes in a recent study presented at the American Heart Association meeting.

Another study, presented at the at the 50th Annual Congress of the European Society for Pediatric Gastroenterology Hepatology and Nutrition demonstrated what careful nutrition-label readers might have already suspected: Gluten-free foods often have more calories than their gluten-containing counterparts. The researchers gathered 655 gluten-free foods, and found that across the board, from pasta to cookies to ready meals, these foods had more fat and calories, and less protein than their 654 ordinary, gluten containing equivalents.

The authors warn that the gluten-free craze might be fueling obesity, as the gluten-free halo might be giving the impression that these highly-processed cookies and cereals are healthier than the wheat containing equivalents. In fact, those gluten-free products were even more energy-dense.

Bottom line

A gluten-free diet is essential for people who suffer from celiac, and might help people with gluten sensitivity.

As for the rest of us, we should be moderating our intake of all highly refined and highly processed grain-based foods -- not just gluten-containing ones. On the other hand, whole grains are foods that are good for our health, and there's no reason to deny ourselves the pleasure of a good whole-wheat or barley based bread in favor of one made with corn and tapioca starches.

Here, you have my permission to enjoy a good loaf of bread.

Dr. Ayala

The downside of gluten-freeing your kids

The gluten-free food industry has seen tremendous growth, and while celiac disease – which requires lifelong complete avoidance of gluten – is also on the rise, consumers who do not have celiac or any other medical reason to avoid gluten are the main engine propelling the gluten-free boom.

Why do they do this, and is this a healthy trend?

Norelle Reilly, gastroenterologist and director of the Celiac Disease Center at Columbia University Medical Center, in a commentary in the Journal of Pediatrics, cites a 2015 survey of 1500 American adults. “No reason” is the most common reason for going gluten free – 35 percent of those surveyed explained their choice just so. 26 percent choose gluten-free food because they think it’s a healthier option, and 19 percent perceive it as better for digestive health.

If gluten-free foods are indeed a healthy trend, the fact that 20 percent of Americans are seeking them for no medical reason might be a good thing. If, on the other hand, gluten free carries risk, this fad might be an expensive gamble.

The risk of gluten free

For people who do not have celiac, wheat allergy, or non-celiac gluten sensitivity, there is no data to support the notion that gluten free is healthy, states Dr. Reilly. In fact, packaged gluten-free food often contains more sugar and fat, and has higher caloric density. Contrary to what people believe, going gluten free without medical supervision can lead to packing extra weight, to insulin resistance, and to vitamin deficiencies, since gluten-free foods are not fortified the way wheat is.

And then there’s arsenic. Gluten-free diets often rely heavily on rice, and rice quite often, contains arsenic, which comes from the soil. The amounts are small, and probably not a problem if one eats a varied diet, but on a gluten-free diet rice becomes the predominant grain, and that can be especially problematic for babies and pregnant women.

A gluten-free diet, just like many other exclusion diets, comes with a quality of life price tag. And these specialty foods often cost more and are sold at a premium.

And since in kids there are only two indications for excluding gluten from the diet: celiac disease and wheat allergy (non-celiac gluten sensitivity has not been described in kids), putting kids on this diet carries risk with no apparent benefits. There is no support to the misconception that gluten is toxic, and no evidence that gluten-free diets treat a myriad of afflictions such as autism, arthritis or obesity.

Dr. Reilly concludes:

“Patients self-prescribing a GFD (gluten-free diet) should be counseled as to the possible financial, social, and nutritional consequences of unnecessary implementation.”

The food industry uses the health halo of the gluten-free health claim to better sell. It’s really important to emphasize that just like one knows that foods that are peanut free are not generally healthier, gluten-free foods are not a panacea; avoiding gluten isn’t a recipe for health for those of us who don’t have a sensitivity or autoimmunity that involves gluten.

Dr. Ayala

Who should be living gluten-free?

According to a new study about one in 140 people in the US have celiac disease.  This is about 1.8 million people who should adopt a gluten-free diet to be healthy.

According to this study, published in The American Journal of Gastroenterolgy, about 1.6 million people in the US are on a gluten-free diet, so it sounds like these two numbers match nicely.

But here’s the interesting part: the study, which looked for celiac in a nationally representative sample of almost 8000 people, (the researchers measured antibodies used to screen for celiac, and surveyed the medical histories and records of all the subjects to make the diagnosis of celiac disease) found that 29 of the 35 people with celiac had no idea they had the disease. 

On the other hand, of the 55 people in the study who were on a gluten-free diet 49 did not have a clinical history or any laboratory evidence of celiac.

Gluten-free as a diet fad

Gluten is probably one of the only food proteins most of us know by name, and now that the name's out and is associated with a bona-fide medical condition – and not an uncommon one – gluten is feared. Gluten avoidance has been adopted not only for celiac, gluten sensitivity or intolerance, but also as a treatment for many other unrelated conditions, and also for weight-loss and as a healthy lifestyle regimen.

Celebrities like Gwyneth Paltrow, Victoria Beckham and Novak Djokovic are touting gluten-free’s slimming powers and positive influence, while other celebrities are feeding gluten-free diets to their kids as an autism remedy.

Is removing gluten indeed a cure-all?

You can lose weight on a gluten-free diet: if you replace muffins and donuts with fruits, veggies and quinoa you’ll also be eating better.

You can also gain weight by going gluten-free if you replace bread with gluten-free chips and cupcakes. It’s not easy to make baked goods without gluten; therefore many gluten-free baked goods have lots of calories and fat.

In fact, gluten-free has nothing to do with weight-loss or with treating autism.

What’s wrong with gluten? 

It’s great that gluten-free standards and products are available -- these foods are important for the health of some of us.

But for 99 percent of the population gluten presence or absence is irrelevant. Gluten-free is as immaterial to the general public as “may contain peanuts” is to people without a peanut allergy.

Gluten-free has become a marketing tool, and we’ve fallen again into the old trap of nutrition confusion feeding us lots of junk. In much the same way that fat-free and low-carb led to highly processed food innovations containing loads of sugars, trans-fat and artificial sweeteners, we’re now running away from gluten, replacing it with whatever’s gluten-free. 

Gluten, my friends, is a component of whole grains, and there’s absolutely nothing wrong with it for most people. Gluten is what gives bread its traditional structure, strength and texture and bread in an historic and cultural staple.

Gluten-free foods can be nutritious or pure junk, and if you're looking to eat well the gluten-free declaration isn't a shortcut -- you'll have look at the ingredient list. 

Dr. Ayala

“Are we really all going to spend our last years avoiding bread, especially now that bread in American is so unbelievable delicious?”

― Nora Ephron, from I Feel Bad About My Neck: And Other Thoughts on Being a Woman

Want milk? Lactose intolerance shouldn’t stop you

Are most Americans lactose intolerant? Do all dairy products contain lactose? How critical is it to stick to a lactose-free diet?

Although most of us know someone who is lactose intolerant, and “lactose intolerance” frequently comes up in health-related conversations, there are many myths and misconceptions regarding this common digestive issue. I’d like to take a look at this malady and at the findings of a recent National Institutes of Health (NIH) consensus conference on lactose intolerance, where experts in many medical fields pored over the relevant medical literature, discussed findings and developed a state-of-the-science statement that includes a few surprises.

(This post is about the common form of lactose intolerance—primary lactose intolerance—and is not about lactose intolerance that arises from illness or intestinal injury, or the rare cases of babies born unable to digest lactose.)

Lactose and lactose intolerance

Chemistry moment (this won’t take long): Lactose is a two- molecule sugar (or disaccharide) made up of one molecule of glucose and one molecule of galactose. In order to absorb lactose our body needs to break the bond between the two simple sugars using the enzyme lactase.

Lactase is abundant in the human intestine in infancy, but its level declines with age in many people. Lactase production is a fascinating example of our body’s ability to turn genes on and off; while the genetic code for producing lactase is in the cell, the cell can turn off production partially or completely.

Those of us with lower levels of lactase don’t break up some or all of the dietary lactose, which will reach the large intestine undigested; there, bacteria will happily feast on the sugar and produce gasses: carbon dioxide, hydrogen and methane. Undigested sugars can also draw water from the intestinal walls, causing bloating and diarrhea.

But low lactase by itself doesn’t define lactose intolerance; most people who have low lactase don't experience signs and symptoms (the common ones being diarrhea, abdominal pain, gas, bloating or nausea). Only people with both low-lactase levels (measured by a health professional) and associated signs and symptoms have, by definition, lactose intolerance.

How common is it?

Surprisingly, the NIH panel concluded that we don’t really know.

Many people with low levels of lactase have no symptoms. Many people with gastro-intestinal symptoms attribute symptoms to lactose intolerance even if they haven’t demonstrated deficiency of lactase; their symptoms may very well be due to other reasons.

What we do know is that low lactase varies across ethnic groups, occurs less frequently in European Americans and more frequently in African Americans, Asian Americans and Native Americans.

Do people with lactose intolerance need to avoid lactose?

Let’s start with an explanation of the big difference between lactose intolerance and serious food allergies or gastrointestinal immune diseases such as celiac.

Food allergies can cause life-threatening systemic reactions after exposure to minute amounts of the offending food. Likewise, the intestine of a celiac patient suffers changes to its surface—changes that can lead to malabsorption, anemia and even cancer—even if exposed to very small amounts of gluten.

But not absorbing some of the sugars in our food is part of everyday life for all of us.

Beans, for example, contain sugar chains—called raffinose oligosaccharides—which no human can break down. The sugar polymers are digested by bacteria in the gut resulting in the well-know bean related flatulence—the butt of many jokes—and can also cause symptoms resembling those of lactose intolerance.

Some people experience no discomfort after eating beans while others limit their intake of beans because large amounts cause them symptoms. There are even individuals who experience such great discomfort that they choose not to eat beans at all. Our individual anatomy and physiology, our intestinal microbial flora, as well as the way we perceive pain and social awkwardness differs a lot. And by no means are beans unhealthy—they are in fact very good to eat!

Milk contains a considerable amount of lactose, much more than the undigested sugars in beans, but the bean analogy can perhaps explain some of the symptom variability we see with lactose intolerance.

So how much milk can people with lactose intolerance tolerate?

The NIH panel looked at the best studies, and concluded that most lactose-intolerant individuals can take in 12 grams of lactose (the equivalent of one cup of milk) in a single sitting with minimal or no symptoms and can tolerate larger amounts if the lactose if ingested with meals or spread over the day. A quart of milk (50 grams of lactose) ingested without food in one sitting will induce symptoms in most lactose-intolerant people. There’s also some evidence showing that the body gets used to lactose, and can tolerate more lactose if routinely exposed to it.

The most important long-term health consequence of lactose intolerance may be calcium deficiency

There are many ways to eat healthy, and dairy is by no means necessary for a balanced diet. Balanced Asian-type and vegan diets are perfectly healthy with little or no dairy. Calcium sources—both naturally occurring or in supplements—are plentiful. (Foods rich in calcium include collard greens, turnip greens, kale, bok choy, soybeans, okra, broccoli, some fish, cultured soy yogurt, tofu, almonds, and calcium-fortified orange juices, soy milks and cereals.)

But dairy products are by far the most prevalent—and least expensive—source of calcium in the Western diet. Since many people with real or perceived lactose intolerance avoid dairy products, they may consume inadequate amounts of calcium and vitamin D (which is added to milk), leading to weaker bones and osteoporosis.

Therefore the diagnosis of lactose intolerance should be made judiciously, and the treatment plan should include assuring that dairy avoidance, if necessary, won’t lead to nutritional deficiencies.

Lactose sources

Milk products vary greatly in their lactose content.

Milk itself has a lot of lactose, but aged cheeses have very little (most of the lactose is drawn away in the whey, and what’s left in the curd is fermented by bacteria and mold). Yogurt with live cultures contains bacteria that break down lactose, and therefore causes fewer symptoms. Butter and full-fat cream cheese contain almost no lactose.

Practical tips

If you think you have lactose intolerance:

Talk it over with your doctor; getting an accurate diagnosis for your symptoms can be important. Some of the causes of recurrent abdominal pain are treatable and it’s not a good idea to commit to an elimination diet for the wrong reason.

If you do have lactose intolerance:

Find a reduced-dairy eating plan that controls your symptoms, while enabling both good nutrition and enjoyment of food.

Eat dairy products with less lactose (cheese, yogurt) and spread your dairy consumption throughout the day. Consume dairy as part of a meal.

Make sure you get enough of the nutrients usually found in dairy, especially calcium.

Consider using lactase products; these are dietary supplements that help digest lactose.

Above all, listen your body—treatment and diet plans can’t ever be one size fits all. Find what works for you and stay healthy!
Dr. Ayala

This entry has been posted as part of The Kathleen Show's Prevention not Prescriptions

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