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Should I go gluten-free?

gluten-warning

The takeaway first

The last five years or so the gluten-free diet has been the most popular way of eating. Even the recent Wimbledon winner Djokavic and the New York Yankees slugger Mark Teixeira have adopted this new way of eating, which excludes wheat, rye and barley. While there is a real, clinical disease called celiac disease, where eating gluten products cause severe gastric problems, the type I’m talking about today is non-celiac gluten sensitivity. Most importantly, I want to know whether the whole thing is…BS.

By the way, Mark Teixieria hit a game winning homerun (update 8/10/15: 30 HR’s) this weekend. Not bad for a 35 year-old baseball player coming out of a year of injuries. He is having one of his best years at an age where most baseball players steadily decline. (I’m a NY Yankees fan)

Just saying…

What is celiac disease?

This disease is an autoimmune disease where your immune system attacks your intestines—but only when there is gluten in your diet. The fancy medical term for the process is small intestinal immune-mediated enteropathy (just in case you want to sound smart at your next cocktail party). Celiac disease occurs in 1% of the population, and the main symptoms include abdominal bloating and pain , chronic diarrhea , pale, foul-smelling, or fatty stool and rapid weight loss . Other common symptoms like chronic fatigue and irritability occur as a result of poor absorption of nutrients.

What is gluten?

Gluten is a protein made out of glutenin and gliadin. The elasticity created when the pizza man kneads dough before throwing it in the air is made from glutenin and gliadin combination. That’s the same molecule that gives bread its chewy texture. Gluten also traps carbon dioxide, which, as it ferments, adds volume to the loaf.

Why would non-celiac people want be on a gluten-free diet?

About 20% of Americans want gluten-free foods (I too choose gluten-free often). The reason why non-celiacs want to eat gluten-free is because they just simply feel great when they’re not eating glutinous grains. Symptoms like gastric bloating, irregular bowel movements and even headaches and joint aches have been relieved just by excluding gluten from the diet. These people suffer from what’s called non-celiac gluten sensitivity. The very first case of non-celiac gluten sensitivity was reported in the mid-1970s where a few young women reported gastric distention

and irregular bowel movements (Cooper et al., 1976) and experienced great relief when they cut gluten out of their diets. Only when gluten was re-introduced did the symptoms return (Ellis et al. 1978).

The science behind a gluten-free diet

Many would say there isn’t any science behind it at all

They just haven’t looked.

In one study, 920 adults without celiac disease and with irritable bowel syndrome (IBS) who self-reported gluten-based sensitivity were asked to maintain a gluten-free diet for 4 weeks. After about two weeks, one group was introduced again to wheat where 30% of them (the wheat group) developed IBS symptoms: abdominal pain, bloating and altered stool consistency (Carroccio et al., 2012).

Another study looked at 34 patients with IBS who self-reported gluten sensitivity and whose non-celiac status was confirmed by expert investigators. They received 16g of gluten per day or placebo for up to 6 weeks. Within the gluten group, 68% reported irritable bowel symptoms, such as abdominal pain, bloating, and stool inconsistencies, compared with 40% in the placebo group.

When comparing baseline parameters, patients with non-celiac gluten sensitivity are generally more likely to have nutritional deficiencies, another autoimmune disease, a lower mean BMI, and weaker bones than the general population; however, non-celiac gluten-sensitive people usually don’t have these extra problems.

In a case series of 1,000 patients with progressive ataxia (loss of control of body movements), 18% of patients were found to be sensitive to gluten consumption (Hadjivassiliou et al., 2013). This doesn’t mean that gluten gives you ataxia, though.

Small studies have even associated gluten consumption to depression (Peters et al. 2014) and psychotic, schizophrenic events (Kalaydjian et al. 2006). While these studies to not prove cause and effect, the association is pretty compelling.

For non-celiac endurance athletes, a short-term gluten-free diet had no overall effect on performance. It didn’t help gastrointestinal symptoms, wellbeing, or indicators of intestinal injury or inflammatory markers (Lis et al., 2015). Of course, this study was performed for about one week and to truly see benefit from a gluten-free diet it take about 90 days of complete abstinence from glutinous consumption.

Criticism of gluten-free diets

One Consumer Reports video makes several claims against the gluten-free label. I have problems with this video.

For example, the video claims, “Fat and sugar are sometimes used to replace the oomph in foods that gluten usually fulfills.” Yes, this may be true, but this claim has just as much oomph as saying that we shouldn’t be vegan because some donuts are vegan.

Sure, some foods marketed as gluten-free are crap, but that’s the worst way to be gluten-free.

The Consumer Reports video also claims that gluten-free foods are “not fortified with the same nutrients that foods with gluten [are fortified with].” Folic acid and iron are two examples given. My response? You can get folic acid, iron, and every other nutrient from foods that naturally contain them. Countless foods that are gluten-free are not marketed as such. Green leafy vegetables, for example, have all the folate and iron you could ever dream of, but nobody is calling them gluten-free.

There are two other big criticisms of gluten-free diets. Some say that gluten-free foods are expensive, but I reply that only the gluten-free label is expensive. All fresh produce is gluten-free, but it lacks the label. Why? Because produce has enough nutritional value on its own that it doesn’t need help from the gluten-free marketing campaign.

My take on gluten-free diets, and what you should do

I prescribe a gluten-free diet to all of my patients because it seems to relieve pain and inflammation. This is my experience, and I do whatever solves my patients’ problems.

Therefore, if you have pain or inflammation, I would suggest you try a gluten-free diet for 90 days. This doesn’t mean you have to buy gluten-free products or offer up your wallet as a ritual sacrifice to the gluten-free gods. All it means is that you cut out bread and pasta.

Same goes for my prostate cancer patients – they go mostly gluten-free as gluten wrecks the gut of most people and promote inflammation. In order to beat cancer you must have a strong gastro-intestinal system

If going gluten-free, follow these simple tips:

All fruits are naturally gluten-free. Eat those that have a low-glycemic index

All vegetables are naturally gluten-free. Eat plenty.

All meat, unless it’s processed, is naturally gluten-free. Go for the best fish (my

favorite is vital choice). Also go for grass-fed, organic meats.

Eggs are naturally gluten-free too, and very good for you. Get those from farms or farmers markets where the chickens roam freely and eat naturally (including worms.)

Many grains like quinoa and buckwheat are gluten-free. Eat them too.

As always, don’t eat processed foods or crappy gluten-free foods. But if you want a treat and will do a 90 day test, then eat a gluten-free treat.

Go easy on the alcohol, even if it’s “gluten-free.” By the way, tequila is gluten-free (wink, wink)

I suspect Djokovic’s and Teixeria’s gluten-free dietary benefits is mainly quicker recovery from the stress induced from playing their respective sport.

I know when I am 100% gluten-free, I can play long games of basketball or train for hours without feeling much pain afterwards.

If you have not done so, try going gluten-free. If anything, you will enjoy the challenge. OK maybe “enjoy” is an overstatement.

References

Carroccio, A. et al. Non-celiac wheat sensitivity diagnosed by double-blind placebo-controlled challenge: exploring a new clinical entity. Am. J. Gastroenterol. 107, 18981906 (2012).

Cooper, B. T., Holmes, G. K., Ferguson, R., Thompson, R. & Cooke, W. T. Proceedings: Chronic diarrhoea and gluten sensitivity. Gut 17, 398 (1976).

Ellis, A. & Linaker, B. D. Non-coeliac gluten sensitivity? Lancet 1, 13581359 (1978).

Kalaydjian, A. E., Eaton, W., Cascella, N. & Fasano, A. The gluten connection: the association between schizophrenia and celiac disease. Acta Psychiatr. Scand. 113, 8290 (2006).

Hadjivassiliou, M. et al. Transglutaminase 6 antibodies in the diagnosis of gluten ataxia. Neurology 80, 17401745 (2013).

Lis D, Stellingwerff T, Kitic CM, Ahuja KD, Fell J. No Effects of a Short-Term Gluten-free Diet on Performance in Nonceliac Athletes. Med Sci Sports Exerc. 2015 May 12.

Lis DM, Stellingwerff T, Shing CM, Ahuja KD, Fell JW. Exploring the popularity,

experiences, and beliefs surrounding gluten-free diets in nonceliac athletes. Int J Sport Nutr Exerc Metab. 2015 Feb;25(1):37-45.

Peters, S. L., Biesiekierski, J. R., Yelland, G. W., Muir, J. G. & Gibson, P. R. Randomised clinical trial: gluten may cause depression in subjects with non-coeliac gluten sensitivity—an exploratory clinical study. Aliment. Pharmacol. Ther. 39, 11041112 (2014).

 

After you read this, you will be a polyphenol fanatic (if you’re not already)

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The Takeaway First

Polyphenols, a kind of antioxidant found in countless fruits and vegetables, hold “great promise” for the future prevention of prostate cancer, according to a review published in the International Journal of Molecular Sciences. These widely available micronutrients work by fine-tuning the existing machinery of our bodies and even altering our gene expression. “Wait…what?!” Read more below.

Know Your Polyphenols

Before we start, know that polyphenols come in four varieties: phenolic acids, stilbenes, curcuminoids, and flavonoids. Phenolic acids and flavonoids make up about 90 percent of all of our dietary polyphenols.

Anacardic acid, a phenolic acid found in the Cuachalalate plant (native to Mexico and commercially available), has anti-inflammatory, anti-cancer, anti-oxidative and anti-microbial properties. It keeps tumors from growing new blood vessels and also regulates gene expression (Tan et al., 2012).

Caffeic acid, another phenolic acid found in coffee, has anti-oxidant and anti-bacterial properties in vitro and promote heart health (Greenwald, 2004).

Ellagic acid makes up half of the antioxidant content in pomegranates and has anti-carcinogenic and anti-fibrosis properties (Thresiamma & Kuttan, 1996; Bell & Hawthorne, 2008).

Gallic acid, found in several fruits, wines, nuts and other plant products, has been found to have chemopreventive properties in mice with prostate cancer (Wolfe, Wu & Liu, 2003; Agarwal, Tyagi & Agarwal, 2006).

Three stilbenes called picetannol, pterostilbene and resveratrol are all found in grapes and grape skins. They all have chemopreventive strength by virtue of their ability to alter signaling pathways in CaP cells.

Epigallocathechin-3-gallate (EGCG) is a classic flavonoid found in green tea that has anti-mutagenic, anti-bacterial, hypocholesterolemic, anti-oxidant, anti-tumor and cancer preventive properties.

Proanthocyanidins are found in apple peel, red kidney beans, pinto beans, cacao beans, cocoa, grape seeds, blueberries, several nuts (peanuts, hazelnuts, etc.), sorghum, and cinnamon, and they also have been found to modulate (Ishida, Takeshita & Kataoka, 2014).

Fisetin, which is a specific type of flavonoid called a flavonol (all these technical names, geez), can be found in onions and cucumbers. It throws a wrench into several prostate cancer lines (Khan et al., 2008).

My Take on Polyphenols

Believe it or not, that list above was incomplete. That’s how abundantly helpful polyphenols are in the fight against disease. The point of all this is that countless polyphenols have a strong foundation in the literature that supports their potential for not only cancer prevention but for the prevention of other diseases as well. No, you don’t have to know all of them, but you do have to eat all of them. (So, knowing would help.)

The foods you want to load up on are berries (organic if you can), green tea (about 6 cups a day), beans (great in salads), grapes, pomegranates, onions, cucumbers and pineapples. Basically, eat a ton of fresh fruits and vegetables, plus coffee or green tea.

Be well!

References

Agarwal, C., Tyagi, A., & Agarwal, R. (2006). Gallic acid causes inactivating phosphorylation of cdc25A/cdc25C-cdc2 via ATM-Chk2 activation, leading to cell cycle arrest, and induces apoptosis in human prostate carcinoma DU145 cells. Molecular cancer therapeutics5(12), 3294-3302.

Bell, C., & Hawthorne, S. (2008). Ellagic acid, pomegranate and prostate cancer—a mini review. Journal of Pharmacy and Pharmacology60(2), 139-144.

Greenwald, P. (2004). Clinical trials in cancer prevention: current results and perspectives for the future. The Journal of nutrition134(12), 3507S-3512S.

Ishida, Y. I., Takeshita, M., & Kataoka, H. (2014). Functional foods effective for hepatitis C: Identification of oligomeric proanthocyanidin and its action mechanism. World journal of hepatology6(12), 870.

Khan, N., Afaq, F., Syed, D. N., & Mukhtar, H. (2008). Fisetin, a novel dietary flavonoid, causes apoptosis and cell cycle arrest in human prostate cancer LNCaP cells. Carcinogenesis29(5), 1049-1056.

Lall, R. K., Syed, D. N., Adhami, V. M., Khan, M. I., & Mukhtar, H. (2015). Dietary polyphenols in prevention and treatment of prostate cancer. International journal of molecular sciences16(2), 3350-3376.

Tan, J., Chen, B., He, L., Tang, Y., Jiang, Z., Yin, G., … & Jiang, X. (2012). Anacardic acid (6-pentadecylsalicylic acid) induces apoptosis of prostate cancer cells through inhibition of androgen receptor and activation of p53 signaling. Chinese Journal of Cancer Research24(4), 275-283.

Thresiamma, K. C., & Kuttan, R. (1996). Inhibition of liver fibrosis by ellagic acid. Indian journal of physiology and pharmacology40(4), 363-366.

Wolfe, K., Wu, X., & Liu, R. H. (2003). Antioxidant activity of apple peels.Journal of Agricultural and Food Chemistry51(3), 609-614.

 

Diet & Dairy Promote Prostate Cancer – new study

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Diet & Dairy Promote Prostate Cancer – new study

Takeaway First

Two research articles from the Physicians’ Health Study revealed that the Western diet, which is high in saturated fat, dairy, red meat, and , significantly increases the risk of death from prostate cancer and all-cause mortality (death from any cause). A plant-based, low-dairy diet can help men increase their life expectancy despite a prostate cancer diagnosis.

Study Details

These authors all studied the same group of 926 men, all of whom were members of the Physicians’ Health Study and had been diagnosed with non-metastatic prostate cancer. They completed regular diet questionnaires over a span of 10 years.

The first paper examined the link between diet, prostate cancer, and all-cause mortality.

The authors looked at two kinds of diet:

Prudent pattern: higher intake of vegetables, fruits, fish, legumes, and whole grains

Western pattern: higher intake of processed and red meats, high-fat dairy and refined grains.

The Western pattern significantly increased the risk of prostate-cancerspecific and all-cause mortality.

The second paper looked at just dairy connection with prostate cancer and all cause mortality. The authors found that men consuming three or more servings per day of dairy products had a 76% higher risk of total mortality and a 141% higher risk of prostate cancer-specific mortality compared to men who consumed less than one dairy product per day.

The association between high-fat dairy and mortality risk appeared to be stronger than that of low-fat dairy, but the difference between them was not statistically significant.

My Take on Diet, Dairy, and Prostate Cancer

I work with dietary lifestyle and prostate cancer virtually everyday of my life, so this news is not surprising. It just confirms my belief that, when working with patients to improve their longevity and quality-of-life, nutrition is real medicine. It’s exactly what Hippocrates said two thousand years ago: “let food be your medicine, and medicine be your food.”

Why do we forget this? One reason is because medical schools are lacking in nutrition classes. The other reason is financial. In our current medical system, physicians actually lose money when they talk to any patient for more than 12 minutes. Medical reimbursements are only substantial when performing procedures, prostate biopsies, cystoscopy, coronary stents, etc.

This is not a critique of physicians as much as one on the medical system which fails to promote discussions of lifestyle and dietary choices between doctors and their patients.

What Should You do?

Eating well all the time is hard, I know. I live in this world, too, and it’s not any easier for me. My fifteen years of research on lifestyle and prostate cancer tells me that eating well to prevent or survive prostate cancer is not an all-or-nothing scenario.

In other words, the harm is in the amount. Scientists call this a “dose-response relationship.”

Notice the dairy research observed a higher mortality rate in those men who consumed more than 3 servings for dairy. 

One serving of dairy equals 8 ounces of milk or about 2 ounces of cheese.

That means that a little milk in your coffee in the morning isn’t a problem, unless you’re pouring in a whole glass.

Besides, if you are aware of the specific amount at which it becomes “too much,” you’re more likely to stick to the plan, no?

The real issue here is that most people “can’t have just one.”

You know yourself. If you can’t keep yourself from eating excessive low-level foods, then consider abstaining from low-level cancer-causing foods altogether. And yes, you can do it.

These “low-level foods are those on the lower end of the CaPLESS 1 to 5 scale:

A very brief summary

12 foods: all refined carbohydrates, fruit juices (not fruits), well-done meats, non-grass-fed meats.

45 foods: all vegetables, especially broccoli, cauliflower, almost all fruits whole, natural grains. Dirty dozen foods are only in this category when they’re organic.

References

Yang, M., Kenfield, S. A., Van Blarigan, E. L., Batista, J. L., Sesso, H. D., Ma, J., . . . Chavarro, J. E. (2015). Dietary Patterns after Prostate Cancer Diagnosis in Relation to Disease-Specific and Total Mortality. Cancer Prevention Research, 8(6), 545-551. doi: 10.1158/1940-6207.capr-14-0442

Yang, M., Kenfield, S. A., Van Blarigan, E. L., Wilson, K. M., Batista, J. L., Sesso, H. D., . . . Chavarro, J. E. (2015). Dairy intake after prostate cancer diagnosis in relation to disease-specific and total mortality. Int J Cancer. doi: 10.1002/ijc.29608

 

Growing Short: Little-Known Facts about Small Penises

Growing Short: Little-Known Facts about Small Penises

PenisSize

The Takeaway First

About half of men in the world have penises that are shorter than average (go figure!), but far fewer men have conditions that actually reduce their penile length. Length can be lost as a result of certain surgical procedures, Peyronie’s disease, and possibly erectile dysfunction. This is not the end of the world, however, as women report that girth is more important than length.

Study Details

As you know if you read my previous post, the average penile size is about 3.5 inches (9 cm) in the flaccid state, whereas the maximally stretched flaccid length, on average, is 5.2 inches (13 cm). Average erect penile length ranges from 5 to 5.7 inches (12.8 to 14.5 cm), and the average penile girth is about 4 inches (10.0-10.5 cm). What is the significance of these findings?

Penile shortening is a phenomenon that is associated with certain medical and surgical conditions. These conditions include prostate cancer patients treated with radical prostatectomy, Peyronie’s disease and congenital anomalies. There is also some evidence that erectile dysfunction may be an independent risk factor for shortening.

Results are mixed for penis shortening post-prostatectomy. In one study, 31 men were examined, and most of them demonstrated a significant penile shortening of up to one centimeter. (Not a huge difference in the end, in my opinion.) About half of them lost more than a centimeter. I said the results were mixed because some patients actually increased in girth after the procedure. Weird!

These data were confirmed by Halioglu et al. in 2006. This research team compared the penis lengths of men who had undergone androgen suppression and radiation therapy. Men who underwent both procedures lost significant length, but men who underwent radiation alone also lost some length.

My Take on This

Although 99% of the men I see who complain of a “small penis”, some do have something called congenital micropenis. By definition, a penis is “micro” when it is 2.7 inches or shorter and otherwise normally formed.

The biological causes stem largely from defects in the hypothalamus, specifically when an inadequate amount of gonadotropin-releasing hormone (GnRH) is released. This may be a primary hypothalamic or an anterior pituitary problem. Lastly, the micropenis can result from embryonic testis failure causing insufficient masculinization. Bladder exstrophy and epispadias also can result in penile shortening, thought to be related to a congenitally shortened anterior corporal length.

Although it is possible to have an abnormally small penis, preoccupation with the size of your Johnson can go to dangerous extremes. In Japan, some men are diagnosed with koro, a psychological condition in which a man fears that his penis is actually shrinking back into his body. This is imagined, and their penises stay the same length despite their fears. However, koro can be debilitating for a man’s confidence and disastrous for his sex life as a result. All this to say: don’t worry too much about it.

Another reason not to worry too much about length is this: studies have shown that, in terms of women’s pleasure during vaginal sex, girth is much more important than length. Fifty sexually active female undergraduate students were asked which felt better, penis width or length for their sexual satisfaction. Apparently, 45 reported that width felt better (Eisenmen 2001). Another study asked 375 women if size mattered and again, girth was more important than length (Francken et al. 2002). Why is this the case? My assumption is that penis width may be important because a penis that is thick at the base provides greater clitoral stimulation as the male thrusts into the female during sexual intercourse.

What should you do?

Besides high-risk surgical procedures and drugs that usually don’t work, there is not much you can do about your size. Remember that, when it comes to pleasing your partner, length is not as important as girth. If you happen to have neither length nor girth, that doesn’t mean you and your honey can’t get creative.

A new surgical procedure, known as the Modified Sliding Technique (MoST) is available for men with penile shortening after surgery or with Peyronie’s. One recent study on MoST looked at over 140 patients who underwent this procedure after a penile shortening from either disease or surgery increase in penile length by 3.1 cm (1.22 inches). (Egydio & Kuehhas, BJU int. 2015)

An excellent urologist surgeon (no bias although he is good friend), Dr. Robert Valenzuela is one of the leaders in the United States of this procedure for the very motivated.

 

References

Eisenman R.Penis size: Survey of female perceptions of sexual satisfaction. BMC Womens Health. 2001;1(1):1.

Francken AB, van de Wiel HB, van Driel MF, Weijmar Schultz WC. What importance do women attribute to the size of the penis? Eur Urol. 2002 Nov;42(5):426-31.

Egydio PH1, Kuehhas FE. Penile lengthening and widening without grafting according to a modified sliding technique. BJU Int. 2015 Jan 28.