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Julia Child had a flair for expression and a palate to match. If I could have a conversation with her I'd counter with, "How can a nation be great, if autoimmune disease is the #3 killer, and its bread has something to do with it?" If you search www.pubmed.com (the government listing of recent medical research) you will find approximately 1,500 references to gluten sensitivity, wheat, and autoimmune disease. These studies wouldn't exist if the connection between gluten and disease was not worth investigating. In this section of a three-part series I will answer some questions most often encountered in my nutrition practice.

1) How would I know if I have this problem? According to the Mayo Clinic, there are no typical signs or symptoms even for celiac disease, the most severe manifestation of gluten-related problems.The simplest answer could be to think about your family's health history. At this juncture it may be the only tell-tale sign. If you or your relatives (deceased or living) had or have any of the 100+ autoimmune illnesses, there is a chance that underlying gluten sensitivity is at work. The following are autoimmune-related: Anemia, Alopecia (hair thinning), Asthma, Dermatitis, Chronic Fatigue, Colitis, Crohn's, Diabetes type 1 and 2, Eczema, Fibromyalgia, Gastritis, Grave's and other Thyroid diseases, Elevated Liver Enzymes or Hepatitis, Irritable Bowel Syndrome, Lupus, Meniere's, Multiple Sclerosis, Myositis (muscle inflammation), Osteopenia, Osteoporosis, Psoriasis, Raynaud's, and Vitiligo (white patches on the skin).

An item of special note is that a family history of Lymphoma, Leukemia, Fatty Liver Disease or Liver Cancer may indicate undiagnosed celiac disease. For some it has been the only (and fatal) manifestation. For susceptible individuals gluten can cause those serious illnesses when the gluten problem goes undetected for years. Yet another factor to contemplate is a growing body of research linking gluten with Learning Disorders (ADD, ADHD), Depression, Anxiety, Eating Disorders and other affective disorders.

2) How is it diagnosed? The best way to find out if there is a gluten problem is to go completely gluten-free for 3 months, and either self-monitor or be monitored by a qualified nutritionist and/or doctor re: symptoms and blood test changes. There are no tests currently available which are sufficiently sensitive and accurate. Blood tests pick up celiac disease with a 33 to 97% sensitivity range and are highly accurate only when the intestines are severely compromised (a condition referred to as total villous atrophy). They are even less accurate with nonsymptomatic gluten sensitivity. There are also genetic tests available (HLA DQ2 and HLA DQ8 are the most common). One test I sometimes suggest to patients is a stool test by Enterolab (see www.enterolab.com), which may provide localized evidence of gluten, dairy, and soy reactions in the intestine. A range of saliva tests, which are easy to do, may be released later this year, and I will review them when appropriate.

Celiac disease (the form of severe gluten sensitivity) is diagnosed by a small intestine biopsy. This test is usually reserved for those with symptoms of chronic diarrhea and abdominal pain, or chronic anemia (adults) and failure to thrive (in infants).

An interesting study compared the predictability of a certain facial morphology (elongated forehead) with mouth ulcers, anemia and recurrent miscarriages (commonly related to celiac disease) and found that specific facial measurements were as reliable as the ulcers in predicting gluten problems.

3) Who should I consult with? Your primary care doctor, gastroenterologist, and/or a qualified nutritionist are key people to go to for consultation. The day-to-day routine is where the rubber hits the road. Going gluten-free is "simple but not easy" in this wheat-based world. The good news - the FDA label laws now require food manufacturers to list all ingredients. The problem is that some ingredients listed are hidden sources of gluten and labels need to be screened. As covered in Part 1, gluten is found in wheat, rye, barley, conventional oats, their derivatives, and other products (eg. soy sauce). Certain makeup and body products can also be an unsuspected source.

A 28 day gluten-free approach is not sufficient to provide feedback or lasting health results. Going beyond 28 days is where nutrition counseling can really help.

4) Can't I just cut down on wheat? No. Some research suggests that as little as 21 parts per million (ppm) of gluten can continue to promote the autoimmune response for an additional 60 - 120 days after a single incident of exposure. An all-or-nothing approach is really needed when trying to figure out the connection between gluten and symptoms. Every time gluten is eaten during this trial period, the mechanism of inflammation (described in Part I) is induced and the autoimmune cycle is promoted.

5) How can I eat in the "regular"world if I'm gluten-free? In Part Three I will share some tried and true strategies for going gluten free. Having done it myself and as a mother of two, I'm out in the trenches dealing with the issue. I can say that it is simple but not easy. As always, any change seems difficult in the beginning stages.

Cardboard boxes probably taste better than some of the gluten free products out on the market, yet there is hope. For now, here are 2 delicious, "family favorite" mixes - Pamela's Gluten Free Bread Mix and Cherrybrook Kitchen's Chocolate Chip Cookie mix. If you bake the bread in the oven, adding olive oil and herbs, you'll wind up with a wonderful, slightly dense crusty loaf of Italian bread. The cookies are among the best I've ever tasted (including gluten-laden cookies). Take heart - eating out is still possible and enjoyable, and a growing number of restaurants have gluten free menus. At our office we provide many tips for maintaining this approach while on-the-go.

I think Julia Child herself would approve of some of the gluten free foods available these days. See you in Part Three.