Navigating Life with Celiac Disease: Insights from Dietitian Experts Nick Trott and Lori Welstead

Episode Transcript
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Kate Scarlata (00:19):
Thank you.
The Gut Health Podcast willempower you with a fascinating
scientific connection betweenyour brain, food and the gut.
Come join us.
We welcome you.

Dr. Megan Riehl (00:34):
Hello friends, and welcome to The Gut Health
Podcast, where we talk about allthings related to your gut and
well-being.
We are your hosts.
I'm Dr Megan Riehl, a GI healthpsychologist.

Hi, and I am Kate Scarlata, a GI dietitian.
We have a really excitingpodcast today with two amazing,
internationally renowned guests.
We're talking about celiacdisease, an immune-mediated
condition that's triggered byeating gluten the protein in
wheat, barley and rye.

Yes, celiac disease affects about 1% of the
global population, and if you ora family member are impacted,
we have a gluten-free treat foryou today.
As Kate said, we're joined bytwo incredibly insightful celiac
disease experts from both theUS and the UK.

(01:26):
That's right, friends.
The Gut Health Podcast has goneglobal.
Nick Trott is agastroenterology expert
dietician covering thespecialist celiac clinic at the
Royal Hallamshire Hospital inSheffield, England.
His areas of particularclinical interest include celiac

(01:47):
disease, gluten ataxia,non-celiac wheat sensitivity and
the low FODMAP diet approach toone of the common topics that
we talk about here disorders ofgut-brain interaction.
In 2017, Nick attained amaster's degree in clinical
research from the University ofSheffield and is currently

(02:07):
pursuing a PhD on the role ofthe dietician in the management
of celiac disease.

Welcome, Nick.

Nick Trott (02:16):
Welcome.
Thank you so much for having me.
Guys, it's a pleasure and anhonor to be on with you Megan,
Kate and Lori.
It's a full circle momentbecause I've shared so much and
read so much of the materialsyou've produced.
Megan, I can't tell you howoften I've shared your
diaphragmatic breathing video topatients.
So, Kate, you've inspired a lotof my interest in the area.
And Lori, lovely to be here andmeet you as well.

Awesome and I get the pleasure of introducing my
dear friend.
I think we're soul sisters fromanother life or something.
Just totally connect with you,lori.
Lori is an amazing celiacexpert dietician and she has
spent the last 20 years atUniversity of Chicago Medicine
in there as a GI dietician, butreally as a nutrition advisor

(03:02):
for their Celiac Center, whichis really world-renowned.
Lori is a member of the Academyof Nutrition and Dietetics and
the Society for the Study ofCeliac Disease.
Her clinical interests includeceliac disease, of course, and
other gluten-related disorders,but also eosinophilic
esophagitis, constipation andagain one of our favorite topics

(03:23):
irritable bowel syndrome.
Lori aims to help improve thequality of life in her patients
by making realistic dietary andbehavioral modifications.
She was diagnosed with celiacdisease in 2015, and it
certainly has impacted her lifeand her career as a GI dietitian
.
So welcome Lori, thank you.

Lori Welstead (03:45):
It's such an honor to be here.
I'm so excited to talkeverything about celiac.

Yes yes, we're so thrilled to have you both and
, as we get started, we like tokick things off with a
myth-busting question.
So let's start with you, nick.
What myth would you like tobust for our audience pertaining
to celiac disease?

Nick Trott (04:05):
Oh, such a brilliant question, Megan, and I think
both me and Lori will have a fewof these to sink our teeth into
.
I think primary one that comesto mind for me is it's not a
condition that always presentswith people who are underweight
or malnourished, necessarily, orpeople who just have GI
symptoms.
So classically we would thinkof celiac disease as presenting

(04:26):
with someone very underweight,maybe chronic diarrhea,
alternating gut pain and thingslike that.
And that's certainly the case.
People do present like that.
But the modern diagnosis peoplecan be a normal weight, have a
slightly elevated body weightand have no GI symptoms at all.
So that's one of the reasons.
It's a bit of a chameleon of acondition.
It presents in a number ofdifferent ways and I think over

(04:47):
the years it has affected ourability to diagnose the
condition because we've becomeeven clinicians come with some
preconceived notions about theillness.
So it's very important that aspart of promoting awareness,
that we say it's not just adisorder of the gut.
My boss, professor Sanders,says the gut is the gateway but
then the disease can affectother parts of the body.
So I'd say that would be one ofthe things I would think of is

(05:10):
presentation cannot just be GI.

Perfect.
Thank you, and Lori, how aboutyou?
I know there's a lot of mythsout there surrounding the
gluten-free diet.
Would you like to myth bustsomething for our audience?
Absolutely.

So I think one of the big ones is that people
automatically think that agluten-free diet is going to be
healthier for like the regularpopulation, right?
So specifically, we know thatthe gluten-free diet is
necessary for celiac disease butfor the rest of the population,
you know, they might not needto be gluten-free.
They might notice if they gogluten-free they might have less

(05:44):
gas and bloating.
But we know, through MonashUniversity down in Australia
they've done some studies andthey find that the fructans,
which are the fermentable partof wheat, rye and barley, are
the ones that are reallysometimes driving those GI
symptoms and it's notnecessarily the gluten which is
the protein in wheat, rye andbarley.
So I think that's a big one.
I see patients all the timeoutside of celiac disease that

(06:05):
feel that they need to be on agluten-free diet, and so I think
it's really trying to opentheir eyes and seeing if they
can tolerate things likesourdough bread versus being
fully gluten-free if they don'tneed to be.

Yeah, that's important because, as you
mentioned, sourdough bread,because of the processing, the
slow leavening, it still hasgluten not appropriate for
celiac disease, but it willreduce the fructans often and
can be tolerated for people thatare fructan sensitive.
So that's a really, reallyimportant point.

So while we all can't travel overseas, Nick,
you are working in the town thatjust hosted the International
Celiac Disease Symposium, sothat's quite convenient for both
you and for us to learn, and wewould love for you to share.
Let's go your top three mostinteresting research updates or
findings from this most recentmeeting.

Nick Trott (07:02):
Thanks, Megan.
Yes, we were very, very lucky.
Not often with theseconferences you have to travel
quite a distance, but I couldjust stay home and it was on my
doorstep just down the road, soit was wonderful to have it in
Sheffield.
We had over 600 clinicians, sothat included psychologists,
dietitians, food technologists,gastroenterologists, as well as
other sort of expert areas.
Charities and patientrepresentatives have come along
from a number of differentcountries.

(07:25):
Representatives have come alongfrom a number of different
countries and I think what cameout in my mind there were
several things that flow intoeach other from diagnosis to
treatment.
So the first thing that cameout is certainly and this is
starting to sort of, I think,get into clinical practice now
is the idea that we can diagnosepeople without a duodenal
biopsy.
So traditionally the diagnosisof celiac disease had primarily
been with clinicians, who havethen been, hopefully, case

(07:48):
finding, so looking for peoplewho likely have the condition,
based on symptoms and based onblood work, and then testing for
it serologically.
We have a number of differenttests that are used around the
world.
Primarily, it's an antibodycalled tissue transglutamase
that is used, as well as someothers called the endomysial
antibody.
In Europe they use deamidatedantibodies as well, and that's

(08:09):
very useful.
But then we need totraditionally follow that up
with a duodenal biopsy, and inpediatrics they haven't been
doing that for a long period.
They've just been using bloodwork.
And now in Europe, post thepandemic and during the pandemic
certainly where I'm from in theUK we issued some interim
advice about using blood workalone.
One of the advantages of that ispeople don't need to have an

(08:31):
invasive procedure and hopefullyit would mean we'd be able to
recognise the diagnosis and getmore people diagnosed.
In the UK it's estimated thatprobably only about 36% of
people have been diagnosed, sothere's a big burden of disease
that goes unrecognized and wethink by just using a
serological diagnosis we may beable to recognize the condition

(08:52):
and reduce the burden ofunrecognized disease.
So we know and Lori willprobably go into this as well
that it can have a knock-oneffect in terms of the
comorbidities and untreatedceliac disease on bone health,
vitamin and mineral status andeven things like there is an
associated risk of small bowelcancer with a condition,
although that is a fairly lowrisk.
So we really want to get thedisease recognized and diagnosed

(09:13):
.
Now there are some issues withthat serological diagnosis.
We have to be very, very, verycareful how we apply it.
It's still considered in thestages where we need to know
more how it's going to impactpractice.
We certainly don't want todilute the diagnosis.
So, if we do go down that road.
It needs to be done in a verycareful way where people are not

(09:35):
just diagnosed on the wronglevel of the marker.
So we use this has to be 10times the upper level of normal
to be a proper diagnosis.
And then people need access totheir celiac dream team.
I know that Megan and Kateoften talk about the IBS dream
team.
That's right.
Yeah, in celiac disease we needa celiac dream team, which

(09:56):
usually is a yeah, it's acombination again of a dietician
, ideally a GI psychologist andthat's something we need to
develop in the UK but alsogastroenterology.
So I think that would be my onebig thing take away the
development of that.
But equally, we need to becareful about how that's applied
.
And I'm just aware that I'mgoing on a bit.
Should I move on quick?

You're good, you're good.
What else?
What else?
Anything really?
Yeah, like just hot off thepress.

Nick Trott (10:22):
Yeah.
So moving on from sort of thediagnosis to treatment, what
we're looking at now, I think,is how we get access to people
that are, you know, mostrelevant to that care and that
treatment.
So for me, obviously, hopefullyit doesn't.
I know it's three dietitianshere but it is about aspect to
GI dietetics and certainly inthe UK that's been a problem
having the specialism available.

(10:43):
So we often think about how wecan get access to dieticians and
I think one of the things thatcame out of work that we're
doing locally in Sheffield butalso my dear friend and
colleague Cristian Costas inBradford and Dr Yvonne Jeanes
down in Roehampton University inthe UK, we're now developing
ways that maybe people canaccess specialist GI services,
dietetic services post-diagnosis.

(11:04):
So Christine is doing digitalwork about digital review and
follow up and myself or Yvonne,we've been looking at digital
webinars.
Hopefully we're developing anational webinar in the UK where
people maybe you can't getaccess, maybe to a specialist GI
dietitian can access that as aservice and even though maybe
that's not individualized likeseeing me and Laurie
individually it means we'regetting in the initial vice out

(11:27):
in those first few months postdiagnosis so people can get
accurate nutritional informationabout how to follow the
gluten-free diet and MeganI think the third thing that
came out and hopefully you'll behappy to hear this is the
steady and I would say it needsto be quicker integration of gi
psychology into celiac diseasetreatment.
We were very lucky to have DrRosie Satherley from Surrey who

(11:48):
presented, and we're workingtogether on integrating dietetic
and psychological practicetogether and how we can do that
to enhance those areas ofpractice.
So for people in celiac diseasea bit like we may see in
patients with DGBIs anddisorders of gut-brain
interaction there's a subset ofthose patients that do present

(12:11):
with maladaptive responses tothe diet or have specific
challenges in terms ofdisordered eating, and Rosie has
done a lot of work in that area.
So we're hopefully going tointegrate recognizing the
condition more, getting accessto GI dietitians more and also
integrating psychologicalpractice.
So those are the three bigthings I would think that came
out of what I found interestingfrom the symposium.

This is fantastic.
So you know, really so manypeople with a variety of GI
conditions deserve that dreamteam and that the evolution of
the dream team is to have somedigital therapeutics available
and also kind of scouring andputting all of this work out on
the internet from reputablesources so that people that are

(12:51):
looking and they're curiousabout this diagnosis they're
finding the work that you'redoing and your colleagues.
So this is really exciting,innovative information coming
out of the UK.

I love it.
Yeah, you guys seem to be just,in some ways, a little bit
ahead of us in even just therole of the UK.
I love it.
Yeah, you guys seem to be just,in some ways, a little bit
ahead of us in even just therole of the dietician.

Nick Trott (13:21):
It's always we're lucky in the center I work in
and a number of differentcenters, and I think that
practice is getting replicatedaround the UK of always a
dietitian with a specialismworking with a GI doc to ensure
that we're working seamlessly,but then getting referrals in
from primary care and maybe evengetting patients referred in
that way.
So it's just another pathwayinto recognizing the condition.

Yeah, absolutely so Lori, I wanted to talk to you
because I always found itYou're just so candid and honest
about your own celiac diagnosisand really the grieving process
of not being able to have someof your favorite foods.
You live in Chicago.
It's like Food Nation.
I don't think we talk enoughabout that grieving process of

(14:06):
losing some of your favoritefoods with the diagnosis of
celiac disease.
Could you share just a littlebit about your own experience
and then also you know how youhelp your patients through that
or just recognize that it issomewhat of a grieving process?

Absolutely.
That's such a great question.
So you know, I was working as adietician for 11 years when I
was diagnosed.
So I already had seen, you know, thousands of patients at that
point.
So it's such an interestingthing for me to get diagnosed,
right, because, yes, I lovegluten.
I always would say gluten wasone of my best friends.
Right, I live in Chicago.
Everything there's just gluteneverywhere.
Right, so it was such a I had areally more in the loss of

(14:44):
gluten, Like it was like afamily member dying or a friend
that passed away, Right, so Imean, I was.
I went through all the stages ofchange.
I was in, you know, denial,then I would be fine, and then
I'd walk by a food truck andjust start crying, right,
because I'm like, oh my gosh,they all know my name at this
food truck, Like that was.
You know I was married to achef and you know we all, we did
everything was about food.
So it was such a big change inmy life, Right.

(15:07):
So what really helped meoverall?
Like even when I was talking topatients, to just to help them
and listening to them andlistening to you know, this is
not easy.
This is a big part of your lifethat you have to, you know,
adapt and change and you knowswap out some things.

(15:28):
So, even with my patients, Ialways say, now, what do you
miss the most?
Right, because it's trying tofind those different things that
you can swap out and you canhave some replacements.
And so even in my, you know,journey, I've tried so many
different foods.
Some things are not that greatand it's not a great swap out.
So I always try to embed thatinto my sessions with patients
to find, okay, what are youreally missing?
Let me see what I can help youto find a good swap out.
Right, Because you want to findsome joy and find some

(15:49):
delicious food, but not just beso doom and gloom about it.
So, and then, another thing thatreally helped me is, you know,
I had two very earlymiscarriages before I was
diagnosed.
So that really helped me to say, okay, I want to be healthier,
I want to, you know, and now Ihave two healthy children that
were born, you know, naturally,right.
So just on a gluten-free dietfor one year.
So I think that also helped toreally motivate me and also

(16:12):
helps to motivate my patients,you know, just to know that just
by making a small change, whichis not easy, can really make a
big difference in your life andyour energy and all of that.
So I really found that Iactually had more sustainable
energy, even though I always hadenergy before.
This was more sustainable afterI went gluten-free and I was
finally diagnosed.

So those are great motivators, right.
So you know talking to if it'sa young woman that would like to
have children or someone that'sfeeling particularly fatigued,
because I know fatigue can besomething.
You know I think of celiacdisease in my patients with
fatigue.
Right, it's a common problem inundiagnosed celiac disease.

And headaches.
Headaches are another one.
Patients where they'll say Ihad headaches and migraines for
years.
That to Nick's point, you knowno other symptoms.
But that was one of thesymptoms that improved once they
got their diagnosis and startedthe diet.

Yeah, so that's a good motivator.
But you know, I think at thesame time we do need and in
certain cases you know, a GIpsychologist could be really
helpful here with patients thatare and I know I just wanted to
touch on this because I thinkthis is a big issue too With
celiac disease or another typeof gluten-related disorder,
there's a lot of food shamingwhy are you on that diet, just

(17:29):
have a bite?
Or holidays like, oh, we've gotto make a gluten-free dessert.
How do you help your patientsnavigate that?
And let's start with you, loriand I'd love you to chime in too
, nick, on this, because I dothink, especially this episode
we're going to be airing nearthe holiday season, and I do
want to address that piecebecause people living with food

(17:51):
intolerance deal with it all thetime.
So could you start with just acouple thoughts on that, Lori?

Sure, so yeah, you know, and again, this is not
a typical someone goes on adiet, you're just going to go
off it for certain times.
So I really try to explain thatto my patients like this is
going to be lifelong and youknow what are the things that
you might miss at your differentfamily gatherings.
Let's see some different swaplots, whether it's you know pie
crust or different things thatyou can have in place and really

(18:17):
just kind of educating andslowly explain to your family.
Because, yes, I have a lot offamilies and even patients that
push back and that cheat a lot.
So it's trying to find what isgoing to help to motivate them
to kind of stay on the diet andto listen to their family
members but also try to educatethem as well in a nice way about
it.
Because, yes, we absolutely getpeople that, oh, no big deal if

(18:38):
I cheat, but we know that ifyou are cheating and not
following the gluten-free dietyou might have that kind of
smoldering inflammation in theGI tract that can spark other
autoimmune or other conditions.
So again, it's all about, youknow, education and the patient
also not wanting to if they dohave overt symptoms, not just
cheating and then feeling sick,even those that don't have overt

(19:02):
symptoms, if they're cheating,really trying to educate them
from the ground up, to explainto their family why they have to
stay on this diet?
Because, yeah?

it's not easy.
It's not easy, and could youlike what would be your elevator
speech to a patient whenthey're visiting with people
that don't understand?
I always do that with theFODMAP diet.
This is what it is, and FODMAPscause me pain and that sort of
thing.
Is there an elevator speech forpatients, maybe that they could
tell their family or friends?

Nick Trott (19:32):
Absolutely.
I just love what Lori wassaying there about smoldering
inflammation as well, becauseyou do see that with patients
and yeah, it's fantastic Really,just following on from what
Lori was saying, I think it's soimportant.
It's friends and family illness.
So when we do group clinics weinvite everyone along.
So that would be sons,daughters, and often the direct
family members need testing aswell.

(19:54):
Incidentally, we wouldencourage that there's a 10%
increased risk in first degreefamily members.
But we always emphasize that youknow this is not a lifestyle
choice.
If you were treated for, youknow, IBD or diabetes, you would
have medication and themedication, the treatment for
celiac disease is the diet.
So it's an autoimmune condition, it is a disease treated by a

(20:15):
dietary approach.
But I think I often like, and Ithink you have, to think about
the individual person and what'sgoing to the situation, because
sometimes you have to, I think,not to use that metaphor of
battles, but you have to pickyour conversations carefully,
sometimes with family andfriends, but sometimes knowing
the underlying tests can beuseful.
I've had this fed back to me.

(20:35):
If you know that, you knowyou've had this elevated tissue
transglutamate, you know you'vehad a duodenal biopsy, what can
be really powerful for patientsis using that language because
it emphasizes a disease, likeyou know, saying "I thought it
was a lifestyle choice, but Ihave a TTG, you know, over 300.
And when I had my biopsy itshowed a mass grade 3A or
subtotal villous atrophy.

(20:55):
So you're explaining thatlanguage and quite often people
will emphasize oh, this is aperson who's actually gone
through that diagnostic process.
This is not just anintervention because I've read
about it in a magazine or I'veheard about it from someone
online.
So that is a strategy that canbe helpful.
But I think it is thatemphasizing this is the
treatment for my autoimmune andit is a multi-system autoimmune

(21:18):
disorder, so we have to take itseriously.
So that's something that we douse, but hopefully most of the
time after a number of knoweveryone's in everyone's
business with diet and makingjudgments and trolling and it's

(21:48):
really.

It's rough out there and people that live with
food intolerance.
It's not just a choice, and soI think, yeah, we just need to
empower them to be strong andfight against the trolls.
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(23:17):
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Nick I wanted to ask you back tothe meeting and I know there
have been alot of differentceliac treatments trying to kind
of come up with other things,whether it's enzymes that break
down gluten vaccines vaccines, anumber of things have been

(23:38):
trialed and everything seems tofizz out by phase two or three.
Was there anything reallyexciting on the pipeline for
celiac disease at the meeting?

Nick Trott (23:49):
Any rumblings?
Yeah, I think this is aquestion that obviously we get
asked a lot in clinical.
Lori, I'm sure you must getasked this a lot as well.
You know, will there ever be analternative to the diet?
Yes, I can follow it, but itwould be nice if there was a
possible alternative.
And I think I would split thesethings up.
Like you say, Kate, they haveto go through this proper sort
of scientific process of humantrials and eventually hopefully

(24:10):
getting regulatory accreditationin the uk and around the world
and in America.
I would say I'd split them upinto things I would call
adjunctive treatments.
So that are things thatprobably will come online first.
I still think we're maybe a fewyears away, but those are the
things that are probably goingto become available.
When we say adjunctive, what wemean is it's not a replacement
for the gluten-free diet.
So these would be things likeyou were saying, kate, things

(24:31):
that maybe block gluten in theGI tract to a degree, or
glutenases that break it downeffectively.
So those would be things thatare probably going to come
initially Again, I think thesethings are a few years away and
then we're looking atimmunomodulating drugs
that may eventually be morethings that are going to
hopefully normalize the immunesystem would mean that people
could go on to a more standarddiet, but those things are still

(24:53):
a number of years off and it isfrustrating.
I think one of the things aboutthe way these things are
reported you see, maybe a trialonline is reported, but we've
got to be aware where it is inthat pipeline of drug
development and like whetherit's an IBD drug or whether it's
a drug for diabetes all theseare the conditions we have to go
through the same process fordrugs for celiac disease.

(25:14):
I think we're at a time wherewe've never been closer, but
we're still a number of yearsoff.
I think in the and Lori, pleasetell me what you feel
I think sometimes, when peoplehear cure for celiac disease,
what they're hearing is aninjection and they're done, and
they're out the door down to apizzeria to get a standard pizza
.
That's not the way it's goingto go at the moment, with a lot
more work to do, and so and Ithink there will always be and

(25:37):
again I'll be interested to hearwhat Lori says I think there'll
always be a subset of patientsthat make the choice that they
want a dietary treatment.
The point is is to have anumber of different tools in our
armamentarium, in our knapsack,and that may be adjunctive
treatments, it may eventually beimmunomodulating drugs, but it
may be a diet.
I think likely.
Like I say, the first thingsthat are probably going to

(25:58):
become available is following agluten free diet, but something
that would protect you whenyou're out and about or on
holiday, and there are nosituations and Lori will know
this from her lived experiencethe big challenge is often
eating out and going on holiday,and I'm sure you could speak to
that, Lori.

Absolutely yes, Lori
any pipeline drugs that you'veheard of or anything going on at
University of Chicago?

You know, I know we have a couple of studies
going on.
I don't know all the exactdetails.
There's like a D-challengestudy going on.
There's a couple of differentthings that we're doing and
there's another one coming downthe pipeline that we're working
on.
That's going to be withColumbia and Vanderbilt and Beth
Israel coming up, so that willbe a clinical trial.
Yeah, so there's some thingscoming down the pipeline but no
outcomes yet.
We do have a brain fog studygoing on at University of

(26:45):
Chicago.
I actually took part in it, Iwas one of the patients.
So there's some interestingthings that they're looking at
to kind of look at thosesymptoms that it's hard to
really explain, right, brain fogwhen it comes to celiac disease
.
So you know there werefunctional MRIs and things like
that after getting a glutenchallenge that they did.
So there's a lot of excitingthings that will probably be

(27:07):
coming out once that study iscompleted.

Yeah, I often think of you know, I've been
doing this for a million years.
So I started dietetics, youknow, late 1980s, right, and
celiac disease.
Like we knew nothing, nothing.
I mean, I was like I had to goto another hospital to get a
gluten-free diet handout.
It was so overwhelming becauseit's, you know, it's a lot right

(27:30):
, there's a lot of nuance andthere was no gluten-free
products.
There's a lot of nuance andthere was no gluten-free
products.
So really seeing this evolve.
And gluten-free bakeriesthere's a new gluten-free bakery
in Boston everyone's ravingabout by this Michelin Star chef
.
It's really nice to see anawareness.
We're diagnosing more peopleand we have more yummy foods to

(27:53):
provide and more educated.
We still lack educateddieticians but there is far
greater interest than there wasin the late 1980s.

Yes, oh, absolutely.
Even when I started I mean evenin my internship I had my case
study was celiac disease and Ihad to do so much research and
that was back in like 2002.
Right, so it was like there wasnot much out there, right.
And then, even when you werediagnosed, you would get a
binder and patients would havethis big, huge binder, and that
it was just very overwhelming,right.
And there was no clear labeling.

(28:23):
So now it is nice, thelabeling's a little clearer.
I mean, I used to calldifferent companies to see what
was in their stuff because therewas nothing.
So we definitely have come along way, for sure.

Nick Trott (28:35):
I think Lori makes such an important point there.
In the UK there was a recentstudy by my friend, Yvonne
Jeanes.
Maybe about 80% of patientswere not getting adequate
education on the diet.
And if you think about thehealth skills we're asking them
to undertake label reading,navigating social situations,
and then, on top of it, what wewant them to do is follow what
we would class as a healthy dietas well, that we're encouraging

(28:56):
everyone to do so.
I think you get this.
You know multiple strands oftreatment burden and one of the
things that I think can befrustrating and again it'd be
interesting to hear what you sayfrom the US perspective, laurie
is like a lot of those foodsthat are culturally relevant for
people.
You know breads, pastas andthings.
They're kind of demonized insome ways, and then we have this

(29:17):
ultra process component cominginto it and, of course, we have
to be aware of overall dietarypatterns.
But it's so important to foodrelated quality of life.
One of the things that we didlocally was actually look we're
waiting for this data to bepublished at the moment, but we
noticed that younger patientstend to have a degraded
food-related quality of lifewith celiac disease and they're

(29:38):
often the people that are mostchallenged in terms of, you know
, going out and socializing, andI think you know labeled
gluten-free substitute foods.
What we need to do is givepeople the health literacy
skills to choose the right oneto fit in an overall pattern
that's going to best supporttheir metabolic health and their
improvement from celiac disease.
But we just don't want todismiss these foods out of hand.

(30:00):
On one hand, I think it's thedichotomy of the gluten-free
space.
People saying gluten is thedevil, it's inflammatory for
everyone.
That's not true.
And then when you're on agluten-free diet, oh, it can be
really harmful to your metabolichealth.
It's like any dietary approachthe truth is in the middle and
we need a moderate, sensibleapproach and give people the
skills to be able to do it in away that's going to support

(30:21):
their long-term health.

So this kind of feeds into why we see some of
the documented connectionbetween anxiety, depression and
celiac disease, and there havebeen several studies that have
shown that both children andadults with celiac are at a
higher risk for developing thesepsychiatric comorbidities when

(30:43):
we compare them to the generalpopulation.
So you're starting to hit onsome of the factors that
contribute to this.
Are there any other things thatcan really validate this
connection for our listeners?
And, Lori, I'll start with you,from you know, maybe your lived
experience, but also your vastexperience talking with patients
about this connection?

Yes, that's great .
So I think, yes, it's verymultifactorial, right.
So for many patients, evenmyself, my primary care doctor,
prior to me getting diagnosed,she was trying to give me all
these like anti-anxiety,anti-depression stuff, and then,
not even a year later I wasdiagnosed.
So then I came back to her,educated her and she said, Lori,

(31:24):
you have changed my practice.
I am checking people for celiacdisease, even if they have,
because I only had constipation,I didn't have that much
diarrhea, and so everyone wouldsay, "oh, Lori, you just have
IBS, right.
And then I just chalk it up andsay I have IBS, okay, okay,
right.
So I think there's a variety ofthings where, prior to you
getting diagnosed, you mighthave and I had low B vitamin

(31:45):
levels, right, b12.
That's very important for youroverall wellness you might have
diminished vitamin D, whichcould affect you in so many
different ways, right, it'salmost like a hormone in your
body.
And then just other things,folate, and again just that
feeling of not feeling very well, right.
So I think that could be priorto diagnosis and then, of course
, after you're diagnosed.
I always talk to my patientsabout this.

(32:06):
I refer many of my patients toour GI psychologist, Dr Alise
Bedell, and so I work with hervery closely, with a lot of our
patients, because I think that'sa huge component, because,
again, when they first gogluten-free, again they're
overwhelmed, they're anxious,they don't know what to eat,
they're scared to eat out at allright, and so there's so many
different components.
So I think, again, listening tothe patient, validating their

(32:28):
experience, and then, you know,working with that dream team for
sure.
And then repleting their vitaminlevels too, if needed.

That's right, that multifactorial approach
that you know you're not justanxious or depressed because you
have celiac disease, it's not ajust, it's probably, you know
again, it could be vitaminlevels, nutrients, the
physiological symptoms of things, and then also you may be
experiencing symptoms of anxietyand depression because you have
this new diagnosis.
So let's look at thingsholistically and Nick any other

(33:00):
factors that come to mind withyour experience.

Nick Trott (33:03):
Yeah, I think Lori summarized it.
It's always that combination ofthe underlying organic
autoimmune that can drivereactions from a sort of
cognitive you know, mentalhealth status.
And we also get people andagain I'm sure Lori would have
seen this people who become,they normalize their symptoms.
So they'll often come intoclinic and I've been told I've
got celiac disease but I feelfine when I'm eating gluten.

(33:23):
And then you can have thatdiscussion and go through things
and they'll come back intofollow-up in four to six months
and go I hadn't realized howunwell I was.
So they've normalized theirpre-morbid state.
So that's something that we'reaware of sometimes.
But equally, I think the otherside of it it goes back to
Rosie's work.
So she's developed a toolcalled the CDFAB, which is

(33:45):
behavioral too, that we can lookat in terms of sort of like
treatment burden, of followingthe diet.
So you will have people thatyou know they'll come and I'm
sure you know we will have allhad this experience in different
GI conditions.
Or you know I don't like to eatout, or I didn't go to my
cousin's wedding because youknow staying home keeps me safe.
So you get this diminishedquality of life because of fear
of symptoms and that can feedinto things like ARFID, you know

(34:07):
, avoidant restricted fooddisorder in some of our patients
.
So I think a lot of more workneeds to be done in how that
area is impacted in celiacdisease and again with work like
Rosie and other GIpsychologists, you know,
pioneering that.
But it's a very importantcombination, I think.
The one other thing I would addin and we definitely need more
research so we work with theneurologists in Sheffield.
One of my colleagues, professorMarios Hajidvassiliou.

(34:30):
He's looked at a number ofdifferent years from the
neurological side of thepatients with celiac disease.
So this thing called glutenataxia that we know can affect a
subset of patients, but again,there's a lot less known about
that than celiac disease andceliac disease in some ways is a
Cinderella condition.
So I think over the next fewyears there's more researches
than in that area We'll know howto identify people that are

(34:52):
having maybe the neurologicaleffects of gluten.
One thing I would say that Ireally want to caution people
about again from the onlinedialogue in this area.
You do get non-traditionalpractitioners saying things
online about gluten.
That is just fear-mongering.
It's so important that ifyou've got a concern about any

(35:12):
symptom that you eat.
When you eat gluten, please donot cut it out of your diet just
because someone online has saidsomething or you've been
emotionally sort of heardsomething online that is
affecting your fear about eatingit.
For the vast majority of peopleit is not going to be a problem
.
We know that gluten can beincluded in the diet for
thousands of years, you know inhumanity.
But I just think when we'retalking about these niche areas

(35:34):
like the neurological effects orthese other negative effects,
it's so important that peopleget adequate, proper, scientific
medical workup for theircondition and don't just go on
to the diet, because that canhave a knock-on effect to your
mental health as well

100%, and can you just tell our listeners what
gluten ataxia is?

Nick Trott (35:52):
Sure, yeah.
So gluten ataxia good idea toexplain it a little bit more.
Ataxia is a balance issue, soit can affect your gait.
For some people it can affecteven the things like their
swallow ability.
It can present, we think, a lotof what we call idiopathic
unexplained ataxia.
A subset of that may be to dowith neurological gluten

(36:12):
sensitivity.
There is a set of antibodiesbeing developed, so in celiac
disease we use something calledTTG2 or tissue transglutamase 2.
There's an antibody for theneurological condition called
TTG6, but it's only available incertain specialist centers.
So it's one of those things Ithink over the coming years that
will get used more and maybeapplied more.

(36:34):
But it's very, very importantthat people do not self-diagnose
, I think, particularly with theneurological side of it,
because we're talking about thebrain and people's balance and
those other conditions.
It can sound very scary, butit's very important that people
get properly worked up medicallyfor that.
In terms of what sometimes Iread online non-traditional
practitioners, if I can word itthat way, the politest way

(36:56):
they're sometimes taking thatscience that's been taken and
misinterpreting in it.
And it's so important that whenwe talk about this yes, we need
to talk about it in a publicway and share that to raise
awareness.
But it's really important thatpeople do not assume they've got
a condition like that withoutproper discussion with a
neurologist and maybe agastroenterologist to a degree.

(37:16):
So it's a condition that we dosee and we support people with a
gluten-free diet but, likeceliac disease, they need
follow-up to monitor theirnutrition, to follow up their
response to the diet.
Patients like that often doneed MRI scans.
They'll need what we call aspectroscopy, something that we
would do locally that looks atcertain chemicals in the brain.
That can be done, so it's veryimportant.
It's a very niche diagnosis.

(37:37):
It's rare.
We don't want to unduly scarepeople about a condition like
that, but it's something that weneed to acknowledge.
That warrants further researchand exploration and treatment
where appropriate.

I just want to interject quickly because you're
saying proper diagnosis, properdiagnosis and the importance of
not mucking around with agluten-free diet on your own,
because we need the presence ofgluten in the diet for proper
diagnosis.
And again, being in dietetics,a million years no one was going
gluten-free on their own, so weknew they were eating gluten

(38:10):
and we tested them.
But now so many people aregluten-free and even the
physicians aren't even askingthat question.
So for our listeners, you needto be consuming gluten and for
proper diagnosis, don'tself-diagnose.
And we're talking like theequivalent of a couple slices of
bread.
I'm going to ask my celiacexperts for about a month.

(38:32):
Is that reasonable?

Yes, we usually recommend.
Okay.

Okay, so I'll leave that there.

Okay, that's a mic drop moment.
We need those that can consumegluten to consume it, and if
we're curious about a diagnosis,we still need you to consume
gluten.
And another thing that youmentioned earlier is ARFID,
which is a complex eatingdisorder where an individual is
consistently avoiding specificfoods or entire food groups, and

(39:00):
this is problematic because itresults in nutritional
deficiencies, weight loss andother just psychosocial
challenges.
And recent research and this isreally emerging is showing that
ARFID is quite common in peoplewith celiac disease, as well as
other GI conditions and thosethat have more ARFID symptoms,
those with celiac disease aremore likely to have higher rates

(39:23):
of anxiety, depression and thatlower quality of life that
you've been discussing, Nick andLori, and so just I'll take
this opportunity what are yourthoughts on this connection and
understanding ARFID a little bit?
We're really early on in this,but how do you see this in your
clinical practice and patientcare strategies that we want

(39:44):
people to be aware of?
Nick, we'll start with you.

Nick Trott (39:48):
Oh, thank you.
Yeah, so I'd be fortunateenough to work with some
specialist eating disordercolleagues more in the looking
at DGBI space on this and Ithink, Kate, you'll be able to
speak to this.
One of the problems we have inGI conditions sometimes is we
don't really have validatedscreening tools in the same that
we would do within the eatingdisorder space.
So I think we have to becareful, a little bit careful of

(40:10):
how we apply some of thosescreening tools.
So I think we have to becareful, a little bit careful of
how we apply some of thosescreening tools.
I will use the short form,ARFID questionnaire, sometimes
with patients, but more as adiscussion tool rather than
obviously as a dietitian.
I can't diagnose anyone with acondition like that.
You know we need the support ofpsychology and specialist
colleagues.
But again, because of thenature of the job that me and
Lori will do and I'm sure Loriwill speak to this as well we

(40:37):
have to have an awareness of howthe diet can impact people and
I think we can signpost peopleto the proper services.
I do see people that I say wouldfall within that range of sort
of symptoms and we have thatdiscussion and then we often
refer them on for furthersupport and assessment.
Locally where I work, there aresome, depending on how they're
presenting, there can be someself-help materials that people
can use or then they might beable to refer it on for further
assessment.

(40:57):
But I think it's again, it's anarea that warrants more
research and we need to haveclinicians have an awareness,
and that's why I would say it'sso important to have this
multidisciplinary approach andto work with colleagues that can
raise this awareness and teachus as GI dietitians.
So in the UK, Kate, I know youwere saying maybe it feels like

(41:17):
in the UK we're further on withdietetic practice in some ways,
but we're so far behind with GIpsychologists and I look with
envy at the US and how well youintegrate it into care.
So I would say we do need morepsychology support and hopefully
with my colleagues like Rosie,we're doing that.
But I would say we do need morepsychology support and
hopefully with my colleagueslike Rosie, we're doing that.
But I'd be very interested,Lori, of your experience as well

(41:37):
.

Yeah, I mean, I think it's a challenge because
if you think about the glutenfree diet, you have to
essentially avoid certain foods,right.
So that again could be achallenge initially and can kind
of drive this right.
So I have patients that willsay I have not eaten out in two
years and I'll say, well, that'sterrible, that's not where we
want you to be right.
Or they'll say I'm gluten-free,dairy-free, soy-free, nut-free,

(42:03):
and they don't necessarily haveto be, but they read some
misinformation, right.
So I'm constantly trying toagain kind of myth bust, like
you know, and I'll explain tothe patients that I also have
celiac disease, that you knowyou could eat out, we can find
places for you.
You don't have to only eat outof only gluten-free restaurants,
right.
So I think there's so manydifferent ways that I'll go
about this.

(42:23):
And also even dairy, right.
So patients think like theymight just be lactose intolerant
, but then they're thinking theyhave to avoid all dairy.
So I really try to help to like, open up my patient's eyes to
say wait a minute, we can addmore variety, decrease that food
fear.
And again, I do work with our GIpsychologists very often for
some of these patients.
So you know, even after an hoursession sometimes with patients

(42:46):
are like, oh my gosh, I feel somuch better now, like you
totally relaxed me, because nowI actually feel more comfortable
, versus always feeling like Ican't eat out, I can't do this,
I can't do that, right.
So, and again, we know, there'sthat study that looked at
individuals with celiac diseaseand the quality of life is
literally people compared it tothose that are on dialysis three

(43:07):
times a week.
For what?
Four to six hours.
So that is not where we want tobe.
So we really want to help toincrease the quality of life
with those with celiac diseasefor sure.
So it's a challenge.
Absolutely.

It is a challenge and I often think about, like,
just what are some of theantecedent factors?
Like who did someone say strictgluten free diet for life?
You know, I mean we used to saythat.
I don't say it like thatanymore, but you know, our just
well-meaning colleagues reallyinstructing and encouraging this

(43:41):
level of hypervigilance thatpatients feel overwhelmed by and
leads them down to this wholefood fear, and I think we do
need to understand that a littlebit so that we can help
patients prevent it, maybe right.

Nick Trott (43:57):
That's so important, Kate.
I think we need to normalizepeople making mistakes.
Obviously, we say it'simportant to aim to avoid gluten
completely, but the truth is alot of people will have
accidental exposure that's justbeyond their control and we need
to normalize that, and often inthe early days that may happen,
but it can be a learningopportunity.

(44:17):
Yes, it may cause symptoms thatcan be very unpleasant.
But equally, I think I wouldalways want to encourage, and I
think we would all do this inour practice.
What we want to do is encouragepeople to share where things
have gone wrong so we can havethat open discussion about how
we can think of strategies whenthey're eating out, when they're
traveling, to minimize thoserisks, but as soon as you eating

(44:38):
out of the home it's aboutunderstanding that it's about
putting strategies in place thatyou know ensure that you're
following the diet as best asyou can, but in the real world
you're only human and mistakesmay happen, and understanding
that, I think, can be useful aswell.

Yes, and I also wanted to touch on, you know,
there's not much research whenit comes to cross contact.
We'd have a paper coming outand I was in charge of that
section and if you think aboutit, there's literally what?
Two fryer studies.
There's not that much data onsome of that.
So I think sometimes yes, asdietitians you know, in my 20
years I probably worried somepatients in the past.
Now it's like, okay, we do needto have more studies, but again

(45:18):
the studies always go to likedrugs versus some of these food
things right, there's not muchmoney and how much cross contact
is in this food, right?
Or whatever, and the differentpractices.
So, yes, I think it's reallyyou know we have a lot of work
to do.

Nick Trott (45:30):
Still that it's really you know we have a lot of
work to do still, that's suchan important point.
When you get a room ofclinicians in this area
interested they're interested inthe immunology which is so
important they're interested inthose things.
When you get a group of peoplewho have the condition, what
they want to know is do I sharetoasters?
What level ofcross-contamination is important
?
Can I share spreads?
You know they want to know thereal practical things.

(45:50):
Anne Lee, who's one of ourdietetic colleagues in the area,
who's one of my dietetic heroesshe's actually, you'll be aware
of this they're undertaking akissing study at the moment and
it's these real life issues topatients that are most important
and that's where we need tofund a lot of the research about
, I would say, things on theground that improve people's
quality of life is knowing thesepractical everyday things.

(46:14):
So we need to recognize thebasic research, but we need to
recognize the patient researchthat's actively going to improve
the gluten-free approach forpeople as well.

Absolutely, and that study was Jessica Lebovits
right.
So, she's at Columbia as welland she has celiac disease and
she was chewing saltine crackersand then, you know, deep
kissing, as she put it and yeah,I don't think kissing is a big
risk.
I think that's the bottom line,right Even if you're eating

(46:44):
saltine crackers that stick toyour teeth.
Let's talk a little bit aboutthe use of oats.
Specifically, we know they aretechnically gluten-free, outside
of contamination and growingand that sort of thing, but some
people have problems with oats.
So what is your approach toincluding oats in the

(47:05):
gluten-free diet for a newlydiagnosed patient?
And we can start with you, Lori.

Okay, yes, this is such a controversial topic,
right.
So I think it's.
You know it has to be veryindividualized.
We do allow patients to consumeoats.
I know not every you knowclinic does that.
We say we want them to becertified gluten free.
If they could be purityprotocol, that's another.
The oats are never grown in thesame field as wheat and all of

(47:33):
that.
There's like another standardfor that.
But we want the oats to belabeled gluten-free.
And again, we want to make suresomeone's eating not too much
oats, right, Because there's somany oats in different products.
I had a patient that was eating10 different things that had
oats in them, right.
So you want to look to see.
You know, it's like one servingof oats per day, right, it
might be like a cup or whateverafter cooked.

(47:53):
But we're just watching for allthe other things that might be
added.
Now, again, there is a smallsubset of patients that do react
to the avenin, which is theprotein in oats.
This was done in Europe and sothere is a small subset of
patients that do react to that.
So we are aware of that.
So, again, kind of treadinglightly and then to kind of
backtrack, say if someone'snumbers are not going down on a

(48:15):
gluten-free diet and their TTGis persistently elevated, then I
like to go over the diet with afine-tooth comb, see where
there might be some issues.
And sometimes we do take theoats out for a short time to see
if we can get those numbersdown.
It has to be very highlyindividualized.
And then, lastly, if you thinkabout oats, they are high in
fiber, right, so they mightcause some gas and bloating.

(48:39):
So I do educate my patients onthat, just to be aware that you
might find some gas and bloatingbut it might be just due to the
fiber content in it.
Excellent.
How about you, Lori's?

Nick Trott (48:45):
Yeah, I mean Lori's describing perfectly what we
would do clinically as well atan individual level.
It used to be in the UK wewould wait six to 12 months
post-diagnosis to introducegluten-free oats.
Obviously the oats like Loriwas saying you know this would
be, I think in America it wouldbe called a purity protocol oats
.
In the UK we would call them,you know, label gluten-free oats

(49:06):
that have been tested below 20parts per million.
That's the only oats that wewould consider suitable.
There has been a lot of researchin Australia with Jason Tye-Din
, whose Professor, Jason Tye-Dinin Australia, has done a lot of
work in this area.
So it looks like from his workalthough I think he was saying
this may be a slightoverestimate maybe about 8% of

(49:27):
the celiac population might havea problem with gluten-free oats
, but it's likely potentiallylower than that.
So I think it's a very smallpatient population that we're
talking about.
For most people in our practicewe would encourage them to
include gluten-free oats fromdiagnosis and, just like Lori
was saying, we would follow themup.
And this is the important thingat the moment is follow up, so

(49:48):
monitoring symptoms, monitoringblood work and seeing how
they're responding, obviouslylistening to individuals about
how their responses are.
I think, like you're saying,Lori, it's that thing between
people maybe having somewhat ofa fiber response to it or maybe
even a slight nocebo.
So nocebo is a placebo's eviltwin.
People will maybe have heardthat oats can be a problem and

(50:10):
then obviously they may developsymptoms from that.
So that's a small subset ofpeople that I think that can
happen with.
So I think the best tools thatwe've got at the moment is
follow-up and monitoring bloodwork.
Jason is looking, hopefully, atanother, maybe a test that
could be done that can help usidentify people more accurately
and earlier on in diagnosis,hopefully in the future.

(50:31):
But I think it's a small subsetof patients but hopefully we'll
have watch this space becausewe may have other tests that we
can identify these people with.

Perfect.
Now what about nutrients ofconcern?
Because I know that thegluten-free diet you know wheat
is fortified here in the US, soa lot of wheat products will
have those extra nutrients.
That's not the case for thegluten-free grains.
Are there particular nutrientsof concern for a new diagnosis,
particularly maybe just becauseof the disease itself and then

(50:59):
the food products being not sogreat in certain nutrients?
Could you speak to that, Lori,briefly?

Oh, sure.
Yes.
So if you think about all thoseB vitamins so B12, folate they
might be low on that atdiagnosis.
And also the foods are notfortified.
And then also iron, so somepeople might be low on iron.
So making sure that thoselevels are repleted and checking
patients again if they'rehaving fatigue, to check what
their ferritin or their ironstudies are.

(51:27):
So those are.
Vitamin D again, calcium couldsometimes be diminished in some
of the patients who want to lookat their bone health.
Make sure they're consumingthose calcium-rich foods as well
.

Yes, very important.
So some of it's disease-related, that they might be low on them
, and then other things, They'rejust not really getting a lot.
And I would say fiber too,because a lot of the stuff is
white rice.
I don't know if that's the samefor you, Nick.
Is it a lot of stuff refined inthe gluten-free space?

Nick Trott (51:58):
It is, and I think it speaks to again about health,
literacy, skills and skillsnutrition skills that we want
everyone have to be able to lookat food labels and to make an
individual choice about theoverall dietary pattern that
you're aiming for.
So I think there's a number ofdifferent elements to this.
One thing I would say I thinksome of the intake issues on the
gluten-free diet it's aspecialist population that needs

(52:19):
support, but they can besomewhat reflected by the issues
we have at a general populationlevel in terms of fiber intake.
You know, if we look in the UK,we look at the National Diet
and Nutrition Survey, theaverage intake of fiber of
people from 18 to 65 is about 19grams of fiber and that's often
reflected in that.
We would aim for 30 grams offiber for most people, although

(52:39):
that can be a little bit highall in one go if you're not used
to it.
So I think some of those thingscan be reflected in the general
population.
But certainly, just like Loriwas saying, for us it would be
calcium intake.
We aim for everyone and I wouldsay a lot of people.
If you're diagnosed post-40,you'd be wanting to have a
baseline bone scan of yourdensity, what we would call a
DEXA scan undertaken to see ifyou need additional

(53:02):
supplementation.
But for everyone with celiacdisease we would say obviously
this may slightly be differentbetween countries about 1,000
milligrams of calcium a day andthat might require some
supplementation.
Obviously, vitamin D in the UK,where we live, in terms of the
climate, we have to have vitaminD for everyone between October
and March, about 400international units and then you

(53:23):
have to individualize it.
We will very occasionally it'sfairly rare to trace elements,
so copper, zinc and selenium,where patients seem to be having
ongoing problems.
And I would say there is someevidence that if you're anemic,
you often present with a moresevere symptoms and often,
sometimes people can be anemicbut without GI symptoms.
So that's why sometimes it canbe picked up.

(53:44):
You may not have the gutsymptoms but you may have iron
deficiency anemia.
So if that's something thathappens, you get tested and
celiac disease haven't beenraised and there's no
explanation.
It's so important to thinkceliac disease in that situation
.

Perfect.

Yes, I've had so many patients that have been on
iron infusions for years, andthen their numbers would never
replete until they werediagnosed.

So, yes, I think it's very important.
Iron deficiency is a big one,yeah.
So, Lori, can you just brieflytalk about some of your top
resources, whether it's adigital app for restaurants or
just a few tools that you mightgive to the patient that arrives
at your office?

Absolutely.
So I love the app forrestaurants Find Me Gluten Free.
It actually was started inDowners Grove, Illinois, where I
went to high school, so it's agreat app and now it's
international, so it's in manycountries.
I love if people are reallyinto cooking.
America's Test Kitchen has abook that's called How Can it Be
Gluten-Free.
It's awesome.
It talks about the science ofall the different

(54:42):
recommendations, and so I lovethat.
The Celiac Project is a podcastand there's also a movie of
documentary called The CeliacProject and they have over 400
episodes and it's a great onethat I do recommend to patients
just to listen to.
I was interviewed for one ofthe episodes and then also I do
like the Gluten-Free Watchdog.
She does kind of third partytesting.

(55:03):
Tricia Thompson she's aregistered dietitian as well
with celiac disease, so she's agreat resource and I reach out
to her very often, even with mypatients.

That's perfect, I love that.

So we could talk to you guys all day, and we
will probably have to have youcome back on for sure, because
we've learned so much from theboth of you and clearly we could
continue talking all day.
We thank you for yourexperience and your expertise in
this area and, as we wrap upour podcast, we like to ask all
of our guests the followingquestion Nick and Lori, what is

(55:37):
something that you prioritizewhen it comes to your overall
health and wellness?
And, Lori, we will start withyou.

So I think one of my big things is joy, right, so
I'm trying to find joy in myexercise, things that will bring
me more energy and fun.
So that was my food and with myexercise, so I'm very big on
that.
You know all the colors of therainbow and then finding joy in
all that I do.

I love it.
Boost those endorphins.

Yes, yeah, Lori is a rainbow queen.
I always wore my rainbow sweaterfor you, but it was too thick
for this day.
But yes, yes all rainbows.
How about you, Nick?

Nick Trott (56:16):
Yeah, absolutely the same.
As I get older a little bitolder now, maybe it's because of
what I do as well I'm trying tofocus on bone health a bit more
, so I do a little bit moreweight training these days.
But like you, Kate, I like toget out into nature.
We're lucky in Sheffield I canget out into the Peak District.
But the other activity for mysoul that I've always done is
music.
I love DJing, so I still dothat a little bit.

(56:38):
So I like to get out there andshare some music and that's
movement as well.

Yes, it is.
My husband was a DJ for a shorttime too.
How cool and loved it.
It was a good side hustle, butI'm glad you do that.

Nick Trott (56:53):
Spreading the musical joy.

Yes it's all about joy, All right.
Well, thank you so much to bothof you for coming.
This was just as perfect as Iexpected it to be and just so
informative for our listenersthat are interested in this
topic.
So please be sure to subscribe,follow and like The Gut Health
Podcast.
Your support means the world,friends.

Thank you for joining us as we grow this gut
health community.
We hope you enjoyed thisepisode and don't forget to
subscribe, rate and leave us acomment.
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Podcast, where we'd love for youto share your thoughts,
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.css-14f5ked{margin:0;word-break:break-word;display:-webkit-box;-webkit-box-orient:vertical;box-orient:vertical;-webkit-line-clamp:2;overflow:hidden;}Navigating Life with Celiac Disease: Insights from Dietitian Experts Nick Trott and Lori Welstead