On the issue of gluten…

On the issue of gluten…

Gluten intolerance is not only a ubiquitous issue, but an entire industry of “gluten-free” foods has been created around it. Here are some of my thoughts on the issue of gluten, taken from Food As Medicine: The Theory and Practice of Food. pages 51-54. If you would like to make a traditional Indian flatbread that reduces gluten to negligible, please review my recipe for sourdough roti, thepla and parantha.

Over thousands of years of experimentation we have learned to process cereals to limit the negative effects of antinutrient factors, including grinding, germination (p. 116), fermentation (p. 127) and cooking. While innovations in modern technology would have us dispense with many of these methods, history demonstrates that when we fail to observe traditional measures there can be dramatic repercussions. Pellagra arose as a mysterious disease in the South-Eastern US during the early 1900’s, just a few years after cornmeal had been introduced as food to feed the poorer classes. Pellagra ravages the body causing skin lesions, chronic diarrhea and dementia, killing the victim in just a few years. It took almost 50 years before a scientist discovered that pellagra was caused by a niacin (vitamin B3) deficiency. Years later it was discovered that the traditional Aztec practice of processing corn with an alkali such as wood ash or lime (called nixtamalization) releases niacin trapped in the outer shell of the kernel.

While pellagra is now a rare occurrence, its underlying cause finds resonance in a whole new epidemic of gluten intolerance. Gluten is a naturally occurring protein found in the seeds of grass species including wheat, spelt, kamut, rye and barley. When ground into a flour gluten gives these cereals a glue-like consistency that allows the dough to rise, trapping the gasses released by the leavening agent like a balloon fills with air. Etymologically the word ‘gluten’ is derived from the Latin word ‘glutinis’ meaning ‘glue’, and it is perhaps no surprise that the sticky properties of gluten are used to good effect in other applications such as paper-making, wallpaper paste, paper-mâché and play-dough.

Given the sticky, glue-like property of gluten and flour it is easy to appreciate that gluten is very difficult to digest. At the extreme end are those who suffer from celiac disease, and exhibit a profoundly negative response to gluten consumption, manifesting characteristic symptoms including abdominal pain, steatorrhea, constipation and malabsorption. Although less than 1% of the population is diagnosed with overt celiac disease, researchers suspect gluten intolerance may be much more common than previously thought,[1] affecting up to 29% of the US population.[2] Beyond the effect on digestion, gluten intolerance is associated with a number of other issues including:

  • weight loss[3]
  • anemia[4]
  • fatigue[5]
  • dermatitis herpetiformis[6]
  • psoriasis[7]
  • autoimmune thyroiditis[8]
  • type 1 diabetes[9]
  • uveitis[10]
  • Addison’s disease[11]
  • infertility[12]
  • inflammatory bowel disease[13]
  • autoimmune liver disorders[14], [15]
  • pancreatitis[16]
  • peripheral neuropathy[17]
  • dementia[18]
  • epilepsy[19], [20]
  • anxiety[21]
  • migraine[22]
  • fibromyalgia[23]
  • arthritis[24], [25]
  • osteoporosis[26]
  • cancer[27], [28]

The typical advice given to confirmed celiacs and those suspected of gluten intolerance is to avoid gluten-containing foods such as bread, pasta, pastries, muffins and breakfast cereal. Gluten however is hidden in many foods, used by industry as an adhesive and excipient in processed and prepared meats, processed cheeses, condiments, sweeteners and candy, as well as breads “made without flour”. Given its prevalence in the food supply gluten avoidance can be a difficult task for the consumer, especially outside of big cities and major centers, and itself can be a cause of chronic anxiety.[29]

Given the association of gluten intolerance with chronic disease it is not surprising that the popularity of gluten-free products has exploded in the marketplace. Manufacturers have found clever ways to use non-gluten flours such as rice, buckwheat, corn, sorghum, teff, tapioca, arrowroot, potato, coconut, soy bean, guar bean and locust bean to make familiar products. While many of these alternatives do seem to lessen the symptoms associated with gluten intolerance, the question arises if we are substituting one problem for another. Very few of these alternatives were traditionally milled into a fine flour and used in baked goods, and many have the same types of antinutrient factors and immune sensitizers as gluten-containing cereals such as wheat.

It could be that much of the issue with the widespread gluten intolerance that seems to have evolved from thin air, like corn and pellagra, is in large part an artifact of not observing traditional methods of food preparation. Traditional methods of bread making, like the nixtamalization of corn, is an involved process that includes sprouting, roasting and stone-grinding the cereal to a coarse flour. The key element is the incorporation of a sourdough culture comprised of naturally occurring bacteria and yeasts. Apart from their use as leavening agents, these organisms ferment starches and produce enzymes in the process that effectively hydrolyze the gluten, turning it into easily digestible proteins.[30] Clinical research shows that when sourdough is used in the preparation of baked goods it is surprisingly well tolerated among patients with celiac disease.[31] Making real sourdough bread however is an artisan skill that requires time and effort to practice (see page 128).

[1] Harrison MS, Wehbi M, Obideen K. 2007. Celiac disease: more common than you think. Cleve Clin J Med. 74(3):209-15.
[2] Fine K. 2003. Early Diagnosis Of Gluten Sensitivity: Before the Villi are Gone. Available from http://www.finerhealth.com/Essay
[3] Nelsen DA Jr. 2002. Gluten-sensitive enteropathy (celiac disease): more common than you think. Am Fam Physician. 66(12):2259-66.
[4] Ibid.
[5] Ibid.
[6] Ibid.
[7] Birkenfeld S, Dreiher J, Weitzman D, Cohen AD. 2009. Coeliac disease associated with psoriasis. Br J Dermatol. 161(6):1331-4.
[8] Ch’ng CL, Jones MK, Kingham JG. 2007. Celiac disease and autoimmune thyroid disease. Clin Med Res. 5(3):184-92.
[9] Bhadada SK, Kochhar R, Bhansali A, Dutta U, Kumar PR, Poornachandra KS, Vaiphei K, Nain CK, Singh K. 2011. Prevalence and clinical profile of celiac disease in type 1 diabetes mellitus in north India. J Gastroenterol Hepatol. 26(2):378-381.
[10] Krifa F, Knani L, Sakly W, Ghedira I, Essoussi AS, Boukadida J, Ben Hadj Hamida F. 2010. Uveitis responding on gluten free diet in a girl with celiac disease and diabetes mellitus type 1. Gastroenterol Clin Biol. 34(4-5):319-20.
[11] Elfström P, Montgomery SM, Kämpe O, Ekbom A, Ludvigsson JF. 2007. Risk of primary adrenal insufficiency in patients with celiac disease. J. Clin. End. & Metab. 92(9): 3595
[12] Collin P, Vilska S, Heinonen PK, Hällström O, Pikkarainen P. 1996. Infertility and coeliac disease. Gut. 39(3):382–4.
[13] Leeds JS, Höroldt BS, Sidhu R, et al. 2007. Is there an association between coeliac disease and inflammatory bowel diseases? A study of relative prevalence in comparison with population controls. Scand. J. Gastroenterol. 42(10):1214–20
[14] Niveloni S, Dezi R, Pedreira S, Podestá A, Cabanne A, Vazquez H, Sugai E, Smecuol E, Doldan I, Valero J, Kogan Z, Boerr L, Mauriño E, Terg R, Bai JC. 1998. Gluten sensitivity in patients with primary biliary cirrhosis. Am J Gastroenterol. 93(3):404-8.
[15] Volta U, Rodrigo L, Granito A, et al. 2002. Celiac disease in autoimmune cholestatic liver disorders. Am. J. Gastroenterol. 97(10):2609–13
[16] Patel RS, Johlin FC, Murray JA. 1999. Celiac disease and recurrent pancreatitis. Gastrointest. Endosc. 50(6): 823–7
[17] Hadjivassiliou M, Rao DG, Wharton SB, Sanders DS, Grünewald RA, Davies-Jones AG. 2010. Sensory ganglionopathy due to gluten sensitivity. Neurology. 75(11):1003-8.
[18] Hu WT, Murray JA, Greenaway MC, Parisi JE, Josephs KA. 2006. Cognitive impairment and celiac disease. Arch Neurol. 63(10):1440-6.
[19] Canales P, Mery VP, Larrondo FJ, Bravo FL, Godoy J. 2006. Epilepsy and celiac disease: favorable outcome with a gluten-free diet in a patient refractory to antiepileptic drugs. Neurologist. 12(6):318-21.
[20] Mavroudi A, Karatza E, Papastavrou T, Panteliadis C, Spiroglou K. 2005. Successful treatment of epilepsy and celiac disease with a gluten-free diet. Pediatr Neurol. 33(4):292-5.
[21] Addolorato G, Capristo E, Ghittoni G, et al. 2001. Anxiety but not depression decreases in coeliac patients after one-year gluten-free diet: a longitudinal study. Scand. J. Gastroenterol. 36(5): 502–6
[22] Gabrielli M, Cremonini F, Fiore G, Addolorato G, Padalino C, Candelli M, De Leo ME, Santarelli L, Giacovazzo M, Gasbarrini A, Pola P, Gasbarrini A. 2003. Association between migraine and Celiac disease: results from a preliminary case-control and therapeutic study. Am J Gastroenterol. 98(3):625-9.
[23] Wallace DJ, Hallegua DS. 2004. Fibromyalgia: the gastrointestinal link. Curr Pain Headache Rep. 8(5):364-8.
[24] Sökjer M, Jónsson T, Bödvarsson S, Jónsdóttir I, Valdimarsson H. 1995. Selective increase of IgA rheumatoid factor in patients with gluten sensitivity. Acta Derm Venereol. 75(2): 130–2
[25] Al-Mayouf SM, Al-Mehaidib AI, Alkaff MA. 2003. The significance of elevated serologic markers of celiac disease in children with juvenile rheumatoid arthritis. Saudi J Gastroenterol. 9(2):75-8.
[26] Kemppainen T, Kröger H, Janatuinen E, Arnala I, Kosma VM, Pikkarainen P, Julkunen R, Jurvelin J, Alhava E, Uusitupa M. 1999. Osteoporosis in adult patients with celiac disease. Bone. 24(3):249-55.
[27] Holmes GK, Stokes PL, Sorahan TM, Prior P, Waterhouse JA, Cooke WT. 1976. Coeliac disease, gluten-free diet, and malignancy. Gut. 17(8): 612–9
[28] Ferguson A, Kingstone K. 1996. Coeliac disease and malignancies. Acta Paediatr Suppl. 412:78-81.
[29] Häuser W, Janke KH, Klump B, Gregor M, Hinz A. 2010. Anxiety and depression in adult patients with celiac disease on a gluten-free diet. World J Gastroenterol. 16(22):2780-7.
[30] De Angelis M, Cassone A, Rizzello CG, Gagliardi F, Minervini F, Calasso M, Di Cagno R, Francavilla R, Gobbetti M. 2010. Mechanism of degradation of immunogenic gluten epitopes from Triticum turgidum L. var. durum by sourdough lactobacilli and fungal proteases. Appl Environ Microbiol. 76(2):508-18.
[31] Di Cagno R, De Angelis M, Auricchio S, Greco L, Clarke C, De Vincenzi M, Giovannini C, D’Archivio M, Landolfo F, Parrilli G, Minervini F, Arendt E, Gobbetti M. 2004. Sourdough bread made from wheat and nontoxic flours and started with selected lactobacilli is tolerated in celiac sprue patients. Appl Environ Microbiol. 70(2):1088-96.

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Diet to balance pitta (bile)

The diet to balance pitta corresponds to the many of the so-called “balanced” diets out there, such as the Mediterranean or Indo-Mediterranean diet, that display a mostly balanced ratio of fats, proteins and carbohydrates. In Ayurveda this diet is good for people that have an average metabolism, neither very fast nor slow, providing a balanced source of energy. In particular, this diet is good for people that have a hot temperament, and tend to get warm easily. Some of the recommendations of this diet are contraindicated for people suffering from excessive coldness.

Pitta-reducing diet
A pitta-reducing diet is predominant in sweet, bitter and astringent flavors, expressing the qualities of cold, light and dry.  This includes a preference for foods such as:

• Soup stock made from vegetables, mushrooms as well as cooling herbs and spices (e.g. Garden Vegetable Soup, p. 150)
• Lean cuts of meat, prepared baked or grilled, e.g. poultry, fish, bison, elk, wild game (e.g. Herb Poached Wild Salmon, p. 166)
• Leafy greens and other vegetables, steamed or eaten raw
• Whole grains and legumes, prepared as soups and stews with cooling herbs and spices (e.g. Goji Quinoa Pilaf, p. 184)
• Raw milk, fresh yogurt, buttermilk (e.g. Khadi, p. 177)
• Fresh fruit, with minimal citrus and sour varieties
• Cooling fats and oils, such as coconut and ghee
• Cooling herbs and spices, e.g. coriander, fennel, turmeric, clove, mint, cumin, licorice
• Cane sugar (jaggery, gur) in limited amounts

How do you know if a pitta-balancing diet is right for you? One way to use the diet is to treat pitta-specific health issues, such as diarrhea, inflammation or bleeding problems, and another way is to use it to balance your constitution. What follows are the features of a pitta constitution, taken from my book Food As Medicine: The Theory and Practice of Food. Please also check out the pages on a vata-balancing and kapha-balancing diet to see if these diets are more suitable. Remember too, that you can be a combination of the doshas, and so the best might be a balanced combination of two or three different diets.

Pitta constitution
Pitta constitution is more sensitive to qualities such as heat, moistness, and lightness, and thus measures are taken on a general basis to balance these aspects by emphasizing qualities such as cold, dry and heavy.  Physically, pitta types have a strong metabolism, strong digestion, and a general tendency to mild inflammatory states.  The body is of average build, with a well-developed musculature and generally less fat than kapha but not skinny like vata.  The features are angular: thinner, sharper and longer, with a medium breadth.  The skin is often quite ruddy and there is a general tendency to excessive heat. Warm temperatures and hot climates are poorly tolerated.  There is a tendency to excessive bile production and gastrointestinal secretions (tikshnagni), loose bowel movements, and more frequent urination. Pitta types are more sensitive to sensory stimuli than kapha, especially light, heat and sound. They tend to be more physically active than the either vata or kapha types, with coordinated, quick and efficient movement, sometimes aggressive, and act with determination and purpose.

Diet to balance kapha (phlegm)

The diet to balance kapha corresponds to the many of the low-fat, mostly vegetarian diets out there including that recommended by Dr. Dean Ornish, as well as those who advocate for raw food veganism. This diet is proportionally rich in antioxidant and antinflammatory nutrients, and typically low in protein and fat. In Ayurveda this diet is suitable for people that have a sluggish metabolism, that tend to gain weight easily on a rich, nourishing diet. This diet is also an excellent choice to promote detoxification, by shifting energy balance in the body towards elimination. As per Ayurveda however, this diet is very cooling, and needs to be balanced with warming herbs and spices. This diet is also contraindication in children, pregnant and nursing mothers, and in immune deficiency.

Kapha-reducing diet

A kapha-reducing diet is predominant in bitter, pungent and astringent flavors, expressing the qualities of hot, light and dry. This includes a preference for foods such as:

• Soup stock made from spicy herbs such as garlic, ginger, onion and chili (e.g. Mulligatawny Soup, p. 149)
• Limited amounts of lean meats, prepared baked or grilled, e.g. poultry, fish, bison, elk, wild game (e.g. Goat Curry, p. 169)
• Leafy greens and other vegetables, steamed or stir-fried with only a little fat (e.g. Garlic-Basil Rapini, p. 156)
• Light and drying grains such as barley, buckwheat, millet and wild rice (e.g. Northwest Wild Rice Infusion, p. 185)
• Most legumes, prepared with warming herbs and spices (e.g. Urad Mung Dhal, p. 180)
• Sour and bitter fruits such as lemon and lime
• Fermented foods, made with bitter and pungent vegetables such as onion, daikon, radish, cabbage, tomato, peppers (p. 158)
• Warming herbs and spices, e.g. ginger, cardamom, cayenne, ajwain, black pepper, mustard
• Honey, in limited amounts

How do you know if a kapha-balancing diet is right for you? One way to use the diet is to treat kapha-specific health issues, such as cough, congestion, weight gain or autotoxicity (ama), and another way is to use it to balance your constitution. What follows are the features of a kapha constitution, taken from my book Food As Medicine: The Theory and Practice of Food. Please also check out the pages on a pitta-balancing and vata-balancing diet to see if these diets are more suitable. Remember too, that you can be a combination of the doshas, and so the best might be a balanced combination of two or three different diets.

Kapha constitution
Kapha constitution is more sensitive to qualities such as heaviness, cold, and moistness, and thus measures are taken on a general basis to balance these aspects by emphasizing qualities such as light, hot, and dry.  Physically, kapha types have a general tendency to weight gain, with a heavy, thick build.  The shoulders are broad and the torso, legs and arms are thick and large; in women the hips are broad and breasts are full.  The musculature is well-developed but usually hidden by a layer of fat, hiding any angularities of the skeleton.  The feet are large and thick.  Facial features are broad and full, and generally well proportioned. The skin is soft and smooth, and the hair is generally smooth, thick and greasy.  The orifices (eyes, nose, ears, mouth, rectum, urethra, vagina) are moist and well-lubricated.  There is a tendency to lethargy or inactivity, although once motivated the energy released can be very powerful, with great endurance and a steady pace. A kapha type might suffer from a slow and weak digestion (mandagni), as well as minor congestive conditions, such as respiratory and gastrointestinal catarrh.  They may display a mild aversion to cold and prefer warmer climates, but if they are physically active they can withstand even very cold weather quite easily.