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

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Type 2 Diabetes – Information for the New Diabetic Patient

shutterstock_128763464When a patient comes into the clinic and is diagnosed with diabetes, they usually have lots of questions.  Often we discover that they are diabetic when they come in for another reason and time is often limited so I thought it would be helpful to discuss some information that I think is important for a newly diagnosed diabetic patient to understand.

Diabetes:  A condition that disrupts the way your body uses blood sugar (glucose).  We classify diabetes as type 1 or type 2.  About 90 percent of people in the United States, Canada and Europe with diabetes have type 2.

To understand the difference between type 1 diabetes and type 2 diabetes, it’s important to understand a little about insulin.  Insulin is a hormone in the body that allows all the microscopic cells inside your body to absorb and use glucose, the fuel for your body.  Without enough fuel (glucose) you can become tired, shaky, and not feel well.  People with diabetes usually have enough glucose (digested from food) in their blood, the problem is that the cells inside the body cannot use it.  Insulin is like a key that unlocks the cells inside our bodies and allows us to absorb the glucose that is present in the bloodstream.  If our insulin level is low or our bodies cannot use our own insulin effectively (the key to letting glucose into the cells so that it can be absorbed and used by our organs), the sugar in body cannot be absorbed and rises in the blood.

Type 1 diabetes  is a problem where the pancreas (an organ inside your abdomen) does not made enough insulin.  Remember, insulin is the key that unlocks cells/organs inside the body so that we can absorb glucose (sugar) from the blood.  Without enough insulin, our blood sugar goes up and cannot be absorbed.  We often treat patients with type 1 diabetes by giving them insulin because their body does not make it at all.  That way the insulin will allow their body to absorb the sugar in their blood and use this “fuel” to live.

Type 2 diabetes is a problem where the body cannot use the insulin that is normally present inside our body effectively.  We sometimes refer to patients who have type 2 diabetes as having insulin resistance because their bodies becomes resistant to the level of insulin that is normally present.  We often treat patients with type 2 diabetes with medications that help the body use insulin more effectively.  Sometimes when patients with type 2 diabetes develop too much insulin resistance we have to give them even more insulin to overcome the insulin resistance.

Many patients are overwhelmed after being told they have diabetes, especially because the treatment involves lifelong lifestyle changes that can sometimes be challenging and difficult.  Treatment includes medications, dietary changes, and exercise routines.  Often weight loss is important in the treatment of type 2 diabetes.

When a patient is newly diagnosed with diabetes, we often recommend that they meet with a registered dietician who can help with dietary changes, a nurse educator who can help teach patients how to take their medications or insulin.  It is also often helpful to meet with a social worker or psychologist to discuss the social/emotional impact of a new medical diagnosis such as diabetes.

Causes of type 2 diabetes:  Medical experts understand that it’s a combination of both genetic and environmental factors that lead to diabetes.  Many people with type 2 diabetes have a family member with the disease as well.  The lifetime risk of developing type 2 diabetes is 5-10x greater in first-degree relatives (sister, brother, son, daughter) of a person with diabetes compared to a person with no family history of diabetes.  The likelihood of developing diabetes is also higher in certain ethnic groups such as people of Hispanic, African and Asian descent.

Environmental factors such as what you eat and how active you are can also affect the risk of developing type 2 diabetes.

Pregnancy:  About 3-5% of patients who are pregnant develop “gestational diabetes” or diabetes in pregnancy.  Diabetes during pregnancy usually resolves after the delivery of the baby however these women are at increased risk of developing type 2 diabetes later in life.

Symptoms of diabetes:  Some people develop symptoms and many people who have diabetes don’t have symptoms.  Possible symptoms include:

1)   Feeling thirsty

2)   Fatigue or feeling tired frequently

3)   Needing to urinate frequently

4)   Blurred vision

Testing for diabetes:  There are several tests to measure blood sugar (glucose) to establish a diagnosis of diabetes:

1)   Random blood sugar:  If you check your sugar and at any time of day regardless of when you ate and your blood sugar is 200 mg/dl or higher, and you have symptoms – it is likely that you have diabetes.

2)   Fasting blood sugar:  A blood test that is performed after not eating or drinking anything except water for 8-12 hours (overnight usually).  If your blood sugar is less than 100mg/dl  – you probably do not have diabetes.  If it’s between 100-125, you have an impaired test and are at risk of developing diabetes if lifestyle changes are not made.  If the fasting glucose is greater than 125, and symptoms are present, you have diabetes.

3)   Hemoglobin A1c:  A blood test that measures your average blood sugar over the past 2-3 months.  The normal value is usually 4-6%.  This test can be done at anytime of day. A result of 5.7-6.4 indicates a high risk of developing diabetes and greater than 6.4 indicates diabetes.

4)   Oral glucose tolerance test:  A patient who is fasting for 8-12 hours usually comes in and then drinks a special glucose solution (usually orange or lemon flavored) and your blood sugar is tested before drinking it and again an hour and sometimes 2 hours after drinking the solution.  If your blood sugar is higher than 200 two hours after the glucose tolerance test, you have diabetes.

Other medical problems:  Often people who have diabetes also have high blood pressure, and/or high cholesterol as well.

Reasons to get your blood sugar under control:  Many newly diagnosed diabetic patients aren’t really sure about the value of having good control of their blood sugars because many people don’t have symptoms when their blood sugar is elevated.  I think it’s important to remind ourselves of the adverse consequences of poorly controlled diabetes:

1)  Increased risk for heart attack/stroke – with poorly controlled blood sugars, you increase your risk of heart attack or stroke dramatically

2)  Diabetic retinopathy – diabetes can cause blindness

3)  Diabetic nephropathy – diabetes can cause permanent kidney damage and is a leading cause for patients to require kidney dialysis

4)  Diabetic neuropathy – diabetes can cause chronic pain or numbness which usually starts in the toes and feet.  This can progress and become very painful with time.

5)  Poor wound healing – when blood sugars are not well controlled, wounds such as a common scrape or cut can take much longer to heal and become prone to infection.

6)  Poor circulation – many patients with poorly controlled diabetes have such poor circulation into their feet or toes that then have partial amputations of limbs performed when chronic infection or death of tissue occurs because of poor circulation.

My recommendations:

1)  Talk to your primary care physician.

2)   Meet with a nutritional counselor to discuss dietary changes that will help bring the blood sugars into control

3)   Meet with a diabetic nurse educator to make sure you understand how to use your glucometer, check your blood sugars and take your medication.

4)   Record your blood sugars every day with a glucometer.  Usually, I recommend that when you first are diagnosed with diabetes that you check more frequently including first thing in the morning before breakfast, 2 hours after breakfast, 2 hours after lunch, and right before going to bed.  Write the dates and times down in a journal or computer spreadsheet and remember to bring this with you when you come to your doctor appointment.  You can also email or fax these records to your doctor if this is easier for you.

5)   Record your blood pressures twice a day – first thing in the morning and also right before going to bed.  Try not to check your blood pressure right after exercise or after drinking a cup of coffee, tea or other caffeinated beverage.

6)   Make a list of all the medications that you take, and bring the list with you each time you go to your doctor.  If your doctor changes any of your medications or dosages, have them write the change on your medication list and update the list at home at your first opportunity.

If you think that you or someone that you know has diabetes, please make sure to be seen by a medical provider.

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

 

Resources:

The following organizations also provide reliable health information.

  • National Library of Medicine

(www.nlm.nih.gov/medlineplus/healthtopics.html)

  • National Institute of Diabetes and Digestive and Kidney Diseases

(www.niddk.nih.gov)

  • American Diabetes Association (ADA)

(800)-DIABETES (800-342-2383)
      (www.diabetes.org)

  • The Hormone Foundation

(www.hormone.org/public/diabetes.cfm, available in English and Spanish)

All About Knee Pain

shutterstock_94626553I often have people come to the Urgent Care who have problems due to knee pain. Pain that originates in the knee can be complex because there are quite a few areas within the knee that can cause pain. The knee is a “hinge” type joint that is at the greatest risk of injury, age-related wear and tear, arthritis as well as infection related arthritis.

Causes: As I mentioned above, there are many causes of knee pain. Several are listed below:

1) Patellofemoral pain syndrome – Group of symptoms that is sometimes caused from overuse of the knee. It can affect running athletes, and is more common in women. The pain is usually in the front of the knee and is made worse with squatting, running, prolonged sitting or when climbing or going down stairs. We also call this Patellar tracking syndrome because it is related to the knee cap (patella) sliding out of the groove that it normally sits in.

2) Meniscal tears – The meniscus is a specialized shock absorber that provides cushion on both sides of the knee. They can become damaged or torn from an acute knee injury or from overuse that comes with age. They have a very poor blood supply, so they don’t heal very quickly

3) Bursitis – The knee is lubricated by joint fluid that is produced by a lubricating bursa (or sac). These bursa sacs can become irritated as a result of injury or even overuse. Inflammation of the bursa is called bursitis

4) Arthritis – This refers to inflammation of the cartilage covering the ends of the bones and undersurface of the knee cap. When it gets worn down, irritated or irregular, it can become painful and is known as arthritis.

5) Tearing of a ligament – The knee is held together by a combination of ligaments including the anterior and posterior cruciate ligaments as well as the medial and collateral lateral ligaments. These ligaments function to hold the bones together and prevent side-to-side or back and forth motion.

6) Muscle strain – If the muscles on the front or back of the knee area become injured, or in spasm they can cause pain around the knee joint. These muscle groups are the quadriceps (located on the front of the top of the knee) and the hamstrings (located on the back part of the leg). These muscle groups work to give support to and move the knee joint

7) Fractures – Broken bones around the knee can obviously cause pain

8) Infection – If bacteria get into the knee joint, this can cause pain, swelling and decreased range of motion

9) Gout – This is caused by the formation of uric acid crystals that build up within the knee joint and is less common in the knee than some other joints

10) Baker’s Cyst – a cyst in the back of the knee can cause pain

Diagnosis: Since there are so many different possible causes of knee pain, it is important to make an accurate diagnosis to treat the underlying problem. In addition to getting a good history from the patient about their pain, a physical evaluation will be performed and sometimes knee x-rays, an ultrasound, or an MRI will be ordered. Additionally, a small sample of synovial fluid is sometimes removed from the knee using a needle. This fluid can be examined under a microscope and/or sent for culture to look for bacteria, crystals or signs of inflammation.

Treatment: The individual patients injury will dictate the kind of treatment that they need to recover the fastest. Physical therapy is often used because it speeds recovery and regain motion. We also often recommend ice, elevation of the leg and muscle-toning exercises when appropriate. Sometimes a knee brace or immobilizer may be appropriate. Medications such as ibuprofen, Aleve or Tylenol may be appropriate for knee injuries. If infection is present, antibiotics may also be prescribed. If injury to the bone or ligaments is the cause, surgery can be helpful in some patients.

Limiting certain activities: Speeding the recovery and helping prevent further injury sometimes involve limiting activities temporarily. Excessive pressure on the knee joint by the following activities should be avoided to help recovery:

1) Kneeling
2) Jogging
3) Squatting
4) Twisting and pivoting
5) Aerobics/Dancing
6) Playing stop and go sports such as basketball or racquet sports
7) Swimming with frog leg or whip kick techniques
8) Rowing machine
9) Stationary bike
10) Stair stepper
11) Leg extensions with weights

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

Change Your Mind to Change Your Weight

<originally published Mar 11, 2009>

Now that we are ten weeks into the New Year, my patients, like many of you, struggle to stick with their resolutions to lose weight. At this time of year I like to offer dieters suggestions for “thinking changes” that can enhance any weight loss program.

Keep reminding yourself that, “The more I do it, the easier it gets.” It’s been said that 75% of resolutions made on New Year’s Day are abandoned by February 1st. This is no surprise because behavior changes are hardest in the first few weeks. This is when we learn new ways of thinking, reacting and behaving. Also, during this time, we discover many things that push us to do the unwanted behaviors.

Dealing with this takes a lot of energy, and, let’s face it, it can be exhausting and overwhelming. One way to stay motivated is to be our own cheerleader by thinking things like:

The more I do it,
the easier it will get.

The beginning is hardest,
it gets easier as I go along.

People do this every day, so can I.

Of course it’s hard at the beginning, so was learning to ride a bike.

Change your focus from “eating less” to “eating more.” If we focus our thoughts on how difficult it is to eat less, we develop a sense of deprivation and maybe even a bit of self pity. This is dangerous, because feelings of deprivation and self pity commonly inspire dieters to cheat or even quit dieting entirely. One way to get around this trap is to find several healthy foods that can be eaten between meals for snacks – or with meals to feel fuller. Decide to focus on eating “as much as I want” of the freebie foods, rather than focusing on how unhappy you are because you have to deprive yourself of off-limits foods. Some examples of food “freebies” include celery, cauliflower, broccoli, cabbage, tomatoes, green beans, commercially prepared broth/bouillon, raw carrots, zucchini and summer squash.

Write down everything you put in your mouth in a Food Log.  Eating and drinking is something most of us do without paying much attention; many of us are on “autopilot” when it comes to our food/drink intake. One of the fastest ways to gain control of our diet is to become aware of how much, how frequently, and exactly what we eat and drink. We can do this by writing down what we eat and when we eat it. After jotting this information down for a week or so, we can identify areas for improvement. It can be quite surprising to realize how much we really consume each day!

Don’t fall for lies we tell ourselves about our eating. It is normal for people to be dishonest with themselves about what, how much, and how frequently they consume; people commonly think that they consume smaller amounts, fewer calories and less meals than they actually do. Although self-deception is common, especially at the beginning of a healthier diet, successful people must take responsibility for their eating behaviors to achieve long-term weight loss. Just knowing we are probably “in denial” can help us take a more honest look at our behaviors. The Food Log is an easy way to keep ourselves honest about our eating behaviors.

Weight loss can certainly be a challenging process, but changes in thinking can make it easier. A physician, nutritionist or psychologist can also provide additional assistance with successful diet and weight loss.

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