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    Venturing Out of the House: Restaurant Realities by Danna Korn


    Danna Korn


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    This article appeared in the Winter 2005 edition of Celiac.coms Scott-Free Newsletter, and is an edited excerpt from Wheat-Free, Worry-Free: The Art of Happy, Healthy, Gluten-Free Living.

    Celiac.com 01/11/2005 - Even the most seasoned wheat-free/gluten-free eater (forgive the pun—"seasoned eater") may feel a little uncomfortable venturing out of the home. Its true that your risk of getting unsafe foods does increase when you leave home, but most people agree that the life experiences of eating at restaurants while traveling, or even just the social aspects or convenience of eating at a restaurant on any given day or night, are well worth it.

    In reality, when you eat at restaurants, some chefs will "get it" and work to ensure a safe meal for you, and others wont. Going to restaurants isnt really about eating as much as it is the ambience, the company, and, well, okay—the convenience. Focus on those primary reasons for going to a restaurant, and make the food secondary, even if theres very little you can eat. If youve heard me speak or read my books, then youve followed my advice and stuffed yourself before you left the house, so youre not hungry anyway.

    Defensive Dining
    Its been said that the best offense is a good defense, which probably applies to restaurant excursions as well as it does to the football field. Im not encouraging you to be offensive; in fact, quite the opposite. Its not, after all, the waiters or chefs responsibility to accommodate your diet. If they do, be prepared to leave a big tip, because their job descriptions definitely do not include understanding the intricacies of this diet. Nor should you fill them in on all the minutiae surrounding the diet.

    A brief education is all they should need, because you should already have narrowed down the choices on the menu that look as though they might be safe, or at least may be prepared in a way that would make them safe. Its okay to ask that your food be prepared in a special manner—people do that all the time even when they are not on a special diet.

    Most important, you need to be aware of specific foods and ingredients to avoid when eating out. Some things are more likely to be okay than others, and you should make it easier on yourself by choosing items that are more likely to be wheat-free/gluten-free.

    Plan Ahead
    Your days of eating at Italian restaurants with ease are probably behind you (although many Italian dishes are made with polenta, which is gluten-free). Pizza joints: also not likely. Chinese: possibly. Dont set yourself up for disappointment by selecting restaurants that will fill you with frustration by the very nature of their menu selection. Instead, choose restaurants with a large selection, or choose a restaurant based on its ethnicity or culture because its likely to offer more wheat-free/gluten-free foods. Thai foods, for instance, are often gluten-free, since they use fish sauce instead of soy sauce for a lot of their marinades and seasonings (although some fish sauces can also contain wheat). Study your ethnic foods so you know the ingredients they contain and can make good choices when it comes to restaurant selections.

    Knowing what to order is just as important as knowing where to go. Consider, for instance, an American-style restaurant like Dennys or Sizzler. For breakfast, youre better off contemplating the eggs (beware: many restaurant eggs are from a mix that contains gluten), hash browns (be sure to check), and bacon (check again) than you are the Waffle-Mania, even if it is only $3.95. For lunch or dinner, you can almost always find a restaurant that will offer you a burger (no bun), fries, and a salad (no croutons).

    Be aware of things that are likely to be problematic. For instance, most sushi is okay, but some of the products, such as imitation crabmeat, usually contain wheat, while other sushi items can contain soy sauce, which usually also has wheat. Cajun cooking often uses beer to cook shrimp and other shellfish, and of course beer is off-limits on a gluten-free diet.
    Make it easier on yourself by choosing foods that are more likely to be safe for you. What you end up with may not be your first choice, and you may find yourself longing for the days when you could order from a menu with your eyes closed. Dont whine about what you cant have, and focus on the things you can. Remember, eating out isnt about the food. Its about the atmosphere, the company, and the fact that youre not cleaning up.

    Talk to the Waiter and Ask the Right Questions
    Sometimes talking to the waiter is an exercise in futility. If you realize this is the case, either order what you deem to be safest, order nothing at all, or leave.

    A cooperative waiter or waitress, on the other hand, is your first line of defense in keeping bad food away. Make friends. Be kind. Tip well. After youve picked what you think could be a safe menu selection or could be made into one, ask questions. Dont be shy; its not rude or uncommon for people to ask questions, even when theyre not accommodating a restrictive diet. Ask if the hamburger patty is 100 percent beef or if it has fillers; ask if the eggs are all-egg, or if they have fillers; check to make sure the fries arent coated with breading, seasonings, or anything else that would make them off-limits. Check sauces and marinades; even if you mention that you cant eat wheat or gluten, people rarely realize, for instance, that soy sauce usually contains wheat.

    Once youve made your menu selection, the waiter isnt dismissed. At this point it gets a little awkward because youve probably already asked a lot of questions, but there are a few more to ask, because how the food is prepared is also important. You need to make sure that the hamburgers arent grilled on the same rack as the buns, and that the croutons arent just plucked out of your salad, but rather that they were never put in. You even need to ask about the oil the fries are cooked in, because if theyre cooked with breaded foods, you really shouldnt eat them.

    At this point, even the most patient of waiters is likely to be giving you a stiff smile with that "Is there anything else youd like to know?" expression. Offer to talk to the chef, if it would make things easier. Chefs, although not often educated in the fine art of accommodating restricted diets, are usually interested in them nonetheless, and are usually quite fascinated when you talk to them about the wheat-free/gluten-free diet. Each time you talk to a chef, youre educating him or her and making it easier for the next wheat-free/gluten-free patron who comes along.
    Do Your Homework
    Many national chain restaurants have lists of their wheat-free/gluten-free products available by phone or on their Websites. Collect lists from your favorite restaurants and fast-food chains, and keep them in a folder for future reference. You may even want to consider putting them in a three-ring binder that you keep in the car.

    Once youve done all the work to find restaurants that work for you, by all means dont worry about getting in a rut. Theres nothing wrong with "tried and true" when your only other option is "guessed and now Im sick." Dont get too complacent, though, because just like products at the grocery store, menu items at restaurants sometimes change ingredients. Check frequently, and remember that even if you think its safe, if something makes you sick, dont eat it!

    BYOF (Bring Your Own Food)
    It probably wouldnt be too cool for a group of eight to walk into a lovely Italian restaurant, with everyone carrying their entire meal in a brown paper bag, simply to enjoy the ambience. But if you go to a restaurant and bring a small amount of food with you—even if its the main course—its certainly not rude. Some (but not many) restaurants have regulations about preparing food, and are allowed to serve only foods that theyve prepared. Most, however, have no problem if you bring in your own pizza and ask them to heat it for you.

    If you do bring your own food, make sure you its wrapped in aluminum foil to avoid contamination during the heating process. Pizza ovens, for instance, sometimes have convection fans that can blow the flour from other pizzas around the oven, contaminating yours. If you bring bread and ask them to toast it for you, theyre likely to put it in the slot of a toaster, contaminating it with "regular" crumbs and ruining your pristine bread. In that case, you might want to explain that it cant be put in a toaster, but if they have a toaster oven or broiler (that isnt blowing flour around), that would be wonderful. If youre asking them to microwave something, of course, theyll just remove the aluminum foil. The most important thing to remember if youre bringing your own food is to leave a big tip.

    Sprechen Sie Gluten?
    When eating at restaurants of different cultures and ethnicities, its a good idea to know the language, especially if the restaurant is staffed by people who speak a language other than your own. Learn the important words to best communicate your special needs. For instance, in Spanish the word for flour is harina, but that can refer to corn flour or wheat flour, so you need to know that the word for wheat is trigo, and corn is maize. Some restaurant cards come in a variety of languages. Additionally, some Websites offer translation capabilities.

    Tipping
    Im aware of the redundancy in my continuous references to tipping and the importance of being extra generous at tip-time, but I believe it bears repeating. When it comes to asking people to accommodate the gluten-free diet, it seems imperative that we express our gratitude to those who generously oblige our requests. As awareness of this diet increases over the next few years, it will be more common for restaurateurs to understand these restrictions and accommodate them. Anything we can do as a community to enhance their understanding and acceptance will benefit us all in the long run.

    Have fun!
    Now that youre armed with some basic restaurant realities, remember rule #1: Have fun! Dont live your life in a bubble just because you have a dietary restriction. Bon appetite!

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    Guest M Pinkley

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    I am new to the celiac scene as my 7 year old just got diagnosed with it one week ago. A very trying time as Thanksgiving is this coming Thursday and we are traveling out of town. This was a very helpful article.

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    Very helpful. I wish they had fun recipes for kids on this site. I will have to buy Danna's book.

    Thanks.

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    Guest Yessica Perez

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    Excellent article since I have a 6 year old son with celiac.

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    Danna Korn
    The key to gluten-free cooking is simple: take a little bit of homework on your part, a dash of extra effort, and dump in a whole lot of creativity - voila! You're a gluten-free gourmet! But some of the greatest culinary challenges are for those meals-on-the-run, which seem to be the most common kind sometimes. Kids with Celiac Disease has extensive menu suggestions for all meals and snacks, but the following is a short excerpt of on-the-go snack ideas:
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    Danna Korn
    This article appeared in the Spring 2005 edition of Celiac.coms Scott-Free Newsletter.
    Celiac.com 06/08/2005 – Theres no point in enjoying the improved health and vitality youll experience on a gluten-free diet if youre just sitting at home pining away for excitement because youre afraid to venture too far away. You have to live life to its fullest—you should be livin la vida loca! Theres no reason whatsoever to limit or, worse yet, give up travel because of this diet. Traveling wheat-free/gluten-free might be a little intimidating at first, but really, it just takes a little more planning, and sometimes an extra suitcase or two.
    Pre-Travel Checklist
    Before you leave, research your destination: Check with a support group in the area youre visiting to see if they have a list of celiac-friendly restaurants or grocery stores. Also search the St. Johns Celiac Listserv archives for frequent posts about gluten-free-friendly restaurants. You might want to go to the Internet and look up your destination city to see if they have one or more health food stores. If they do, call the store(s) and ask what gluten-free products they carry—if you have a favorite product, ask them to order it for you before your trip so they will have it in stock when you arrive.
    Be aware of legal considerations when crossing borders: Some countries have laws about what foods can be imported. Make sure you know what the laws are, and dont try to bring foods with you that might be confiscated. My family and I had an – umm – interesting experience at the Mexican border when we brought gluten-free pancake mix in an unmarked, vacuum-sealed plastic bag.
    Know the language (at least key words): Learn at least a few key words of the language spoken in the country youll be visiting. Make sure you can say wheat, flour, and other key words. Bring restaurant cards written in the language(s) of the country youre visiting (see www.celiactravel.com), or use translation software to create your own. Ask for rooms with a kitchenette, or stay in a condo: Even a small kitchenette with a microwave, refrigerator, and sink will make your life a little easier.
    Ship food to yourself: If youre traveling a long distance or are going to be gone for a long period of time, consider shipping some of your favorite products to your ultimate destination so theyre waiting for you when you arrive.
    Carry a "kitchen in a suitcase": If youre accustomed to making your breads, cookies, and other baked goods from the mixes that you order online or find in specialty stores, bring them with you, as it may be difficult to find them at your ultimate destination. Bring your specialty tools or appliances, too, like your bread slicer, if you plan on cooking while youre away.
    Grab your gadgets: Manufacturers offer some ultra-convenient travel gadgets these days, even for the traveling eater. Most sporting goods stores carry a small refrigerator (there are several brands) that plugs into the cigarette lighter of your car, making it easier to bring yogurt and other perishables on long drives. And we all know how toasters can present a problem since "regular" toast seems to spray its crumbs everywhere, contaminating them for gluten-free eaters. A travel toaster available on the Internet:
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    BYOF: Even gluten-free bread travels well if you slice it and pack it in a hard plastic storage container. Hard-to-find cereals, pretzels, and favorite treats—even pre-baked frozen cookies—make great snacks en route or when you arrive. Dont forget to pack food for the trip itself, as well as food for your stay at the destination.
    There are grocery stores everywhere you go: When you arrive at your ultimate destination, stop in at the local grocery store and stock up on some of the basics. Dont forget to buy aluminum foil and resealable bags, which work well to store leftovers from restaurants, or any foods that you may have brought with you.
    Remember your restaurant rules: Use the tips mentioned in my books or in past issues of Scott-Free for eating out at restaurants, since youll probably be eating out more than you do when youre at home. If youre traveling to certain places in Europe, you might be pleasantly surprised to find that in some countries like Sweden McDonalds offers two types of hamburger buns: gluten-free and "regular."
    Getting There
    When planning how and what youre going to eat on your trip, you have to first decide where youre going and how youre going to get there. How much and what you bring depends on whether youre taking planes, trains, or automobiles.
    Driving: Driving allows you the most flexibility, and is easiest when youre trying to accommodate a restricted diet. If youre driving in the United States, there will most certainly be national fast-food chains all along the way. Even if you dont want to rely on greasy burgers and fries as a staple for your entire drive, you know that you have a backup—just in case. National restaurant chains (even those that are not of the fast-food, greasy-burger variety) have branches in all major cities—find out which restaurants are along your driving route (you can check www.mapquest.com or a similar Website), and check the restaurants Web sites or contact them for their lists of wheat-free/gluten-free products (this is where your three-ring binder with restaurant lists that you leave in the car comes in handy). There are also commercial gluten-free restaurant guides available, such as the one at www.celiac.com.
    Most important, BYOF. You will probably bring snack foods to munch on while you drive, so just make sure youre loaded with snacks that are easy to eat in the car, travel well, and of course, meet your dietary restrictions (and dont forget the paper towels or wet wipes!).
    Flying, cruising, and riding the rails: Theres less flexibility in how and where you can eat when youre at the mercy of a commercial airliner, ship, or train—but you still have a number of options. Many commercial airlines offer a selection of specialty meals, including gluten-free ones. Be careful, though, and read the labels if the food has them, because sometimes our gluten-free meals have come with fluffy, doughy bagels (that obviously arent gluten-free). If mistakes are made, dont be mad. They tried, and at least they considered having a gluten-free meal as an option. Be glad they made the attempt, and consider writing a polite, gratuitous letter to the food supplier offering information on whats gluten-free and what isnt.
    These days, airlines restrict the number of carry-on bags, so youll have to be more efficient in packing snacks and meals for the flight. Snack items that you might include in a sack lunch usually make good take-along foods for the airplane.
    Cruise ships always have executive chefs. Theyre accustomed to accommodating restricted diets, some of which can have dangerous consequences if mistakes are made, so they take the subject very seriously. By contacting the administrative offices of the cruise line several weeks in advance, you can arrange for the chef to provide you gluten-free meals throughout your cruise.
    Trains are tougher, since most of the foods found in café cars are usually along the lines of packaged sandwiches, croissants, pastries, and other oh-so-not-nutritious goodies. I highly recommend bringing food on the train, and not just because of your restricted diet, if you know what I mean.

    Danna Korn
    This article originally appeared in the Winter 2006 edition of Celiac.com's Journal of Gluten-Sensitivity.
    Celiac.com 04/30/2010 - The gluten-free lifestyle is a big part of who we are.  So when friends, relatives, and loved ones don’t get it—I should clarify—when they seem to choose not to get it—we sometimes get a little cranky.
    I know—I was reminded of how it feels when loved ones don’t choose to get it this past Thanksgiving when one of my relatives who shall remain nameless glutenized the mayo jar.  Now I realize it may seem petty to get tweaked about someone dipping a knife in a mayo jar—but it had gluten all over it, and worse yet, she did the same thing last Thanksgiving, and I threw a tizzy about it then.
    Realizing the first dip alone contaminated the entire jar (of course it was the club-sized jar that is the size of a small Volkswagen), there was no point in stopping her from doing it again.  But I watched incredulously as she taunted me, dipping the knife into the jar—then onto the (gluten) bread—over, and over, and over again.  How many gobs of mayo does one need on a piece of bread?!?  I found myself seething, and my blood boiled with every dip-and-spread motion; I swear she was doing it intentionally.
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    Whatever the reason that stuttering has not been reported in the medical literature in association with gluten ingestion, a number of personal disclosures and comments suggesting a connection between gluten and stuttering can be found on the Internet. Abid Hussain, in an article about food allergy and stuttering said: “The most common food allergy prevalent in stutterers is that of gluten which has been found to aggravate the stutter” (10). Similarly, Craig Forsythe posted an article that includes five cases of self-reporting individuals who believe that their stuttering is or was connected to gluten, one of whom also experiences stuttering from foods containing yeast (11). The same site contains one report of a stutterer who has had no relief despite following a gluten free diet for 20 years (11). Another stutterer, Jay88, reports the complete disappearance of her/his stammer on a gluten free diet (12). Doubtless there are many more such anecdotes to be found on the Internet* but we have to question them, exercising more skepticism than we might when reading similar claims in a peer reviewed scientific or medical journal.
    There are many reports in such journals connecting brain and neurological ailments with gluten, so it is not much of a stretch, on that basis alone, to suspect that stuttering may be a symptom of the gluten syndrome. Rodney Ford has even characterized celiac disease as an ailment that may begin through gluten-induced neurological damage (13) and Marios Hadjivassiliou and his group of neurologists and neurological investigators have devoted considerable time and effort to research that reveals gluten as an important factor in a majority of neurological diseases of unknown origin (14) which, as I have pointed out previously, includes most neurological ailments.
    My own experience with stuttering is limited. I stuttered as a child when I became nervous, upset, or self-conscious. Although I have been gluten free for many years, I haven’t noticed any impact on my inclination to stutter when upset. I don’t know if they are related, but I have also had challenges with speaking when distressed and I have noticed a substantial improvement in this area since removing gluten from my diet. Nonetheless, I have long wondered if there is a connection between gluten consumption and stuttering. Having done the research for this article, I would now encourage stutterers to try a gluten free diet for six months to see if it will reduce or eliminate their stutter. Meanwhile, I hope that some investigator out there will research this matter, publish her findings, and start the ball rolling toward getting some definitive answers to this question.
    Sources:
    1. Toft M, Dietrichs E. Aggravated stuttering following subthalamic deep brain stimulation in Parkinson’s disease--two cases. BMC Neurol. 2011 Apr 8;11:44.
    2. Tani T, Sakai Y. Stuttering after right cerebellar infarction: a case study. J Fluency Disord. 2010 Jun;35(2):141-5. Epub 2010 Mar 15.
    3. Lundgren K, Helm-Estabrooks N, Klein R. Stuttering Following Acquired Brain Damage: A Review of the Literature. J Neurolinguistics. 2010 Sep 1;23(5):447-454.
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    Jefferson Adams
    Celiac.com 06/14/2018 - Refractory celiac disease type II (RCDII) is a rare complication of celiac disease that has high death rates. To diagnose RCDII, doctors identify a clonal population of phenotypically aberrant intraepithelial lymphocytes (IELs). 
    However, researchers really don’t have much data regarding the frequency and significance of clonal T cell receptor (TCR) gene rearrangements (TCR-GRs) in small bowel (SB) biopsies of patients without RCDII. Such data could provide useful comparison information for patients with RCDII, among other things.
    To that end, a research team recently set out to try to get some information about the frequency and importance of clonal T cell receptor (TCR) gene rearrangements (TCR-GRs) in small bowel (SB) biopsies of patients without RCDII. The research team included Shafinaz Hussein, Tatyana Gindin, Stephen M Lagana, Carolina Arguelles-Grande, Suneeta Krishnareddy, Bachir Alobeid, Suzanne K Lewis, Mahesh M Mansukhani, Peter H R Green, and Govind Bhagat.
    They are variously affiliated with the Department of Pathology and Cell Biology, and the Department of Medicine at the Celiac Disease Center, New York Presbyterian Hospital/Columbia University Medical Center, New York, USA. Their team analyzed results of TCR-GR analyses performed on SB biopsies at our institution over a 3-year period, which were obtained from eight active celiac disease, 172 celiac disease on gluten-free diet, 33 RCDI, and three RCDII patients and 14 patients without celiac disease. 
    Clonal TCR-GRs are not infrequent in cases lacking features of RCDII, while PCPs are frequent in all disease phases. TCR-GR results should be assessed in conjunction with immunophenotypic, histological and clinical findings for appropriate diagnosis and classification of RCD.
    The team divided the TCR-GR patterns into clonal, polyclonal and prominent clonal peaks (PCPs), and correlated these patterns with clinical and pathological features. In all, they detected clonal TCR-GR products in biopsies from 67% of patients with RCDII, 17% of patients with RCDI and 6% of patients with gluten-free diet. They found PCPs in all disease phases, but saw no significant difference in the TCR-GR patterns between the non-RCDII disease categories (p=0.39). 
    They also noted a higher frequency of surface CD3(−) IELs in cases with clonal TCR-GR, but the PCP pattern showed no associations with any clinical or pathological feature. 
    Repeat biopsy showed that the clonal or PCP pattern persisted for up to 2 years with no evidence of RCDII. The study indicates that better understanding of clonal T cell receptor gene rearrangements may help researchers improve refractory celiac diagnosis. 
    Source:
    Journal of Clinical Pathologyhttp://dx.doi.org/10.1136/jclinpath-2018-205023

    Jefferson Adams
    Celiac.com 06/13/2018 - There have been numerous reports that olmesartan, aka Benicar, seems to trigger sprue‐like enteropathy in many patients, but so far, studies have produced mixed results, and there really hasn’t been a rigorous study of the issue. A team of researchers recently set out to assess whether olmesartan is associated with a higher rate of enteropathy compared with other angiotensin II receptor blockers (ARBs).
    The research team included Y.‐H. Dong; Y. Jin; TN Tsacogianis; M He; PH Hsieh; and JJ Gagne. They are variously affiliated with the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School in Boston, MA, USA; the Faculty of Pharmacy, School of Pharmaceutical Science at National Yang‐Ming University in Taipei, Taiwan; and the Department of Hepato‐Gastroenterology, Chi Mei Medical Center in Tainan, Taiwan.
    To get solid data on the issue, the team conducted a cohort study among ARB initiators in 5 US claims databases covering numerous health insurers. They used Cox regression models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for enteropathy‐related outcomes, including celiac disease, malabsorption, concomitant diagnoses of diarrhea and weight loss, and non‐infectious enteropathy. In all, they found nearly two million eligible patients. 
    They then assessed those patients and compared the results for olmesartan initiators to initiators of other ARBs after propensity score (PS) matching. They found unadjusted incidence rates of 0.82, 1.41, 1.66 and 29.20 per 1,000 person‐years for celiac disease, malabsorption, concomitant diagnoses of diarrhea and weight loss, and non‐infectious enteropathy respectively. 
    After PS matching comparing olmesartan to other ARBs, hazard ratios were 1.21 (95% CI, 1.05‐1.40), 1.00 (95% CI, 0.88‐1.13), 1.22 (95% CI, 1.10‐1.36) and 1.04 (95% CI, 1.01‐1.07) for each outcome. Patients aged 65 years and older showed greater hazard ratios for celiac disease, as did patients receiving treatment for more than 1 year, and patients receiving higher cumulative olmesartan doses.
    This is the first comprehensive multi‐database study to document a higher rate of enteropathy in olmesartan initiators as compared to initiators of other ARBs, though absolute rates were low for both groups.
    Source:
    Alimentary Pharmacology & Therapeutics