Celiac Disease – Adopting a Gluten Free Diet to Manage Intolerance or Sensitivity

shutterstock_146760950One of the hottest topics in medicine these last few years has been the gluten free diet.  I’ve had countless numbers of patients ask me about “going gluten free” to help with weight reduction, low energy levels, gas, constipation, heart burn, or for various other reasons.  The information about gluten and reasons for avoiding it are rather widespread – some of the information released is valid while others are rumors or just downright advertising.

What is Celiac disease, gluten intolerance and gluten sensitivity?  In the medical field we refer to a condition called Celiac disease which is a condition that affects perhaps up to 1% of our population.   The affected patient’s immune system can damage their small intestine as a reaction to Gluten, a common protein found in most modern day diets. People with the condition are advised to avoid wheat, rye, barley and many prepared foods because they may feel very ill if they consume these products.

Celiac disease is also called gluten sensitive enteropathy, Celiac sprue or nontropical sprue.  Gluten intolerance may also be sometimes called gluten sensitivity, a less severe disorder that affects perhaps up to 10% of our population.  Symptoms may be milder than with Celiac disease and may affect other areas of the body in addition to the gastrointestinal tract. The definition of gluten intolerance has been changing over the years as we work to understand more about the condition.

The small intestine is the part of the body which absorbs nutrients from the food that we eat.  In patients with Celiac disease, the small intestine becomes damaged by the immune system so patients have problems absorbing nutrients from the food that they eat.  Gluten is fairly indigestible in most people and some experts believe that there is a certain amount of gluten intolerance in all of us.

What are the symptoms of Celiac disease?  Patients may experience diarrhea, weight loss, abdominal discomfort, excessive gas and vitamin/mineral deficiencies.  Patients with gluten intolerance may be more prone to osteoporosis, iron deficiency anemia, autoimmune problems with the thyroid, liver, type 1 diabetes, and nervous system problems.

In addition, patients with Celiac disease may be more likely develop lymphoma which is a cancer of the intestinal lymph system.  This is uncommon but we think that avoiding gluten can help prevent the development of lymphoma.  Celiac disease has also been associated with a skin condition called dermatitis herpetiformis.  This causes itchy, raised fluid filled areas on the skin mostly in areas such as the elbows, knees, buttocks, lower back, face, neck, trunk and sometimes in the mouth. The symptoms of this skin condition are mostly the intense itching and burning.  Once the blisters rupture, the itching is relieved but scratching the blisters can rupture them and leave dark areas of skin and permanent scarring.  Eliminating gluten for the diet may help the condition improve after several weeks of remaining on a gluten free diet.  A medicine called Dapsone may be taken to help with the itching but this medication does not help heal the intestine which was damaged by the immune system.

How can you test me for Celiac disease?  If you have symptoms that are very suspicious for Celiac disease there are a variety of tests that can help make the diagnosis in addition to being evaluated by a medical provider.  One of the gold standard tests to help us determine whether you have Celiac disease is to take a biopsy of the lining of the small intestine.  A small sample of tissue from your intestine is examined with a microscope after it has been collected during a procedure called an endoscopy.  As you can imagine, this is not a procedure that is done while patients are awake so it is usually performed in the hospital or an outpatient surgical center where nurses and other medical providers can give you medication through an IV to help make you comfortable.

There are also blood tests that can help determine whether a patient has Celiac disease.  These tests are often part of a “Celiac blood panel” but can be ordered separately.  They are antibodies called the anti-total tissue transglutaminase (TTG) and anti-endomysium antibody (EMA) total imunoglobin A (total IGA), anti DGP antibody, antigliadin antibody (AGA), anti-F-actin test and sometimes antireticulin antibody (ARA).  Your medical provider will help determine which tests are appropriate and interpret the results.

There is not a test however for gluten intolerance.  The blood tests and intestinal biopsies may be completely normal for those who have gluten intolerance but they simply feel better eating a gluten free diet.

Who gets Celiac disease?  We aren’t sure why people get Celiac disease but we think there is a genetic component.  It is rare if people from northern Asia or Southern Africa and more common in patients from Europe, North and South America, South Asia, Middle East and North Africa.

Treatment:  About 70% of people feel better two weeks after they stop eating foods with gluten.  The blood antibody levels often return back to normal as patients stop eating foods with gluten.  Gluten is the group of proteins found in wheat, rye and barley.  It’s also hidden in a large number of prepared foods and supplements.  It can be very challenging to eliminate gluten from your diet because it takes some major lifestyle changes.  It is important to avoid eating gluten and being exposed to it in the air as well.

I recommend consultation with a dietician who specializes in helping patients with Celiac disease.  They can help patients learn what foods to avoid and what foods you need in order to get a balanced diet.

There are a large number of stores that are now offering gluten free foods in certain areas of the United States.

1)      Examples of gluten free foods are rice, corn, potato, beans, legumes (beans, etc.), nuts, seeds, and soy

2)     Foods to avoid are obviously anything with wheat, rye, barley, brewer’s yeast, oats (unless labeled gluten free), and malts

3)     Some people with Celiac disease cannot tolerate oats even if they are labeled gluten free

4)     Wine is usually gluten free unless it contains gluten free flavorings

5)     Most beers have gluten unless they are labeled “gluten free”

6)     Many people with Celiac disease have trouble with dairy products until their intestines return to normal.

7)     Make sure you are getting enough calcium and vitamin D

8)     If you have Celiac disease, you should have blood tests for iron, folic acid, vitamin B12 and vitamin D to make sure your levels are adequate.

9)     There is concern about patients with Celiac disease developing osteoporosis (low bone density) so some clinicians recommend getting a bone density test (DEXA) to measure your bone density.

I think that I may have gluten sensitivity, gluten intolerance or even Celiac disease – should I try a gluten free diet?  I suggest you talk with your health care provider and a dietician before starting a gluten free diet because cutting out gluten doesn’t mean you will be healthier.  After consultation with a medical provider, perhaps you be get tested for Celiac disease with some blood work and/or a biopsy.  If these tests are negative, you can still try a gluten free diet to see if you feel better, but I’d recommend getting help from a dietician to make sure you understand where “hidden sources” that are not obvious in the foods that we eat.  You also don’t want to miss out on the vitamins and minerals that wheat products provide.  Manufactures of gluten free products may add sugar or fat to their products to simulate the texture of foods that contain gluten have.  Gluten free products also often contain less iron, vitamin B and vitamin D than bread products so it’s important to make sure you’re getting enough of these in your diet from other sources.

Where can I find more information about Celiac disease? 

1)      American Celiac Disease Alliance:  www.americanCeliac.org

2)     American Gastroenterological Association:  www.gastro.org/patient-center/digestive_conditions/Celiac-disease

3)     Celiac Disease Foundation:  www.Celiac.org

4)     Gluten Intolerance Group of North America:  www.gluten.net

5)     National Foundation for Celiac Awareness (NFCA):  www.Celiaccentral.org

6)     National Library of Medicine: www.nlm.nih/gov/medlineplus/Celiacdisease.html

7)     North American Society for the Study of Celiac Disease:  www.nasscd.org

8)     Celiac.com:  www.Celiac.com

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.


I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

References:  Ciclitira PJ, King AL, Fraser JS. AGA technical review on Celiac Sprue. American Gastroenterological Association. Gastroenterology 2001; 120:1526


Treating Gout Pain Naturally – Try eating pineapples

shutterstock_114066385Gout is a relatively common condition caused by the build up of uric acid crystals that happens in our joints.  The most common symptoms include severe pain, redness, swelling, and disability. The  most common location is at the base of the great toe (first metatarsophalangeal joint, known as podagra).  Other joints can be involved as well including the  ankle or instep, wrist, finger,  shoulders, hips, knees and knees.  Gout can cause problems with the kidneys as well if crystals form there.

If you’ve been diagnosed with gout, it is important to avoid foods that are known to trigger a gout attack.  Some of these foods are red meat, seafood, beer (also other forms of alcohol), foods high in high fructose corn syrup.  Once attack occurs, however you’re searching for relief.  When you go to the doctor and the diagnoses is established, your doctor may offer you treatments for your immediate pain including non steroidal anti-inflammatory medications such as ibuprofen or naproxen.  They might also offer you treatment with colchicine or injections of steroid medications into the affected joint. For many, these treatments work well, however  they can be expensive and they can also have substantial side effects.

I’ve recommended natural treatments of gout to my patients including foods which have increased levels of  Bromelain.  Bromelain is a proteolytic enzyme extracted from the pineapple plant. It has natural anti-inflammatory properties that are ideal to reduce the inflammation of gout. I’ve had patients tell me that eating pineapples after experiencing gout pain is much more effective for treating their pain than any traditional medications.  It can be taken as a supplement or eaten naturally in the foods which contain it such as pineapple. As with any supplements, make sure you talk to your doctor before starting them.

Also, make sure to keep  your body very well hydrated  because this makes uric acid crystal formation much more difficult. And by drinking lots of water on a daily basis, you are helping your kidneys to process and excrete uric acid from your body more easily.  Drink a minimum of twelve 8oz glasses of water during every day.

For more information:  National Library of Medicine

National Institute of Arthritis and Musculoskeletal and Skin Diseases

American College of Rheumatology

The Arthritis Foundation

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.


I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

5 health reasons to not quit coffee

Okay, so I’m a coffee drinker and I’m always looking for reasons to support my habit. I read this article posted by Kerri-Ann Jennings, a dietician who works for EatingWell Magazine. I thought you might be interested…

By Kerri-Ann Jennings, M.S., R.D., Associate Nutrition Editor at EatingWell Magazine

I really like coffee. The morning ritual of brewing a cup, the smell that perks me up before I take a sip and, of course, the flavor all make it my favorite beverage aside from water (water’s delicious!). As a registered dietitian and a nutrition editor for EatingWell Magazine, I know that coffee is fine in moderation. It has lots of antioxidants and is low in calories if you don’t load it up with cream and sugar. Nonetheless, I always feel slightly guilty about drinking it—you know, in a “it’s so good, it must be bad” kind of way.

Which is why I’m always delighted to hear of new reasons that coffee is good for your health…and there are plenty! Over 18,000 studies on coffee have been published in the past few decades, revealing these benefits, many of which Joyce Hendley wrote about in the March/April issue of EatingWell Magazine:

1. It protects your heart: Moderate coffee drinkers (1 to 3 cups/day) have lower rates of stroke than noncoffee drinkers, an effect linked to coffee’s antioxidants. Coffee has more antioxidants per serving than blueberries, making it the biggest source of antioxidants in American diets. All those antioxidants may help suppress the damaging effect of inflammation on arteries. Immediately after drinking it, coffee raises your blood pressure and heart rate, but over the long term, it actually may lower blood pressure as coffee’s antioxidants activate nitric acid, widening blood vessels.

2. It diverts diabetes: Those antioxidants (chlorogenic acid and quinides, specifically) play another role: boosting your cells’ sensitivity to insulin, which helps regulate blood sugar. In fact, people who drink 4 or more cups of coffee each day may have a lower risk of developing type 2 diabetes, according to some studies. Other studies have shown that caffeine can blunt the insulin-sensitivity boost, so if you do drink several cups a day, try mixing in decaf occasionally.

3. Your liver loves it: OK, so the research here is limited, but it looks like the more coffee people drink, the lower their incidence of cirrhosis and other liver diseases. One analysis of nine studies found that every 2-cup increase in daily coffee intake reduced liver cancer risk by 43 percent. Again, it’s those antioxidants—chlorogenic and caffeic acids—and caffeine that might prevent liver inflammation and inhibit cancer cells.

4. It boosts your brain power: Drinking between 1 and 5 cups a day (admittedly a big range) may help reduce risk of dementia and Alzheimer’s disease, as well as Parkinson’s disease, studies suggest. Those antioxidants may ward off brain cell damage and help the neurotransmitters involved in cognitive function to work better.

5. It helps your headaches: And not just the withdrawal headaches caused by skipping your daily dose of caffeine! Studies show that 200 milligrams of caffeine—about the amount in 16 ounces of brewed coffee—provides relief from headaches, including migraines. Exactly how caffeine relieves headaches isn’t clear. But scientists do know that caffeine boosts the activity of brain cells, causing surrounding blood vessels to constrict. One theory is that this constriction helps to relieve the pressure that causes the pain, says Robert Shapiro, M.D., Ph.D., associate professor of neurology and director of the Headache Clinic at the University of Vermont Medical School.

Now, that’s not to say that coffee doesn’t have any pitfalls—it does. Some people are super-sensitive to caffeine and get jittery or anxious after drinking coffee; habitual coffee drinkers usually develop a tolerance to caffeine that eliminates this problem (but they then need the caffeine to be alert and ward off withdrawal headaches). Coffee can also disturb sleep, especially as people age. Cutting some of the caffeine and drinking it earlier in the day can curb this effect. Lastly, unfiltered coffee (like that made with a French press) can raise LDL cholesterol, so use a filter for heart health.

But if you like coffee and you can tolerate it well, enjoy it…without the guilt.

There is sun today in Seattle, now get some vitamin D!

shutterstock_115649197As you’re probably aware, Vitamin D has been a popular topic during the last few years.  Most of what we need in our younger years can be achieved through sun exposure – even as little as 10 minutes of exposure is said to be enough to prevent deficiencies according to Mayo.  What we’ve been learning recently is that when measuring the level of vitamin D in our patients, a great many are deficient.

Does this mean that we’re not getting enough sunlight?  Well perhaps in Seattle that might be the case (especially if you wear lots of sunblock) because there are less sunny days here.  It might also mean that we need to be taking in more vitamin D in our diet from it’s natural sources such as fish, eggs, fortified milk, and cod liver oil.

What happens when you don’t get enough vitamin D? Well if you read the media, you’ll find sources that suggest a link to vitamin D deficiency and the following:

A)  Diabetes
B)  High Blood Pressure
C)  Multiple Sclerosis
D)  Certain Cancers
E)  Depression
F)  Chronic Fatigue
E)  Chronic Pain
F)  Osteoporosis and even Rickets
G)  Peripheral Vascular Disease
H)  Rheumatoid Arthritis
I)  Parkinson’s
J)  Alzheimer’s Disease
K)  Prostate Cancer
L)  Weight Gain
M)  Tooth Retention
N)  Seasonal Affective Disorder (SAD)
O)  Muscle weakness

Many of these associations have been found through observational studies, and thus aren’t necessarily the best studies to determine whether a deficiency in vitamin D actually leads to these diseases.  Studies are ongoing.  We do have fairly substantial evidence even now that a deficiency of vitamin D can lead to poor calcium absorption and that can predispose to developing osteoporosis (low bone density).  Without enough calcium in the bones, they become more fragile and trauma such as a fall can cause bone fractures more easily.

How do you know if your vitamin D level is too low? If you’re getting a healthy diet rich in vitamin D,  and at least 10 minutes of sunshine every day, you’re probably not deficient.  Risk factors are:  Obesity, dark skin (blocks the UV light), the elderly (have reduced capacity to synthesize vitamin D in the skin when exposed to UVB radiation), breast-fed infants, patients with inflammatory bowl disease(Crohn’s disease or Ulcerative Colitis), cystic fibrosis and even certain medications including those used to prevent seizures.

The test is called 25-OH vitamin D and can be performed when ordered by your medical provider.  If indicated, I routinely order this test on my patients to establish their vitamin D levels and help them increase the levels of vitamin D to the recommended range.

Can I get too much vitamin D?  Yes, if you take too much you can get a syndrome called Hypervitaminsosis D. The symptoms include constipation, decreased appetite, dehydration, fatigue, irritability, muscle weakness and vomiting.  I recommend talking with your medical provider about managing vitamin D levels.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.


I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com