Valley Health Magazine

by Lisa Herzig, Ph.D., R.D., C.D.E.

What is Celiac Disease?

Celiac disease (CD), also known as celiac sprue and gluten sensitive enteropathy, is a disease of the small intestine. CD is a complex disease including genetic, environmental and autoimmune factors caused by the body’s atypical response to gluten. Gluten is a protein found in bread, cereal, and pasta, items that often contain wheat, barley, rye, and sometimes oats. In sufferers of CD, when the small intestine is exposed to gluten, inflammation occurs due to the body’s inability to absorb the sugars, proteins, fats, vitamins and minerals that are components of gluten. One of the primary challenges of CD is the struggle to correctly diagnosis the condition, which usually leads to prolonged exposure to gluten, and further damage to the small intestine. Because CD includes a wide spectrum of nonspecific signs and symptoms, diagnosis is often delayed and/or mistaken for other diseases of the gastrointestinal (GI) tract, resulting in ongoing suffering and lack of  immediate treatment.

Who Gets CD?

The true prevalence of CD is unknown because many individuals have very few symptoms. A clinical nutrition trial published in the American Journal of Clinical Nutrition found that approximately one percent of the world’s population has CD. CD can show up at any age, but is most often identified in childhood. Signs of CD may manifest after the initial introduction of gluten in children ages six to 18 months. Symptoms can include diarrhea, vomiting, weight loss, irritability, bloating, gas, foul-smelling stools (because of the body’s inability to absorb fats and carbohydrates), fatigue and “failure to thrive.” Failure to thrive includes poor physical growth, but is not limited to children. Adults, as well, may suffer from failure to thrive due to poor nutrition. When evaluated, children with CD may present muscle wasting, swelling of the feet and ankles, loss of fat stores, distended stomach, and irritability after meals. Iron anemia and bone thinning are common because of the malabsorption of iron, calcium and vitamin D. This can lead to short stature, delayed onset of puberty, increased cavities, joint pain, clubbing of fingers and toes, and skin rashes.

For those suffering from undiagnosed CD, and experiencing any number of the maladies  associated with “failure to thrive,” the risks are even greater. For example, a study published in the Journal of Nutrition in Clinical Practice identified that nutritional deficiencies, coupled with dairy intolerance, cause low bone density and an increased risk of fractures. The American  Dietetic Association’s Evidence Analysis Library likewise determined that problems caused by nutritional deficiencies additionally impact brain function and increase the risk of depression, dementia and behavioral problems. Lastly, because the symptoms of CD are often mistaken for other GI problems, sufferers are often sent home with instructions to follow a diet for that particular disease, i.e. diverticulosis, which usually requires a low-fiber diet to treat. However, a low-fiber diet contains gluten, and only exacerbates CD symptoms.

Why the Increase in CD?

The latest research from the Mayo Clinic has found that CD has increased among adolescents, young adults, and the elderly over the past decade. This is called late-onset CD. Symptoms range from mild to severe diarrhea, gas, stomach distention, pain, constipation, nausea, indigestion, GERD, and chronic vomiting. Other symptoms include complaints of the joints, skin, and the reproductive, musculoskeletal, and neurological systems. Autoimmune diseases such as Type 1 Diabetes Mellitus  inflammatory bowel disease (IBD), and thyroid  disease can also trigger CD. Diagnosis of CD can be delayed because of overlapping CD symptoms with other  autoimmune diseases. Untreated CD can lead to fertility issues, elevated liver enzymes, certain cancers, and osteoporosis.

The Mayo Clinic proposes that CD is becoming a major public health issue. It is four times more common than it was 60 years ago and affects about one in 100 people. The Mayo studies found that undiagnosed CD can quadruple an individual’s risk for other symptoms and/or conditions that are associated with CD. Several probable causes for the increased incidence of CD are surfacing, including the “hygiene hypothesis.” The Science Daily stated that today’s “clean” world of vaccinations, antibacterial soaps, and airtight doors and windows that keep out dirt and disease-causing bacteria, has effectively prevented many germs from spreading illness and infection. But, this “clean” world may ultimately be responsible for an increase in allergic reactions in the body. The body’s immune system is intended to fight infections, and the invention of vaccines and antibacterial cleaning supplies may be resulting in weakened immune systems that are now taxed with fighting off threatening diseases that lead to allergies and autoimmune conditions. If the body is never forced to strengthen by  being confronted with necessary stimuli, the opposite result, allergies and autoimmune reactions, occur.

A second theory according to researchers at the Mayo Clinic suggests that the way wheat is processed has caused an increase in CD. Much of our modern wheat is crossbred, which has increased the amount of gluten content in the grain. The more wheat consumed, the more gluten consumed, which over time has contributed to the prevalence of CD and gluten sensitivity.

By comparison, an article in Food and Behaviour Research revealed that the incidence, age, and presenting symptoms of CD have simply changed over the past 20 years. A single-center study was conducted that focused on screening high-risk children, which included those with a first-degree relative with CD, and those with Type 1 Diabetes, Down syndrome, or an autoimmune thyroid or liver disease. At the time of evaluation, the children were asymptomatic but were screened due to the fact that they were considered high risk. The study found that by screening children sooner, researchers were able to identify those that had antibodies for CD and treatment was then started sooner. By following a gluten-free diet, the quality of life of the children was significantly improved. Finally, an increase in the prevalence in CD is due, in part, to an increased awareness of the disease, and practitioners paying more attention to non-classical symptoms.

How Does CD Develop?

A study published in the New England Journal of Medicine found that CD has a strong hereditary association, with genetics at play in 90 to 95 percent of all cases. Environmental factors also play a role in the development of CD. The greatest environmental factor is the exposure to gluten products. The protein content of gluten is poorly digested in the upper intestinal tract. Gliadin is the alcohol-soluble fraction of gluten that contains the majority of the toxic parts. It is the  undigested parts of the gliadin that are resistant to the enzymes in the small  intestine, causing an inflammatory response. There is new evidence that CD is an autoimmune disease, as antibodies are produced causing a chronic state of inflammation that damages the intestinal mucosa – the innermost layer in the small intestine. The height of the villi (small fingerlike projections on the mucosa) are reduced and flattened over time by the continual inflammation, leaving less intestinal surface to absorb proteins, fats and sugars. CD also results in a decrease in digestive enzymes. The body’s inability to digest and absorb necessary nutrients manifests as weight loss, loss of muscle, compromised immune system, and malabsorption syndrome that can quickly turn into malnutrition. Failure to treat CD can result in unnecessary suffering and death. Medications can help with alleviating symptoms, but only 100 percent elimination of gluten products can resolve the disease fully.

There are other factors that may increase CD as well. For instance, gastrointestinal surgery, pregnancy, introducing gluten too soon (before six months of age), and viral infections have all been associated with the development of CD. There is some evidence that breastfeeding can delay the onset of CD, but it cannot prevent CD from developing over the course of a lifetime. Nonetheless, breastfeeding does offer some degree of protection, and its benefits are maximized if the introduction of gluten is delayed until the weaning period. Introducing gluten before six months is associated with an increased risk of CD, whereas waiting until after seven months has been correlated with a lowered risk of developing CD. The overlap of breastfeeding and waiting until your child is older may be the key to minimizing risk. If women are unable to breastfeed and there is a possibility of high risk, or the infant has already been diagnosed with CD, it is important to make sure that the baby formula selected is gluten-free. Similac Advanced is one example of a gluten-free alternative, but health food and specialty stores may offer other options.

Diagnosis of CD

Diagnosing CD is done via a biopsy of the small intestine mucosa that determines if the villi are damaged. Another biopsy, performed after gluten has been completely eliminated from the diet can then ascertain if the villi has been able to repair itself in the absence of gluten, serving as the final proof. Although invasive, the biopsy still remains the gold standard. During the biopsy procedure, the physician will insert a long endoscope through the mouth and into the top part of the  intestine, most likely under sedation. The biopsy instrument is then used to obtain samples of the intestinal lining. Several samples will be taken in order to ensure a correct diagnosis. A pathologist will then examine the samples to determine a loss in the villi and identify other characteristics of CD.

Secondly, CD may be determined by identifying the presence of antibodies associated with gluten such as:

• Anti-tissue transglutaminase

(anti-tTG)

• Endomysial IgA (EMA)

• Anti-gliadin (AGA)

The anti-tTG is the most common test used and has greater than 90 percent sensitivity, which means that over 90 percent of individuals that test positive are correctly diagnosed with CD. However, false-positive results are possible, and it is important to have the test performed again after following a gluten-free diet for at least a year. More tests are also being developed to provide both inexpensive and rapid screening. In most patients, CD is easy to diagnose; however, in 10 percent of cases the biopsy is imperative for diagnosis, otherwise the individual will not know the full extent of the damage to the villi.

Treatment

Diet is the key to managing CD, and adhering to a 100 percent gluten-free diet indefinitely is the only solution. Further, complete avoidance is the single, sure-fire way to prevent future risks for other conditions, such as the fertility issues, cancers, gastrointestinal problems, etc., described above. Once gluten is eliminated from the diet, the villi generally return to normal and maldigestion and malabsorption discontinue. A study published in the American Journal of Gastroenterology revealed that a small percentage of individuals do not respond to a gluten-free diet because of other underlying diseases or conditions. If CD has been identified and symptoms persist, developing a lifestyle plan and other treatments with your physician should be pursued immediately.

Although maintaining a completely gluten-free diet for the rest of your life may sound difficult, even consuming a relatively modest amount of gluten can still put you at risk. For example, one study showed that an amount greater than .05g of gluten per day over three months caused further damage. Considering that the average slice of bread contains 4.8g of gluten, the need for total gluten elimination is clear. Oats are also usually not recommended because most of the commercially available products are contaminated with other grains that contain gluten during the growing, transportation and milling processes. Recent research suggests that no more than 50g per day of oats is considered safe (slightly more than half a cup of uncooked oats); however, the individual must be on a gluten-free diet before adding oats, even with trace amounts of gluten, back into the diet. The good news is your body is so powerful that eliminating gluten can result in improvements within just a few days up to two weeks.

Leading A Gluten-Free Life

It is important to remember that gluten is also found in medications and supplements, and that many food products that do not naturally contain gluten are processed in factories or plants in tandem with grains that do. Read your labels carefully. Fortunately, as public consciousness heightens, the options for CD sufferers are increasing. Gluten-free bread, pasta, cereal, and more, are readily available at specialty markets and health food stores.  Some restaurants offer gluten-free variations, and many chain supermarkets are catching on as well. There are many reputable national resources that can be of use in identifying and educating yourself about safe food sources (see Celiac Resources sidebar).

By increasing awareness of CD and utilizing screening tools, such as biopsy and antibody testing (especially for those who are considered high risk), which are now more readily available among physicians, the quality of life and treatment for those with CD will continue to get better and easier. While early diagnosis is the key to long-term health and avoiding other complications, it is never too late to take control of your CD and start realizing the benefits of improved health.

About the Author: Lisa Herzig, Ph.D, R.D., C.D.E., received her B.S in Community Health Nutrition from Georgia State University, a Masters of Science in Nutrition from the University of New Mexico, and a Ph.D. in Humanities from the California Institute of Integral Studies. Dr. Herzig has achieved a wide range of clinical experience working for both national and local entities. She currently serves as the Assistant Professor of Dietetics and Didactic Program Director in the Department of Food Science and Nutrition at California State University, Fresno.

By Mikell S. Parsons,  D.C., C.C.N., D.A.C.B.N

There are some vitamins that are so common they often get left out or forgotten, especially if they are not considered exciting, new, “cutting edge,” or trendy. One such sadly overlooked staple is poor ol’ taken-for-granted vitamin C.

Now, let’s take a brief walk through time. In 1497, Vasco De Gama lost 100 of 150 of his crew members to scurvy. In 1536, Newfoundland Indians told the French  explorer Jacques Cartier about drinking tea made from Spruce tree needles, which contained high quantities of vitamin C, to help sustain him. By 1747, James Lind had performed an experiment on men who were severely ill with scurvy. The men who received lemons and oranges survived. He then recommended that all sailors receive lemons and oranges while at sea. (Whiskey just didn’t do the trick!) In 1928, Albert Szent-Gyorgyi first isolated vitamin C from the adrenal glands of an ox to produce supplements for human consumption. But, not to worry, current vitamin C products do not come from this source. Finally, we have reached modern times where vitamin C is readily available. We now have easy access to a wide array of fresh citrus year round, and a variety of powders, pills, chewable tablets, and other vitamin C supplements that grace the shelves of nearly every supermarket in America.

BENEFITS OF VITAMIN C

Aside from preventing scurvy, why should we care about vitamin C? Keep reading and decide which of the following benefits of vitamin C you don’t want in your life:

Detoxification – This is the process the body uses to eliminate toxins from the blood stream, organs, and cells, including additives, preservatives, stabilizers, colorings (all things found in processed foods), herbicides, pesticides, perfumes, cosmetics, etc. Essentially, all of the man-made things that are eaten, absorbed through the skin, or breathed in must be turned into a substance that the body can eliminate. This also includes the hormones that we make each day and any toxins that may result from an intestinal imbalance of bacteria, yeast or parasites. The liver and kidneys do a lot of the work, but the reality is that every cell in your body detoxifies its own cellular waste. If you are missing one of the components that is necessary to make your “detox factory” run (such as a sufficient amount of vitamin C), then you start to store these toxins in your fat, which can lead to weight gain, asthma, brain fog, and fatigue… just to name a few. You likely know many people who are suffering from poor detoxification, and it may simply be that they aren’t getting the vitamin C their bodies need.

Antioxidants – This will help protect your body from free radicals. Free radicals are produced in the body, which is a normal and natural process. However, free radicals can also be made when the body is exposed to toxic environmental chemicals and substances. Free radicals are unstable. If you produce or are exposed to more free radicals than you have antioxidants to bind to them, well, Houston, you have a problem. These unstable molecules will wreak havoc on your cells, right down to each cell’s very own DNA. When DNA is destroyed, your body loses its ability to regenerate and recover from toxic exposure, almost like a copier that starts to run out of ink. However, antioxidants, like those obtained from vitamin C, can slow this process and protect you from conditions such as heart disease and cancer.

Aids the absorption of iron – This is especially critical if you are still menstruating. Iron assists in the transportation of oxygen from the lungs to the tissues of the body. We should get it from food, and then digest it. But, if we don’t have enough vitamin C, it is difficult to actually get it from the intestines into the blood stream, where it needs to be to do its job.

Production of thyroid and adrenal hormones – A common functional problem  for many patients is with the thyroid and adrenal glands, which can be thought of as “sisters.” They aren’t twins, because they are distinctly different, but when one is having problems, the other feels the pain. As a result, both glands end up mired in dysfunction, reducing your overall physical and possibly mental functioning. For example, vitamin C (in addition to B5 and B6) is a key nutrient in keeping the adrenal gland running. The adrenal gland has many functions, one of which is the famous “fight or flight” response. For women who are transitioning from their child-bearing years into menopause, a healthy adrenal gland starts to produce hormones that help ease this change and reduce the occurrence of hot flashes and night sweats. Yes, it is possible to avoid these symptoms when the body is in balance.

Collagen synthesis – Wrinkles are caused, in part, by a lack of collagen, so logically, helping your body to create collagen is vital to maintaining that youthful look we all desire. The best way to do this is to get enough vitamin C in your diet and supplements.

Carnitine synthesis – Carnitine is a byproduct of an amino acid that is found in nearly every cell, and it helps burn fat and gives you energy. Guess what? If you aren’t making carnitine, which is another important function of vitamin C, you may be making fat instead.

Antihistamine effects – For all of you overly sensitive folks out there who have lots of food and/or airborne allergies, this is a piece of your puzzle. Dosages of over six to eight grams of vitamin C can often combat allergy issues. (See below to determine your own personal dose.)

Degradation of cholesterol – Vitamin C is one of many things that may help to  reduce high cholesterol.

Immune system support – Vitamin C will actually bind to your white blood cells to help your body fight infection.

HOW TO GET ENOUGH

Because the human body is unable to make vitamin C, it is vital that we get the amount our bodies need from quality food and supplement sources. And before you ask, drinking orange juice is not the answer to obtaining and maintaining healthy levels of vitamin C. First, juice is full of sugar and makes your pancreas release a lot of insulin to counter the sugar load. When the pancreas has to work harder to deal with your “sweet tooth,” you run the risk of burning out your poor pancreas over time. Us folks in the health care business call this diabetes. Type II diabetes is something that is usually preventable when you eat a balanced diet and avoid overindulging in sugar. (You know who  you are!)

Secondly, do the math. If we consider that the typical therapeutic dose of vitamin C (for example, the ever-popular powdered packets of vitamin C) is 1,000 mg (1gm) a day, and take into account that one cup of orange juice has an average of 124mg, that would mean that we would need about eight cups of orange juice each day. Now, who drinks eight cups of juice each day? Hopefully, no one who is reading this article. That would mean that you are ingesting 192 grams of sugar without the benefit of fiber to slow the absorption down.

Finally, vitamin C is a water-soluble vitamin, which means it needs to be taken every day. In contrast, other important vitamins (such as vitamin D) are fat-soluble, and as long as your gallbladder is healthy, your body will store this vitamin for future use (which does NOT mean you don’t need to be conscious of consuming enough). However, vitamin C is constantly flushed out of the system and needs to be replenished on a daily basis to ensure your body is reaping the powerful benefits of this ever-important vitamin.

Needless to say, we need to eat a variety of foods and/or take a quality supplement to ensure that we have enough vitamin C for our bodies to function optimally.

VITAMIN C DEFICIENCY

Some of you may be wondering if there are symptoms of deficiency. Below is a list of symptoms that may indicate a vitamin C deficiency:

• Fatigue

• Weakness

• Shortness of breath

• Muscle cramps

• Aching bones, joints and muscles

• Dry skin

• Fever

• Easy bruising

• Bleeding gums

• Secondary infections

• Hemorrhage

HOW MUCH VITAMIN C DO YOU NEED?

If you want to see how much vitamin C your body needs, you can do your own scientific study at home. If you suffer from kidney stones, however, it is important to talk with your doctor before trying this at-home test. As mentioned before, vitamin C is a water-soluble vitamin, so anything  you don’t use will be passed in your urine.

To identify your personal dose, here is what you do. (This is for adults only; a child’s dose will be less.) Each waking hour take 1,000 mg of vitamin C until you hit what is referred to as “bowel tolerance.” Bowel tolerance means that when you have surpassed the level of vitamin C that your body needs, you will have an urge to move your bowels. To clarify even better, you will get “frothy diarrhea,” similar to the froth on the head of a root beer (think of this the next time you’re craving a high fructose-ridden root beer soda) when you hit your threshold. For example, if the diarrhea begins after you took eight, 1,000 mg (8 grams) doses of vitamin C, then your body probably needs 7,000 mg (7 grams) per day. Ideally, you would stay on this daily dose until “bowel tolerance” occurs again, at which time you can lower the dose by another 1000 mg until the bowel intolerance hits again. Think of this process as filling up your empty vitamin C gas tank. Once your tank is full, you do not need to put as much in every day. There will be many of you who will get up to 20 grams a day, which is a lot of vitamin C. I challenge you to take your own vitamin C study and report your experience, the good, the bad and the ugly.

About The Author: Mikell S. Parsons, D.C., C.C.N., D.A.C.B.N. is a chiropractor who specializes in clinical nutrition and functional medicine. She has been in practice for over 15 years and currently sees patients at the Natural Path Health Center.

By Jennifer Jennings

Iron is an essential part of blood and plays a role in taking oxygen molecules directly to the cells of the body. Not  having enough, or having too much, can be potentially hazardous. Vegetarians, children, and women who are pregnant, need to pay closer attention to the amount of iron in their diet to ensure they are getting the proper amount for optimal cell and total-body function.

So how much is enough? According to the American Dietetic Association, women need 18mg of iron per day, and men need eight mg per day. Iron is found in a variety of foods and can be separated into two categories: heme and non-heme. Heme sources of iron most easily absorbed and utilized by the body, and these include meat, fish and poultry. Non-heme sources are typically plant sources, such as beans, nuts, grains, and dark green vegetables. Many breads, pastas, cereals and flours are fortified with iron because of the  importance of iron in the diet.

Too Much?

It is possible for your body to store significantly too much iron, although iron deficiency is a much more prevalent concern. According to the National Institutes of Health, hemochromatosis is a condition that may be hereditary, or potentially caused by anemia or alcoholism. Hemochromatosis occurs when the body takes in and stores more iron than needed. While many effects of hemochromatosis may go unnoticed, such as lethargy or  fatigue, liver damage is by far the most  serious risk, which is why the condition is associated with alcoholism and cirrhosis. The modest treatment for this condition, prior to advanced damage, includes cutting back on high-iron foods, such as fortified cereals and meat products, as well as having blood drawn to test your iron levels periodically.

Too Little?

As mentioned above, women need  a significantly higher amount of iron than men. This is mainly attributed to menstrual cycles and the subsequent blood losses. However, when iron levels are low, every individual may suffer the consequences. The most common symptoms of iron deficiency are fatigue and trouble sustaining body temperature. A severe deficiency of iron may cause anemia and may cause more serious symptoms.

Although women need much more iron than men, pregnant women need even more! The recommendation for pregnant women is 27mg per day, compared to the 18mg recommended for all women. According to the American Dietetic Association, iron deficiency is present in 30 percent of low-income pregnant women. Women who are anemic prior to pregnancy are even more likely to have a harder time resolving anemia once they become pregnant. Also according to the American Dietetic Association, pregnant women with anemia could need supplements with up to 60mg of iron per day to accommodate previous deficiencies. Treating iron deficiency anemia is  important for all adults, but particularly so for pregnant women, as the conditions may affect the baby and increase the risk of low-birth weight and/or preterm delivery.

Children and adolescents are also at risk for iron deficiency, but for very different reasons. Young children, from six months of age to four years, who consume cow’s milk, may become deficient because of the lesser amount of iron found in dairy and many standard formulas. Breast milk, by contrast, and iron-fortified formulas can help growing children obtain the amount of iron needed for growth, cell function and overall wellbeing. Iron deficiencies in  infants may be harder to diagnose because of overall reduced mobility, but babies can still suffer the  effects of lethargy, and a lack of iron may also inhibit proper development of cognitive and motor skills. Adolescents are in need of iron, too, because of the growth spurts they experience during the teen years. This additional need, combined with poor food choices, can result in iron deficiency.

Vegetarians and vegans can have trouble consuming enough iron due to the fact they do not eat meat, which may be compounded by a lack of dairy. While dairy is not a sufficient primary source of iron consumption and relying on it heavily can result in other excesses, it may help limit the risk of deficiency. Since these  diets only contain plant-based or non-heme iron food sources, individuals may be more responsive to the enhancers and  inhibitors of other foods, as described below. This means that vegetarians and vegans need to be particularly careful about choosing iron-rich food sources  in tandem with the rest of their diet,  because they may be consuming more of the types foods that impede iron absorption.

Getting It Just Right

The rule of thumb on consuming enough iron is “food first.” The iron found in food products is absorbed more easily by  the body than the iron consumed  via supplements. Additionally, iron consumed from supplement sources may result in constipation, and extra fiber and water are needed to counterbalance these side effects. The American Dietetic Association states that cooking with an iron skillet can help contribute to obtaining enough iron; the iron from the skillet leaves trace amounts in the food, which is readily absorbed by the body.

Many different types of foods can enhance iron absorption, as well as decrease it. Substances that hinder the absorption of iron include calcium, compounds found in tea and coffee, acid from spinach and chocolate, and the phytates (sometimes called “anti-nutrients” because of the way they hinder absorption of many vitamins) present in whole grains and legumes. Food sources that increase iron absorption are the Vitamin C present in fruits and vegetables, and the sugars in fruits, meat, fish, and poultry.

Iron is an essential part of a healthy diet and can easily be consumed from many different food sources. Women and men should strive to consume the proper amount to stay healthy, and parents should be conscious of choosing quality, iron-rich foods to help their children grow. Consuming an adequate amount of iron in tandem with foods high in vitamin C is the perfect recipe for combating anemia. The good news is, a healthy, balanced diet that provides all of the essential vitamins and minerals the body needs will include iron, and you won’t even have to try! For more information on iron-rich food sources, visit www.eatright.org.

About the Author: Jennifer Jennings graduated from California State University, Fresno with a B.S. in Food and Nutritional Sciences. She is currently a Dietetic Intern at Fresno State and looks forward to soon working as  a Registered Dietitian in the Central Valley. This article was written under the guidance of Tina Slenders, R.D. at Madera Community Hospital.