Nutritional deficiencies from elimination diets

I work extensively with clients who have tried numerous diet to help heal their body, including Paleo, low FODMAP, elemental, Bi-Phasic and GAPS. it is my job as their dietitian to help determine what diet is right for their body and will give them the nutrients to heal while controlling symptoms. I always remind my clients that just because these diets exist doesn't mean they are right for every person. Case in point, with the popularity of the Paleo diet, I have seen numerous nutritional deficiencies that cause these patients to get worse, not better. After running an extensive micronutrient test, we can determine where their nutrition gaps are and add the necessary food and supplements to get their body back to a good place. Most elimination diet are needed only in the short-term; problems usually result when they are continued for long periods of time. Work with an experienced health professional to find the eating style that works for you and doesn't further deplete your nutrients.

The downside of almond milk

I frequently recommend plant based milks to my clients due to lactose intolerance or milk protein allergies and sensitivities. It has become such a commonplace milk that almost every cafe offer it as an option in coffee or smoothies. Is almond milk as good as it seems? To start with, almond milk that you buy in the supermarket is mainly water. Most of the almond solids are strained out. If the almond solids were kept in the milk, it would be very gritty, thick and high in fat. Check out the fat content of almond milk and you will see it is very low in fat (usually <2g fat). In addition, it is very low in protein. At my child's daycare, they allow almond milk as a protein substitute for cow's milk. When in actuality, this is a low protein food. It is okay to have a low protein almond milk as long as you are getting adequate protein elsewhere. One of my biggest issues with MANY of the big almond milks is how much CALCIUM CARBONATE they add to the product. If you have ever seen commercials from the almond milk companies advertising that their product has as much calcium and sometimes more as cow's milk, that is because they are adding it in the form of a supplement called calcium carbonate. This form of calcium is cheap and fairly concentrated. 1 cup ranges from 350-450mg of calcium for most brands. Too much of this calcium can be a bad thing contributing to calcium based kidney stones and more commonly constipation and bloating. So, if you are drinking more than 2 cups of almond milk per day, you may want to switch to a brand that uses a less concentrated (and less constipating) form of calcium called tricalcium phosphate. Speak to your dietitian for more recommendations. In the meantime, remember that the best source of calcium doesn't come from the "milk" aisle, it comes from dark green/leafy vegetables (kale, collards, swiss chard, broccoli, mustard greens) and foods like almonds (better to eat the almonds), sesame seeds, and even oranges.

Glucose or lactulose breath test for SIBO?

A breath test is used to detect the presence of hydrogen or methane-dominant bacteria in the small intestine. The test is conducted by having the patient drink a solution of glucose or lactulose and then breathe into test tubes over a period of 3 hours. The difference in substrate, glucose or lactulose, is that they detect bacterial growth in different areas of the small intestine. Glucose is a sugar that is fermented in the upper (proximal) part of the small intestine; while lactulose is fermented in the lower (distal) part of the small intestine. In my practice, I prefer to do combination glucose and lactulose testing to ensure that the test is highly accurate and avoids any false negatives due to the limitations of using only one test.

Packing gluten free school lunches

As the school year ramps up again, that means packing lunches for the kiddos. Here are some of my favorite healthy options.

-Greek yogurt with chopped nuts and added fruit

-Homemade chicken salad with gluten free crackers

-Rice and lentils with turmeric and butter/margarine (if heating an option)

-Bento box - turkey breast slices, raw veggies, hummus, grapes or apple slices, nuts 

-Cottage cheese with pineapple and chopped nuts

-Gluten free wrap with almond butter and jelly

-Rice noodle salad with sliced peppers, green onions, tofu chunks and peanuts


Kudos Starbucks! You did gluten free right!

Many restaurants offer gluten free menu items. However, it's not uncommon to see fine print indicating the risk of cross-contamination. Starbucks began offering a gluten free breakfast sandwich that is sealed in a package and heated that way so there is no cross-contamination. It is also quite tasty! I think that the 2 slices of Canadian bacon is a little would suffice. Would love to see more gluten free options like this!

Kudos Starbucks! Celiacs thank you for the safe gluten free offering!

Enzyme for gluten cross-contamination??

AN-PEP (Aspergillus niger-prolyl endoprotease enzyme) is an enzyme that is unique in that it works in the stomach where the environment is acidic. In research studies, this enzyme has been shown to break down gluten in the stomach of gluten sensitive individuals who were fed a porridge with wheat containing cookies added. While these studies did not test gluten degradation in people with celiac disease, this enzyme may offer some promise in reducing symptoms caused by accidental cross-contaminations such as in a restaurant. It does not allow a celiac to eat gluten intentionally, but this early research suggests that it may degrade accidental gluten in very small amounts and therefore reduce or eliminate the problematic symptoms caused by accidental gluten contamination. I encourage anyone with celiac disease to consult with a health professional to determine if an enzyme make be helpful in maintaining their gluten free diet.

Metagenics currently offers a product called SpectaZyme Gluten Digest that contains AN-PEP similar to what was used in the studies. 

Spectrum of Lactose intolerance

Lactose intolerance is not an all or nothing condition. There are different degrees of lactose intolerance. There are also different types of lactose intolerance. The two most common types of lactose intolerance are: 

  • Primary lactose intolerance - deficiency of lactase enzyme that generally develops over time. Certain populations including Asians and African Americans have higher rates of lactose intolerance than other groups.
  • Secondary lactose intolerance - reduced production of lactase enzyme caused by another condition that damages the small intestine, including celiac disease, small intestinal bacterial overgrowth (SIBO), and IBD. After the gut heals, production of lactase enzyme may return.

For those with either type of lactose intolerance, they may find they are still able to tolerate some dairy products. For example, hard aged cheeses are extremely low in lactose and can be tolerated by even the most lactose intolerant. However, cow's milk, yogurt, cottage cheese, ricotta cheese, and cream cheese contain higher levels of lactose. Small amounts cooked into foods may be better tolerated. In addition, lactase enzymes can be taken with higher containing lactose foods to help with digestion.

Because dairy products are a concentrated and convenient source of calcium, those with lactose intolerance need to ensure they are getting adequate calcium from other foods in their diet. Foods such as fortified plant based "milks", calcium enriched tofu, dark green leafy vegetables (kale, collard greens), and nuts like almond are good sources. Consult with a dietitian to ensure your diet is nutritionally adequate.

Chop, Chop! Get your kids in the kitchen

Getting your kids in the kitchen at an early age can teach them an important skill that will help them throughout their life. Here are some tips to get your kids involved in cooking.

-Don't worry about the mess. Put your kids in a cooking apron or clothes that you don't mind getting messy. Don't stress about the mess on the floor or counters. You can clean it up later. Now is time for cooking fun!

-Start with simple recipes like a baked good or a smoothie. Even relatively young children can help with tasks such as cracking eggs in a bowl, gathering ingredients, mixing ingredients in a bowl, and measuring ingredients can be great ways to get your kids involved in the cooking process. Avoid having them work with raw meat or hot pots on the stove.

-Keep them safe. Avoid burns by keeping kids away from the stove when cooking. Remind them to not put their hands near their face or in their mouth while cooking. Keep kids away from knives and other sharp objects like vegetable peelers and food processor blades. Mixing spoons, handheld whisks, and potato mashers are safe for even very young ones.

-Get them excited about the process of cooking. Have your kids pick out a recipe that looks fun to them. Take pictures of your kids while they are cooking. Let them taste some of the individual ingredients in their basic form (e.g. cocoa powder, raw vegetables). Turn on the oven light so can peek in on the work in progress.

-Have your kids present the final product to friends or family members. Let them take pride in the food that they have created and showcase their work to others. 

Here's my favorite recipe, Cocoa Banana Bread, to get your children involved in cooking.



Will my SIBO ever go away?

I hear this question frequently in my office. I have been seeing patients with recurrent SIBO in my office regularly for the past 5 or so years. I am always hopeful about client's ability to conquer SIBO. There is so much more known about SIBO today than even 5 years ago. Some important questions that I aim to answer to ensure that we get the best chance of conquering SIBO and avoiding recurrences are as follows?

  • What are the causes of SIBO in this particular individual? They range from GI surgery, antibiotic use, proton pump inhibitor medication, GI viruses and food poisoning and even stress. If we don't address the underlying cause then recurrence is more likely.
  • Has the individual had follow up breath tests to determine if treatments have been effective? After every treatment, a follow up breath test should be done to determine how effective the course of treatment was in eradicating bacteria. If it is not effective or doesn't reduce the bacterial count significantly, then a different course of action is necessary.
  • Does the individual have hydrogen and/or methane dominant bacteria? The treatment course is different depending on the type of bacteria. I always urge my clients to get a copy of the report.
  • Has the individual modified their diet during or after treatment? Dietary modification is important but should be closely monitored by a skilled dietitian to ensure nutritional deficiencies don't develop and that the diet is not more restrictive than necessary.
  • What types of dietary supplements is the individual taking during and after treatment? This is a very important topic. Probiotics, enzymes and amino acids are some of the most common supplements used for SIBO. However, supplements need to be carefully reviewed to ensure that they are helping and not hindering treatment results. Also, they need to be used at the appropriate time of treatment.

Exercise and auto-immune disorders

When you have an autoimmune disorder such as Hashimoto's (hypothyroidism) or fibromyalgia, it is important to consider the type and frequency of exercise that you choose. So often I come across clients who are trying to push themselves with high intensity exercise of long duration. When you have an autoimmune condition, it's important to listen to your body and not add further stress. Exercise such as nature walks, Pilates, and restorative yoga are all excellent choices for most individuals with autoimmune disorders. If you find that you cannot do 30-60 minutes at a time, break it up into small chunks throughout the day. You still experience the same benefits. As with many aspects of our health, it is so important to heed those message that are body is giving us. This is particularly important when it comes to exercise as well.