Celiac.com 04/18/2016 - In the last 3 years, there has been an evolving spectrum around celiac disease and gluten sensitivity. The acceptance of Non-Celiac Gluten Sensitivity (NCGS) in the medical community as a distinct clinical entity has gone from that of being an orphaned child crying in the world for recognition, to an accepted, unique component of the triad of gluten-related disorders.(i) Differentiating among gluten-related disorders, guides clinicians in making an accurate diagnosis and recommending specific dietary, nutritional and other medical advice; however, clinical and laboratory diagnosis is complex and evolving.(ii)

Gluten sensitivity is a state of heightened immunological responsiveness to ingested gluten in genetically susceptible people. It represents a spectrum of diverse manifestations, of which, the gluten sensitive enteropathy known as celiac disease is one of many. Adverse reactions to the toxic family of gluten proteins found in wheat, barley, rye, and their derivatives may trigger a heterogeneous set of conditions, including wheat allergy (IgE), NCGS, and celiac disease, that, combined, affect between 10–35% of the population.(iv,v,vi,vii)

TRUE or FALSE
1. Even in the presence of negative small bowel biopsy, positive Endomysial antibody (EMA) IgA predicts development of celiac disease.

2. The prevalence of celiac disease varies by race/ethnicity, with a marked predominance among non-Hispanic whites.

3. With more sophisticated diagnostic markers now available, the majority of celiac disease cases are being recognized.

4. Complete histological normalization of the small-intestinal mucosa occurs in the majority of adult patients after commencing a gluten-free diet.

5. An American College of Gastroenterology Task force recommends that patients presenting with diarrhea-predominant IBS type symptoms should be serologically tested for celiac disease.

6. What percent of individuals with NCGS suspect they may have a problem with wheat?
A. 32%
B. 76%
C. 50%
D. 12%

7. Of the following three scenarios, which is the most dangerous for increased mortality in celiac disease?
A. Total villous atrophy
B. Positive celiac serology with negative villous atrophy
C. Increased intraepithelial lymphocytes (IEL) with negative serology and negative villous atrophy

8. In differentiating wheat sensitivity from IBS, which one of the following features is significantly more frequent in wheat sensitive patients compared to IBS patients?
A. Anemia
B. Self-reported fructose intolerance
C. Weight gain
D. Self-reported lactose intolerance

9. Compared to patients with celiac disease, what are the characteristic features, other than self-reported wheat intolerance, of patients with wheat sensitivity?
A. Anemia and family history of celiac disease
B. Weight loss and increased IEL count
C. Coexistent atopy and food allergy in infancy
D. Increased serum C reactive protein and erythrocyte sedimentation rate

Current therapeutic protocols for celiac disease, NCGS and wheat allergy include dietary counseling from a trained professional, nutritional therapy addressing biomarkers of malabsorption and creating a more balanced intestinal environment.(ix) Currently, there are no approved pharmaceutical treatments for this silent epidemic, however a number of Phase 3 trials are underway. Promising gluten-based research is currently being done including wheat alternatives and wheat selection, enzymatic alteration of wheat, oral enzyme supplements and polymeric binders as exciting new therapies for treatment of celiac disease.

There appears to be at least two distinct groups of NCGS individuals. There are those who are sensitive to wheat and those who have multiple food sensitivities. Furthermore, the multiple food sensitivity group had a higher prevalence of coexisting atopy or food allergy in infancy.(xi) It is critically important to identify whether a NCGS individual has multiple food sensitivities or exclusively has NCGS.(xii) This suggests the world of NCGS is greater than just one mechanism and invites the clinician to explore its pathophysiology.

ANSWERS
1. True
2. True
3. False
4. False
5. True
6. C
7. C
8. A
9. C

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References
(i) Ludvigsson JF, Leffler DA, Bai JC, Biagi F, et.al., The Oslo definitions for coeliac disease and related terms, Gut. 2013 Jan;62(1):43-52
(ii) O'Bryan T, Ford R, Kupper C, Celiac Disease and Non-Celiac Gluten Sensitivity-An Evolving Spectrum, in Advancing Medicine with Diet and Nutrients, Johns Hopkins, CRC Press, December 2012
(iii) Carroccio A, Mansueto P, Iacono G, Soresi M, et.al., Non-celiac wheat sensitivity diagnosed by double-blind placebo-controlled challenge: exploring a new clinical entity, Am J Gastroenterol. 2012 Dec;107(12):1898-1906
(iv) Catassi, C. and Fasano, A. 2008. Celiac disease. Curr Opin Gastroenterol 24: 687-91.
(v) Anderson, L.A., McMillan, S.A., Watson, R.G., et al. 2007. Malignancy and mortality in a population based cohort of patients with coeliac disease or 'gluten sensitivity'. World J Gastroenterol 13: 146-51.
(vi) Ferguson, A., Gillett, H., Humphreys, K., and Kingstone, K. 1998. Heterogeneity of celiac disease: clinical, pathological, immunological, and genetic. Intestinal Plasticity in Health and Disease. 859: 112-20.
(vii) Constantin, C., Huber, W.D., Granditsch, G., Weghofer, M. and Valenta, R. 2005. Different profiles of wheat antigens are recognised by patient suffering from coeliac disease and IgE–mediated food allergy. Int Arch Allergy Immunol 138:257-66.
(viii) Vermeersch P, Geboes K, Mariën G, Hoffman I, Hiele M, Bossuyt X. Diagnostic performance of IgG anti-deamidated gliadin peptide antibody assays is comparable to IgA anti-tTG in celiac disease. Clin Chim Acta. 2010 Jul 4;411(13-14):931-935.
(ix) Ibid, reference 2
(x) Stoven S, Murray JA, Marietta E., Celiac disease: advances in treatment via gluten modification, Clin Gastroenterol Hepatol. 2012 Aug;10(8):859-62
(xi) ibid reference 3
(xii) Bondsa, R., Midoro-Horiutib, T. and Goldblum, R. 2008. A structural basis for food allergy: the role of cross-reactivity. Current Opinion in Allergy and Clinical Immunology 8: 82-86.
(xiii) Kurppa K, Ashorn M, Iltanen S et al. Celiac disease without villous atrophy in children: a prospective study. J Pediatr 2010;157:373–380
(xiv) Kurppa K, Collin P, Viljamaa M et al. Diagnosing mild enteropathy celiac disease: a randomized, controlled clinical study. Gastroenterology 2009;136:816–823
(xv) Mayo Clinic, news release, July 31, 2012
(xvi) Rubio-Tapia A, Ludvigsson JF, Brantner TL, Murray JA, Everhart JE., The prevalence of celiac disease in the United States. Am J Gastroenterol. 2012 Oct;107(10):1538-44
(xvii) Tuire I, Marja-Leena L, Teea S, Katri H, et.al. Persistent duodenal intraepithelial lymphocytosis despite a long-term strict gluten-free diet in celiac disease, Am J Gastroenterol. 2012 Oct;107(10):1563-9
(xviii) Sanders DS, Aziz I. Editorial: non-celiac wheat sensitivity: separating the wheat from the chat! Am J Gastroenterol. 2012 Dec;107(12):1908-12
(xix) Ludvigsson JF, Montgomery SM, Ekbom A, Brandt L, Granath F., Small-intestinal histopathology and mortality risk in celiac disease, JAMA. 2009 Sep 16;302(11):1171-8
(xx) Carroccio A, Mansueto P, Iacono G, Soresi M, et.al., Non-celiac wheat sensitivity diagnosed by double-blind placebo-controlled challenge: exploring a new clinical entity, Am J Gastroenterol. 2012 Dec;107(12):1898-906

Celiac.com 04/12/2016 - Vitamin B12 is a group of cobalt containing compounds described by Alan R. Gaby, M.D. in Nutritional Medicine called cobalamins. Methylcobalamin is the coenzyme form of B12 that is critical for human health. Hydroxocobalamin is a more stable form of B12 but it first needs to be converted to an active form before use in metabolism.

Vitamin B12 is important in DNA synthesis, red blood cell formation, homocysteine metabolism and the production of S-adenosylmethionine (SAMe). Adequate B12 is essential for proper neurological and immune function.

The importance of Vitamin B12 in health and anemia management began during the Depression era when animal protein foods were limited in the American diet. Three physicians who reversed pernicious anemia in dogs were awarded the 1934 Nobel Prize for medicine. Dr. George Hoyt Whipple and two other physicians fed the dogs and humans 1/2 pound of fresh liver per day as a means to control anemia.

Animal proteins—meat, poultry, fish, eggs—are the sources of Vitamin B12 for humans. Plants do not need or produce B12. How B12 gets into your blood is a complex dance of stomach acids and intrinsic factors that starts with pepsin in the stomach splitting off the B12 from the protein compound. The intrinsic factor made by the parietal cells of the stomach attaches to the B12 to be shuttled to the ileum where receptors pull it into the blood.

Once in the blood, B12 is picked up by transcobalamin to be carried to cells throughout the body. Any excess is stored in the liver or excreted in the urine.

If inadequate intrinsic factor is available—loss from aging or proton pump inhibitor use—B12 deficiency symptoms such as macrocytic anemia, neurological disorders and psychiatric symptoms (memory loss, depression, confusion, paranoia) may occur. Severe B12 deficiency can result in intestinal damage, hyper-pigmentation of the skin, hypotension, and immune dysfunction.

The Institute of Medicine indicates that only 2 to 4 mcg Vitamin B12 is needed daily. The average American diet contains 5-15 mcg per day according to NHANES studies. Vegetarians and infants breastfed by vegan mothers are at greatest risk of developing B12 deficiency.

Other factors increase the risk of developing Vitamin B12 insufficiency. Achlorydria secondary to gastritic, gastric bypass surgery, and ileal resection for Crohn’s disease need assessment due to malabsorption. Apathy abounds throughout the medical community despite the 2009 Centers for Disease Control and Prevention statistics indicating 1 out of every 31 people over 50 being B12 deficient. With increasing numbers of gastric bypass patients and Crohn’s resections, this deficiency could be significantly higher.

Adverse symptoms can first be noted with the CBC test indicating large RBC or macrocytosis—a folate and B12 deficiency. Other symptoms may include balance problems, numb hands and feet, leg pains, early onset dementia, pre-Parkinson’s-like disease, infertility and depression.

Many physicians are poorly educated on Vitamin B12 importance since it is a vitamin and easy to treat. Treatment with methylcobalamin injections with few definitive ways to test efficacy seems to be a primary factor. A complete medical history assessing for gut inflammation, celiac disease, GERD, recent nitric oxide use in surgery, and genetic factors like MTHFR should trigger a closer look at B12 adequacy even with a normal homocysteine (HCY) plasma test. High levels of B12 on standard blood analysis usually indicates poor absorption and not intoxification of Vitamin B12. Elevated B12 results >800pg/ml frequently indicate PPI use or low stomach acid malabsorption. Lab results <350pg/ml may still be inadequate for a patient with celiac disease, gluten enteropathy or gastric bypass surgery, so supplementation should be considered.

Medications matter when considering Vitamin B12 status. Below are common drugs that impair absorption:

• Antacids- maalox, MOM, Mylanta, Tums
• Histamine blockers- Zantac, Tagamet, Axid, Pepcid
• Proton Pump Inhibitors- Prevacid, Prilosec, Nexium,. Omeprazole, Acidhex
• Colchicine
• Questran
• Metformin, Glucophage
• Celexa, Effexor, Elavil, Nardil, Paxil, Prozac, Zoloft, Wellbutrin
• Ativan, Librium, Valium, Xanax
• Viagra, Cialis, Levitra
• Compazine, Haldol, Risperdal, Tegretal

Vitamin B12 supplementation is probably the safest medical treatment available. Many people need B12 injections to show improvement in their symptoms. Effectiveness of injections depends more on frequency of administration than on amount given with each injection. Those who improve with injections rarely improve with oral or sublingual products no matter how large the dose because the routes of administration are not capable of achieving high enough absorption levels.

Treatment with Vitamin B12 needs to be continued for life. Until more research on efficacy and safety of oral B12 is available, intramuscular daily or weekly injections should be considered a standard of care, especially in celiac disease and those with gastric bypass surgery.

A 20 page handout on Digestive Wellness is available for $15 from Dr. Betty Wedman-St Louis, 17920 Gulf Blvd, Ste 606, St. Petersburg, FL 33708. It includes information on how GMO foods destroy health which will be covered in a future article.

Celiac.com 04/05/2016 - These fresh-tasting burgers make an easy weeknight meal. No buns here; you can serve these wrapped in romaine or Bibb lettuce leaves and eat them with your hands. Make sure your millet isn't too dry or the burgers won't stick together!

Serves 6

Ingredients:

• 1 cup millet
• ½ teaspoon sea salt, plus a pinch for cooking millet
• 1 tablespoon ground flax seeds
• 3 tablespoons water
• 1 large carrot, peeled and grated
• 4 scallions, thinly sliced
• 1 handful fresh basil leaves, finely chopped
• 2 tablespoons freshly squeezed lemon juice
• 2 ½ teaspoons freshly grated lemon zest
• ½ teaspoon freshly ground black pepper
• 3 tablespoons coconut oil
• 6 large romaine or Bibb lettuce leaves
• 1 recipe Mango Salsa, for serving
• Large drizzle Cumin Cashew Cream Sauce, for serving

Directions:
Cook the millet with a pinch of salt. Set aside to cool.

Combine the flax seeds and water in a small bowl; set aside for 10 minutes until the mixture forms a gel, then mix well.

While the millet is cooking, combine the carrots, scallions, basil, lemon juice, lemon zest, salt, and pepper in a large bowl. Once the millet is cool, add it to the bowl with the flax seed mixture and mix well. Using your hands, shape the mixture into six burgers.

In a large skillet, heat the oil over medium heat. Place the burgers in the pan and cook until golden brown, 7 to 8 minutes on each side. Serve warm wrapped in lettuce leaves with a dollop of Mango Salsa and a drizzle of Cumin Cashew Cream Sauce on top. Uncooked burgers will keep for up to 4 days in the refrigerator or 1 month in the freezer, stored between pieces of parchment paper in a sealed container.

Mango Salsa

Makes 1 ½ cups

Ingredients:

• 1 ripe mango, peeled, pitted, and finely diced
• 1 medium English cucumber, finely diced
• 3 tablespoons finely diced red onion
• 3 teaspoons finely chopped fresh cilantro
• 2 teaspoons freshly squeezed lime juice
• Sea salt and freshly ground black pepper, to taste

Directions:
Combine all of the ingredients in a large bowl; toss to combine, and serve. Add more red onion, if desired, for a spicier salsa. Serve immediately.

Cumin Cashew Cream Sauce

Makes 1 ½ cups

Ingredients:
1 cup raw cashews
¾ cup water
¼ cup freshly squeezed lemon juice
½ teaspoon ground cumin
¼ teaspoon sea salt

Directions:
Combine all of the ingredients in a blender and blend until smooth. Serve chilled or at room temperature. Store leftover sauce in a sealed container in the refrigerator for up to 5 days.

Text excerpted from EATING CLEAN, © 2016 by AMIE VALPONE. Reproduced by permission of Houghton Mifflin Harcourt. All rights reserved. Author/Recipe photo © LAUREN VOLO.

Celiac.com 03/30/2016 - The woman's voice, polite but firm came over the line: "We cannot accommodate your mother."

"You can't accommodate her?" I wondered if I'd heard wrong.

"No. We just had a team meeting and it was decided we cannot accommodate your mother because of her diet."

"Oh." The line hummed as I took in both the news and the woman's frosty tone. The previous week the woman, the admissions coordinator of the nursing home, had been all warm and inviting, even eager to have my mother.

Finally I came out with, "Well…thank you for letting me know," and the line clicked dead as the woman hung up.

I had not seen this coming. I hadn't realized that a nursing home would, or could, turn down a patient based on the need for a therapeutic diet. I thought the reason for a nursing home was to care for ill people.

When I toured the nursing home, the woman proudly proclaimed the facility as being on Newsweek's top recommended list, and gave the appearance of understanding my mother's gluten-free diet, saying, "My niece has told me of it. She's convinced me to eat more gluten-free." The woman went so far as to take notes on my mother's preferences, her love of sleeping in and drinking coffee, and then plopped in my arms a thick packet of Medicare forms. In all ways she had been exceedingly pleasant. Indeed everyone I met at the facility had been pleasant. Purring cats roamed the facility's hallways, birds sang from cages, and they even had a pot-bellied pig in the shade of a tree that could be seen through a window, all for the comfort of the patients. It struck me that they could do these many things for their patients, but feeding one small woman with celiac disease a gluten-free diet was beyond them.

My mother is eighty-eight years old, a pixie with a contagious smile and genteel Southern manner. She was diagnosed with celiac disease at the age of seventy-five. At that time she was on daily use of a nebulizer, sleeping half days and could not leave home and the bathroom unless she took Imodium. The diagnosis and strict adherence to the gluten-free diet returned her to an active life. She took up painting and driving her aging neighbors out to enjoy shopping.

A year ago, in rapid succession, a mass was found in one of her lungs, glaucoma took her sight and a stroke impaired her right hand and memory. For months, she required caregivers around the clock. Today she is mobile with the aid of a walker and can manage nights on her own. She can do one thing for herself, and that is get herself to and from the bathroom. Everything else must be done for her—bathing and dressing and maintaining clothes, medications, food preparation, working the television and her bedside radio. On occasion she will get confused and afraid, so I try not to leave her alone for more than an hour. With the aid of private caregivers and hospice assistance, I have been able to keep her in my home, where she has lived for the past six years. However, her funds are depleting for private care, and there is no one to help me care for her.

After the disappointing phone call from the nursing home admissions coordinator, I sat thinking over all the above facts and allowing myself a sizable hissy fit. Then I gathered myself together and took another look at the nursing home facilities in my area.

For the next two weeks, I sought more information and made lists. My plan was to be better prepared in knowledge and approach. Running on the theory that it is lack of knowledge that causes the fear of a situation, I put together information on my mother: a list of her conditions, needs and food preferences. Because of no longer having teeth, nor wearing dentures, and her advanced age, she needs soft foods, her favorites being eggs and Vienna sausage, puddings, bananas. At the time she would eat mashed chicken and some vegetables, all simple things. I wanted to reassure the admissions director and staff of the nursing facilities that my mother was easily cared for, and that I was willing to help with her food. I also had two brochures from Gluten Intolerance Group: a single sheet on celiac disease itself, and a color glossy brochure, put together in cooperation with the National Foundation for Celiac Awareness, entitled Celiac Disease in the Older Adult. I hoped to engage the interest of people whose primary aim and business is providing healthcare to the elderly.

What I discovered is a general lack of any interest in the welfare of the elderly.

The young woman admissions coordinator of my second choice of facilities, a modern, airy facility, answered my question about their kitchen and possible meeting with the dietary manager, with, more or less, "I've shown you around the building. I don't know what else you want to know." Then she added, "And right now we don't have any female beds available."

At another facility, the admissions coordinator brushed aside any idea of speaking with the dietician. She did not know what celiac disease was, but assured me they could, "probably handle it."

The best facility that I found had a waiting list of at least forty names. They stayed so full that they did not provide temporary respite care. Even so, the admissions coordinator showed me around the building, which was very old, and the sight of an elderly blind woman slumped uncomfortably in a wheelchair in the hallway haunted me. Yet their menu posted on the bulletin board seemed promising. "We do home-cooking," the coordinator said proudly. Then she glossed over my request to see their kitchen and meet the dietician. She admitted to never having heard of celiac disease, but said, "We've had many people with uncommon conditions," and put my mother's name on the waiting list. My eye followed her fingers working the pen far down the yellow legal pad. When I offered to leave the brochures about celiac disease with her, she did not even glance at them, but dismissed them with a sweeping wave, saying, "Oh, there's no need."

Weeks passed. My mother's hospice social worker joined in on the search. She found a facility willing to give the respite stay a chance. "They've had a previous celiac patient," she said.

By now I was quite skeptical, but also curious with this news. The facility she suggested was the closest near my home, and I could easily visit each day. I agreed to meet with the admissions coordinator.

The woman said that, yes, the facility had had a previous patient with celiac disease. It was the experience with this patient, who had been uncooperative and would steal food off other patients' trays, that caused the hesitation on their part. "But we're told your mother wouldn't do that," she said.

Upon studying the fact that my mother was quite incapable of snatching food anywhere, the admissions coordinator said they were willing to offer respite care. I was impressed (surprised is the better word) when the coordinator called the dietary manager to meet me. He read the diet listing I had made up for my mother and said they would have no trouble in providing for her. I volunteered to bring her favorites of chocolate pudding and canned peaches and Vienna sausage for times they might have things she could not eat, and of course any homemade gluten-free cakes.

We packed my mother up, and she went for her week respite at the facility. Her long-time caregivers went as well to provide support in the strange environment, help her learn her way to the bathroom, and to circumvent the inevitable glitches.

The first day for lunch in the dining room, my mother was brought Vienna sausages (which I had provided), nothing else. My mother's caregiver went to the kitchen and inquired of the cooks, surveyed the kitchen and the menu of baked chicken and broccoli and how it was cooked and said, "She can have that." We began to wonder how the previous patient had been fed. I also began to wonder if anyone even glanced at the diet I had printed for my mother.

However, the glitches that week were small. My mother ate well, enjoying their broccoli and branching out to embrace canned spinach. We learned the main reason the facility could and did for that week, succeed in feeding my mother quite well was that they had a full working kitchen and did not rely on food service, where all the meals come prepackaged.

The respite week also worked because of my mother's private caregivers. They monitored the food and educated the kitchen staff. The dietary manager went so far as to voice his gratitude to one of the caregivers for helping them learn what my mother and could not eat.

While it appeared no one read any of the dietary information, over all the stay went well enough that a month later, I decided to try it for long term care. The plan was to have her private caregivers ease my mother through the transition for approximately a month, and then gradually reduce their hours, as the nursing home staff learned my mother's needs. We believed it possible to educate the staff.

The first week went fairly smooth, with a few expected glitches. After that, things went downhill. A semi-soft diet had been requested; this never materialized. My mother's food would be placed on her tray in her room, and left, covered. Either my mother's private caregivers or I had to come in and help my mother eat. Mom's private caregivers continued to mash any meat and large chunks of vegetables, such as sweet potato served still in the skin. They continued to intercept sandwiches on bread and dishes of cake and snack cookies left on her tray. Throughout all of this, my mother's caregivers or I consulted with the dietary manager and the kitchen staff. We thanked them for the good food when it came. We explained again what she could and could not have. We formed the habit of checking each day's menu and writing out foods from that menu that my mother could eat. The kitchen staff accepted these menus and taped them near the stoves. When there was nothing on the menu that my mother could or would eat, we suggested easy canned substitutions. Sometimes she got these substitutions, sometimes not.

Then came the day when I was told that for the evening meal my mother had been served a hotdog and fries of some sort, both too hard for her, or anyone, to eat. (Keep in mind we are paying for this food.) My mother's caregiver took her back to the room and served my mother her snack cakes and pudding I had provided. Her roommate shared in the cakes, because she had come in too late from her dialysis treatment to get dinner. Why her tray had not been saved for her, I have no idea. I had never seen this woman provided any sort of special diet, and she was both diabetic and had kidney disease.

The following morning I also I learned one of the kitchen staff responsible for following the therapeutic diet said to my mother's caregiver: "Oh, she doesn't need that diet. That's all made up."

I faced the fact that providing for my mother was too much trouble for the staff, and they were simply unwilling. My mother was never going to get the food nor the care in eating that she would require at this facility.

As of this writing, my mother is back home. Private caregiver hours have been drastically reduced. I am able to do this, for now.

Here are some chilling facts: Studies indicate that today in our country not only are the incidents of celiac on the rise in all age groups, but the median age for celiac diagnosis is just under 50 years of age, with one-third of newly diagnosed patients being over the age of 65.* (Celiac Disease in the Elderly, Shadi Rashtak, MD and Joseph A. Murray, MD)

This is the age group who are the primary caregivers for themselves and their parents. This is the age group who more often must undergo surgeries and stays in rehabilitation nursing facilities.

Couple the above figures with the fact that we are an aging population. At the current rate, the number of people age 65 and older is projected to double between now and 2050. The baby boomers, responsible for the great population growth, now average over the age of 65.* (An Aging Nation: The Older Population in the United States, by Jennifer M. Ortman, Victoria A. Velkoff, and Howard Hogan, U.S. Department of Commerce, Economics and Statistics Administration, U.S. Census Bureau.)

These simple facts paint a picture of a growing challenge. We must be able to provide short and long term nursing home care for the many celiac patients around us today—my mother, myself, the number of over-60 celiacs I've talked to—as well as the tidal wave looming on the horizon.

In addition, we have other food intolerances on the rise, and we have the needs of those with diabetes and kidney disease and other conditions requiring dietary restrictions. At present, all of these people, not only those with celiac, are being overlooked and discounted.

I have no solid answers to this immense problem. I do have suggestions on things that can be started.

The celiac community must recognize and begin to talk seriously about the problem of dietary care in nursing homes. Printing up a glossy brochure with the advice to have the doctor write an order for a therapeutic diet is a start. We have to step out more aggressively with ways to educate and implement therapeutic diets in a real way. We have programs in place educating restaurants and the food industry. Let's get aggressive with the health industry.

Of course, my experience is that these facilities do not want to be educated. This is where legislation is required. We need to lobby for legislation that requires compliance in the nursing facility industry, in the same way that food labeling compliance was attained.

Further, we need to support the push for legislation for a required number of CNAs per patient in nursing home facilities. At present, there are laws only governing the minimum number of RNs required per patient in nursing facilities. * (Minimum Nurse Staffing Ratios for Nursing Homes, Ning Jackie Zhang; Lynn Unruh; Rong Liu; Thomas T.H. Wan, Nurs Econ. 2006;24(2):78-85, 93.) There are no mandatory minimums for the number of CNAs, the people who actually do the bulk of the patient care—those who would monitor a person's diet and help that person to eat. At present the nursing home facility is allowed to choose for themselves the number of CNAs they need.

I remarked to a friend that there were a number of camps for children with celiac disease, places the child could get away and enjoy and eat safely.
"Well, what about for the elderly?" my friend said. "It seems if they can do it for kids, they could do it for the elderly."

What about the elderly? This is our new challenge—to make certain those elderly people with food sensitivity needs are well cared for.

Celiac.com 03/23/2016 - Often when people hear that someone is "going gluten-free," they think that just means people are not eating wheat. This kind of thinking focuses on the obvious—since gluten is in foods it means watching what is eaten. They may associate this change in diet with some biological process or disease issue. In the world of the general public, they're not really sure what "gluten" is and they're not totally convinced that eliminating it will improve health. But for those of us who make a commitment to going gluten-free, it is far more than just eliminating certain food products. It is a personal transformation of self. What people don't often talk about is it being a psychological and social change as well.

In many ways, making a commitment to seriously go gluten-free is an act of Zen. The Urban Dictionary defines Zen as "a state of focus that incorporates a total togetherness of body and mind. Zen is a way of being. It also is a state of mind. Zen involves dropping illusion and seeing things without distortion created by your own thoughts." What I've found is that going gluten-free requires thoughtful practice, observing the body, monitoring the mind, and seeking knowledge that one integrates into regular practice. The result is the personal expression of insight into daily life.

Going gluten-free isn't just about eating. It is also about personal discipline. It has a lot to do about how we think and how we live. When we started going gluten-free we thought it was just going to entail a dietary switch. What we've learned over the last decade is that going gluten-free is an act of Zen. Our journey into becoming gluten-free started because health issues forced us down that path. We didn't willingly choose to go there. We would have been content with gorging on Texas toast, pasta, and Oreos for the rest of our lives. But if we did, we would have been chronically sick. The Universe pushed us onto the gluten-free road. At first, we did not go gracefully. We stumbled and fell and made a mess of going gluten-free. Going gluten-free seemed miserably hard and terribly inconvenient. We couldn't find products that tasted good, and those we found were expensive and weren't necessarily healthy (the amounts of eggs, butter or oil in many of them were mind-boggling). We spent too much money on poor-tasting products that were very difficult to find. We griped and complained. We felt alienated and imprisoned. Going out to eat was life-threatening because most restaurants didn't cook dishes that were safe, or if they did they cooked them in an environment in which they could be cross-contaminated. The idea of having to eat awful-tasting food and not being able to go out to eat for the rest of one's life was dreadful and depressing. Eating is one of the joys of life, and feeling like one was never going to be able to eat delicious food again felt like a fate worse than death. Going gluten-free seemed doomed to be an act of suffering. Sometimes, it is only through making a mess of our lives that we figure out how not to.

Such is the case with our going gluten-free. What we didn't realize until later was that we had created this negative reality in our minds. You can go gluten-free smoothly, effortlessly, inexpensively, and easily with no disruptions in your daily lives. It need not be a big deal. This process may take a bit of time. The secret in this transformation has little to do with the gluten-free foods available. It has more to do with what is going on in our heads.

Years of diligent practice, trial-and-error, patience and persistence, and learning have helped us to transform our perception of going gluten-free into an easy, inexpensive, and delicious way of eating. It has also fostered a different relationship with what we eat, why we eat, and how we eat. It has changed our relationship with food itself, how it is prepared, and how it is consumed.

Thinking you can eat anything you want and not get sick is illusion for people who must go gluten-free. It requires mind-over-matter self-control when we're hungry and desire foods that may not be safe. Giving in to that longing for a certain cookie or a bite of Grandma's homemade lasagna can make a person with celiac very sick. Being mindful of why that food item creates desire in us is a useful mental exercise. Certain foods evoke memories and emotions that are more delicious than the foods themselves. We can still enjoy the memories without eating foods that aren't good for us.

Food is very social and relational. Eating something served that isn't safe in order to please or not to appear rude, when it has a high likelihood of making us sick, isn't being kind to oneself. There have been times we've gotten annoyed when what-should-be-safe food has been contaminated. On the surface, it shouldn't be a big deal to redo the dish. But the symbolic message conveyed by serving someone with celiac glutened food is more problematic because it reflects that the server didn't really care about our needs. What happens to our relationships with family, friends, or certain establishments who go out of their way to make sure we can eat good foods, safely, in a no-big-deal manner? We care for them all the more. Frankly, we secretly want to see what goes on in the kitchen and read the ingredients on a product and not just take a waiter's declaration that "I'm sure it's gluten-free" to be an accurate reflection of reality until we are sure that what they say accurately reflects how actively sensitive they are to the needs of others who have dietary needs that are different from their own. Issues of trusting others, and trusting ourselves, is part of the gluten-free process. Helping to teach those who didn't understand the importance of being gluten-free in a constructive and thoughtful manner is much better than getting angry at them and refusing to eat with them again.

Going gluten-free requires mindfulness. It gives us a relationship with our food as well as with others. Eating whole and healthy foods is better for us. Taking time to understand what's in our food really matters. Cooking ingredients in a thoughtful, less-hurried way creates lovelier dishes. Consuming them with gratitude and in communication with others makes them even more delicious. We want to know where the food came from, how it was cooked and what it was cooked with, and details of the dish's preparation. Were those oats grown next to a wheat field? Did these nuts get processed on machines that also processed other items that contained glutens? Were there croutons on the salad that you just picked off? Asking questions in a non-combative way is an art. Learning to read labels and knowing the list of unsafe ingredients must be transformed from being a big deal to it being just another routine step in an ordinary day. Learning how to shop, cook, clean, serve and eat are all actually complicated steps that require attention to detail. It is in the transformation of managing all these details into a smooth, seamless and calm process that going gluten-free becomes Zen.

It took us a long time to realize that going gluten-free successfully has more to do with what's going on in our heads than what's going on in the kitchen. Look upon going gluten-free as a Zen experience, in which you have to change one pattern of behavior for a new, better one. You, like we, may find you have to change attitudes toward eating in general and eating gluten foods in particular—and you will be all the better for it.

We'd love to help you to learn more about our approach to going gluten-free. Check out our book, Going Gluten-free, which is available from Amazon and NorLights Press, and let us know how your journey is going!

Celiac.com 03/15/2016 - "Creating health comes down to the food we eat and how we choose to live our lives." – Dr. Terry Wahls

Lots of people find it hard to believe that such a common food as wheat/gluten could possibly be implicated in causing skin diseases. They say something like this: "Everyone eats wheat, but not everyone gets skin troubles—so it can't be wheat!" This logic is flawed. I have written this book so that you can read all of the evidence about gluten-related skin disease in one place. "Cutaneous gluten sensitivity" is one of the new terms applied to the group of gluten-related skin diseases.

Max belongs to this leg in the photo. He is very itchy and sore. He is 18-years old and not getting any better—in fact he has been getting worse. He came to me seeking help. Mum wrote,
"Max has been suffering from debilitating dermatitis over his whole body for the last 3 years. He is withdrawn, self-conscious, covered with sores, and feels he will never get better. Unfortunately, the creams he is putting on just seem to irritate him."

So, I am investigating him for gluten-related eczema. It will be a relief for him if the tests come out positive for gluten. What should be the strategy to get him better?

I don't want him to go through the rest of his life like Elizabeth Whitesell, from the Gluten Zero Facebook page, who explains:

• "I was frantic with itching before my celiac diagnosis. The dermatologists never addressed the possibility of celiac, just gave me new treatments for my itching. I cannot name all of the creams, oils, pills and ointments I used, along with a blue-light treatment. Steroid shots, creams and pills were a major part of my treatment."
• "I received some temporary relief and never traveled without my creams. Itching on my hands was so fierce that I carried a frozen ice block (the kind used in coolers) in my purse. When we were at a public event, I gripped my hands around the ice to ward off a noisy itching attack. Ice was my godsend to keep the itching from following its neurological path. All of my blouses had blood dot stains from clawing my upper arms like I was an ape when into full-time mode."
• "My best treatment was freezing 2-liter bottles of water and holding them between my knees as I laid down to go to sleep. If I could fall asleep before the freaking stage began, I was on a roll. More frozen bottles were kept in a cooler by my bed for when the thaw came and I was too tired to walk downstairs to replace them."
• "What a saint of a husband I had. Once I went gluten-free, so many changes came for the better. I did not suddenly notice the absence of itching but, one day, looked back and realized I was not traveling and sleeping with frozen bottles anymore. I hope dermatologists are more informed now."

Skin Diseases Associated with Celiac Disease

Gluten is known to cause skin disease. Gluten can definitely cause itchy skin. Collectively, these skin-diseases provoked/triggered/caused by gluten can be called "cutaneous gluten sensitivity". This is an umbrella term which includes:

• Dermatitis Herpetiformis (DH);
• Celiac associated skin diseases;
• Non-celiac associated skin diseases.

So what is the evidence?

1) Dermatitis Herpetiformis: To summarise the previous chapter, the classic skin complaint is dermatitis herpetiformis. It usually affects the elbows, knees, buttocks, scalp, and back. It begins as little bumps that then change into little blisters. People say that they are driven mad by the itching. It is caused by an immune reaction to gluten in the skin. Microscopic clumps of immune-complexes get deposited just under the skin. This creates the very itchy rash. These tiny particles of immunoglobulins can take years to clear up once you start on a gluten-free diet. It is reported that it can take up to ten years before you make a full recovery.

2) Celiac Associated Skin Diseases: Marzia Caproni and co-workers have detailed the skin diseases that have so far been associated with celiac disease (and perhaps by implication, with gluten).

In their paper, "Celiac Disease and Dermatologic Manifestations: Many Skin Clues to Unfold Gluten-Sensitive Enteropathy" they include common skin complaints that most people do not associate with gluten-illness:

• Dermatitis Herpetiformis
• Psoriasis
• Alopecia Areata
• Chronic Urticaria
• Hereditary Angioneurotic Edema
• Cutaneous Vasculitis
• Atopic Dermatitis Eczema
• Vitiligo

They also remind us that enamel defects, delayed eruption, recurrent aphthous ulcers, cheilitis, and atrophic glossitis are gluten-associate conditions and that "the diagnosis of celiac disease can sometimes be made from a smile!"

Their important message is that anyone with any of these conditions should be investigated for celiac disease.

3) Non-celiac Associated Skin Diseases
The skin is a frequent target organ in gluten-sensitivity. The skin, hair and teeth can all be disturbed by gluten. However, eczema is a much more common manifestation of gluten-sensitivity.

Humbert and his dermatology colleagues (Gluten intolerance and skin diseases, 2006) wrote this about gluten and skin disease:

• "Gluten sensitivity, with or without celiac disease symptoms and intestinal pathology, has been suggested as a potentially treatable cause of various diseases. There have been numerous reports linking celiac disease with several skin conditions. Dermatitis herpetiformis is actually a skin manifestation of celiac disease. Autoimmune diseases, allergic diseases, psoriasis and miscellaneous diseases have also been described with gluten intolerance."
• "Dermatologists should be familiar with the appraisal of gluten sensitive enteropathy and should be able to search for an underlying gluten intolerance. Serological screening by means of anti-gliadin, anti-endomysial and tissue-transglutaminase antibodies should be performed. Gluten intolerance gives rise to a variety of dermatological manifestations which may benefit from a gluten-free diet."

This is an important statement.

In 2010, Korossy reported a skin eruption that he called "gluten-sensitive dermatitis" which he says is clinically indistinguishable from dermatitis herpetiformis but lacks the IgA connection. (Non-dermatitis herpetiformis gluten-sensitive dermatitis: a personal account of an unrecognized entity, Korossy, 2010).

Cutaneous Gluten Sensitivity

Bonciolini et al (2015) have made a study of the skin manifestations of people with Non-Celiac Gluten Sensitivity (NCGS) Cutaneous Manifestations of Non-Celiac Gluten Sensitivity: Clinical Histological and Immuno-pathological Features, Bonciolini et al 2015

They have adopted the term 'cutaneous gluten sensitivity'. They describe 17 consecutive patients affected by NCGS. They had excluded celiac disease and wheat allergy. They said:

• "The skin lesions observed were similar both to eczema and psoriasis and did not show a specific histological pattern. Furthermore, no serological marker was useful to identify these patients. The only data common to most of these patients affected by NCGS associated to non-specific skin manifestations are:
• the itching;
• the presence of C3 at the dermoepidermal junction;
• a rapid resolution of lesions when adopting the gluten free diet.

Therefore, dermatologists must be familiar with the cutaneous manifestations and symptoms of gastrointestinal disorders. An appropriate understanding, work-up, consultation and management will help to identify the important cutaneous–gastrointestinal connection and ensuring that this important gastroenterological disease in patients with skin manifestations is not ignored.

Finally, we suggest an accurate follow-up of all patients who report intense itching and gastrointestinal disorders, even when histology and morphology of the skin lesions do not identify a specific skin disease.
We also suggest the adoption of gluten-free diet for at least three months assessing any positive effects."

A Family Affected by Cutaneous Gluten Sensitivity

• Katrina Ojakaar writes this about the severe skin problems in her family that were eventually shown to be related to gluten-harm:
• "I had terrible eczema on my legs as a child. As an adult I had recurrent eczema on my eyelids and hands in addition to severe dry, itchy skin on my scalp, back, and legs. I also developed rosacea on my face that was treated unsuccessfully with antibiotics and topical ointments. At the age of 44, I had a lab test that showed gluten was making me sick. I immediately stopped eating food that contained gluten and within weeks watched my skin transform. I no longer have raw eczema patches or dry skin; and my rosacea has disappeared."
• "My daughter, Lila, had horrific diaper rash as an infant and nothing seemed to heal her sore bottom. Even as she grew out of diapers, her bottom was always irritated. Lila's skin was also very dry and irritated. Lotions and even plain bath water caused a sting. But when Lila stopped eating gluten, her skin simply healed. She now has smooth, soft, and moist skin without irritation and enjoys a relaxing bath."
• "My mother suffered from psoriasis on her legs and scalp until she stopped eating gluten at the age of 72. She is now 75, and the psoriasis has disappeared. Her skin is healthy, and she doesn't eat gluten, dairy, or oats."
• My father had rosacea on his face and was diagnosed with the autoimmune disease called lichen planus about 12 years ago. He had raw, bleeding sores on his scalp. And his fingernails and toenails disintegrated where he was left with only tender skin. Three years ago my dad stopped eating gluten, and two months later, his fingernails started to grow back. He now has a thin narrow layer of nail at the age of 80. The lesions related to his lichen planus disease on his scalp are gone. And, my father's rosacea, like mine, also healed when he stopped eating gluten."

Keratosis Pilaris

Keratosis pilaris, or sometimes called 'chicken skin' is blamed on gluten by many people. It is very common, occurring in about 10% of people, and there seems to be a hereditary nature to it. It tends to lessen with age, being prominent in toddlers. Any gluten connection remains speculative.

Anne Luther writes:

• "One of the many pleasant surprises I had when I stopped eating gluten was the disappearance of three different skin rashes. There were non-itchy bumps on my back and arms, non-itchy red bumps on the soles of my feet and a very itchy rash on my legs behind my knees. None of these were ever diagnosed by a doctor but they all disappeared after I had totally eliminated gluten from my life."

Keratosis pilaris is skin condition characterized by rough patches of skin caused by small, acne-like bumps. It is found mostly on the upper arms, upper thighs, and cheeks. It can feel a bit like sandpaper or goose-flesh. These little bumps are usually white, but can be red. They do not hurt. Sometimes they can feel a bit itchy.

Keratosis pilaris seems to be caused by a build-up of keratin, the protein that helps create the protective skin barrier. Once keratin has formed into a hard plug at the opening of the hair follicle, this can block the oil and sweat glands. Consequently, these substances cannot escape out onto the skin, and results in these patches of rough, bumpy skin.

I see a lot of keratosis pilaris in my Clinic. The gluten connection not clear, but many parents report its disappearance on a gluten-free diet.
What happened to Max?

Remember Max's legs at the beginning of this Chapter? Well it turned out that Max had two copies of the HLA gene DQ2 which gives him a 1-in-7 chance of developing celiac disease. It also increases his likelihood of having gluten sensitivity. However his blood tests for gluten (AGA) and celiac disease (tTG) were negative. But he did have evidence of a wheat allergy from his EAST tests. His total IgE levels were extremely high as well (over 4000), showing his heightened allergic status.

So he has now embarked on a trial of a gluten-free diet. Mum says, "I feel that we are starting to get to the bottom of it now." It will be another 6 months before we know his results of his gluten-free diet. It can take a long time to heal.

This was an excerpt from Dr Rodney Ford's latest eBook: "Dermatitis Eczema: Gluten Wheat – Solving the Eczema Puzzle." Available at: Open Original Shared Link

Celiac.com 03/09/2016 - Many of us continue to struggle with a wide range of health concerns, digestive complaints, neurological symptoms, and/or apparently unrelated wellness issues such as low energy levels or continuing episodes of brain fog. Yet, we are gluten-free to the best of our ability. Some of us expend inordinate periods of time preparing all our own meals to ensure the strictness of our diets. Yet the symptoms persist or continue to escalate. For many of us, our health care providers are unable to help. They order more and more testing as they seek more and more obscure possible causes for our repeated visits. You may even be one of those people who simply gives up on the medical profession, and either continues to seek answers on your own, or just tries to accept your current, less than optimal state of health. Many of us continue to believe the faulty information in the "Food Pyramid" and "My Plate". These and other such guides erred with respect to our celiac disease, but we continue to accept flawed claims about the health benefits and dietary importance of grain fiber. Thus, while having eliminated gluten grains, we continue to consume other grains for these benefits. Yet, if the authors of My Plate, etc., could be so wrong about the gluten grains, surely all of their claims should be suspect. Or, if we have great faith in them, we should at least examine the evidence that supports their claims.

We know, by virtue of the celiac's leaky gut, that additional food sensitivities are common among those who were diagnosed as adults. Similarly, those who strayed from careful gluten avoidance will also be likely to have triggered immune reactions to a variety of other food proteins and peptides. Further, Dr. Marios Hadjivassiliou and colleagues have long reported that when there are neurological symptoms that are associated with either celiac disease or non-celiac gluten sensitivity, those individuals need to be even more vigilant than most celiacs about avoiding even tiny traces of gluten. Thus, whether you are continuing to experience celiac symptoms, neurological symptoms, or other health problems that may be driven by diet, I have some good news. There is a new kid on the block.

His name is Peter Osborne, D.C., and he has written an exciting new book about gluten sensitivity and more, much more. Titled No Grain No Pain, Osborne's book brings a breath of fresh air to the many stale controversies that hover over the health issues that are driven or aided by various grains. As the title suggests, his primary focus is on the chronic and acute pain that can be caused by eating various cereal grains. In addition to the gluten grains, he identifies several immune and hormonal pathways and dynamics by which the consumption of storage proteins from other grains can cause pain. Meanwhile, he shows that antibody delivery, via the lymph system, is reliant upon movement and muscle contractions because, unlike blood circulation, we don't have a dedicated organ for pumping lymph. Additionally, he points out that these families of storage proteins bear a striking resemblance to those found in gluten grains and sheds light on them as important forces behind many forms of chronic pain.

Dr. Osborne's plain language explanation of the differences between selective and innate immune reactions, and how they impact on the protein and peptide sensitivities we develop is really quite impressive. I have never read a clearer, more concise explanation of these two facets of human immune systems and how they can interact when things go awry. He presents a series of compelling case histories that show the very dynamics he identifies as problematic, also explaining exactly what these individuals did to recover from their painful symptoms. And this is the most ingenious facet of his book. Osborne identifies the dynamic, then provides an illustrative case history to show both how and why the ailments developed, and how and why the patient gets well again.

He also acknowledges that each of us is unique, making such statements as "Never make the assumption that a food is safe or healthy for everyone." That, I think, is the most telling statement in his aptly titled new book: "No Grain No Pain". His explorations touch on the bacteria that populate our intestines, for good or ill, and how grain consumption can alter those populations. He also explores the elegant interplay between various critical vitamins, minerals, bacteria, and macronutrients that is both unique to each of us, and can have a profound impact on each of our immune systems. His discussion of imbalanced intake of omega 3 and omega 6 oils is another important feature of our individuality.

While excess omega 6 oils will induce inflammation in anyone, and adequate omega 3 oils will counter inflammation in all of us, each of us has her/his own unique capacities for emulsifying, absorbing, and metabolising these fats. Nonetheless, Osborne provides some clear guidelines for balancing our intake of these essential fats toward reducing inflammation. Most of us are currently getting more omega 6 fats than we need, and not enough of the omega 3 fats. That leads to unnecessary inflammation and pain.

I must admit that I was initially put off by the book's central argument, especially since it was presented before the enormous body of supporting information. After all, there is a limit to how many foods I can stop eating! However, I soon warmed to the topic as I saw that it is not much of a step to eliminate the other grains he identifies as problematic. After all, that still leaves us able to eat many healthful fruits, vegetables, berries, and meats.

I was also taken by his discussion of what he calls "grainbesity". The explanation of AGEs is, I think, critical to understanding how important these substances are to the extensive damage they can wreak on all parts of the body and brain.

Similarly, zinc and magnesium, while very important to the proper function of our immune systems, are also critical to managing blood glucose and insulin levels. And unwanted weight gain is often accompanied by deficiencies in these minerals. As we gain weight, our joints are compressed, resulting in joint damage and pain. Weight loss, is the obvious answer, but without these critical minerals, that task may be close to impossible. Further, additional food sensitivities may also be a factor in the vicious, downward, weight-gain spiral.

Dr. Osborne also explores the broad world of unintended consequences from a variety of over-the-counter and prescribed medications. I was aware that many NSAIDs can cause or increase gut leakage of food proteins and peptides into the bloodstream, resulting in autoimmunity and other damaging dynamics. However, I also learned that Ibuprofen can damage the stomach lining and small intestine. Since vitamin B12 deficiency is common in my family, with many members getting regular shots because their intrinsic factor appears to be compromised, it may be worthwhile looking at their ibuprofen use. Similarly, he examines a variety of dietary deficiencies that can be corrected with supplements, and he provides a host of recipes along with a dietary program that gradually weans the follower off the gluten-free, standard American diet.

He has a revolutionary, detailed view of the whole field of gluten sensitivity and he assures the reader that if they will just follow his dietary plan for 30 days, she or he is very likely to discover a pathway that will reduce or eliminate their chronic pain.

On a personal level, many readers are already aware of the substantial relief that my mother got just from avoiding gluten grains. She was able to stop taking morphine, go back golfing, and lose one hundred pounds. (Accumulating that much extra weight is no small feat on a woman who wasn't quite five feet tall.) She lived a much longer life than was likely more than twenty years ago. Yet, when she arrived at the first of two seniors' homes, to live in what is called "assisted living", her dietary needs were not met. In theory, a gluten-free diet was available. In reality, she watched while others consumed tasty treats for dessert, while she was given the same old fruit plate, or Jello. Predictably, she started to cheat. By six years ago, she was frequently eating gluten-laden desserts. In an attempt to "start over" and be closer to my wife and I, she and my step-father moved to another assisted living facility. I spoke with the chef before they agreed to move. He assured me that he would address my parents' needs.

Yet after he had seen my mom cheat a few times, he stopped providing for her gluten-free diet, as he said that if she wasn't making the effort, why should he? I was sympathetic to his point of view until I discussed it with the community health nurse. She said that "We don't stop accommodating diabetics' needs just because they falter on their diet. Why should he do that with her?" Having thought about it, I returned to the chef and pressed him to provide her with gluten-free food. He promised to do so. It was not long before my mother was lapsing into more and more pain. I then spoke with the manager of the facility. She agreed to provide mom with gluten-free food.

By two years ago, mom's mind was going, she couldn't remember what foods had gluten in them, and she forgot to ask for gluten-free alternatives. She steadily re-gained about fifty pounds. Concerned about her weight and her pain, she wanted to return to the diet, but was simply unable to do so. She would forget and eat treats with her neighbors. I watched her eyes light up when one of them brought yet another such deadly treat to share with her.

My own experience is that pain is very forgettable. I doubt that women would give birth to a second child, in this day of available birth control, if pain weren't so easy to forget. It is only when I revisit a particular source of pain that I recall its intensity. I suspect that is true for my mom as well. If so, it is my hope that Dr. Osborne's book, and all the subsequent publications about dietary grain and the pain it causes will enlighten enough folks that cooperation at such extended care facilities will become easier to enlist.

In the meantime, I find myself reading every book on the subject of celiac disease and/or non-celiac gluten sensitivity that comes my way, especially those that explore chronic pain and/or weight gain. In the case of No Grain No Pain, I had the privilege of reading it before its publication. A representative of Simon and Schuster contacted me with a copy of this book, asking me to write a promotional blurb for it. I was happy to read it. Then, I was very pleased to be able to give her the positive blurb she requested, in time for its release late in January 2016. Doubtless, they have contacted many others who have provided similar comments, and I hope that they found it as valuable and compelling as I did.

My mom passed away on June 30, 2014, from a massive stroke. I authorized that she be unplugged from life support systems, as the doctors believed that she would not have any intellectual capacity in the unlikely event that she did recover. She had told me, many times, that she was tired of the pain, tired of the confusion, and tired of living. I'll miss my mom, and I have many second thoughts about how I handled or failed to handle the situations she found herself in. I'll never know, for sure, if my decisions were right or wrong. For myself, I'm pleased that she is no longer in pain, and I have re-dedicated myself to the dietary re-education of as many people as I can. And I hope that Dr. Osborne's new book will help others to avoid the "extended care" trap that my mom fell into.

Source:
1. Osborne P., NO GRAIN, NO PAIN. Touchstone, New York. 2016.