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From the Townsend Letter
December 2016

Letter from the Publisher
by Jonathan Collin, MD
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Yum: Plant-Based Recipes for a Gluten Free Diet
Recently I have been focusing on food allergies, sensitivities, and intolerances. While there has been a backlash among media columnists and late-night comedians about gluten sensitivity, the issue is real and sadly underappreciated by medicine. It is not uncommon to be evaluating new patients with a myriad of symptoms and conditions, treated with polypharmacy, using extensive supplementation, but not restricting gluten or other foods. Food antibody testing for allergy and sensitivity has been criticized as well, despite the fact that the allergist's pinprick food allergy testing is generally replete with falsely negative results. It should be noted that there has been innovation in food allergy testing, including the ALCAT procedure that assesses leukocyte reactivity to food as compared with IgG and IgE antibody testing. When a patient is found to be sensitive to gluten, dairy, and other foods, it is an easy matter for the practitioner to recommend avoidance of these foods; it is no easy time for the patient to comply. For the family member who loves to prepare new recipes, a food avoidance program or rotational diet may not be problematic. For the person who cooks simply or prefers prepared meals, gluten and dairy restriction is a major undertaking.
Of course, there are numerous gluten-free recipes compiled on websites and in cookbooks. The question is whether these recipes are easy to prepare, tasty to eat, and kid-friendly, use inexpensive ingredients that are easy to shop for, and make complying with food restrictions fun rather than a chore.
Enter Theresa Nicassio, PhD, a clinical psychologist, who developed health problems while in her 30s that led her to rethink her diet. She discovered that, like many others, she was sensitive to gluten and dairy. When she began to explore what was available to guide her in modifying her diet, she was dismayed that most recipes were arduous to make, YUMnot very palatable, and not fulfilling for the appetite or soul. Worse, when she put the meals on the table, her husband and daughter reacted with a grimace. Theresa always enjoyed cooking and she became inspired that she could do a better job on a gluten- and dairy-free meal. At first she would tinker with the recipes that she could find, but eventually she found herself stepping out of the box, bringing together ingredients in unique ways that would emphasize taste and pass muster with her harshest critic, her 12-year old daughter. It didn't take long for Theresa to engage her older daughter, Alex, in her nutrition adventure as well as her husband. In 2013 Alex and Theresa embarked on more formal training in preparing cuisine, attending the Living Light International Culinary Institute in California. Both became raw food chefs and were certified as nutrition educators. The result is that Theresa, Alex, her family, and other collaborators developed dozens of recipes that not only satisfy a gluten-free and dairy-free diet, but are also mostly sugar, egg, and potato free. Some recipes are vegan as well. The recipes are compiled in her book, YUM, and Theresa updates them on her YUM website. The one distinguishing aspect of the recipes is that Theresa writes them with a social consciousness – how will the meals make the family feel? For Theresa, living on a restricted diet not only should heal the body but also empower the planet, and most of all it should be fun.
Here is YUM's "Raw Kale & Avocado Salad," reprinted from the book:

The ingredients are: 4 cups chopped baby or de-stemmed kale; ½ cup chopped chives; 1 cup diced tomatoes; ½-1 red pepper, thinly sliced; 1 avocado, chopped in small pieces; juice from 1 lemon or 2-4 tbsp apple cider vinegar, to taste; 1 tbsp extra virgin olive oil; 1 tbsp nutritional yeast; Himalayan salt and black pepper to taste.

Here's a perfect version of a kale salad we have been making for years. An important trick when working with fresh kale is to "cook" by massaging it with your hands in the oil (in this case, olive oil combined with fresh avocado) and acid (lemon juice or vinegar), squeezing the kale as you do so. This process not only helps to make the kale softer, but also improves its taste—a fun method that most people have never heard of. It can take you back to your days of finger-painting in schools. Kids will love this process too, and it's a great way to turn them on to eating this incredibly nutritious food. I used to think that kale was boring and didn't taste very good. It was this recipe and method that changed my mind forever, and it's been a great transformer for many others as well. Avocado-massaged kale – YUM! Serves 2-3.
Directions: Toss together the kale, chives, tomato and red bell pepper, then add and massage with the avocado, lemon juice or vinegar, olive oil, nutritional yeast, salt and black pepper. Serve immediately with the garnish of your choice.
Theresa's Tip: I know these ingredients sound weird. But as you massage in all these ingredients you are, in effect, creating the dressing for the salad. The tomatoes break down and break down with the avocado and other items, resulting in an amazingly delicious creation!

Thierry Hertoghe, MD, and Testosterone Hormone Replacement Treatment
If any treatment is the face of anti-aging medicine, perhaps testosterone hormone replacement treatment best fits that role. Undoubtedly, one of the chief proponents and teachers of male HRT is Thierry Hertoghe, MD, president of the International Hormone Society. For the male who has symptoms and physical signs of testosterone deficiency, together with laboratory tests confirming the diagnosis, Hertoghe believes that testosterone replacement is mandatory.
But what is the optimal testosterone level? How does one diagnose testosterone deficiency? What are the typical complaints and physical signs of male hormone deficiency? What are best laboratory tests for diagnosing it and how does one interpret these tests? What are the different treatment modalities for optimizing testosterone levels and how are they best utilized? Finally, what considerations are needed to ensure testosterone safety?
In this issue, Hertoghe examines testosterone deficiency, its diagnosis and treatment. Hertoghe and colleagues offer advanced education on hormone diagnosis and treatment at the A4M meeting this December in Las Vegas.
Alan McDaniel, MD, and 5-Alpha-Reductase
Readers should be familiar with Dr. McDaniel, who graces this issue's cover: in April 2016, he penned an important clinical article on fungal hypersensitivity. I love Alan's clinical style: he presents cases and dissects the pertinent pathology, physiology, and laboratory relevant to evaluate and treat the patient. McDaniel likes to challenge our clinical acumen, presenting clinical symptomatology and lab data indicating lack of progress or relapse, asking what we should do next. He charts date-sequential hormone laboratory data together with therapeutic interventions; this makes for an intelligent way to evaluate hormone replacement therapy. I think that McDaniel's hormone charting should be included in university endocrinology fellowships.
In this issue, McDaniel tackles the clinical importance of 5-alpha-reductase (5alpha-R) and male testosterone hormone replacement therapy. In a word, 5alpha-R is the enzyme responsible for converting testosterone to 5-alpha-dihydroxytestosterone (DHT). The problem in testosterone HRT is that if there is excess 5alpha-R activity, too much testosterone is converted to DHT. As McDaniel explains, this excess conversion of testosterone of DHT causes men to not experience the touted benefits of testosterone treatment. One of the chief problems of testosterone replacement is that prescription gels and compounded creams applied to the skin are subject to increased 5alpha-R activity due to the skin's increased enzyme activity. Not unexpectedly, intramuscular injections of testosterone obviate this problem. McDaniel's article is a must-read for testosterone prescribers.

Jonathan Collin, MD
1.  Lipkin W. The coming trials of generation Zika. Wall Street Journal. Sept. 7, 2016:A15.
2.  Galchen R. Keeping it off: for obesity, diet and exercise rarely work. Increasingly the solution is surgical. New Yorker. Sept. 26, 2016:32–37.
3.  Dhaliwal P. State-funded homeopathy no longer available in the North of England. British Humanist Association. Oct. 6, 2016.

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