Category Archives: gluten

Non-celiac gluten sensitivity

Gluten is protein, not carbs.  A gluten-free diet is frequently low-carb, because most dietary gluten comes in the form of bread (and wheaty foods).  But believe it or not, bread is an incredibly complex food… many different proteins, carbohydrates, and nutrients that could be problematic for some people (more on this later).

Gluten is not a FODMAP, but most gluten-containing foods are.  Gluten is actually very rich in the amino acid glutamine.  Gluten, not bread.

So we have three studies on purified “gluten,” asking if it’s the gluten, FODMAPs, or something else in wheaty food that is problematic.

Study #1. No effects of gluten in patients with self-reported non-celiac gluten sensitivity after dietary reduction of FODMAPs (Biesiekierski et al., 2013)

Strong study design; patient population was people who thought they were gluten sensitive (but definitely not celiac).

This is the study which led journalists to claim non-celiac gluten sensitivity doesn’t exist, and it’s really sensitivity to FODMAPs, in part, because of this:

 

 

low FODMAPs and gluten free

 

 

Baseline = low gluten diet
Run-in = low gluten and low FODMAPs

 

Here’s the fly in the ointment:

 

symptoms returned in all participants

 

After the run-in period, subjects still followed their gluten-free diets but also received either 16g relatively pure gluten/d (High gluten), 2g gluten + 14g whey protein (Low gluten), or 16g whey protein (placebo).  GI symptoms returned in all participants.  So, low FODMAPs worked for about a week, but then symptoms returned regardless of whether they were eating gluten or not.  In other words, neither low FODMAPs nor low/no gluten worked very well in this study.

But this study may have introduced a brilliant new confounder: food intake was strictly controlled — the experimental diets were different from their normal diets.  Restricting gluten and FODMAPs may have provided some transient benefit, but if the new experimental diet introduced something else that caused problems, then that may explain the gradual return of symptoms…

bollixed?

 

 

Study #2. Small Amounts of Gluten in Subjects with Suspected Nonceliac Gluten Sensitivity: a Randomized, Double-Blind, Placebo-Controlled, Cross-Over Trial (Di Sabatino et al., 2015)

It was another high quality study design: “Randomized, Double-Blind, Placebo-Controlled, Cross-Over.”  And it was addressing a basic question: do people who strongly suspect they have non-celiac gluten sensitivity (NCGS) really have NCGS?  Alternatively, is NCGS real?

Intervention was strong:

1) 4.375 grams of gluten or placebo (rice starch) daily for a week.  This is roughly equivalent to two slices of bread (note: this is way more than enough gluten to destroy the intestines of a patient with bona fide celiac disease).

2) important: they defined the what they would classify as NCGS prior to starting the trial.  A priori.

61 patients strongly suspected of NCGS started the trial, and one withdrew due to gluten-related symptoms in both the gluten and placebo groups.

 

Results:  regardless of whether they were assigned to gluten or placebo FIRST (prior to the crossover), most patients reported gluten-related symptoms.  More importantly, 3 of the 59 patients exhibited significantly worse symptoms on gluten relative to placebo according to the endpoint they defined prior starting the trial.  In one sense, this could be interpreted to mean 5% of people who strongly believe they have NCGS actually have NCGS.

 

gluten sensitive patients

 

Two patients reacted just as selectively strongly to the placebo as the three “real” NCGS patients did to gluten.  Rice-starch sensitivity?

 

See here for a more detailed description of the statistics involved in this study.  I’m willing to accept the “5%” rate, despite the strength of the placebo-responders, whereas the author of that blog post is not.  That’s fair, imo.

And here is another article which questions the legitimacy of NCGS based on this study.  I don’t think that’s totally fair.

And Raphael’s post, where he humorously concludes: “[Gluten-free] does not include advice to sport a gas mask when walking past bakeries.”

 

 

Study #3. Effect of gliadin on permeability of intestinal biopsy explants from celiac disease patients and patients with non-celiac gluten sensitivity (Hollon et al., 2015)

 

 

gluten increases intestinal permeability

 

 

“Delta TEER” is basically the amount of intestinal permeability in intestinal explants exposed to media + gluten (experimental condition) minus those exposed to plain media (control condition).  A better control condition, imo, would’ve been something like they did above: substitute gluten with another protein like whey protein.

 

NC: healthy people
RCD: celiac patients in remission
ACD: celiac patients with active disease
GS: non-celiac gluten sensitivity

 

Active celiac samples responded significantly worse than those in remission, which is good as it functions as a positive control for the experimental protocol.

 

However, gluten sensitive samples responded significantly worse than celiac remission samples; actually, they responded just as badly as celiac samples with active disease.  Celiac disease is supposed to be a million times worse than non-celiac gluten sensitivity… and statistically speaking, even permeability the normal samples declined as much as NCGS samples.

 

This led some to conclude that gluten is bad for EVERYONE.  I’d say it means the assay is bollixed.  Occam’s razor?

 

 

My advice: don’t be anti-science, but don’t use bad science to justify diet choices.  We simply need better studies on non-celiac gluten sensitivity and FODMAPs.

If bread doesn’t work for you, don’t eat bread.  You’re not missing much.

 

calories proper

 

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Mediterranean Diet Fail – Nutrition Disinformation, Part I.

Do not get your hopes up, do not pass GO!  do not collect $200.  The Mediterranean Diet.  Fail.

Primary Prevention of Cardiovascular Disease with a Mediterranean Diet (Estruch et al., 2013)

This is one of the biggest diet studies we’ve seen in a while, and no doubt it was a very good one.  It very effectively put the Mediterranean Diet to the test.

I felt compelled to write about this study out of fear for the nutrition disinformation that it would likely inspire.  The Mediterranean Diet is associated with all good things, happiness, red wine and olive oil; whereas the Atkins Diet is associated with artery clogging bacon-wrapped hot dogs and a fat guy who died of a heart attack.  Nutrition disinformation.

If you ran a diet study with 3 intervention groups for 5 years, and by the end of the study everybody (in all 3 groups) was on more prescription medications, would you conclude any of the diets were “healthy?”  If so, then we should work on your definition of “healthy.”

Study details: big study, lasted roughly 5 years, and the diet intervention was pristine.  Mediterranean diet plus extra virgin olive oil (EVOO) vs. Mediterranean diet plus nuts vs. low fat control.  They even used biomarkers to confirm olive oil and nut intake (hydroxytyrosol and linoleate, respectively).  Compliance was good.

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Paleotard, meet potatotard, Op. 132

(credit to Dylan and Woo, respectively, for introducing me to those terms)

Empty calories – the potato

While it has a decent amino acid profile, with only 3 grams of protein it’d take a diabetic amount of potatoes to fulfill your daily protein.  By “diabetic,” I mean about a thousand grams of starch.  potatoes are just as glycemic as white bread.

potato

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Fish oil. Pills or directly from the source? Opus 118.

As a proponent of consuming fatty fish (sardines, salmon, etc.), I was interested to read the new fish oil study; as an opponent of meta-analyses, however, not so much.  A meta-analysis is a type of study whereby the researcher thinks of something they want to prove, then cherry picks studies that best support their point.  Or perhaps I’m just biased.  Nonetheless,

Association between fish consumption, long chain omega 3 fatty acids, and risk of cerebrovascular disease: systematic review and meta-analysis (Chowdhury et al., 2012)

In brief, regarding whole fish consumption, 3 servings per week reduced stroke risk by 6% and 5 servings by 12%.  Surprisingly, there was no effect of fish oil pills that contained ~1.8 grams of long chain omega 3 fatty acids.  What this study lacks is any information about the dose of EPA and DHA (the major bioactive fatty acids in fatty fish); and with 38 studies analyzed, I’m not about to try to figure it out (sorry team)…  a serving of fish can have anywhere from 0 to 1 gram of EPA and DHA; 1.8 grams of long chain omega 3 fatty acids can have anywhere from 0 to 1.8 grams of EPA and DHA.  Therefore, I’ll resort to reviewing two of my favorite fish studies of all time: DART and GISSI.  For a more detailed review of fish oils and these studies, check out The poor, misunderstood calorie (chapter 9).

divide and conquer

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Protein bar takedown, part III (or V)

No more pretense or cute backstory; I just like reviewing ingredient profiles of protein bars.  It’s a hobby of mine:
Candy in disguise, Op. 73 (circa April 2012)
Decepticon Promicor (soluble corn fiber), Op. 81 (June 2012)
Candy in disguise II, Op. 87 (July 2012)
Protein bar round-up, take II (September 2012)

See?

This is a review of Netrition’s “highest rated” bars.  Important notes about this category: these are not necessarily “new” protein bars, or even the bars everyone buy (“best sellers”).  They are the bars everyone who votes like the most.  They’re not the healthiest either… but some come close.   Continue reading

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Corn. A riddle, wrapped in a mystery, inside an enigma.

Utterly.  Shocked.  is how I feel gazing upon the ingredients listed on one particular popular snack food.  And it isn’t one of those fancy gourmet all-natural whole food snacks, it is a classic that is probably in the kitchen of every child-wielding household.

Corn, corn oil, and salt.  And salt doesn’t even count, so it might just as well have said corn and corn oil, which could be summarized as “corn.”  Ladies and gentlemen, I present to you, the reigning champion of snack food sorcery, the red-headed stepchild (no offense) of international superpower PepsiCo… Fritos.  Using only corn, the wizards of Frito-Lay are turning this:into this:

and that’s without the use of trans fat, gluten, artificial additives, dairy, msg, onions, or soy.  They’re Kosher too.

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Almonds: nutrition’s coolest drupe, Op. 89

(it’s a “drupe,” not a nut.  [Thank you Wikipedia.])

Should almonds be upgraded from “snack” to food?  Should almond flour be used in place of some or all white flour?  Yes and yes, IMHO.

In 2007, Josse and colleagues did a quick-and-dirty study on almonds and glucose tolerance.  They fed a group of volunteers 50 grams of carbs from white bread and either 0, 30, 60, or 90 grams of almonds and then measured blood glucose over the following two hours.  “Quick” because they probably had almonds and bread in the refrigerator, and glucometers in their desk drawers; “dirty” because there were a lot of uncontrolled variables; for example: fiber, protein, and fat content of the test meals differed wildly:In a proper study, they might have tried to feed everyone the same amount of fiber, protein, and fat, because each of these is known to affect blood glucose.  In any case, the result was pretty cool:

Whole almonds dose-dependently blunted the blood glucose response to the test meal.  Conclusion: almonds = anti-hyperglycemic.  But almonds are complex lil’ things; they’re made of protein, fat, fiber, and a lot of nutrients; so what’s responsible for all the anti-hyperglycemic effect?  this post is not simply an academic pursuit; indeed, almond flour and almond oil are commercially available, affordable, widely used, and are comprised of different fractions of the almond.  So Mori and colleagues decided to study.

Acute and second-meal effects of almond form in impaired glucose tolerant adults: a randomized crossover trial.  (Mori et al., 2011)

In this excessively high quality study, the effect of 4 different types of almond preparations on glucose tolerance was assessed.

What was tested (in a FIVE-WAY crossover study):
WA = whole almonds
AB = almond butter
AF = defatted almond flour (remember this stuff? lacks all the bifidogenicity of regular almond flour )
AO = almond oil
V = vehicle: negative control.

Basically, the participants were fed a breakfast of OJ and Cream of Wheat with the equivalent of 33 almonds (42.5 grams) for a total of 75 grams of carbs, and blood glucose was measured over the next 2 hours.

Notable nutritional differences between the almond preparations:  they all contain a similar fat content except for the defatted almond flour; whole almonds and almond butter have 2-3 times more fiber than almond flour and almond oil; almond oil has half the protein as all the others.

In brief, no almond preparation affected insulin or free fatty acids.

Whole almonds, almond butter, and almond oil, on the other hand, all blunted the glycemic response.  Defatted almond flour, which only really differs in its lack of almond fat, did not.  Thus, according to last post, almond fat is a potent bifidogen (i.e., good for gut bacteria); and now we see it’s also responsible for the anti-hyperglycemic effect of almonds.  These two effects are probably unrelated, however, as any effect on gut bacteria will take significantly longer than a few hours as the almond fat hasn’t even reached the large intestine by then… (the anti-hyperglycemic effect is evident within 2 hours; the bifidogenic effect noted by Mandalari was 8-24 hours).

OK, almond fat slows the absorption of glucose, so what? this is not exciting… it’s common among most fats- “dietary fat reduces the glycemic index of food.”  But this has a greater implication: one could alternatively conclude that almond flour’s lack of fiber was at fault, as dietary fiber is also known to slow glucose absorption.  However, almond oil, which has even less fiber than defatted almond flour, was also anti-hyperglycemic.  So it’s not the fiber (… perhaps because almond fiber is predominantly insoluble).

With regard to all-things-almonds: almond fat, not almond fiber, is anti-hyperglycemic and bifidogenic (what can’t it do?).

Almond fat: +2

Solution: whole almonds (with meals?), almond oil (with whatever), and regular [non-defatted] almond flour (for baking?).  WRT the latter, get all the benefits, a boost for the gut microbiota, and significantly fewer carbs than with white flour (while actually attenuating the glycemic impact of said white flour).

An argument for almond flour: most baked goods are made with white flour.  These foods are predominantly empty calories, the bane of human health and well-being.  Substituting almond flour for white flour is one way to decrease the emptiness of those calories, and thus of life itself (it’s gluten-free too).

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Candy in disguise II, Op. 87

Rundown on a few new protein bars, pro’s & con’s, etc.

Perfectly Simple by ZonePerfect
The catch: 3 new bars with 10 or fewer ingredients.  All are gluten-free and have 10 grams of protein.

as the number of ingredients increases, so does the sugar

Sweeteners:
Peanut Crunch: “invert evaporated cane juice”
Toasted Coconut: “invert dried cane syrup”
Cranberry Almond: “date paste”

It takes more sugar in the form of “date paste” (Cranberry Almond, 19 g sugar) to compensate for the lack of “invert evaporated cane juice” (Peanut Crunch, 14 g sugar) or “invert dried cane syrup” (Toasted Coconut, 16 g sugar).  Invert sugar is basically table sugar (sucrose) that has been broken down into glucose & fructose.  1) It’s sweeter, which is why you need less of it; and 2) it’s essentially identical to high fructose corn syrup = used in everything from candy and crackers to cigarettes and soda.  Not good.

Active X Energy Bar
Kosher, organic, but not gluten-free.

Pro’s: less sugar and more fiber than ZonePerfect’s Perfectly Simple. 

These bars rely on the sweetener brown rice syrup which is primarily glucose (significantly less fructose than invert sugar), but it’s complimented with agave (significantly more fructose than invert sugar)… end result?  Organic high fructose corn syrup (a polished turd).

Good2Go bars

High protein, moderate sugar, and preservative-free.

These bars are sweetened with honey, brown rice syrup, invert sugar, and a little coconut sugar.  These bars have more protein and less sugar than both Perfectly Simple and ActiveX.

Last but not least, my personal favorite in the “coolness” department: Chapul.

Pro #1: they owned it!  “sugar” actually appears in the list of ingredients.

Pro #2: while it’s only 6 grams of protein, you’ll never guess where it comes from… crickets!  Yes crickets.  Baked, then ground into a fine powder.

Con: the most sugar and least protein of all.

To put this all into perspective: relative to the nutritional profile of Quest protein bars, these noobs pale in comparison.

Conclusion: candy in disguise.  just sayin’.

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Dark chocolate meets probiotics; the bifidobacteriomance continues

or the next big thing in functional foods, Op. 84

Altered gut bacteria can cause a whole host of problems, anywhere from depression and fatigue to ADHD and heartburn.  Thus, while running my daily search for “bifidobacteria,” I happened across these little goodies: 

The Attune Foods Dark Chocolate Probiotic Bar.  Combining probiotics (e.g., bifidobacteria, acidophilus, etc.) with chocolate?!  And with 68% cocoa, I’d expect this bar to deliver at least some of the benefits of dark chocolate (e.g., improved insulin sensitivity). They’re gluten-free and even contain inulin! (my second favorite bifidogenic prebiotic.)

And it packs a big, or rather huge, probiotic punch (6.1 billion B. lactis HN019, L. acidophilus NCFM, & L. casei LC-11).  Attune loses a little cred by trying to disguise their sugar as “evaporated cane juice,” like it’s something inherently healthier than plain old sugar… just like all-natural agave syrup, honey, and organic coconut blossom sugar.  just own it for crying out loud.  On the other hand, at only 6 grams, the sugar in Attune’s bar is harmless especially in the context of the high cocoa content, inclusion of inulin, and whopping dose of probiotics.

But, chocolate & probiotics?  Alas, the curiousity bug had bitten.

Apparently, a lot of companies think dark chocolate is a good vehicle for probiotic delivery.

GI Health’s Probiotic Chocolate is gluten-free and contains a half billion L. helveticus R0052 and B. longum R0175 per serving.  A half-billion is low by conventional standards*, but such standards might be irrelevant if the delivery vehicle (i.e., chocolate) is superior.

*Most probiotic products are rated (by me) by the number of live bacteria per serving, or “colony forming units (cfu).”  This is usually in the billions because most die in transit, thus the importance of the delivery method.  Yogurt and apparently now chocolate seem to be good delivery vehicles, however, yogurt and most probiotic pills require refrigeration; these chocolate products do not.  And neither do Nature’s Way Probifia Pearls, although they are the only pill that doesn’t (I suspect alien technology).

gimme Probiotics Dark Chocolate Candies, Youngevity Triple Treat; the list goes on and on.  Apparently, I was late to the game… (expect to see these in your local grocer soon.)

Enough shameless promotion, what about the data?

Possemiers (2010) set out to test how well probiotics survived in a robot gut simulator when mixed in chocolate.  1 billion L. helveticus CNCM I-1722 and B. longum CNCM I-3470 were mixed with either chocolate or milk.  An astounding 85% of the probiotics survived when administered in chocolate compared to only 25% with milk.  FYI the study was funded by Barry Callebaut, a fancy Belgian chocolate maker who is currently developing their own line of probiotic chocolates … it’s not a conflict of interest, it’s what companies should be doing IMO (while an independent third party would be optimal, any data are better than none).  I have no idea how well their robot gut simulator emulates actual human digestion, but these results suggest that chocolate is [at least] potentially a good candidate to deliver probiotics.

An additional benefit of loading probiotics into chocolate is that cocoa itself can function as a prebiotic.  Tzounis (2011) gave real-life live humans cocoa every day for 4 weeks and showed that bifidobacteria increased dramatically.  These findings were confirmed by Fogliano (2011), who showed (via another robotic gut simulator) that water-insoluble cocoa fractions (e.g., cocoa fiber) alone markedly stimulated the growth of bifidobacteria.

So: 1) chocolate is a good vehicle to deliver exogenous bifidobacteria; and 2) cocoa promotes the growth of endogenous bifidobacteria.  win-win.

Why is this relevant?  because probiotics by themselves don’t survive the trip!  They die off somewhere between the factory and your large intestine.  In a study by Prilassnig (2007), 7 people were fed one of 6 different commercially available probiotics for a week.  2 of the products contained bifidobacteria, Omniflora and Infloran.  None of the bifido in Omniflora survived in any of the volunteers, and the bifido in Infloran was detectable in only 1 out of 4.  Feeling lucky?

Thus, chocolate may be not only viable, but an optimal way to administer probiotics.  The bifidobacteria can feed on the cocoa while in transit (from the factory to your cupboard to your bowels), and the cocoa can directly stimulate them along with your native gut flora.

And chocolate with GOS?!  according to Davis (2010), chocolates enriched with 10 grams of GOS increased endogenous bifidobacteria a whopping 3-fold.

Formula for the healthiest chocolate on Earth? >70% cocoa, a billion bifidobacteria, and a few grams of GOS… don’t get your hopes up, however, this won’t likely be made any time soon.  Despite all of the data showing the remarkable health-promoting properties of GOS, it’s still not widely commercially available.  In the meantime, Attune’s use of inulin will have to suffice.

 

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Gluten vs. gut bacteria, Op. 78

Whether it is being used to treat Celiac disease, autism, or Paleo-deficiency,  a gluten-free diet (GFD) is probably the most inconvenient diet.  There’s no health risk imposed by recreational gluten avoidance; actually, it might even be healthier.

For example, cereal fibre (aka whole grains) provides the majority of gluten in the Western diet.  I have not been shy about my stance on cereal fibre in the past.  In the seminal DART study (Burr et al., 1989 Lancet), people who were instructed to eat more cereal fibre had a higher mortality rate.  There are definitely many nuances and specifics, etc., yada yada yada, but this finding should be your mind’s pantheon for all-things-gluten.

gravitas

One example of how my brain organizes information:   gluten-free diets include GFCF (duh), Paleo, and Atkins.  The low FODMAPs diet is indirectly gluten-free because cereals and grains are excluded.  N.B. these are all healthy diets… I repeat: GFCF, Paleo, Atkins, and low FODMAPs are all healthy diets.  But don’t take my word for it, Miley Cyrus and Kim Kardashian are also gluten-free (so it MUST be true; there’s no hiding from the Glutenista!).  No grain, no pain!

A downside?  One possible side effect of gluten avoidance is potentially detrimental alterations in gut bacteria.  For example, de Palma and colleagues (2009) showed that a strict GFD significantly reduced bifidobacteria (one of the good guys) in healthy adults.  A GFD is the only clinically effective treatment for Celiac disease, but my gut tells me (no pun intended) that the beneficial effects are not due to reduced bifidobacteria… I’m waiting for a study where a GFD is supplemented with bifidobacteria and inulin/GOS to test this.

On the bright side, the anti-bifido effect of gluten avoidance is not universal.  De Cagno and colleagues (2009) showed that children with Celiac disease have less bifidobacteria in their gut and this is reversed by a GFD (phew!).

gluten - hiding in plain sight... everywhere

Crackpot theory of the week:  could inulin/GOS increase gluten tolerance?  He and colleagues (2008) gave lactose-intolerant patients supplemental bifidobacteria in the form of capsules (1.8×10^9  cfu B. longum) and yogurt (3×10^10 cfu B. animalis) which significantly improved their lactose tolerance (it nearly cured them).  In this study, yogurt provided the prebiotics necessary to ensure survival of the supplemental bifidobacteria.  I imagine inulin or GOS
would’ve had a more profound effect.

Celiac disease, lactose-intolerance, IBS, and veganism are all associated with reduced bifidobacteria and could theoretically benefit from inulin/GOS supplementation.  You could try a diet high in onions, garlic, and breast milk, but cost, availability, and potential for halitosis favor the supplemental route  (finally found a source of high quality GOS).   And it sure as hell beats eating shit.

calories proper

Gluten-free food pyramid

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