Diets and diets

Daniel Engber has an interesting article up in Slate today about gluten-intolerance. Well, I wouldn’t call it a news article so much as a review-plus-editorial, really. But still, thoughtful and interesting.*

This article made me feel defensive. I don’t have Celiac Disease or a gluten-intolerance, but I do have an autoimmune digestive disease, and like many people with such illnesses, I have had to live with my share of food intolerances and a pretty sensitive gut. I started feeling the painful effects of lactose intolerance pretty young (and that was while continuing to eat a steady quantity of lactose-containing foods, not after increasing or decreasing my consumption). My intestine really just sucks at some things.

And there is some evidence that diets that restrict certain difficult-to-digest foods might alleviate symptoms (long-term, not just as a short-term effect like the one Engber describes) of these kinds of diseases. A popular diet to try for this “treatment” is the alleged research precursor to the gluten-free diet, now known as the Specific Carbohydrate Diet. The SCD is extreme and it is difficult to maintain; and because of the side effect of food restriction that Engber discusses in some detail in his article (that your body rapidly stops producing digestive enzymes you no longer need), it is actually dangerous to start and stop the SCD in fits and starts, if you have an immune disease that is triggered by the presence in your gut of substances you can’t properly digest. It’s practically a one-way ticket to a major flare-up. That said, unscientific as it may be, the patient testimony is impressive: done strictly**, the SCD may have success rates for maintenance of remission that are not unlike many of the medications prescribed for autoimmune digestive diseases (how much it can do in an active flare is less clear, I think). I don’t recommend the SCD or think doctors should prescribe it, because it is so difficult, but it probably does work.

I was a patient on the SCD for three years and saw a long-term lessening of symptoms and very long remissions of my disease. I have now reintroduced almost all of the restricted foods (hooray!) and am still in that remission, though sooner or later I will probably have another flare-up, and would have even if I had stuck with it (the diet is not a cure. There is no cure). Reintroducing foods after being on that kind of diet is tricky, no doubt about it, and I do believe that’s related to the issues Engber raises about how enzymes work in our digestive systems. But I don’t especially regret that.

The fact that “going G-free” means eating fewer cupcakes and less pasta suggests another source of relief. It is, after all, an elaborate diet—and so delivers all the psychological benefits of controlled eating and self-denial. “Once G-free, you are no longer simply robot-eating bag after bag of pretzels,” writes Hasselbeck, in a chapter of her book titled “G-Free and Slim as Can Be!” Gluten intolerance may be a medical condition, but according to Hasselbeck, it’s also an approach to eating—like South Beach or Skinny Bitch—that’s supposed to make you lose weight and feel good about your body.

Here he hits the nail on the head. Well, on the one hand, some people will use any new trend or idea to push weight loss, and for a profit. But that’s not what I mean. The mentality that comes along with being on a strict, restrictive eating regimen for disease management is essentially the same as the one that pops up with any weight loss dieting (including “lifestyle changes”), and they are both basically the same as the psychology of disordered eating. Honestly, it took a long while before the SCD was so second-nature that I stopped thinking about it. But I think that while “dieting for health” (ugh, I hate to call it that. I do not think healthy = thin; I’m really only talking about disease management) can absolutely lead a person into obsession and orthorexia, it is nonetheless different in some ways: If you are truly removing a few foods from your daily diet because they make you extremely ill, there’s no reason to reduce everything else. And it’s not about guilt or being a bad person if you mess up — it’s about not putting yourself in agony or even in danger. When it’s really, truly for your health, because you will hurt or be on an operating table or die otherwise***, 1) it is much more of a necessity, and 2) there’s no reason to stop enjoying the rest of your food, or to stop figuring out filling, satisfying substitutes for the things you can’t eat anymore. That’s why after a while I was able to stop thinking about it and to get back to a mentally healthier place. I wasn’t reducing quantity, I was still getting every necessary nutrient (the diet is decidedly not low-carb), and I was enjoying my food and eating until satiation every day. Intuitive eating is decidedly more difficult but is possible while on a gluten-free diet.

Frankly, overall I think I benefited from trying a poorly studied and controversial dietary treatment. Maybe that was dumb luck. But my gut had a chance to heal (a result that Engber acknowledges) and that did me worlds of good. I don’t know if I’d put myself through it again, but I am probably today at a lower maintenance medication dose than I would be otherwise. (If you don’t know how medicating works with autoimmune diseases: many of those illnesses become drug-dependent, so that over time you need stronger and stronger medication to treat flares and maintain remissions. Staying in remission on a low dose of one of the less-nasty treatments is a huge long-term benefit.)

I’m also a scientist. The graphs Engber includes in his article are compelling, though I wonder how big those spikes are when the y-axis isn’t normalized, or when you consider any of the hundred other factors that might have been occurring concurrently. Assuming causation there because the peaks line up (what is with the time lag in one plot, though, and not in the other?) is fun and exciting for my brain, but it isn’t the best science. I do like to do the best science!****

For what it’s worth, the additional expense of eating gluten-free (which I basically did for a long time, even after leaving the fanatical SCD) is minor. Rice pasta is pricey but rice itself is cheap, and in a pinch I could have been making a lot more straight-up rice and still been eating filling, tasty foods. And I wouldn’t take a dietmonger’s advice on how to eat G-free to lose weight as normal behavior among people who don’t eat gluten – a great many people are not embarrassed about our needs and would never throw a cookie on the floor because somehow that would be less rude than just politely saying “no thanks.” And only assholes are annoyed because their friends, family, or guests have allergies. Get better friends.

Ironically, the people who may benefit most from the current vogue are those who have been G-free all along. The proliferation of gluten-free products has made life for a full-blown celiac easier than it’s ever been, and a greater awareness of gluten-related disorders has more celiac patients getting diagnosed than ever before. (There are still thought to be millions of undiagnosed cases in the United States.) Let’s hope those gains aren’t erased when the conventional wisdom shifts again and we leave this diet craze behind us.

This is a major reason I’m writing this post. I suspect Engber has not personally been gluten-intolerant, or made meals regularly with someone who is. That proliferation of products means that if you truly cannot eat wheat, your life is now SO MUCH EASIER than it was 5 or 10 years ago. And going after gluten-free products as superfluous seems misdirected. People DO benefit immensely from the widespread and ready availability of those foods. Maybe only 1% of people, but that’s still a lot of people. I frankly do not care if those foods are so much more available now because there was a fad diet that made them popular.

The diet mentality goes much deeper than gluten-free, or lactose-intolerant, or whatever-the-hell is the latest not-well-tolerated food (that might or might not follow the latest diet craze that eliminated that same food). Dieting is socially pervasive, and predicated on this weird systemic belief that we are all incredibly unhealthy and that that makes us bad people. (Oh and unattractive, which makes us even worse people.) Self-denial is penance. If you try to point out that we are living longer, healthier lives than ever, they want to plug up their ears and yell LALALALA. Oh and Daniel Engber, I’m sure the continuation of these mindsets and promotion of fad diets has nothing whatsoever to do with anyone in your line of work. Just saying. (Though I don’t mean you. You’re pretty okay.)

* The title annoys me, though. No, we are not being “too tolerant of gluten-intolerance.” People deserve compassion and, yes, tolerance for their needs and choices. What are you going to do, shame someone for not eating gluten?

** The motto of people on the SCD is “fanatical adherence.” Not even joking.

*** No, “obesity” really doesn’t count, and if you don’t know why, go here or here, to start.

**** There is something to the gut flora argument, however. Even post-SCD but still gluten-free, my microbes were not happy campers. Well, some of them were. Just not the ones I wanted. Anecdatal support!

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