Getting out the gluten

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The Sensitive Gut
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When your digestive system is running smoothly, you tend not to think about it. Once trouble begins, your gut — like a squeaky wheel — suddenly demands your attention. This Special Health Report covers the major sources of gastrointestinal distress: irritable bowel syndrome, gastric reflux, upset stomach, constipation, diarrhea, and excess gas. It also includes a special Bonus Section describing how emotional stress and anxiety can cause gastrointestinal distress.

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Celiac disease (an autoimmune disorder whose symptoms are triggered by gluten, the protein content in wheat, barley, rye, and spelt) is on the rise. That's one reason for the rise in popularity of gluten-free food.

Celiac specialists say the disease isn't diagnosed as often as it should be. As a result, many people suffer with it for years, often after getting other — and incorrect — diagnoses and useless treatments.

But a growing number of the people dodging gluten fall into a gray area: they don't have celiac disease but seem to be unable to digest gluten properly. There are no tests or strict criteria for this problem, aside from simple trial and error with a gluten-free diet. Some people may be getting caught up in a food fad. But many others probably do have trouble digesting gluten or perhaps the sugars in some of these grains (like the lactose intolerance that makes it hard to digest dairy foods).

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's 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.

Eating out is one of the biggest issues for people with gluten problems. Vegetables get contaminated because they are steamed over pots of pasta water. Fish and chicken are floured to hold seasonings. But many restaurants are beginning to offer gluten-free items. And there are some celiac-friendly cuisines, even if they are not overtly gluten-free. Ethiopian (which uses teff), Indian, Mexican, and Thai are good possibilities.

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Coping with Anxiety and Stress Disorders
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Everyone worries or gets scared sometimes. But if you feel extremely worried or afraid much of the time, or if you repeatedly feel panicky, you may have an anxiety disorder. Anxiety disorders are among the most common mental illnesses, affecting roughly 40 million American adults each year. This report discusses the latest and most effective treatment approaches, including cognitive behavioral therapies, psychotherapy, and medications. A special section delves into alternative treatments for anxiety, such as relaxation techniques, mindfulness meditation, and biofeedback.

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Performance anxiety

Q. I am a 38-year-old junior executive. My work gets good marks from my supervisors, but I have a problem that may hamper my career. Every time I have to make a presentation, I get terribly nervous, making it very hard for me to get through my talk. I've heard there is a pill that can help, but I don't want to take tranquilizers. What do you suggest?

A. Although your symptoms occur in a corporate boardroom, not a theatre, your problem is best known by its popular name, stage fright. It's a common problem that doctors diagnose as performance anxiety. And it responds beautifully to treatment.

The best drugs are beta blockers. First introduced for the treatment of angina around 1970, these medications are not tranquilizers or sedatives. They don't help ordinary anxiety, they're not habit forming, and they don't act on the central nervous system. Instead, they slow the heart rate, lower the blood pressure, and help calm certain tremors.

Beta blockers work by preventing your heart rate from racing when you start to speak in public. Without a racing heart, your body doesn't signal anxiety — because your body feels calm, your mind stays calm. It's a nice example of the unity of mind and body; when your body's response to mental stress is blunted, your mind is tricked into feeling calm and confident.

Beta blockers are prescription drugs, and they should be used with care, especially by people who have asthma or diabetes and by people taking other cardiovascular medications. But since only a single low dose is required, beta blockers are safe for nearly everyone with performance anxiety. Doctors often prescribe propranolol (Inderal and other brands) in a dose of 10 to 20 milligrams to be taken about 30 minutes before public speaking. If your doctor agrees with this approach and gives you a prescription, take a test run before your big presentation to be sure the dose works for you.

Although beta blockers provide a simple solution for most folks with performance anxiety, there are alternatives. Cognitive behavioral therapy can help, as can coaching or classes in public speaking. Finally, be sure that your stage fright is not a symptom of social anxiety disorder, a more troublesome problem that produces distress during a broad array of interpersonal interactions. Social anxiety disorder also responds well to treatment, but beta blockers won't do the job.

— Harvey B. Simon, M.D.
Editor, Harvard Men's Health Watch