Doctors from the Royal Hallamshire Hospital, Sheffield published an article in this month’s edition of the British Medical Journal on the subject of gluten sensitivity, and whether it actually exists, in the absence of coeliac disease [1].

What is gluten?

Gluten is the molecule formed by the bonding of two proteins, glutenin and gliadin in the endosperm of cereal seeds such as wheat. The endosperm comprises the majority of the seed and is the initial source of energy the seed utilises when it germinates. Gluten is limited to grasses, although there are a wide range of similar protein composites in other plant seeds.

Man cannot live on bread alone?

Man cannot live on bread alone?

What is coeliac disease?

Coeliac disease is an autoimmune disease that affects the small intestine and is characterised by symptoms such as diarrhoea and fatigue.  The modification of the gluten proteins by the enzyme tissue transglutaminase (tTg) factors in the condition. Upon biopsy of the small intestine the defining sign is a marked change in the villi (small hairs) that line the inner surface of the gut (villous atrophy).  As these hairs vastly increase the surface area of the gut epithelium, reduction in them causes a reduction in the efficiency of uptake of nutrients from food.

Wheat Allergy

Coeliac disease is not to be confused with wheat allergy, which is a much rarer condition involving immunoglobulin E (IgE) mediated allergy to wheat seed storage proteins, including gluten, but also including albumins and globulins.

But what of those who claim to suffer from gluten-like abdominal symptoms, yet display normal tissue on biopsy? Do such individuals, as the paper’s authors suggest, belong to a “no man’s land”, with clinicians unsure how to treat them? There might well be a significant proportion of the population who fall into this category.  For example, in one study conducted in Scandinavia in 2000, of 94 adults complaining of abdominal problems after ingestion of cereals only 9% were found to have coeliac disease (as evidenced by villous atrophy). Of the remaining patients, all were negative for tTG antibodies, whereas 40% produced gliadin antibodies [2].

New evidence…

The authors cite a soon to be published study in which dietary trials on a much larger group of patients (n=920) with abdominal symptoms were conducted.  In the words of the authors:

“… a third of patients (n=276) showed clinical and statistically significant sensitivity to wheat and not placebo, with worsening abdominal pain, bloating, and stool consistency. The evidence therefore suggests that, even in the absence of coeliac disease, gluten based products can induce abdominal symptoms which may present as irritable bowel syndrome.”

As a result of this confusion, as of this year there is now a simplified nomenclature for the range of conditions [3]:

  • coeliac disease
  • wheat allergy
  • non-coeliac gluten sensitivity (this is potentially our 40% of those not displaying villous atrophy in the above study)

Gluten: a lone wolf?

Yet gluten is not the only possible culprit for these bowel issues when consuming cereals. Wheat contains a number of other molecules which are implicated in the irritation of the bowel – carbohydrates such as fermentable fructans for example, or sugars such as sorbitol and mannitol (part of a family of short-chain carbohydrates known collectively as FODMAPs).

So what should I eat…..?

If 40% of those in the Scandinavian trial suffered from non-coeliac gluten sensitivity, then it’s not an unreasonable idea to try eliminating gluten from your diet if you too suffer from similar symptoms.  This is difficult unless you are prepared to make some serious changes (giving up bread and pasta for example). However, like all things, stick with it and you might be very pleasantly surprised by how quickly your symptoms clear up.

Mine did!


[1]. Aziz I, et al.: Does gluten sensitivity in the absence of coeliac disease exist? BMJ 2012; 345:e7907

[2]. Kaukinen K et al.: Intolerance to cereals is not specific for coeliac disease. Scand J Gastroenterol. 2000 Sep;35(9):942-6.

[3]. Sapone A, et al.: Spectrum of gluten-related disorders: consensus on new nomenclature and classification. BMC Med. 2012 Feb 10:13.

How to live, Part 1: Keeping Fit

There are a vast number of magazines and books out there telling us what to do in order to stay fit and healthy.  However, this leads to two problems: first, information overload.  The advice forms one large, indigestible bolus that just isn’t adsorbed. Second, profit. Personal trainers and magazine columnists aren’t going to confess that staying fit is actually reasonably simple.  At its heart are a few resistance exercises that require an Olympic bar and conditioning work that requires, well, nothing. That doesn’t exactly sell magazines and equipment does it?

So what should you look to do in order to keep fit and healthy? That depends on your goals.  My current goal is to hit a double body weight deadlift (which is really quite a modest goal).  Why? Because this involves strengthening my posterior chain which leaves my core stronger and as a result I’m able to react to tasks or situations which require something to be heaved, shifted or flipped.  I’m on 350lb and will need to reach 372lb by September next year.  Achievable will slow, incremental increases in the weight I lift over the course of the year. What your fitness goals are will vary, and indeed how you even define ‘fitness’.  I see it as the ability to react to unexpected physical challenges.

In order to progress I’ve read a lot by the leading authors in this field (Pavel Tsatsouline, Dan John, Jason Ferruggia, Ori Hofmekler, Mark Rippletoe to name a few) and the same points come up over and over again.

So, in no particular order:

1. Lift heavy weights.Whatever programme you choose to follow, the weight you lift should be a challenge. It provides the stimulus for muscle growth, hormonal response and nervous system coordination by taxing you. In order to lift weights without injuring yourself you must play the long game.  You should view strength training as a life skill rather than a temporary phase. So what is a heavy weight? That depends on you, and your current level of strength. Do not compare yourself to others or feel you have to match a training partner’s lift.

#1: Lift big.

2. Progressive, incremental increases work. You will make better long-term progress by building progressively, adding to the weight you lift in very small increments and never sacrificing form and quality for ego-boosting extra 45lb plates before you’re ready. You are more likely to plateau and stall in your progress if you try and ‘jump up’ the weight rather than making more regular, modest gains.

3. Allow time to observe the results of change.  Jason Ferruggia recommends at least 12 weeks. It is a myth that you need to keep switching things up in order to stimulate growth and response. It is this myth that has generated the endless fancy variations on isolation exercises (e.g.: the plethora of bicep curl exercises).  Besides which, if you are starting out on a weight lifting programme, the chances are you are trying to watch what you eat, get more sleep and ditch the booze.  If this is the case, then so many variables have been changed that it’s hard to know what changes are proving beneficial and which aren’t.  I followed Jason Ferruggia’s Muscle Gaining Secrets for a year, and am now on a one lift a day programme as described by Dan John for 12 months. Be patient.

4. Each training session has a point.  There’s a reason for it, and it’s crucial to know what you are going to do before you enter the gym.  You are not there to just ‘get a workout’. Wandering in, seeing what equipment is free and coming up with a session to suit the situation is the surest way to a wasted training session that doesn’t meet your long term goals.  To that end, record your results with a training log.  The majority of training logs out there are a waste of money: I simply carry a pencil and a piece of SCUBA diving slate to the gym.  On that I write my previous performance with any exercise and my intended weights for the session.  At the end of the week I transfer the information to my diary.  Whatever works for you.

#5: Compound movements rule!

5. Compound movements.  At the core of your training should be what are known as compound movements.  Anything that involves moving your body through space, or weight around your body counts.  The classic compound movements are the Olympic lifts: snatch and clean and jerk.  But you can add to that list squats, deadlifts, pull-ups, cleans, dips and presses as these all recruits a large number of muscle groups.

6. Leave feeling strong and fresh. Simple really. This means your session should be hard and fast.  No more than 45 minutes.

7 Prioritise.  Each session should have a compound element at its core. When you find yourself in an overcrowded public gym, dance music pumping over the music system, constantly distracted as other gym users strip the weight off your bar when you stop to grab something out of your bag, get your core lift done and get out.  Life’s too short.

#8: Ease into your workout after a day spent pushing paper around your desk…

8. Warm up properly. Warming up seems to mean five minutes on a treadmill for some reason.  However, if you are going to do a compound movement such as squats, you need to ease into them, especially if you’ve been sat at your desk all day and feel like the Hunchback of Notre Dame.  Air squats followed by plyometric jumps are a good start.  Before you start your work sets, perform warm up sets.

9. Conditioning work. The problems with regular long distance running and cycling (traditional ‘cardio’) soon stack up when you examine them: testosterone levels drop, the immune system is compromised, cortisol levels are raised and mechanical repetition injuries accumulate. Conditioning is quite different. It involves short, sharp bursts that focus on power generation, speed and recovery. Typical activities are hill sprints, tyre flips, farmer’s walks or rope climbing. Try adding these to your training programme in the place of the endless sessions on the treadmill that cause your shin splints and constant head colds!

#9: Tyre flipping will get your heart rate up!

10. Fat burning.  I’ve written before about the benefits of being keto-adapted: having your body recognise and mobilise its fat reserves as your principal source of energy.  Think walking, jogging or cycling daily.

… so what do I do in the gym? My current programme is based upon a one month cycle:

Week 1: 7 sets of 5 reps
Week 2: 6 sets of 3 reps
Week 3: 1 set of 5 reps, 1 set of 3 reps, 1 set of 2 reps
Week 4: rest

Each week breaks down as:

Day 1: Squat
Day 2: Push press
Day 3: Deadlift
Day 4: Bench press

That’s it! One lift a day. If you feel fresh and strong after the planned training is done, then some body weight muscular endurance training or conditioning work can be added. On the other three days of the week play sport, stay mobile, rest and eat big!

As a last word, here are two pearls of wisdom from strength coach and author Dan John:

  •     The body is one piece
  •     There are three kinds of strength training: putting weight overhead, picking it up off the ground &  carrying it for time or distance

Next post – How to live, Part 2: Things to eat.

The rehabilitation of animal fat begins…

This weekend BBC Radio 4’s Food Programme discussed the facts behind the myths and distortion surrounding animal fats, but lard in particular.  Have a listen!  The website also has a feature on how to make your own if this programme sparks your interest in cooking with this fat – particularly worth doing if you like to fry (high smoke point) or fancy making perfect short-crust pastry.




“Big Food” faces court date?

As reported by the BBC News website today, the American lawyer who took on Big Tobacco and won (with an out of court settlement) is setting his sights on what he calls “Big Food”: the large processed food manufacturers such as Kraft who market products that, despite labels claiming the product to be healthy, actually contain added sugar.  A scan of any supermarket shelf, for example of reduced or fat-free dairy products, reveals the problem: typically fat is replaced by sugar (in all its synonyms).  That the companies willfully label these products as healthy, knowing the contribution they must be making to the current obesity epidemic in America, is the basis of the case.

Just as large manufacturers such as Philip Morris produce a variety of tobacco ‘brands’, distinct only in the minds of their marketing departments, so industrial giants such as Kraft produce a wide variety of processed food.  Any concessions these large manufacturers are forced to make will have a major impact upon, at the very least, labelling on processed foods. If a ‘smoking gun’ might be found, in this case internal documents that tacitly admit the culpability of the manufacturers in contributing to the obesity epidemic, then the floodgates will be well and truly open for class-action lawsuits. Fingers crossed some unredacted memos appear!

Image courtesy of Convergence Alimentaire.

Optimize Everything!

It’s rare to find as vague a concept as ‘lifestyle’ encapsulated so neatly.  Here’s a wonderful poster from Dan’s plan.  I’m not recommending his plan per se, as I’ve no idea what it involves: for all I know you may need to subsist on a diet of seal fat 365 days a year.  But fancy graphics always sway me.  Enjoy.

P.S. A diet of seal fat might just be perfect for you.  More on that soon!

Hunter Gathering in the press

My first blog post after an extended absence – a wedding, honeymoon and revision for impending medical school exams have left me little time to contribute here.  I shall try and be a little more frequent over the next few months!

Writing in today’s New York Times Sunday Review, Herman Pontzer highlights the fact the our last remaining hunter gatherers, in this instance the Hadza of Tanzania, don’t remain free of the scourge of obesity by virtue of greater energy expenditure.  The article summarises the full publication in July’s edition of PLOS One.

In essence, a team tracked the activity levels of a small number of Hadza men and women as they went about their daily lives.  The conclusions were fairly straightforward:

  • Hadza men and women aren’t any more ‘efficient’ in their physical activities, nor do they compensate for raised activity levels with changes to their metabolic rate
  • Activity levels in the Hadza were not significantly different to Western societies
  • Their % body fat was lower than western populations
  • There was no correspondence between % body fat (adiposity), activity levels and daily energy expenditure

So perhaps the constant protestations from the popular press for us to stop frittering our lives away in front of The X Factor, to jump onto a treadmill and mindlessly grind-out two and a half hours of aerobic activity each and every week until we’re 64 are all a waste?

Worse still, our obsession with always being in an ‘aerobic zone’ whilst we conduct our physical activity misses the point to be learnt from our svelte Tanzanian cousins.  They walk miles each day (mean values of nearly 6km for women, 11km for men), the women carrying heavy loads of fuel and water, the men hunting game and collecting honey. In other words, their typical activity levels fall either side of the aerobic zone: they burn adipose fat happily all day by not depleting their glycogen reserves with extended bouts of aerobic work.  They also drag game, climb trees and dig up tubers: short duration work, more likely to rely upon the immediate energy (ATP) stored in the muscles or anerobic breakdown of gylcogen over a short period of time.   Perhaps it is this mix of polar opposite exercise types that, although not reflected in the dry statistics of daily energy expenditure, has a critical role to play?  I’ve blogged before about the myriad positive hormonal effects of short duration intense activity.

Maybe the answer lies in their energy consumption (or put another way, what they don’t eat)?

  • A lack of processed food
  • No reliance on grains
  • No seed oils

As an afterburner, for all those fretting over macronutrient ratios, note that the Hadza must consume some carbohydrate with all those tubers!

Enjoy the weekend!

Food for thought…

Gluten-free Novak Djokovic!

I am currently watching Novak Djokovic’s amazing performance at Wimbledon.  Can I attribute it to his gluten-free diet?  Why not? After all, according to this study, (and this one)’Atkins-style’ diets raise all-cause mortality… and if you can’t see the holes in these studies, here’s a starter for ten… they involve Food Frequency Questionnaires….

New balls please!