gluten

 It seems that celiac disease is on the rise and is becoming a major public health issues. I remember when I was a kid at summer camp we all ate at the same table. By the time I was a camp counselor there was a special "peanut-free table" and admission to it was enforced through inspection. I am imagine at my children's camps there will probably be a new gluten-free table. 

But celiac incidence has risen and fallen in several cases, most notably in Sweden. In the 1980s, the incidence rate among children under two increased fourfold, then suddenly declined around 1995. Epidemiologists looked for what else had changed during this time and came up with two major factors

breastfeeding, the other was use of gluten-containing infant cereals. Further study into the matter produced a rather strong body of evidence that breast-feeding protects against celiac disease. A possible mechanism is the gut flora. I have written before about the unique properties of prebiotics in human breast milk and their role in establishment of gut flora. C-sections also interrupt establishment of gut flora, and not surprisingly they have also been connected to celiac.

One of my favorite quotes is by Joan Gussow: "I trust cows more than chemists."

I also trust millions of years of human evolution more than chemists. Breast milk is the perfect and most appropriate food for human infants. I become quite disappointed in continous misdirection in citing rare cases in which breast-feeding is literally impossible, such as adoption or after breast-cancer. In countries where breast-feeding is considered the default and formula is considered a last resort, such as Norway, breast-feeding rates are very high (around 99% of women breast feed in the first week) and many out of the remaining 20% receive donor milk. As long as formula is considered a good alternative, governments, employers, and hospitals will have an excuse not to provide support. 

 "This whole gluten intolerance thing is just a Western upper middle class fad. People are just orthorexic. Why would gluten intolerance increase all the sudden?"

Well, actually it's not a Western upper middle class fad. People in poor countries can be celiac, but they just die and people think it's from something else. When you are a refugee wasting away from chronic diarrhea, that's not so abnormal unfortunately. When you are in Central Illinois and suffering from the same, it is abnormal and you see a doctor and hopefully get a diagnosis. 

Why is gluten-intolerance increasing? Doctors are more aware than ever of this condition and are doing more tests. More tests = more diagnosis. Symptoms that were dismissed as "IBS" or one of many other made-up symptom cluster illnesses are being re-diagnosed as gluten intolerance. 

So what's the population with the highest level of celiac disease? Preschoolers on the Upper East Side? Nope, the Saharawi, an Arab-Berber refugee population. And maybe they aren't the highest since they were just unlucky enough to be refugees served by doctors interested in celiac research. Testing found that 5.6% of them have celiac. Unfortunately wheat flour is their staple food (I wonder what that started?). Before celiac was diagnosed, people thought their children were merely dying from a malnourishing diet or GI illness. Researchers are now finding celiac hotspots across the Middle East, India, and Africa. 

This is interesting because so much government food aid contains gluten. How many of the children you see on those "save the children" campaign ads are really suffering from celiac like this child?? How many such starving children will be given gluten-containing food aid and will die as a result? 

Another major question is why celiac disease incidence is so high in the region that gave birth to agriculture? The theory that CD was higher in populations that have adopted agriculture more recently like the Irish or the Finnish has not survived now that other populations have been examined more closely. The Finnish and Irish have high levels of CD because they have high DIAGNOSIS levels. Finnish children are tested at birth. 

What involves the exposure of government health conspiracies, the realization that exercise doesn't make you thin, restricting calories doesn't work very well, and a take-down of low-fat diet foods?

If you are thinking Good Calories, Bad Calories you are right, but there is another community that accepts these things that's not really on the low-carb/paleo radar.

Because it's the fat acceptance community, sometimes known as Health At Every Size. Yes, you read that right. I bought Linda Bacon's book Health at Every Size because I was curious about the fat acceptance community's views. I heard about the movement because yes, I googled my own name, which I share minus one letter with fat acceptance blogger (among other things) Melissa McEwAn.

Now that NYC Paleo is doing beginner's workshops, I'll be fielding more questions than ever and dealing face-to-face with people interested in the diet. Besides that, I'm interested in overall compassionate approaches to human problems.

Some of those people inevitably will be interested in weight loss. Which is interesting for me because that's not how I got into evolutionary eating. I was really sick and looking to feel better. I was also pretty chubby, but that wasn't a huge priority for me.

Three years later I weigh thirty pounds less. But that's not why I'm happy with paleo. I'm happy with paleo because I don't have chronic pain, my digestion is good, my blood sugar is stable, and my inflammatory markers are low. For me, paleo is an overall health strategy, not a weight-loss gimmick. I think this is the philosophy of most successful long-term paleo dieters.

I would like the paleo community be about overall health and not about weight. So many skinny sedentary computer nerds have told me that they are glad they don't have to do anything like paleo because they aren't "fat."

I wonder if they'd feel this way if I told them that studies show that "overweight" people who are in shape have death rates lower than skinny unfit people and actually quite similar to "normal" fit people? In fact, some "fat" people are metabolically healthy, while some "skinny fat" people aren't. Appearances aren't everything.

What if paleo was the opposite of the vegan low fat movement which shames people into eating nutritionally bankrupt foods by calling them "fatties" in rude books like Skinny Bitch? Apparently they are so busy thinking themselves so compassionate to animals that they forgot about people.

The more I study weight the more I think we need this approach. Why do people weigh more than they used to? Why do people find it so hard to loose weight? We ain't in the paleolithic anymore and this is more complex than people not exercising enough or eating too much. Epigenetics, gut flora, pollution, and the complexity of metabolic set-points messed up early in life or with yo-yo dieting make weight a difficult issue.

And in the end…are we sure we know how much people in the paleolithic weighed? Pictures of tribal women show many with modestly round bellies. Is not being svelte a health risk? Consider that, on average, "overweight" people live longer than "normal" weight people. A study of angiograms shouldn't that for every 11 pound increase in weight there was an associated 10-40 lower chance of atherosclerosis.

I don't want people setting unrealistic goals. When people come up to me and tell me they are having a tough time meeting their weight goals on paleo, I look at them and think how great they look. They can run for miles, have glowing skin, feel awesome, and certainly aren't "obese". I tell them that it might be worth trying to adjust their diet, but that they should think about having more health-based goals like higher energy and vitamin-D levels.

I think emphasis on weight often leads people to nutritionally bankrupt diets like low-fat veganism, but also to excessive calorie restriction in general. This can be dangerous for most Americans, who are already pretty low in many nutrients. Lots of the studies on weight loss are also as flawed as those that show how saturated fat is evil. The evidence is that just losing weight doesn't fix many of the problems that doctors say it does.

So how does this effect my approach to paleo? What if you gave me 30 women who wanted to get healthier? They weigh more than they want to, but most importantly they have high inflammation, autoimmune conditions, and impaired insulin sensitivity.

The first step I recommend is ditching processed foods and adding nutrient-rich foods into their diet. I think calorie restriction should come only after people are nourished. And most Americans, even if they look "over nourished," are vitamin, essential fatty acid, and mineral deficient.

It's possible that many of the studies cited in this book that show how bad calorie restriction can be have been done mostly on malnourished individuals. Because studies done on nutrient-emphasizing diets like intermittent fasting and CRON (link) show exactly the opposite.

Then I would target specific goals like improving insulin sensitivity and decreasing inflammation. I would do this by altering the quality of their diet, not the quantity. Once their systems aren't completely deranged I would recommend occasional intermittent fasting.

So about this book. There is a lot of useful information, particularly about the exercise myth and whether being "overweight" is really unhealthy. Some might find her self-esteem building chapters useful. But I find her dietary recommendations to be problematic. She basically says enjoy your food, don't feel guilty, but increase fiber intake dramatically and lower your meat/saturated fat intake. First part is good, but the rest is what happens when you drink only half the government-sponsored health recommendation Kool-Aid.

She says fiber is what makes you feel full and will prevent digestive difficulties. Which actually flies in the face of what scientists now know about digestion. It's not the fiber per-se that matters, but the bacteria in the gut. Where is the recommendation for probiotics? It's not there despite a few paragraphs on how "fat" people have different gut flora. Instead she recommends things like whole-grain toast. Maybe she hasn't seen the evidence that gluten is harmful for everyone because of its inflammatory effects. Not to mention the fact that wheat basically strips minerals from women's bodies.

As for fat it seems odd that she says the government scare-mongering about OMGFATPEOPLERUININGTHECOUNTRY is wrong, but their fat recommendations are right…hmmm. At one point she says weight and hunger are more complex than just leptin and then at another she warns that high-fat diets can reduce leptin. That study she cites used a low-carb diet of WHOLE WHEAT BREAD, commercial mayo (vegetable oil redux), margarine, and canola oil. She also fails to mention that high leptin levels might be bad.

The paleo diet gets a shoutout when she mentions that the wild game meat our paleolithic ancestors ate was different, but uses that fact to say eat less meat instead of eating the meat that's available that IS like what our ancestors ate. In fact, she doesn't mention the nutritional differences between wild/grass-fed meat/fish and factory-farmed crap at all!

I also agree the exercise is not the key to losing weight, particularly chronic cardio, which is unfortunately the method that most people use. I know lots of people who have lost weight with chronic cardio and none of them have kept it off. The benefits of exercise are far beyond weight loss, but it's important to do something that's a source of fun activity rather than a slog. I remember getting up at 5:30 AM as a freshman in college to run the treadmill. My weight never budged and I felt stressed and miserable all the time.

I agree with her that hate-mongering against "fat" people is bad. It leads to justification for ineffective government problems as well as dehumanization of human beings. She also exposes the tragic facts of bariatric surgery, a practice that kills people (7.5% of men who have the procedure!) or leaves them malnourished for life. It typifies the approach to weight in this country: malnourishment is AOK as long as you lose weight! I think in the future bariatric surgery will be considered similar to corsets and foot-binding.

I also don't like the idea of food consumption being a moral issue. I don't think some foods are good and others evil. Even high-fructose corn syrup is not evil. Inanimate objects cannot be evil. Demonizing, guilting, and self-punishment should not be part of a rational paleo diet. Some foods ARE bad for you. You should educate yourself about them and avoid them as best as you can. You should acknowledge that it will be hard and might take time to learn how to exclude things like gluten and processed sugar. In the end, you shouldn't be afraid to love food and enjoy it often. Luckily, unlike the low-fat diet, the paleo diet actually includes foods that are delicious and not just as "sometimes foods."

But according to some, the paleo diet excludes "normal" food. I guess it depends on your perspective, but in my view the paleo perspective is refreshing in that it's about foods, not numbers. There has also been a collective quashing on things that might lead to disordered eating like fat-restriction or quasi-religious food guidelines. One of the only problems I see is that some people try fasting before their bodies might be ready... and then they feel sick and post about it on paleohacks. Fasting should never make you feel unwell.

When I think about how we treat people who aren't thin, I think of my grandmother who is healthy at over 90 despite not being thin according to government guidelines (by the way, the BMI system is pretty messed up). Would she feel comfortable at a paleo meetup? This book was part of a study where they took one group of "overweight" women and had them read a copy of this book and have consultations with the author. The other group followed conventional diet advice. The HAES women showed decreases in bad cholesterol, lower blood pressure, higher activity levels, and greater self-esteem.

What if a paleo-type program were included in that study? I think we'd do even better. Most paleo books are positive about health and don't spend much or any time on emphasizing weight loss. I think paleo wins hands down because it targets actual health problems (and let's be honest, most people who follow is DO lose weight). Linda Bacon falls into exactly the trap of conventional diet gurus when she doesn't look outside the box and see that specific foods might be more important than macro-nutrient ratios or calories.

This series of interesting blog posts about the paradox of metabolically healthy "fat" people highlights an important point:

As a important caveat, there are countless other health issues brought on by carrying excess weight that are not always metabolic (i.e. joint problems due to excess load, skin infections, etc.). Thus, it is often argued that despite being metabolically-healthy these individuals may still be far from optimal health.

My own opinion is that overemphasis on weight is a problem and that many people can't lose weight very easily, but that there really are real disadvantages associated with weight that have nothing to do with stigma. Unfortunately, weight is also more complex than "eat less, move more." In fact, it's even more complex than just "eat paleo, lose weight." YES, there are long-term paleo dieters that are "fat" by BMI standards. Their health has improved, but it's possible they might never be "thin." This new Taubes interview discusses how metabolic damage might not be completely reversible. It might be similar to crooked teeth. Yes, such problems are not present in societies eating traditional diets, but once they are there they are there. You could go 100% paleo for years and it's not going to make your teeth straight.

I think the obesity set point posts on Whole Health Source are a great starting point for exploring this topic. I'm not saying to give up. I'm saying that this is hard stuff and it's more productive to focus on holistic health. There are too many women and men out there waiting to lose weight to buy nice clothes or to enjoy life. Enjoy life now, eat some paleo foods, and enjoy the overall benefits of being outside.

And now for some reader questions:

Q: Dru from Idaho asks "Is this paleo?" sending along this attached picture:

A: No. You got Dim Sum and got a bunch of bread? Dude, where are the writhing sea creatures drenched in various rich possibly-alcoholic sauces? Do they even have Dim Sum in Idaho anyway? 

Whew, thanks for sending along easy questions! Remember that if you want to ask a question, please use the contact form and not comments. If it takes me five gazillion years to answer your question, I'm totally sorry. Let's just say that my inbox is in quite a state these days.

Q: 

I think we've "virtually met" via PaleoHacks but I'm in the process of starting a Paleo meetup in the San Francisco bay area ala what you and John have got going for NYC. I was wondering if you'd have any advice for a dude just starting out with this whole meetup thing. I've emailed John as well but was hoping if I could get your input. Would really appreciate any direction you could give.

A: Running a meetup is hard work and I can't say we do it perfectly. I guess our strategy is a

1. Diversity: We have many types of meetups from fitness to parties to eating out. I think this allows us to attract a wide variety of people. Also, if you do meetups that cost money, also do some that are free. I don't know about SF, but in NYC another major challnege is "provincialism". People in upper Manhattan and reluctant to go to events in Brooklyn, so we try to have Meetups in many different places.

2. Have co-organizers and draw on members to help. It's tough work planning events. I used to plan events full time and I'm happy I don't do *that* anyore. When members propose meetups we encourage them to be involved in the planning process.

3. If a meetup costs money, any money at all, require FULL payment to RSVP. We've tried being nice and doing deposits, but it just leaves up calculating stuff grumpily at the end of the meetup.

Q:

hey completely off topic but i just read your post on GERD on MDA and had a question for ya. i've been paleo for 6 months and have been under a lot of pressure at work/home (selling house, moving etc) when i started to notice a dull ache causing me pain in my stomach that subsided when i ate...except i never felt hungry :( so i went to the dr and she gave me nexium. i only took it for 3 days and had to stop because the side effects were worse than the pain! i've started drinking an ounce of aloe juice 2x daily and have been drinking 1/2c kefir once daily and doing zero fruit (except figs since they are highly alkaline). after you began your diet healing process, how long until you noticed some relief? i know every individual is different but i just can't see the answer in taking a PPI for 30 days...stopping a natural body process entirely seems...well wrong to me! any advice? thanks!

A: It made big news when scientists found out ulcers were caused by h.pylori. The problem was that they completely threw out the past proposed cause: stress. Stress might not tear a hole in your stomach itself, but it can definitely contribute to things do this. I definitely wouldn't take nexium, since it does not address the root cause of the problem. The proof is in the fact that the number of patients who are healed by the 30 day cycle the box advertises is virtually zero. Peter at Hyperlipid has written extensively about the dietary causes of bacterial overgrowth and recommends a very high fat nearly zero carb diet, which is the protocal I followed for several months. It's also very important not to take NSAIDs (AKA aspirin and ibuprofen) because they can contribute to ulcers. I don't really think kefir is as effective as a good commercial probiotic supplement since there is little evidence that bacteria in fermented milk can survive the journey to the gut, but it probably won't hurt anything. I personally take Jarrodophilus, which is expensive, but worth it. I would also recommend taking the NOW Foods Super Enzymes Robb Wolf recommends.

I would also say that perhaps you should consider making some rich nutritious bone stocks and if you can find sea buckthorn products near you there is strong evidence that it helps heal ulcers.

I would also recommend eating more than you want in the morning to get the gastric juices stimulated. My own routine in the morning, which I completely hate, but it's helped me through plenty of stress, is to do some intense exercise for 30 minutes or so and then eat a big meal. There is evidence that exercise can blunt the effects of stress. 

How long does it take to get rid of stomach problems with paleo? It can take anywhere from 1 week to a six months. I think it's important to stay completely gluten-free and to eat enough calories in order to speed up the process. I would do very low carb for 2 weeks to a month until stomach pain subsides and then follow the Cooling Inflammation protocol which recommends some vegetal fiber in order to support a better GI flora.