When Wheat is to Blame

We’ve heard reports accusing the pharmaceutical industry of manufacturing and promoting diseases in order to boost drug sales, so called “disease mongering.” Could it be that the health food industry is doing the same?  More and more of my patients and peers are going gluten-free.  Does this reflect the successful marketing of this food niche? Or, is it based on a growing recognition of real disease?

Wheat can causes health problems in two main ways—food allergies and genetically-based Celiac Disease.  The prevalence of Celiac Disease within the American population is approximately 1 in 100, making it, in fact, a common disorder.  Ninety five percent of afflicted individuals have the genetic profile, HLA-DQ2 or HLA-DQ8.  Typically 10% of first degree relatives are affected. This “auto-immune” disease is characterized by a T-cell mediated immune response to gluten, which results in inflammation in the duodenum and jejunum of the small intestine, causing destruction of the normal intestinal lining and diminishing one’s ability to absorb nutrients, such as vitamin D, calcium, and iron.  The clinical manifestations include diarrhea, abdominal pain and frequently weight loss. There also can be neurologic manifestations (cerebellar ataxia and peripheral neuropathy) and a blistering skin condition called dermatitis herpetiformis.  Celiac disease may be asymptomatic or minimally symptomatic for years.  Those left untreated are at higher risk for osteoporosis, lymphoma and adenocarcinoma of the small bowel.   Those afflicted are also more likely to have other autoimmune conditions, such as autoimmune thyroid disease and type I diabetes. The diagnosis of Celiac Disease can be made by screening a patient for particular antibodies in the blood—the endomysial antibody and the tissue transglutaminase antibody, which are highly sensitive and specific for Celiac Disease.   IGG and IGA antibodies should be measured.  In the past antibodies to gliadin were used as a diagnostic, however their low specificity (high false positive rate) has been recognized--approximately 10% of non-afflicted people have detectable anti-glaidin antibodies.  The diagnosis of Celiac Disease is confirmed by upper endoscopy and small bowel biopsy, which shows the characteristic findings of flat crypts and lymphocytic infiltration of the intestinal epithelium. Treatment is fairly straightforward with the elimination of gluten in one’s diet.  Success with treatment can be monitored through repeating the diagnostic antibody panel.  Antibodies typically normalize within 6 to 9 months of instituting a gluten-free diet, with elimination of wheat, barley and rye, and possibly also oats, which may be cross-contaminated with gluten containing cereals.  

Recently I diagnosed a patient after a routine physical, which uncovered unexplained severe iron deficiency (in the absence of anemia).  On further questioning the patient was also having trouble with episodic diarrhea and abdominal cramping—though this had not been a major complaint at the time of his physical.

In contrast to Celiac Disease, wheat allergy refers to an immune mediated reaction characterized by increased levels of serum IgE to wheat antigens that results in clinical symptoms of allergy affecting the skin, gastrointestinal tract or respiratory tract.  Diarrhea, abdominal pain, worsening of atopic dermatitis (an allergic skin rash), and asthma are common clinical manifestations.  In children there are six foods implicated in the vast majority (over 80%) of food allergy—peanuts, tree nuts, milk, eggs, soy and wheat.  Estimates of the prevalence of wheat allergy in the pediatric and adult population are difficult to determine but fall into the range of .5 to 3 % depending on what criteria are used for diagnosis.  Many adults who have positive serum levels of wheat antibody detectable on allergy testing report no clinical manifestations of allergy.  In contrast, many children whose parents report sensitivity to wheat products have no objective evidence of the allergy on either skin prick testing or serologies.  While clinical symptoms of food allergy are fairly prevalent in the pediatric population, most kids tend to outgrow their allergies between ages 3 and 5.   In general, the most accurate way to diagnose a suspected food allergy is through oral challenge testing performed in conjunction with serum or skin testing demonstrating an immune response.

Wheat is also a rare cause of a more severe type of allergy known as Wheat Dependent Exercise Induced Anaphylaxis (WDEIA), which manifests as anaphylaxis with exercise.  Anaphylaxis is when an allergy causes massive histamine release, resulting in chest tightness, shortness of breath and collapse of the circulatory system with a dropping of blood pressure—it is life threatening.  Other rare manifestations of wheat allergy are “Baker’s Asthma,” bronchial constriction triggered by the inhalation of raw wheat, and contact urticaria (hives) cause by use of topical wheat products in cosmetics.

Food is such an emotional topic for people.  It’s interesting to me to see how many are eager to embrace food as the cause for, or the remedy of their ills.  However, whether it’s pharma or the health food industry, one must be equally skeptical.  Take the recent Federal Trade Commission complaint against POM Wonderful pomegranate juice, which accused the company of false advertising.  It appears that in the case of the gluten-free market there is good reason for these products to be made available to those who truly need them. But, before you jump on the bandwagon, make sure that the evidence to blame your symptoms on wheat is solid.

For further information on Celiac Disease, the following are useful links:

http://www.mayoclinic.com/health/celiac-disease/DS00319

http://www.mayoclinic.com/health/gluten-free/MY01651

http://www.celiac.nih.gov/Materials.aspx

Georgia Healthcare Legislative Priorities 2011

On February 11th I had the opportunity to join other primary care physicians at the state Capitol to lobby for healthcare legislation in Georgia. The “Day at the Capitol” was hosted by the “Patient-Centered Physicians Coalition of Georgia.” This group is comprised of members of the Georgia Chapter s of the American College of Physicians, the American Academy of Pediatrics, the Georgia Academy of Family Physicians, the Georgia Osteopathic Medical Association and the Georgia OB-Gyn Society.

We learned about key legislative issues facing our state this year. Each group presented its list of priorities.  Unfortunately, as with the nation, Georgia is facing significant fiscal challenges.  We heard from Alan Essig, Executive Director of the Georgia Budget and Policy Institute.  Georgia’s current unemployment rate is 10.2% and the general funds budget is down 14.6 % compared to the pre-recession FY 2009 budget.  Healthcare comprises 20% of the general funds budget.   Education, the largest sector, comprises 53% of Georgia’s budget. Consequently, we are facing cuts to Community Health (3.8% in 2012) and the State’s Medicaid program (1% in 2011).

The legislative priorities identified by the physician coalition include:

• Protect the Medicaid budget from physician cuts

In 2011 there will be a 1% cut in the Medicaid budget—we oppose this cut.  As reviewed by David Cook, Director of the Georgia Department of Health and Human Services, Medicaid insures 1.6 million in the state. The ACA calls for an expansion of Medicaid beginning in 2014 to an additional 500,000 uninsured people in our state by 2019. The average Medicaid visit (cpt 99213) is reimbursed at 41 dollars (compared to 72 dollars for Medicare). Medicaid reimbursement rates have been stagnant at this level since 2003.  This reality has had devastating impact on pediatricians and OB-Gyns who practice in rural Georgia and has diminished access for Medicaid patients.

• Support state funding for Patient Centered Medical Home pilot programs (within Medicaid and/or the State Health Benefit program)

Although private insurers have started to fund Medical Home pilot programs, Georgia was not chosen as a location for one of the Medicare-sponsored national pilots.

• Support the Prescription Drug Monitoring Act

This program would create a state wide monitoring program for the prescription of controlled substances. Several other states have similar registry programs that are alleged to have efficacy in reducing the incidence of prescription drug trafficking and abuse.

• Scope of Practice

The physician coalition has safety concerns over aspects of proposed expansion to the scope of practice for non-physician medical providers; for example, the expansion of narcotic prescribing capability to physician assistants and nurse practioners.

• Support the Prompt Pay Act

HB 167 requires that third party managers of health insurance programs be required to pay physicians on time (within 15 days of receipt of claims). Currently 30 to 40% of payers do not abide by this regulation. It was vetoed last year by the governor—apparently despite bipartisan support.

• Support Comprehensive Tort Reform

In 2005, Georgia Governor Sonny Perdue signed SB 3, which placed caps on noneconomic damages in medical malpractice suits at $350,000.  There were other components of this comprehensive tort reform legislation. In March 2010, the limit on noneconomic damages was declared unconstitutional by the Georgia Supreme Court. Other parts of the legislation were upheld.

• Prepare for the Accountable Care Act

Georgia needs to begin preparation for the impact of the ACA.  However, Georgia has been one of the 20 states to file suit against the federal government over its “individual mandate” to purchase health insurance. Georgia currently has the opportunity to establish its own health insurance pools for small business and individuals who are uninsured to select from. If Georgia refuses to participate in the planning process the federal government will step in to design our state’s options. The ACP encourages Georgia legislators to be active and engaged in this process.  Representative Stacey Abrams (D) acknowledged that denial about the reality of the ACA could be a barrier to appropriate state planning.

At “Day at the Capitol” I sat with another internist, two pediatricians and one family practioner—from Albany, Statesboro, Brunswick and Decatur. The topic of conversation at our table was primarily a sharing of stories related to the adoption of electronic health records and the how to meet requirements for “Meaningful Use” payout.  In addition, we spoke of the threat of additional cuts to Georgia Medicaid, particularly in light of the ACA expansion of 2014. This certainly remains at the forefront of concern amongst primary care physicians in our state, who are both concerned about access for their patients, but also concerned about their practices’ ability to thrive if faced with further cuts.  As is pointed out in a recent New England Journal of Medicine Perspective piece, Georgia is one of eight states projected to face the biggest challenge with the ACA expansion.  As noted, in these states “demand for care by newly insured patients could outstrip the supply of primary care providers.”  Overall the day was very well organized. We had a great turnout and I was happy to see my fellow physicians moving beyond partisan politics to advocate for health in Georgia at a grassroots level. 

The Therapeutic Relationship in "The King's Speech"

Recently I saw "The King’s Speech." The film is about King George VI, Duke of York, and his struggle with a speech impediment—a stammer. The story tells of how King George IV, “Bertie,” worked with an actor turned speech therapist, “Lionel,” to overcome a chronic ailment, which was the source of significant psychosocial stress. I found myself reflecting on what aspects of the therapeutic relationship displayed within the film were so successful. Despite his lack of official credentials, I felt that Lionel Logue displayed tremendous professionalism as a care provider.


One aspect, I believe, was the genuine friendship that developed between the two men. Whether it is advisable for doctors and patients to be friends has been a matter of debate. Within the field of psychiatry this has been seen as a boundary violation that is fraught with problems.  However, within other fields of medicine boundaries may not be as rigidly enforced.  In my view friendship, at times, can enhance a therapeutic relationship.

Another successful aspect of this therapeutic relationship was Lionel’s exploration of not only the biologic, but the psychosocial contributors to King George’s speech disorder, which had roots in his childhood family dynamics. I am a believer in the biopsychosocial model of medicine. In order to understand and treat illness, one needs to understand not only the biological factors, but the psychological and the social context in which the illness occurs. This is also known as “holistic medicine,” though this terminology is widely misused today by those who confuse it with “naturopathy” or “homeopathy.”

A third aspect that enhanced the patient-caregiver relationship was that it was non-hierarchical, neither Lionel was “Doctor,” nor Bertie was “King.” It was important to Lionel that each man should be equal in the context of treatment—and he insisted that each call the other by his first name.

Finally, Lionel was very discreet, serving as trusted guardian of his patient’s confidential health information. He protected his patient’s privacy and autonomy.

Medical Professionalism is one of the core competencies of the American College of Graduate Medical Education used in the evaluation of medical trainees. A growing movement has attempted to define the best way to measure and teach professionalism. The core attributes of Medical Professionalism were defined by a Charter drafted in 2002.  A recent paper in JAMA discusses specific behaviors and systems that support medical professionalism.
Some key elements described in The Charter are:

• Professional competence

• Honesty

• Protecting patient confidentiality

• Maintaining appropriate relationships with patients

• Commitment to scientific knowledge

• Improving quality of care

• Improving access to care

• Allocating a just distribution of resources

• Maintaining trust by managing conflicts of interest

• Participating collaboratively within the profession to maintain professional standards

I see professionalism, not as a static set of values and behaviors, but as flexible standards that are shaped throughout the course of one’s career both through observation and through trial and error.

In "The King’s Speech" Lionel admits to Bertie that he has pushed too hard, was insensitive, and took a wrong tact. He comes to apologize to his difficult patient. The willingness to admit fallibility and error is another important aspect of medical professionalism.

This film could be a great tool for teaching medical trainees.