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Should we all go gluten-free?

William F. Balistreri, MD

February 04, 2016

The question of whether to adopt a gluten-free diet is especially timely, given its impressive increase in popularity over the past decade. In fact, gluten avoidance has become the most popular dietary trend in the United States, with approximately 100 million Americans consuming gluten-free products last year.

Presently, there are at least three proposed clinical syndromes related to gluten ingestion: celiac disease, an autoimmune-mediated disorder; wheat allergy, an immunoglobulin E (IgE)-mediated entity; and gluten sensitivity, in which celiac disease and wheat allergy have been ruled out. Therefore, the decision to “go gluten-free” is either mandatory or elective; a gluten-free diet is mandatory for those individuals with appropriately diagnosed celiac disease and possibly wheat allergy. However, many individuals elect to follow a gluten-free diet because of a presumed sensitivity. While approximately 1% of the population are believed to have celiac disease, it is estimated that as many as 60% of Americans believe that a gluten-free diet will improve their physical and/or mental health.[1-4] It is their choice to follow a gluten-free diet in the hopes of improving digestion and bolstering their immune system, while also enabling enhanced performance and weight loss.

This belief has been fostered by the testimony of celebrities and athletes who attribute their success and well-being to adherence to a gluten-free diet. A survey done by Lis and colleagues[5] of 910 world-class athletes and Olympic medalists found that 41% followed a gluten-free diet, the majority because of a self-diagnosis of “sensitivity to gluten” and perceived ergogenic or health benefits. The same authors investigated the effects of a gluten-free diet on exercise performance, gastrointestinal symptoms, perceived well-being, intestinal injury, and inflammatory responses in nonceliac endurance athletes.[6] The short-term gluten restriction had no overall beneficial effect on any of these outcomes. In addition, numerous books and websites cater to this gluten-free phenomenon. Claims have even been made that gluten can be harmful to all of us.

The appeal of a gluten-free diet has become big business, leading to greater gluten-free product availability and a wider variety of dietary options. The market for gluten-free foods continues to expand and is estimated to have reached over $4 billion in retail sales in the past year. However, there are barriers to going gluten-free, including the cost and long-term safety of gluten-free foods and the potential for gluten cross-contamination of products. In addition, a gluten-free diet could present social restrictions, possibly leading to nonadherence.[7-9] Continue Reading

Nonceliac Gluten Sensitivity

Nonceliac gluten sensitivity (NCGS) is the newly minted term used to describe a clinical disorder related to ingestion of gluten or gluten-containing cereals.[8-13] Lebwohl and colleagues[14] suggest that a more accurate term for this condition is simply “people who avoid gluten.”

Clinical Spectrum

NCGS has largely been characterized by a series of self-reported gastrointestinal symptoms such as abdominal pain, gastroesophageal reflux, gas/bloating, nausea, diarrhea, and/or constipation.[15] However, a wide variety of nongastrointestinal symptoms has also been reported, including headache, fatigue, “foggy mind,” anxiety, depression, muscle aches, and skin rashes. A similar spectrum of symptoms has been reported in children.[16,17] Aziz and Hadjivassiliou[9] demonstrated that in patients with NCGS, gluten is independently associated with depression, which might share pathophysiologic mechanisms with other neurologic manifestations observed in gluten-related disorders, such as ataxia and encephalopathy.

Working Definition

A recent report by Fasano and colleagues[8] reviewed the current understanding of NCGS and outlined steps to dissipate some of the confusion related to this disorder. They propose a working definition as follows: “a clinical entity induced by ingestion of gluten leading to intestinal and/or extraintestinal symptoms that resolve once gluten is eliminated.” This definition requires that celiac disease and wheat allergy have been ruled out. They further propose that NCGS is associated with prevalent gluten-induced activation of innate—rather than adaptive—immune responses in the absence of detectable changes and mucosal barrier function. Gluten sensitivity was similarly defined by an international panel as the occurrence of intestinal and extraintestinal symptoms related to the ingestion of gluten-containing food in subjects without celiac disease or wheat allergy.[18-21]


Aziz and colleagues conducted a survey in order to estimate the prevalence of self-reported NCGS in the general population and the frequency of adherence to a gluten-free diet outside of celiac disease.[1,22] They determined that 13% of the population (79% female; mean age, 39.5 years) self-reported gluten sensitivity, only 0.8% of whom had a valid diagnosis of celiac disease. During investigation of another cohort of 200 patients with presumed gluten sensitivity (84% female; mean age, 39.6 years), 7% were found to have celiac disease and 93% to have NCGS.[1,22] All patients with celiac disease were HLA (human leucocyte antigen) DQ2 or DQ8 positive compared with 53% of the subjects with NCGS. Nutritional deficiencies, autoimmune disorders (23% vs 10%), and a lower mean body mass index were significantly associated with celiac disease compared with NCGS.

In a survey of more than 1000 Australians, 7% reported adverse effects when ingesting wheat products, although the majority had not undergone formal assessment for celiac disease or wheat allergy.[23]

Biesiekierski and colleagues[15] also surveyed a series of adults who believed that they had NCGS. They learned that a gluten-free diet was most commonly self-initiated among respondents (44%) and was less often prescribed by alternative health professionals (21%), dietitians (19%), or general practitioners (16%). Initiation of a gluten-free diet without adequate exclusion of celiac disease was common; no investigations to rule out celiac disease had been performed in 15% of respondents. In 25%, symptoms are poorly controlled despite gluten avoidance.

CDC: Coming Flu Season may be severe

On Wednesday, the CDC announced that the strain of influenza virus chosen as the basis of this year’s vaccine does not match the common strains of flu virus now circulating. On Thursday, the CDC warned of the severity of the upcoming flu season. David Muir interviewed ABC’s Chief Medical Editor Dr. Richard Besser on ABC World News (12/4, story 7, 1:15, Muir) about the CDC’s concerns over the flu. Muir reported that “Tonight, the CDC now pointing to what it calls a concerning sign that this flu season will be a bad one.” Dr. Besser explained that the makers of the flu shot “guessed wrong” in their selection of the virus to base the shot on. “Between the time they selected the strain for the vaccine in February and now, the flu strain in the community mutated. So, that the vaccine no longer provides protection,” he added. Besser explained that the shot is “not going to work the way a flu vaccine normally works. But it should provide some level of protection and some protection is better than none.” Besser said the flu season is “going to be severe for two reasons: one is, it’s a bad match. But the particular strain that’s in the community in past outbreaks has caused more severe disease, more people in the hospital.” The CBS Evening News (12/4, story 7, 0:25, Pelley) briefly reported, “The CDC told us today the flu shot that you got this year may not be as effective as you would hope … while flu vaccines are usually about 60 percent effective, this season it could be 40 percent.” NBC Nightly News’ (12/4, story 4, 1:35, Holt) Dr. Nancy Snyderman reported that “The CDC has issued a warning tonight about the flu virus… It has mutated, meaning that the flu shot or mist that millions of people got to protect themselves won’t provide nearly as much protection as usual.” Snyderman said that “it’s too late to make a new vaccine for this season, so people who think they may be getting the flu should see their doctor right away,” adding that “the most effective drugs…work best in the first 48 hours of getting sick.”
In continuing coverage from yesterday’s announcement, the Washington Post (12/5, Bernstein) reports that “the government on Thursday recommended immediate vaccination for anyone who hasn’t taken that precaution and urged people who come down with the flu to seek anti-viral medication from their doctors.” According to the CDC announcement, five children have already died this year from the flu, and the strain of the virus circulating, H3N2, has been indicative of a severe flu season in three of the last 11 seasons. The strain has led to increased deaths and hospitalizations in past years. Dr. Thomas Frieden of the CDC noted that only one of every six people suffering from the flu get antivirals, saying those drugs “aren’t a substitute for vaccine. Vaccine prevents flu, but anti-virals are an important second line of defense … and this year treatment with anti-viral drugs is especially important.”
While the H3N2 flu strain is the dominant variety, three other strains are also circulating, according to USA Today (12/5, Szabo). The H3N2 strain “has doubled rates of hospitalizations and deaths in the past, especially among older people, very young children and people with chronic health conditions, said Frieden.”
The New York Times (12/5, Mcneil, Subscription Publication) adds that Frieden said “Flu is unpredictable, but what we’ve seen thus far is concerning.” Though H3N2 is not the only strain of virus circulating, the Times writes that “91 percent of the approximately 1,200 samples tested thus far are of the H3N2 subtype of influenza A, Dr. Frieden said,” and “almost all the rest were influenza B.” The Times notes that none of the strains seen so far are descendants of the swine flu virus. Of the H3N2 samples, 45% were of the subtype against which this season’s flu shot does not protect.
The Wall Street Journal (12/5, Mccabe, Subscription Publication) writes that the flu virus mutation has “drifted,” according to the CDC. Dr. Frieden said, “Getting a vaccine that provides at least partial protection may be more important than ever.”
The Los Angeles Times (12/5, Morin) explores the process of developing the flu shot. Because of the delay between when the flu vaccine has to be manufactured and when it is actually administered, the flu virus has ample opportunity to mutate or drift. Manufacturing begins four to six months before the flu season takes off, meaning scientists must guess or predict which virus strain will be dominant.

Fit kids = smart kids

A new study of 9- and 10-year-olds finds that those who are more aerobically fit have more fibrous and compact white-matter tracts in the brain than their peers who are less fit. “White matter” describes the bundles of axons that carry nerve signals from one brain region to another. More compact white matter is associated with faster and more efficient nerve activity. 
The team reports its findings in the open-access journal Frontiers in Human Neuroscience
“Previous studies suggest that children with higher levels of aerobic fitness show greater brain volumes in gray-matter brain regions important for memory and learning,” said University of Illinois postdoctoral researcher Laura Chaddock-Heyman, who conducted the study with kinesiology and community health professor Charles Hillman and psychology professor and Beckman Institute director Arthur Kramer. “Now for the first time we explored how aerobic fitness relates to white matter in children’s brains.”
The team used diffusion tensor imaging (DTI, also called diffusion MRI) to look at five white-matter tracts in the brains of the 24 participants. This method analyzes water diffusion into tissues. For white matter, less water diffusion means the tissue is more fibrous and compact, both desirable traits. 
The researchers controlled for several variables– such as social and economic status, the timing of puberty, IQ, or a diagnosis of ADHD or other learning disabilities– that might have contributed to the reported fitness differences in the brain. 
The analysis revealed significant fitness-related differences in the integrity of several white-matter tracts in the brain: the corpus callosum, which connects the brain’s left and right hemispheres; the superior longitudinal fasciculus, a pair of structures that connect the frontal and parietal lobes; and the superior corona radiata, which connect the cerebral cortex to the brain stem. 
“All of these tracts have been found to play a role in attention and memory,” Chaddock-Heyman said. 
The team did not test for cognitive differences in the children in this study, but previous work has demonstrated a link between improved aerobic fitness and gains in cognitive function on specific tasks and in academic settings. 
“Previous studies in our lab have reported a relationship between fitness and white-matter integrity in older adults,” Kramer said. “Therefore, it appears that fitness may have beneficial effects on white matter throughout the lifespan.”
To take the findings further, the team is now two years into a five-year randomized, controlled trial to determine whether white-matter tract integrity improves in children who begin a new physical fitness routine and maintain it over time. The researchers are looking for changes in aerobic fitness, brain structure and function, and genetic regulation. 
“Prior work from our laboratories has demonstrated both short- and long-term differences in the relation of aerobic fitness to brain health and cognition,” Hillman said. “However, our current randomized, controlled trial should provide the most comprehensive assessment of this relationship to date.”
The new findings add to the evidence that aerobic exercise changes the brain in ways that improve cognitive function, Chaddock-Heyman said. 
“This study extends our previous work and suggests that white-matter structure may be one additional mechanism by which higher-fit children outperform their lower-fit peers on cognitive tasks and in the classroom,” she said.

Entering Summer…treating sunburn

What dermatologists tell their patients

Even mild sunburn can cause psoriasis to flare. To protect your skin, use a fragrance-free sunscreen. Fragrance can irritate the skin and cause psoriasis to flare.

Dermatologists recommend that everyone, including their patients who have psoriasis, use a sunscreen that offers:

  • SPF 30 or higher
  • Broad-spectrum (UVA/UVB) protection
  • Water resistance

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