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Dr. Ayala

Dr. Ayala
Philadelphia, Pennsylvania, USA
V.P. Product Development
Herbal Water
I’m a physician (Pediatrics and Medical Genetics), artist, and mother of 3 school age active kids. I recently co-founded Herbal Water Inc. (www.herbalwater.com) with my husband, Albert. I am a serious home cook, and love to entertain. My expertise is vegetarian food (I have been a vegetarian all my life). I strongly believe that eating healthy and enjoying good food go hand in hand. My main interests are science, nutrition and art, and I am overall a very curious person that tries to learn something new every day. Dr. Ayala (Ayala Laufer-Cahana M.D.)


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MAY 25, 2009 8:08AM

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

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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

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Dr. Ayala,
Thank you for an informative post on stuff i sort of knew .33% about. "Celiac disease", "gluten", etc. Wonderful that with our daily helping of cynicism, apocalyticism, and just plain goofy observances of life's contingencies, we can get some good hard info...

So! An ignoramus at this pt might query: why don't we just outlaw gluten....? But i shall not. It is a mostly healthy thing (ie for most people), correct? But .05 to like .30 percent of the population has a severe autoimmune reaction to it. I guess I thought gluten was some slimy shit the manufacturers put into the food for some nefarious reason....

but no, it betokens an interesting field of inquiry....stuff like peanuts, etc, we "normal" people can eat, but which sends other, genetically-sensitive, people to the hospital. Alot of these type things, yes?

To get grandly philosphical or poetic here: it's much like life...some large proportion gets thru unscathed, while the few, here and there, have....an unfortunate "auto-immune", ie self-protective, reaction to something in it we cannot handle. I wish it was as easy to legislate some of the other, more...numinous...things that hurt us out of life...

very good. Jim E. rated
Thanks James!
Enjoyed your philosophical angle.
Good piece. Thanks for talking about this. I have a very good friend with celiac disease and restaurants can be a real gamble. She can be out of commission for days because of a so-called "gluten free" meal.

I, on the other hand, have been consuming less gluten because it just makes me feel better. I think, similar to dairy, we can have varying degrees of allergies to wheat products.

Before, I was consuming way too much pasta and breads, etc. It often made me feel bloated, lethargic and I suspect its caused some other problems as well over the years.

I genuinely enjoy this gluten-free movement. Its nice to have alternatives. My gluten free bread is expensive but really good, for instance. Same with my pancake mixes and such.

I had pasta tonite. Whole wheat pasta. I'm guessing if you have any allergies to wheat, it doesn't matter whether you eat whole wheat pasta or regular. But my pasta...sigh. I can't give it up completely. It's a longstanding love affair.
I know you are trying to get a point across about a Gluten Free Diet but it also sounds like you are like so many other Doctor's. Like you are just blowing off the serverity of Celiac Disease. You think "Oh, once you stop eating gluten, you will be fine." HA!... it doesn't happen that fast. If you really read about it, the older you are it can take month, even years. Now there is a new release that in older people they may never heal. In Elizabeth Hasselback's book, Dr. Green writes that it is well know in Europe, but here in the US... they don't want to acknowledge it because there is no money in it for the drug companies. The only cure is eating Gluten Free. What a great health system we have! Try listening to some of the stories of people that have Celiac, and all the years of suffering and multiple doctors before they get any answers. And most people just end up diognosing themselves.
Celiac disease is a serious, even life-threatening condition. When my husband was conclusively diagnosed with it a few years ago, we were relieved that he didn't have intestinal cancer! Since then, packaged foods are ALL suspect until proven innocent.

People with celiac should realize that they must eat a great variety of proteins to replace the ones they must give up. We were vegetarians and have a vegetarian physician who advised that at least a small amount of animal protein is essential for well being.

Some celiac people also have more difficulty absorbing calcium and B12 and must take precautions to maintain a healthy level. They are far more prone to osteoporosis and to dental problems.

There is a wonderful network of people willing to share information with celiacs and their families. If you are in this category, take advantage of it. If not, be glad and enjoy your good health.