Sunday, 4 October 2015

Gluten free bread: is it really so bad?

Investigative food journalist Joanna Blythman's Bad Food Britain is a brilliant book: a devastating critique of much about what is wrong with our country's diet and attitudes towards food which, almost ten years after publication, is still relevant and valid. Since, I have tried to make a point of reading what she writes, and although I don't always agree with her, she is consistently one of the most thought provoking commentators on what we eat.

Today's Sunday Times The Dish food supplement carries a short article by her on gluten-free bread. Blythman is a staunch critic of 'Big Food', processed food, industrially produced food ... call it what you will - so it's not a surprise that it's a bit of an expose' of the quality of what we might find in 'free from' supermarket aisles.

It's the ingredients which are the focus of the attack: hydroxypropyl methyl cellulose, calcium propionate, xanthan gum, transglutaminase enzymes and their like, which add important functionality - such as preservation or structure - to breads. 'Chemical' sounding names may sound scary, but aren't necessarily: unless you wish to alarm yourself about the several pints of dihydrogen monoxide in your body, or avoid all-natural eggs thanks to their chemistry-set ingredients.

Elsewhere, she rightly outs the dubious practice of adding treacle or burnt sugar to breads to colour them a healthy brown, but doesn't really tackle the fat or calorie content of many mass-produced GF breads, which are higher than their gluten-containing counterparts, on the whole.

Andrew Whitley, author of Bread Matters, is a quoted fellow cynic: arguing that GF bread companies are exploiting those who mistakenly perceive gluten free as de facto 'healthier' by charging inflated prices. But the false perception of most gluten-free bread as a health food is not necessarily the work of the gluten-free bread manufacturers - except when it arguably is. I have written about Genius Breads' questionable marketing a number of times, but I don't see similar behaviour from all GF bread producers - such as Newburn Bakehouse, for example. Unfair to tar all with the same brush? Blythman says she finds it difficult to find justification for the high prices, but the cost of free from isn't merely about ingredients - as Michelle Berriedale-Johnson of the FreeFrom Food Awards explains perfectly in this article.

There are some other valid points made. The underlying message is that we rely too much on on-shelf, heavily processed foods, rather than try more 'natural' or artisinal producers, such as ABO Bakery - which Blythman champions - and that's a fair call. But, while ABO may well make delicious breads, would they be able to supply the NHS with the quantity required by coeliac prescriptions, without sacrificing their natural and time-heavy bread-making techniques?

Mass produced GF bread is not without flaw, but anyone who recalls the state of the GF bread market a mere ten years ago will know how far it has come. Some credit must go to the brilliant Lucinda Bruce-Gardyne of Genius for her innovative work - and it would have been good for the sake of balance to hear from her in Blythman's article. It's a shame some benefits of mass-produced GF breads weren't covered. For many, coeliac children included, the arrival of palatable sliced breads have revolutionised lives. I have heard Bruce-Gardyne speak of the parents who call her offices in tears to offer thanks that their kids can lead normal lives at school and at birthday parties.

We also should remember that prescription GF foods have to meet stringent standards - including meeting complicated labelling regulations accurately. Artisanal producers may be less likely to get this right: indeed, ABO make a 'naturally gluten free' claim on their packaging, which is not permitted in EU legislation.

During the Genius recall of earlier this year, some coeliacs swore they would avoid the larger brands in the future, as they felt they could no longer trust them. But some felt this may be misplaced: as Berriedale-Johnson argued the real contamination danger for coeliacs " ... was more likely to come from small companies whose protocols and risk management systems were less sophisticated so the chances of mistakes were higher".

The primary concern for coeliacs is to keep away from gluten, and for many, to enjoy the simple everyday pleasure and convenience of a simple sandwich. It's not always about additive-free, preservative-free, home made, traditional, 'clean eating' and neither should it be, as nutritious and health-giving as this may be. Coeliac voices weren't heard in Blythman's article: more confirmation, if needed, of the degree to which 'gluten free' has slipped from their grasp.

Coeliac UK have responded to the Sunday Times article - click here to read. 

Wednesday, 30 September 2015

Non-coeliac gluten sensitivity: it's gonna take some time ...

This new article - Exploring the Strange New World of Non-Celiac Gluten Sensitivity - just published in Clinical Gastroenterology and Hepatology, is short and well worth a read. It considers the key recent studies into NCGS - their strengths, their complexity, their limitations, their inconsistencies - and the small steps we are making in understanding what is happening.

There are a number of stand-out extracts.

1. The authors speculate that those interpreting the mixed results may be inadvertently biased: "The viewer ... draws interpretations that are based on his or her prior beliefs about NCGS."

In other words, if you believe in NCGS, you may see evidence for it in the studies; if you don't, you see the holes and flaws.

2. "There are no proven biomarkers for NCGS ... This is particularly important to emphasize in light of the fact that patients are looking for answers and may be offered testing for NCGS via non-evidence-based tests of blood, stool, or saliva".

In other words - stay away from paid-for online / high street tests - at least for the time being.

3. "... it is undeniable that gluten exerts a large nocebo effect on a significant number of patients ..." 

In layman's terms: if you think you get ill by eating gluten, and you eat gluten or think you're eating gluten - you get ill. The harsher critics will say 'all in your head!' - but while this indeed may at least be partly psychosomatic, it doesn't invalidate what patients are experiencing, as the authors point out in another key extract ....

4. " ... it is counterproductive to debate whether NCGS is “real”; the patients are real and seeking our care. Some of these patients are in a great deal of distress, and we should try to help them."

Shifting the discussion away from whether it's real, and trying to find out what it is (be it singular or plural - as it may be several distinct conditions), will surely help those with symptoms. As I've argued before, even if NCGS turns out to be psychogenic, patients should be respected and not be dismissively told they're imagining their symptoms by the Daily Mail, unsympathetic doctors or commentators such as Rod Liddle.

5. "NCGS is a complex entity and will not give up its secrets easily. As such, studies with more limited but focused aims are likely to be more effective in providing important incremental knowledge." 

And here's the crux: there's an awful lot we don't know; it's going to take us an awful long time to get there. Science moves slowly; it's about adding jigsaw pieces over weeks and months to finally get the satisfaction of the picture at the end. We're just going to have to be patient ...

Tuesday, 22 September 2015

Sunrise Bakery: nut free and seed free

A friend of mine's latest hobby is 'yellow stickering', as she's dubbed it: doing the supermarket rounds during late hours for ultra-reduced products set to turn past their sell-by or best-before at midnight.

Well, I just inadvertently stumbled into a yellow stickering frenzy at my local Morrison's, and dodged enough shoppers' elbows to come away with some Sunrise Bakery Bulla Cake for 5p. Naturally, my interest was purely professional and not motivated whatsoever by cake-gluttony: Sunrise Bakery products, which I'd previously spotted and shared with followers on Facebook, have a 'nut and seed free' claim on their labelling. (I take nuts to include peanuts, but haven't confirmed.)

You get three flat cakes, that look like very large squashed hamburger buns, but are a fair bit weightier. They are quite dry, quite dense (texture is not unlike some of the gluten-free bread you used to get pre-Genius), very sweet. I enjoyed the cake more toasted. Homemade jam spread atop a slice made it too sweet; marmalade worked better, but still too sweet for me. The Sunrise Bakery website recommends eating it with avocado; to be frank, I can't imagine two more non-complementary foods, but perhaps that's the traditional way to go, and in fairness it would balance out the excessive sweetness. Anyway, kids I'm sure would like the cake. Although nut free and seed free, the Bulla Cake contains wheat/gluten and soya. No egg or milk - neither in ingredients nor 'may contain' - and it appears to be vegan, although only vegetarian is claimed. 

They also do Caribbean sliced bread, hard dough bread and spiced buns - all of which are made with wheat flour, but are nut free and seed free, as the company operate a no nut or seed policy at their bakery. You can find them online at Morrison's, but I've struggled to find them elsewhere. You can, though, get the Small Spiced Bun at Amazon. I'll add further links if I come across them. 

Sunday, 20 September 2015

Relatively speaking, we've got it good

Some months ago I tweeted a link to an article about the Saharawi people of the Western Sahara - an isolated and displaced people with a coeliac disease prevalence of around 6% - and it appeared to strike a chord with followers.

Their coeliac rate is the highest in the world for any people or nation. To the best of my knowledge, it's over double that of the next highest - countries such as Mexico, Finland, Sweden - which are believed to be around 2-3%. We hear a lot about the Irish and the Italians having the highest rates of coeliac disease. They don't. Theirs is around 1%. They just have good awareness, good gastroenterologists and medical care - and reliable access to an ever-growing selection of safely gluten-free foods, as many of us in Europe, North America and Oceania have.

The Saharawi have none of these things. It is possible that the humanitarian aid they have received from the West has in fact worsened their situation over the years in some respects - by introducing higher levels of gluten into their diet than they would normally consume.

The Italian coeliac charity AIC launched an initiative some years ago to offer support to the Saharwi communities via regular deliveries of GF flour and other support - but I don't know whether it's still in place.

Anyway, their story deserves a wider airing. The translation from Italian isn't perfect, but you can read about it here. The piece dates from 2013, and I can find no further updates on their situation online. If you know of any more recent developments, please add a comment. 

Wednesday, 2 September 2015

May contain nuts - and peanuts too?

Most readers will know that tree nuts are one of the key 14 allergens, and that peanuts - a legume, botanically, not a nut - are another of the 14. Accordingly, when either is present in a food product, it or they must be named individually and treated separately. But what about when it comes to precautionary labelling?

A question raised on Facebook - asking whether 'may contain nuts' could include 'peanuts' too – gave cause for me to dig deep within the many Food Standards Agency documents concerning allergy and food labelling on their website to get confirmation of the answer - which may surprise many.

'May contain' labelling is not legislated, is voluntary, so there are no regulations - only guidelines. Regarding the matter in hand, this FSA document on technical guidance for labelling is revealing. I’d draw your attention to Clause 71 which reads:

The use of the generic term ‘may contain nuts’ to cover both nuts and peanuts is permitted if the risk of contamination is from both foods. There is no need to provide details of specific nuts under this type of voluntary labelling.

I'm not quite sure why this is so – is it really so hard to just add ‘and peanuts’? - but I seem to remember a sad case - possibly related to me by Allergy Action's Hazel Gowland - of a peanut allergic but tree-nut tolerant young man who spotted a 'contains tree nuts' warning on a product, which also contained peanuts (both peanuts and tree nuts were listed in the ingredients, but he'd missed the former), and suffered a fatal reaction.

'Contains' statements or boxes are now banned, and I don't know of any such incidence with a 'may contains' warning - there has never been a 'may contain' death - but it's still a stark reminder that you can never be too careful when dealing with severe food allergies. 

At a time when the overuse of 'may contain' labelling has rendered the warnings almost meaningless, according to a new report, not to mention the cause of huge widespread frustration, and the attitude towards such labelling varying greatly (some ignore them, some maintain a strict wide berth), this is a further reminder of just how confusing this matter can be – and that when it comes to food allergies, nothing should ever be assumed.

Tuesday, 18 August 2015

Daily Mail, NHS and Gluten-Free Prescriptions: the same old story

"Doughnuts and Pizzas on the NHS" - the latest attack on the NHS from the Mail. The story originally claimed £116m of gluten-free junk food was being made available on prescription, as the cover page below shows, but this has later been changed, as you can see from the web version, to '£116m of food for special diets including junk food'.

I expect we have Coeliac UK's strident response to thank for that correction. They pointed out that in fact only £27m was spent annually on gluten-free prescriptions, most of it on staples.

From what I can tell, that figure has been drawn from the total of the eight gluten-free food categories given in this document from the HSCIC published last month, by adding the eight numbers in the fifth column (see Section 8, Table 9.4). You'll note that the junk food spend (biscuits) was £1.3m.

The coeliac community were rightly pissed off. Coeliac UK's Sarah Sleet was interviewed throughout the day on various radio stations. The Independent journalist Siobhan Norton gave a good response. Blogger Kevin Gollop found the funny side.

Despite the events of yesterday, the Mail has continued with its attacks by today publishing a piece which I consider to be a lot worse, because it's by a doctor - Dr Max Pemberton. You can read it here.

In the third paragraph he claims: "... the number of people claiming to be intolerant to foods - especially gluten ... - is rising at an astonishing rate and, with it, the cost of providing 'free-from' foods on prescription"

To imply such a causal link is reckless and careless. Gluten-free food should not be prescribed to the self-diagnosed. Prescription food is not routinely available to those properly diagnosed with other food hypersensitivities, let alone those who have self-diagnosed or taken an IgG test.

Elsewhere, he recycles tired old figures; he perpetuates the myth that diabetics necessarily need special foods (he's a doctor, remember); he attacks people who think they are ill, because that's what the Mail does, repeatedly, as I have blogged before. Some of these patients may well have psychologically-mediated issues with food - and you'd expect a mental health specialist, as he is, to have more sympathy with them.

We have been here before with Dr Max Pemberton, of course. Click here for my thoughts on a very similar article he published five years ago (whole stretches of text are identical), in which he criticised the attention-seeking 'mass delusion' of people who believe themselves to be unwell, and dismissed a friend with lactose intolerance for avoiding milk, but eating chocolate biscuits, a story he churns out again in today's Mail piece.

The Mail may quietly correct, and they may even issue a more formal correction - as they did previously on the prescription story they ran in 2011 which claimed that a loaf of bread cost the NHS £32, which you can still read here (although the original story itself is no longer online) - but I doubt they will ever apologise for the damage they have caused the coeliac community, or the resources Coeliac UK have had to spend on defending their position.

As I wrote in yesterday's blog, gluten-free diets and foods are on average nutritionally inferior to gluten-containing diets. Some coeliacs - especially vulnerable ones in remote areas or with limited accessibility - need the support prescriptions provide. We have to keep defending this while it's needed.

Sunday, 16 August 2015

The Gluten Free Diet: for better or for worse?

I'm still processing last month's anti-gluten Twitter campaign from ex-Dragon Duncan Bannatyne - a man who, remember, warned hundreds of thousands of followers against accepting nutritional advice from dietitians trained to give it, and in the same unqualified breath dished it out himself. Failing to see the irony - perhaps due to a surprisingly mediocre intellectual capacity which revealed itself along with an almost comic unpleasantness - he refused attempts to be reasoned with, as countless coeliacs and nutrition experts learned. The futility of trying to make him see sense eventually dawned: we were challenging someone to a battle of wits - but who turned out to be unarmed.

In the discussions which followed, the question of whether the gluten free diet (GFD) was better or worse than the gluten-containing diet (GCD) cropped up a fair bit. This is a vexed issue, because no two people's diets are identical, and although we all need the same nutrients to stay alive, different individuals need different levels, depending on size, age, sex, health profile, etc.

GFD vs GCD - which wins? 
I fell into an exchange with someone who argued, because he'd been following a GFD for years, with no ill effects, that the diet was not nutritionally poorer. This was a flawed argument, because it was a conclusion drawn from the experience of just one person - himself. I'm always surprised when people fail to grasp they don't get to decide on the truth or falsehood of a medical matter, any more than their vote gets to determine the outcome of an election. I may as well argue that because I didn't vote Conservative in May, Cameron didn't win. You see this failure of logic regularly in discussions about food intolerance tests: 'I took a test and it worked for me therefore these tests work'. Wrong.

It's the big picture we need to explore - lots of people. And we need measurements. An election is easy: everyone gets one vote. But nutrition is complicated. What to measure?

There are two things:
1/ The nutrient content in GF foods versus comparable GC foods;
2/ The nutritional intake of GFD followers versus GCD followers.

Let's look at the first of these.

This study in a Canadian Journal of 130 GF and GC foods concluded that packaged GF foods were higher in fat and carbohydrates, and lower in protein, iron and the B vitamin folate, which a study by nutritionist Tricia Thompson also foundThis study found that GF breads were higher in fat, lower in protein, and higher in glycaemic index values than GC breads.
GF foods: on average, higher in fat and sugar

Let's look at the second.

This study found half of those on a GFD for 10 years had a poor vitamin status. This one, on children, found GF kids had higher carb intake and lower folate. 'Dietary inadequacies are common' reported this UK study (which recommended fortification of GF foods). This German research found that coeliacs on the GFD had lower than national average intakes of B vitamins, iron and magnesium. 'Following a diet based on GF foodstuffs could suppose a nutritional imbalance in celiac patients as well as non-celiacs who follow a diet that includes many GF rendered foodstuffs' - was the conclusion of this Spanish research, and this one found that trace mineral intake was worryingly low in men and women on the GFD. The GFD may even negatively impact the microbiome and your immunity.

There are more out there.

So what do such studies mean? 
Here's what they don't mean.

They don't mean that your GFD is necessarily bad, or that your best friend's GCD necessarily good. They don't mean my GCD is better, the same or worse than your GFD or your neighbour's GFD. They don't mean that a nutritionally adequate or even excellent GFD is impossible.

They do mean that, given our particular food culture, and typical diets, and available products on our shelves, and lifestyles, the average GFD is less likely to be nutritionally complete, more likely to have unhealthy quantities of sugars and fats, less healthy overall, and tougher to follow, than a GCD.

These are the consistent findings of many Western studies, of the many researchers and scientists who have conducted them, and on which experts such as dietitians' opinions are based.

They get to decide - not you nor I - and until Western diets alter drastically and the nutritional profiles of the free-from foods on our shelves improve via fortification or otherwise, this is the way it will remain.

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Friday, 24 July 2015

Dragon's Din

I've said it before but to repeat: I have no issue with people following the diet they choose, but I do with those who urge others to follow suit, without recourse to medical or dietetic advice, and on the basis of false logic.

"It worked for me therefore it will work for you" is an example of such logic, one Novak Djokovic has apparently failed to see the flaw in. And today another expression of it came from entrepreneur Duncan Bannatyne, in a sequence of tweets, encouraging his several hundred thousand followers to alter their diet and 'go gluten free for a better life', as gluten was 'becoming a health risk'.

I objected, pointing out that was not good advice, not supported by dieticians, and asked him to reconsider his statement. This was batted away: he made the baffling claim that gluten-free "is not a diet". Further attempts at reasoning didn't work; other voices objected but were rejected too. He was rude to several. I was told I talked "terrible rubbish that allows many people to suffer the effects of too much gluten". Read more here, if you care; you'll find other ill-informed noise on his stream, which he continued to tweet, despite the concerns raised. The sorry saga culminated in today's key accomplishment:

Why is he so deluded? I can only suppose from his stream it's because he had a transformative experience on the gluten-free diet (good for him), has come to regard gluten as evil, and believes it needs to be banished from everybody's diet. This is a depressingly common arrogance: a failure to appreciate that one's own body is not the same as everyone else's body, and an insult to the medics and dieticians who are the only ones qualified to adjudicate on the truth or falsehood of medical issues.

Gluten is known to be evil only to those with gluten-related disorders, as peanut is evil to those with peanut allergies. I've written extensively before about why casually giving up gluten is not advised, so will only remind readers that, if you have undiagnosed coeliac disease, it is important to keep gluten in your diet until the diagnostic procedures are fully completed, and that if you switch to an elective gluten-free diet, the best advice is do it with the support of a trained dietitian, who understands that a GFD can be difficult to follow and may leave you vulnerable to nutritional deficiencies, if you don't know what you are doing. It's not to be taken lightly.

Someone needs to advise Bannatyne about all this, before he continues to misinform those who follow him. I've asked some health bodies to act on what he wrote today, and hope some people continue to politely point out the folly of his advice, should he dish it out again. I no longer can.