Appreciate the opportunity to contribute to my home institution.
Who knows how many times they tried to get Caesar before he met his Fate? I would bet every celiac knows that friend or foe, the next inadvertent exposure is around the corner. With a seemingly endless use of the word “gluten” these days, several issues come to mind.
Gluten-Free Menu or Caveat Emptor
Just because you have a few gluten-free options on your menu, doesn’t mean you should call it a gluten-free menu. Sorry Hula Hut.
If your multi-page menu contains a couple entrees, but one is a burger without a bun or salmon without rice, you just aren’t trying. To be complete, the gluten-free menu of the restaurant in question offered four salads (two needed to be ordered without dressing), a guacamole appetizer, and a flan dessert. That sets the bar a little too low in my opinion. I typically have an 80/20 rule, if 80% of the items on the menu clearly contain gluten, it probably isn’t the best place to eat. Could you get a gluten-free option at a place like this, maybe, but there are always other options. What about Einstein’s, 99% gluten-free bagel. Nice try, but that would be 1 in 100, slightly higher than 20 parts per million. So again, trying to make a buck not helping those with celiac disease (to date the largest population in society that REQUIRES a gluten-free diet). I appreciate that they are warning those of us with celiac disease, but what about the new celiac or someone who doesn’t get enough education. In Einstein’s defense, they recognize that a bagel shop is full of gluten, so just trying to “protect”? And Domino’s, since Patrick Doyle, CEO seems like a decent guy, I will hold back my treatise on their gluten-free pizza crust.
When in doubt, don’t risk it
A few catch phrases when dining out always make me squirm:
There is rice on that you can’t have
It depends how sensitive you are to gluten….
Now I’m not so naïve to think that every restaurant is preparing my food in a gluten-free vacuum, but there is no such thing as “a little bit pregnant”. Even some top restaurants in Houston have collided with the Celiac Universe. The first, a restaurant with Italian boy’s name, where they go out of their way to provide gluten-free options, a chocolate soufflé’ was offered to me as gluten-free. I didn’t even get excited for a split second, as I have watched enough Food Network to know that a soufflé is made from, chocolate, eggs, and um, what’s that stuff called, oh yeah, FLOUR! So, I politely told the waiter that I didn’t think soufflé is gluten-free, and after he asserted it was and a few exchanges later, I asked if he would check. Sure enough, he came back to inform me that I was indeed correct. Big Shocker! It was also a bonus that my father-in-law who is learning about the diet, saw the conventional lack of wisdom in action. A waiter (at yet another male given name establishment) brought me a “yes, I will make sure it is gluten-free” seafood dish, on top of a pile of gluten-filled pasta. No, I can’t just move it aside. Maybe I should have washed it down with a gluten-free Shiner Bock (sorry, folks, not available). I was at a work dinner trying to recruit a colleague to come, and we had gone there because it was a top spot. Another challenge is one of the “greener” restaurants. They have a series of restaurants, and early on, came home with a to go order and some not-so gluten-free pasta. They also cook their wood-fired pizza with their gluten-free pizza, and think that turning up the heat gets rid of the leftover gluten. I wouldn’t eat the pizza, and not aware of any data that would have me suggest it to any reader or patient. A recent addition from this new chain, sent me home with takeout that when I got home to find another wanna be gluten-free, but clearly regular pasta. Think Leo Getz, in the Lethal Weapon series. The “take home” is that you should always be en garde.
Do it right, or don’t do it at all.
This poor cupcake on the right, has the sorriest icing decoration compared to its gluten-filled friend. This was taken at a cupcakery in San Diego. In 2013, the consumer wanting gluten-free foods should expect to pay a premium, but only for a premium product or at least equivalent to the “real” thing. Too many companies are putting a GF label or gluten-free wording on a product hoping to gain a little market share. I make it a habit to try as many new gluten-free items that I can and always adventure to a local bakery or restaurant in the area. I recently visited a bakery in Pittsburgh, and they offered cupcakes, cakes, cookies, sandwiches and even mixes. My sugar cookie was $2.50, and it was better than the similarly priced cake. Don’t get me wrong, it is nice to have dedicated gluten-free bakeries, especially when traveling. However, don’t buy things just because they are gluten-free, they should look good and taste good too. Aussie Bakery in San Antonio has some good items, but some are just pretty average.
I will start tracking my favorite gluten-free restaurant city lists and sites and my own restaurant thoughts and stories with a scoring system a la glutenfreeportland with a twist. I hope to improve the gluten-free options at the restaurants I try, and if I happen to tweet and get Matsu-ed only my wife will really care…..
Using a standard A,B,C to F system followed by a 1, 2, 3 or 4. So the first A1 goes to the amazing Merriman’s in Kapalua, Maui, and the A+ view at sunset isn’t bad either. I will go ahead and give Erik’s Gondolen in Stockholm, high marks for the view and the A1. It just isn’t fair to give them an A2, if my Swedish isn’t very good and felt the need to ask a few questions. Corbett Fish House in Portland gets an A1 for an everyday restaurant.
Gluten-free Mostly Safe (1), Gluten-free Friendly But Ask Questions (2), Gluten-free Friendly But Be Warned (3) and my addition,
A few Gluten-free options on the menu, beware (4). I don’t eat at 4’s. I order a glass of wine and probably not much else. Until next time.
New study from Finland evaluates utility of NEW ESPGHAN criteria for celiac disease. Published in the Journal of Pediatric Gastroenterology and Nutrition this Month.
My take home is that if you have low or borderline TTG, caution should be used in diagnosing celiac disease. With a TTG >100 (depending on the scale), and DQ2/DQ8 positive, there is a high likelihood of having celiac disease. The ESPGHAN guidelines suggest if TTG >100 and genetics positive, a biopsy may not be necessary. Not sure if this data is as applicable for children at this point where TTG not as sensitive. Keep in mind the high rate of DQ2 and DQ8 positivity in the general population…..Further prospective studies will be necessary before this is adopted as the new “gold standard” in the United States.
Utility of the New ESPGHAN Criteria for the Diagnosis of Celiac Disease in At-risk Groups.
*Pediatric Research Centre, University of Tampere and Tampere University Hospital, Tampere †Department of Medical Genetics and Research Program for Molecular Medicine, Biomedicum Helsinki, University of Helsinki, Helsinki ‡Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland.
: Demonstration of small-bowel mucosal damage has been the basis of celiac disease diagnosis, but the diagnostic approach is undergoing changes. The European Society for Pediatric Gastroenterology, Hepatology, and Nutrition recently stated that in a subgroup of children, high positive transglutaminase 2 antibody (TG2ab) values may be sufficient for the diagnosis. The utility of these new criteria was evaluated by applying the human red blood cell TG2 antibody test (RBC-TG2ab) to a large cohort of children and adults belonging to at-risk groups.
: RBC-TG2ab and endomysial antibodies (EmA) were measured in 3031 family members or other relatives of patients with celiacdisease. The RBC-TG2ab values were classified as weak (20-29 U), moderate (30-99 U), and strong (≥100 U) positive. Seropositive subjects were further tested by human recombinant TG2ab (Hr-TG2ab) and for the presence of celiac disease-associated human leukocyte antigen-DQ alleles. Gastroscopy was recommended for all with positive RBC-TG2ab, EmA, or Hr-TG2ab, or weak positive RBC-TG2ab and symptoms.
: Strong positive RBC-TG2ab has good correlation with EmA and Hr-TG2ab and positivity of DQ2/8, and the diagnosis was established in 94% of both children and adults. In contrast, moderately positive (≥30 U) RBC-TG2ab showed poor correlation with the other tests, and celiacdisease was diagnosed in 69% of children and 86% of adults. Most participants with weak positive RBC-TG2ab were negative for EmA and Hr-TG2ab.
: In accordance with the new European Society for Pediatric Gastroenterology, Hepatology, and Nutrition criteria, strong positive RBC-TG2ab showed good accuracy and excellent correlation with the other antibodies and celiac-type human leukocyte antigen. In contrast, low or moderately positive RBC-TG2ab values were of unsatisfactory prognostic value for a subsequent diagnosis.
Risotteria tops NYC GF list. Check out http://newyork.cbslocal.com/top-lists/best-gluten-free-food-in-the-city/
Coming soon, my national list of top GF restaurants….
http://www.ncbi.nlm.nih.gov/pubmed/22160259 by Badarau, Collighan and Griffin.
Noosa Yoghurt! Yes, Noosa Yoghurt! Likely to make just about anyone love yoghurt.
Noosa is an amazing town north of Brisbane on the Sunshine Coast (Queensland, AUS) with beautiful secluded beaches, and some fantastic golf courses. This yoghurt was equally perfect.
I sampled the mango version at Central Market in Houston, and it was amazing, so bought the peach too! They have several other flavors including blueberry, strawberry rhubarb and raspberry. I look forward to trying them all. Noosa yoghurt is an Aussie-style treatmade in Colorado. And of course: Gluten-Free!
Amazingly creamy, and only 6 grams of fat (in 4 ounces), 14 g carbs (9 g sugar). Add a little honey if you need any more sweetness, but the fruit mix is perfect. The only downside is that the dual-serving container can easily be devoured as breakfast or late-night snack for one! They have it at several W. Coast Whole Foods @wholefoods.
Check it out at:
It comes very close to the Kapiti yoghurt, passion fruit and mango I recently had all over New Zealand, which I would love to see in the US as well.
The decision to be on a gluten-free diet is not one to be taken lightly. Not everyone can play tennis like Novak Djokovic (ranked #1 in the World Tennis rankings http://www.atpworldtour.com/Rankings/Singles.aspx), but a gluten-free diet has been attributed to his success. I would imagine that with a career earnings of over $30 million dollars http://en.wikipedia.org/wiki/Novak_Djokovic, the cost of gluten-free bread likely wouldn’t phase him, anymore than one of my passing shots.
Compared to the $4 billion dollars spent on regular old sandwich bread, (Baking and Milling News 2010), the gluten-free food industry is seeing unparalleled growth. $2.6 billion was spent on gluten-free foods in 2010, and estimates of a $6 billion dollar industry by 2015 (Packaged Facts 2011).
In preparation for a recent hospital grand rounds, I visited a few local grocery chains, to price a few basic gluten-free items. For sandwich bread, a basic “Mrs Baird’s”compared to a loaf of “ENER-G” gluten-free brand differed four-fold (7 vs. 30 cents/ounce). Both products were on sale, but the Mrs. Baird’s was buy-one get-one free. The difference was even more striking if you wanted to make your own bread. Compare Gold Medal All Purpose flour at 2.6 cents/ounce compared to 18 cents/ounce for Bob’s Red Mill Gluten Free Flour, almost seven times more expensive. That price differential didn’t include the xanthum gum, which cost $13.49 for 8 ounces. And what may be surprising to many readers, is that certain products @WholeFoods and similar stores were CHEAPER than the larger national and regional chains evaluated.
When I first began the gluten-free diet, two things were evident, the specialty food was neither tasty, nor cheap. The relative expense to taste ratio was also too high, and I was on a resident’s budget. Fortunately, with a growing industry comes increase competition and improved quality (translation=taste).
So how does one on a budget, keep expenses to a minimum while still keeping the gluten-free diet convenient and tasty?
1) Balance cost and time. While driving to three stores in a city might provide you the maximal combination of favorites, it is somewhat impractical. It is important to know which stores offer products you like, while at the same time developing a rapport with the stores.
2) Be a smart shopper. Clip coupons. Stock-up when your favorites items are on sale, and try new items when they are on sale.
3) Buy as many products that are naturally gluten-free and/or available universally. Try local produce, or sample farmer’s markets.
Keeping these tips in mind will improve the everyday gluten-free shopper’s experience, and make specialty diets easier on the pocketbook (even if you are the #1 tennis player in the world).
Despite nudging from Jay Leno and compromise with the President, I was disappointed to see M&M candies and frosted cookies given out at the White House for Halloween. And while the BMI (body mass index) of Houston children is likely greater than our military children, the “Let’s Move” program needs a little help. Maybe it needs its own rider to allow for “falling of the wagon of healthy eating” when it comes time for special holidays. From October to February, the holidays with the tastiest treats are luring us all away from our dietary programs. Halloween, Thanksgiving, Christmas, Hanukkah, Valentine’s Day and a few other joyous occasions add up to only a few thousand calories PER HOLIDAY. We all need balance in our life, but also compromise. Shouldn’t the compromise be on the side of health, finding healthy alternatives, or portion size allocations for these special holidays.
I’m sure the White House Pastry Chef Bill Yosses. has some healthy and tasty treats in his repertoire. Even in Bravo’s Top Chef Season 7 in Washington DC, the contestants were challenged to cook a 4 course meal using healthy AND TASTY items for a school lunch (Sam Kass Assistant White House Chef, was EVEN one of the judges).
It is time for a referendum on healthier eating for the holidays. Maybe more tricks and less treats at this holiday, and more thanks and giving in November.
October/November 2002 (St. Louis)
I took that next weekend, to participate in what I currently refer to as a “Gluten-Fest” including a trip to The Cheescake Factory, and a few of my other favorites gluten-filled hangouts.
Monday morning, I called the office to schedule my procedure. Because tTG can be falsely positive, and some of my other symptoms, I had requested both an upper and lower endoscopy. For those of you who have never had an endoscopy (If you are age 50+ or have a family history please go to http://www.ccalliance.org/screening/who_and_when.html), the upper is the easy part. The lower (colonoscopy) is the reason that those of you are supposed to have already had one- Have Not. And so for all of those patients that think we GI docs are miserable because they torture their patients with the “prep”, I can safely say, I took mine. Fortunately, there are now some better preps for patients, but my Fleet Phosphosoda prep made me feel terrible. And yes, I do remember that experience every time I order a “prep” for a patient awaiting a colonoscpy. How could you not remember? But, it was probably healthier than the gluten I had probably been eating for years?
The night before the procedure, NPO (nothing by mouth), and I was the first case of the morning. I remember changing into the typical hospital gown, entering the procedure room, and requested they send a particular stain on the upper (EGD) biopsies. Then, I remember fading off under monitored anesthesia. I have some vague memories of the rest of the day: my mom drove me home and we stopped off at the local election booth. Yes, I voted, but I couldn’t tell you who or what I voted for. Although, I am sure I used some thoughtful semi-sedated thought process. I went to stay at my parent’s house, slept on the couch for a good four hours and woke several hours after dinner. Went to sleep that night, and went to work the next day, feeling very refreshed.
I went to see the pediatric dietician to load up on gluten-free samples. Then, to the grocery to take my first stroll down the gluten-free aisles at Dierberg’s(@Dierbergs), and the brand new Whole Foods Market in Brentwood (@wfmgalleria). I still have a tendency to check out a few grocery stores in the same day to my wife’s dismay……
It was a long week, and the conclusion to an interesting few months. Friday morning, I called the pathologist, to see if they would review my slides with me.
A quick aside. A few years before, I was taking a review course in Chicago. At one of the breaks, a small group of us were chatting and talking about medicine, St. Louis, and Jewish geography (the equivalent of the Kevin Bacon game if you are Jewish).One of the guys in the group, proceeded to ask me the most unusual question I have ever been asked directly.
“Do you know Doug Fishman?” I turned to my friend in the group, smiled, and responded, “I am Doug Fishman, who are you?” This was a son of my parent’s friends, but we never made acquaintance until that day. Fast forward back to 2002.
I walked over to meet with the poor pathology resident, one of my own peeps. I can claim some ignorance as a resident, so I didn’t feel bad that I was about to look at my own biopsy. And reflecting back on my Jewish geography experience, the following wasn’t so strange. The resident asked, “Can you tell me a little about this patient, I have to present at a conference next week.” How about, 27 year-old pediatric resident with a tTG of 238?
So we looked at the biopsy, identified the blunted villi, intraepithelial lymphocytes, abnormal crypt to villous ratio (all classic findings of celiac disease) and I left with a new identity: Pediatrician with Celiac Disease,
So like a Jedi, I would embrace my new skill, and begin mastery of the Gluten Free-Celiac Universe.
Sept 16, 2002
Breaking of the fast, for Yom Kippur. An annual ritual in the Jewish religion, in which after fasting from the previous night, family gathers to “nosh”. For me, it was always a question of how many bagels and how much spinach casserole (just a little flour) I could eat. Unfortunately several hours later, I’ve never had to run to the bathroom so quick in my whole life. Was it something I ate? Did anyone else get sick? No. But, I felt otherwise well, and by the next day, pretty much back to normal.
Sept 27, 2002
Shan et al. from Stanford provide the evidence that tTG is the auto-antigen in celiac disease in the prestigious journal Science
On most call nights I would have a late night snack, which consisted of a few “Uncrustables”, a Smucker’s version of peanut butter and jelly sandwich, or an order of chicken strips with dipping sauces. Sometimes both! Not exactly part of the food pyramid (http://www.fns.usda.gov/tn/kids-pyramid.html)that we preach as pediatricians, but it gave me enough juice (juice also not particularly good for you)to keep going. Check out this link from the NY Dept of Health http://www.youtube.com/watch?v=62JMfv0tf3Q
However, after an evening of call, I remember rounding in the morning, having not felt like dinner, but felt like a new person. I noticed a general loss of appetite for a few days, but again felt quite good. I was calculating calories every day for patients, estimating how much weight a baby or child should gain, but I knew I wasn’t eating more than 1500 calories a day (unless it was a call night). I also recall a day where my shoulder hurt (arthalgia) to the point that it was difficult to put on my seatbelt. As a former-medical student, turned doctor, I tried to give myself a unifying diagnosis, unfortunately the two options in my mind were Crohn’s disease (ccfa.org), and celiac disease (celiac.org).
I knew how to test for both, but I needed a middle-man, one of my future peers, an adult gastroenterologist to complete my evaluation. I had seen a GI doc during winter vacation in college for abdominal pain, and given an anti-spasmodic with a presumptive diagnosis of irritable bowel syndrome or IBS. I had an upper GI and small bowel follow through (UGI-SBFT) with barium, that did not demonstrate any evidence of Crohn’s disease. Interestingly, it did suggest stomach inflammation. (To this day I have never seen an otherwise healthy patient with that description type on an UGI-SBFT).
Now, at what point in my career should I have figured out that eating cereal without milk, or eating pizza without all of the cheese to eliminate lactose wasn’t exactly my problem.
I went back to a different GI doctor, to help figure me out what was going on. But, I had my own agenda, a CBC (complete blood count) and a tTG (tissue transglutaminase for celiac disease).
We went through my history and proceeded to get reassurance that I indeed had Irritable Bowel. Irritable Bowel Syndrome, you have to be kidding me. No freaking way, I was leaving with that diagnosis, and I proceeded with the following dialogue. Fortunately, this doctor was Danish, and Scandinavians have the throne for celiac awareness in my eyes.
What I remember saying: “I am playing the best golf of my life (with a recent round at the Orchards, still career best of 93) and I just accepted a fellowship at Harvard in GI. I understand that these symptoms are vague, but this is not IBS. I would like to have a CBC and tTG and perhaps we can go from there.” I am not sure what he thought about that, but I had been preparing for a career in this field, and it just felt different.
48 hours later, I called the lab (pre-HIPAA), 4 pm on a Friday afternoon and got the 411. Actually it was 238, my tTG was a whopping 238. (Normal in this lab was less than twenty). I remember pacing in my apartment a few minutes.
I don’t remember at what point I decided that I would invoke my first professional courtesy call to my future GI colleague. I left a message with his answering service, and he called me back. As I would with one of my attending physicians, I reported my TTG, and normal CBC, and proceeded to ask, “What day next week can you do my endoscopy?” We needed to confirm a diagnosis of celiac disease. Was I really, 27, a new celiac disease patient? Was that even possible? Of course it was. It was 2002, and celiac disease although around for centuries was just warming up. This week of my life I remember as it was yesterday.