Dear HEALTHbeat subscriber,

Ten years ago, I bet few of us had ever seen a “gluten free” product—or would have known what it was. But these days, you may have noticed a rise in the number of gluten-free food options available in your local grocery store. This issue of HEALTHbeat discusses gluten intolerance and celiac disease, and why you might be hearing more about both than in the past. Also in this issue, Dr. Celeste Robb-Nicholson, editor in chief of the Harvard Women’s Health Watch, answers a reader question about whether the smell of cigarette smoke is as worrisome as secondhand smoke.

Wishing you good health,


Nancy Ferrari
Managing Editor
Harvard Health Publications
HEALTHbeat@hms.harvard.edu

Do you have a gluten problem?

The classic and most immediately noticeable symptoms of celiac disease are, not surprisingly, gastrointestinal: bloating, flatulence, and diarrhea, sometimes with smelly stools. People who can’t digest gluten or grain sugars may have similar symptoms.

Celiac disease can severely impair the absorption of nutrients. In children, this may lead to stunted growth; in adults, the consequences include anemia (because iron isn’t being absorbed) and weaker bones (because calcium and vitamin D aren’t getting into the body). Anemia causes fatigue and malaise, but some people with celiac disease feel that way without anemia.

Doctors sometimes miss the celiac disease diagnosis because they’re looking for the classic gastrointestinal symptoms, not the vaguer ones that stem for the most part from malabsorption of nutrients.

One major difference between celiac disease and grain-related digestion problems is that when it’s just a digestion problem it typically doesn’t lead to malabsorption and nutritional deficiencies.

Women with untreated celiac disease have higher-than-normal rates of menstrual abnormalities and infertility. A large study published in 2007 found an increased risk of pancreatitis in people with celiac disease. It’s not clear whether these associations suggest a cause-and-effect relationship or if celiac disease and these conditions happen to share an underlying cause.

Grains for the gluten-challenged

We’re often too quick to depend on pills instead of first working to change our diet and exercise habits. But with celiac disease, there’s no pill, and a fairly radical change in diet is the only treatment. Drug companies have started to take some interest in the disease, and treatments that would block the absorption of gluten are being investigated, but none so far are close to gaining FDA approval.

Until you need to avoid gluten, you probably don’t realize how ubiquitous it is. Gluten is used as a thickening agent and filler in everything from ketchup to ice cream. The inactive ingredients in many medications are gluten-based. And even when gluten isn’t an ingredient, it may inadvertently get into a food because a wheat-based food was processed in the same factory, or wheat was grown in a nearby field. At home, wooden utensils and toaster ovens are gluten “hot spots.” Oats don’t contain gluten, but many people with celiac disease avoid them because of contamination problems.

The gluten-free diet has traditionally depended on starch from rice, corn, and potatoes. Food makers have also learned how to use xanthan and guar gums to replace gluten’s elasticity: a common complaint about gluten-free baked goods is that they are powdery. But these formulations can also leave diets short of fiber and B vitamins. Melinda Dennis, the nutrition coordinator at the Beth Israel Deaconess Medical Center Celiac Center, encourages patients to eat foods made with unconventional but nutritionally well-rounded substitutes, including amaranth, buckwheat (no relation to wheat), millet, quinoa, sorghum, and teff. She calls them the “super six” because of their high vitamin and fiber content.

Q: A family friend just started smoking again. He doesn’t smoke while my young daughter and I are there, but his house is saturated with the smell. Is this secondhand smoke? Should I be concerned?

A. Secondhand smoke is defined as the combination of sidestream smoke, which comes from the burning end of a cigarette, and mainstream smoke, which is smoke exhaled by the smoker. While the smell of smoke doesn’t necessarily correlate with the amount of secondhand smoke in a room, you and your daughter are being exposed to some level of smoke toxins.

There are good reasons to avoid secondhand smoke. It increases the risk of lung cancer, heart disease, chronic respiratory problems, and possibly cancers of the cervix, breast, and bladder. In children, it’s been linked to middle ear infections, bronchitis, and asthma. Exposure in the womb is associated with low birth weight and sudden infant death syndrome.

More than 250 chemicals in secondhand smoke are known to be toxic or carcinogenic. They can linger in the air as gases or particles and may be absorbed through the nose, mouth, or skin. Some become carcinogenic only after they’re activated by enzymes in the body and become part of a cell’s DNA.

In June 2006, the Surgeon General issued a report, The Health Consequences of Involuntary Exposure to Tobacco Smoke, which concluded that there is no safe level of secondhand smoke exposure. It also stated that cleaning the air or ventilating buildings cannot completely eliminate secondhand smoke exposure. Banning smoking in indoor spaces is the only way to fully protect nonsmokers.

You and your daughter probably get very little exposure to secondhand smoke when you visit your friend, but your visits are not risk-free. The safest route is to have him visit in your home, with the understanding that he’ll go outside if he wants to smoke. Of course, whatever you can do to encourage him to stop smoking will be good for everyone.

This Question and Answer first appeared in the October 2006 Harvard Women’s Health Watch, available at www.health.harvard.edu/women.