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Medical Forum / Diseases and Disorders / Sinusitis / March 2006

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JohnD - 11 Mar 2006 19:18 GMT
Hi,

I have had sinus problems for about 9 years and had endoscopic surgery to
open them up about 5 years ago.
my sinuses where about 50% better but within 18 months, they started to get
blocked again even though I was trying to keep them clean. The last 3 years
have been awful.
Until a week ago, I was waking up choking  because I had thick clear jelly
like stuff trapped at the back of my throat.

The thing is, I think I have cured them myself very simply.
My sinuses opened up and for the first time in years and I can breathe out
of both nostrils.
I had tried all of the remedies, even pushing Garlic up my nose in
desperation to get rid of congestion. :-)

My cure isn't new as I got the idea from Google.
Usually nothing I try ever works so I am very excited about this and hope
some of you will give it a go. I  reckon you must try this especially if you
are thinking of surgery.

I cut out wheat as much as possible. No bread or pasta, cakes or biscuits.
Potatoes and rice are fine.
A good side effect is that I lost about 11lb in 2 weeks.
I feel great and my stomache which was getting bigger and bigger has shrunk.
I also don't have indigestion anymore. I'll eat anything rather than bread
or pasta.

3 nights ago, 8 days after I last ate bread I started to get unblocking
sounds from my nose. Little pops and hisses.
That has happened the last 3 nights and I can't believe that something so
easy to do seems to have cured me (touch wood) I woke my girlfriend to tell
her my sinuses seem to be unblocking at 3 am :-)
I think within 14 days a lot of sinus sufferers could find a lot of relief,
it's like a miracle to me.

If it works for anyone, could you post on this group so I can see.

All the best
Tony Parker.
Michael Wilson III - 11 Mar 2006 23:02 GMT
> Hi,
>
[quoted text clipped - 36 lines]
> All the best
> Tony Parker.

I haven't tried it but it sounds like the diet change is what caused your
improvement. Maybe it will only help a small percentage of people who have
your particular bacteria/virus, but it's worth a try. I am curious as to
what the exact cause of the improvement was. A reduction in carbohydrates?
Some co-occuring factor that is only present in wheat based foods? Another
thing that I am not thinking of? Until some systematic research is done on
this topic we will not know for sure.
Susan - 11 Mar 2006 23:29 GMT
> I haven't tried it but it sounds like the diet change is what caused your
> improvement. Maybe it will only help a small percentage of people who have
[quoted text clipped - 3 lines]
> thing that I am not thinking of? Until some systematic research is done on
> this topic we will not know for sure.

The high sugar and insulin levels triggered by a high starch diet are
associated with higher inflammation.  If the OP was wheat allergic or
sensitive, it could also contribute to congestion.

Most folks with GERD, IBS, indigestion report that it's gone or improved
as soon as they stop eating high starch diet, anecdotally.

Susan
Don Brady - 12 Mar 2006 00:03 GMT
>The high sugar and insulin levels triggered by a high starch diet are
>associated with higher inflammation.  

Yes but that would only be in a really high-carbohydrate diet.  How much wheat
do you suppose he was eating?  I will bet it was minor.

>If the OP was wheat allergic or
>sensitive, it could also contribute to congestion.

That is more likely in my opinion.   Gluten intolerance.....

>Most folks with GERD, IBS, indigestion report that it's gone or improved
>as soon as they stop eating high starch diet, anecdotally.
Susan - 12 Mar 2006 16:29 GMT
> Yes but that would only be in a really high-carbohydrate diet.  How much wheat
> do you suppose he was eating?  I will bet it was minor.

It's not true only on a high carb diet; it's also true of insulin
resistant folks on a moderate carb diet.  Insulin sensitivity falls off
throughout life, especially after 30, precipitously after 40.

>>If the OP was wheat allergic or
>>sensitive, it could also contribute to congestion.
>
> That is more likely in my opinion.   Gluten intolerance.....

I don't see that we have enough information to form an opinion in one
direction or the other.

Susan
Don Brady - 12 Mar 2006 19:14 GMT
>It's not true only on a high carb diet; it's also true of insulin
>resistant folks on a moderate carb diet.  Insulin sensitivity falls off
>throughout life, especially after 30, precipitously after 40.

It seems to me that a couple of  slices of bread (or some cereal) is not likely
to make that much diffence to overall carbohydrate intake.   To the extent  it
does, it is probably because of the high-fructose corn syrup that they tend to
put  into everything, and I would agree to try to stay away from that (as a
amtter of fact, it may be the real culprit in the increase in diabetes).  I do
agree that  98% of bread and cereals are not really good foods, because you are
basically eating high-fructose corn syrup with a litle wheat.

I think that excess caloroic intake is probably the greatest singla factor in
metabolic syndromes.

Is it overall carbohydrate intake  that is the problem or is it unrefined
concentrated carbohydrates not balanced by adequate mono or poly-unstaturated
fat and protein?

If it is overall carbohydrate intake, what percentage of calories would you
recommend should come from carbohydrates?

If you just tell peopl to cut carohydrates, aren't a lot of them going to gorge
on saturated fats instead and excess protein,a s wella s cut out fruits and
vegetables?

I would agree that a diet with a good percentage of poly and mono-unsaturated
fats is the best all-round answer, and am on such a diet myself to great
results on all measures (including cholesterol, triglycerides, and blood sugar,
although the latter two were always ok fo me anyway) .  Mostly nuts with some
salmon and fresh fruits and vegetables.   However, most peoplel will not even
consider such a diet so sometimes
Susan - 12 Mar 2006 19:44 GMT
> It seems to me that a couple of  slices of bread (or some cereal) is not likely
> to make that much diffence to overall carbohydrate intake.

It can have a HUGE impact, depending on the bread.

   To the extent  it
> does, it is probably because of the high-fructose corn syrup that they tend to
> put  into everything, and I would agree to try to stay away from that (as a
> amtter of fact, it may be the real culprit in the increase in diabetes).  I do
> agree that  98% of bread and cereals are not really good foods, because you are
> basically eating high-fructose corn syrup with a litle wheat.

Wheat is as high glycemic as table sugar; even whole wheat is not much
lower. I don't know where you shop, but there is nothing coming into my
house with any fructose added, ever.

> I think that excess caloroic intake is probably the greatest singla factor in
> metabolic syndromes.

That puts you at odds with all the good science.

> Is it overall carbohydrate intake  that is the problem or is it unrefined
> concentrated carbohydrates not balanced by adequate mono or poly-unstaturated
> fat and protein?

It's overall carbohydrate intake.  Insulinogenic nutrition promotes
inflammation, CVD, DM, GERD...

> If it is overall carbohydrate intake, what percentage of calories would you
> recommend should come from carbohydrates?

For whom?  There's no such thing as the right diet plan to fit
everyone's needs.  What I would recommend is getting one's nutritional
needs met by leafy, colorful things, and not oxidizing, nutritionally
inferior and high glycemic starches.

> If you just tell peopl to cut carohydrates, aren't a lot of them going to gorge
> on saturated fats instead and excess protein,a s wella s cut out fruits and
> vegetables?

No, people who cut starches are typically eating plenty of protein
already.  I eat boatloads of veggies and salads to *replace* the starch
other folks fill up on,  with healthy fats from fish, avocadoes, nuts,
and can also have as much sat fat as I feel like.  I lowered my
cholesterol 100 points on this plan, while simultaneously doubling my
HDL.  While I moderate saturated fat, I have not, in years of trying,
found a single study in which it was established as a health risk.  Any
study that controlled for carbs found that even a high sat fat diet
reduced CVD risk markers, including in DM patients.

I eat ten times more veggies now that starch is off my plate.

Susan
Susan - 12 Mar 2006 19:53 GMT
> It's overall carbohydrate intake.  Insulinogenic nutrition promotes
> inflammation, CVD, DM, GERD...

To illustrate:

Kopp W.
High-insulinogenic nutrition--an etiologic factor for obesity and the
metabolic
syndrome?
Metabolism. 2003 Jul;52(7):840-4. Review.
PMID: 12870158 [PubMed - indexed for MEDLINE]
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1
2870158&dopt=Abstract
>

the author writes:

    "This report postulates a critical role for the quantity and quality
    of dietary carbohydrate in the pathogenesis of obesity and the
    metabolic syndrome. Significant changes in human nutrition have
    occurred during the last 10,000 years, culminating in the current
    high-glycemic/high-insulinogenic nutrition. A high insulinogenic
    nutrition represents a chronic stimulus to the beta cells that may
    induce an adaptive hypertrophy and a progressive dysregulation of
    the cells, resulting in postprandial hyperinsulinemia, especially in
    genetically predisposed subjects. Significant evidence suggests that
    postprandial hyperinsulinemia promotes weight gain and the
    development of insulin resistance/metabolic syndrome. The hypothesis
    is able to explain the current epidemic of obesity and the metabolic
    syndrome in most industrialised countries, as well as some of the
    genetics of obesity, including the extreme high incidence of obesity
    and the metabolic syndrome in certain ethnic groups."

-- High-Grain Diet May Increase Risk of Cardiovascular Disease

American Journal Clinical Nutrition January 2003 77: 43-50

When humans consume more carbohydrates than can be stored, the excess
carbohydrate energy is converted to fat by the liver. This process may
maintain blood sugar control and prevent diabetes in the short-term,
however it may also increase triglyceride concentrations, which may
increase the risk of cardiovascular disease.

In the last decade, researchers established that fat production by the
liver varies depending on dietary habits and health status.

The typical Western diet has a high fat content, which means that only
a limited amount of carbohydrates are available for liver fat
production, and liver fat production tends to be very low among
individuals who eat this type of diet. However, when too many
carbohydrates were consumed, both liver fat and sugar production were
increased.

A very low-fat (10 percent of energy) and very high-carbohydrate (75
percent of energy) diet also leads to increased liver fat production,
with the increase being even more pronounced when more than half of
the carbohydrate was consumed as simple sugars. This points to the
importance of carbohydrate quality, as another study using 68 percent
of energy from complex carbohydrate resulted in minimal liver fat
production.

However, it was found that obese individuals with high insulin levels
who consume a high-fat (40 percent of energy) diet had a liver fat
production rate three to four times higher than that of lean
individuals with normal insulin levels. But, both normal and high
insulin groups had lower liver fat production on the high-fat diet
than on a low-fat, high-carbohydrate diet.

Moreover, the low-fat, high-carbohydrate diet caused an increase in
triglyceride concentrations, a risk factor for coronary heart disease,
which was associated with the liver fat production in both normal and
high-insulin individuals.

Researchers concluded that the low-fat, high-carbohydrate diet might
not be ideal, as it can induce liver fat production and insulin
resistance. This is especially true when most of the carbohydrate is
in the form of simple sugars.

--

Susan
Don Brady - 12 Mar 2006 21:15 GMT
>Researchers concluded that the low-fat, high-carbohydrate diet might
>not be ideal, as it can induce liver fat production and insulin
>resistance. This is especially true when most of the carbohydrate is
>in the form of simple sugars.

Right - low-fat , high carb is bad.  A very useful insight.

This says nothing about moderate amounts of carb. being bad...
Susan - 13 Mar 2006 03:20 GMT
>>Researchers concluded that the low-fat, high-carbohydrate diet might
>>not be ideal, as it can induce liver fat production and insulin
[quoted text clipped - 4 lines]
>
> This says nothing about moderate amounts of carb. being bad...

You must not have read the rest of what I posted.

Susan
Don Brady - 12 Mar 2006 21:13 GMT
>> I think that excess caloroic intake is probably the greatest singla factor in
>> metabolic syndromes.
>
>That puts you at odds with all the good science.
I'm not talking about my opinion.  

http://www.americanheart.org/presenter.jhtml?identifier=4756

lists

Abdominal obesity (excessive fat tissue in and around the abdomen) as the
number one factor.  So do all of the other authorities.

I will amend what I said to rever to obesity rathr than caloric intake as such
if you prefer, although I would say that one is the cause of the other.

You know perfetly well that obesity and excess caloric intake is the major
factor in diabetes and its  precursors..

>I eat ten times more veggies now that starch is off my plate.

Did you  no know that veggies are carbohydrates.

Did you mean "avoid refined carbohydrates"?
Susan - 13 Mar 2006 03:23 GMT
>>>I think that excess caloroic intake is probably the greatest singla factor in
>>>metabolic syndromes.
[quoted text clipped - 9 lines]
> Abdominal obesity (excessive fat tissue in and around the abdomen) as the
> number one factor.  So do all of the other authorities.

The AHA and the ADA are the worst places to get information about
prevention of heart disease or diabetes.

> I will amend what I said to rever to obesity rathr than caloric intake as such
> if you prefer, although I would say that one is the cause of the other.
>
> You know perfetly well that obesity and excess caloric intake is the major
> factor in diabetes and its  precursors..

First of all, don't ever tell me what I know.  Second of all, that's
overly simplistic.  Studies show that overeating is triggered by
insulinogenic nutrition, the cause of the metabolic syndrome in
susceptible folks, and worsening lipids in non DM folks.

Visceral adiposity is specific for insulin resistance, not mere
overeating.  It's a marker.>

>>I eat ten times more veggies now that starch is off my plate.
>
> Did you  no know that veggies are carbohydrates.

Yes, did you read my posts?  I distinguished between these and starches,
which are the only carbs I suggested limiting.

> Did you mean "avoid refined carbohydrates"?

Did you READ my POSTS?  I meant what I said.  Avoid starches.

Susan
Don Brady - 13 Mar 2006 06:41 GMT
>>>I eat ten times more veggies now that starch is off my plate.
>>
[quoted text clipped - 6 lines]
>
>Did you READ my POSTS?  I meant what I said.  Avoid starches.

You said "high carb" repeated;y, eg.

"It's not true only on a high carb diet; it's also true of insulin
resistant folks on a moderate carb diet.  Insulin sensitivity falls off
throughout life, especially after 30, precipitously after 40."

Anyway starches (complex carbohydrates) are the predominant component of
"veggies"   http://www.carbohydrateaddicts.com/kinds.html   
Susan - 13 Mar 2006 14:24 GMT
>>>>I eat ten times more veggies now that starch is off my plate.
>>>
[quoted text clipped - 8 lines]
>
> You said "high carb" repeated;y, eg.

Because if one is getting carbs from high fiber and leafy veggies, one
is eating low carb, even if eating a very large volume of them.  If one
is eating starches, one is eating high carb even with small serving sizes.

> Anyway starches (complex carbohydrates) are the predominant component of
> "veggies"   http://www.carbohydrateaddicts.com/kinds.html   

Complex vs. simple carbs has been tossed out as nutritionally valid.
Potatoes are more insulinogenic than table sugar, for example.

It doesn't matter that veggies are carbs, as a % of total nutrition,
they're low carb, with high nutrition content.

Susan
Don Brady - 13 Mar 2006 18:02 GMT
>Because if one is getting carbs from high fiber and leafy veggies, one
>is eating low carb, even if eating a very large volume of them.  If one
>is eating starches, one is eating high carb even with small serving sizes.

You are evidently using a different definition of starches.  Veggies are
largely starches.

>> Anyway starches (complex carbohydrates) are the predominant component of
>> "veggies"   http://www.carbohydrateaddicts.com/kinds.html   
>
>Complex vs. simple carbs has been tossed out as nutritionally valid.
>Potatoes are more insulinogenic than table sugar, for example.

Have ytou checked veggies?  I'll bet they are the same.

>It doesn't matter that veggies are carbs

and starches

> as a % of total nutrition,
>they're low carb, with high nutrition content.

I think your wording will be to confusing to people ("even though they are
carbs they are low carb") .
Susan - 13 Mar 2006 18:23 GMT
> You are evidently using a different definition of starches.  Veggies are
> largely starches.

You are evidently having a problem with reality.

>>>Anyway starches (complex carbohydrates) are the predominant component of
>>>"veggies"   http://www.carbohydrateaddicts.com/kinds.html   
[quoted text clipped - 3 lines]
>
> Have ytou checked veggies?  I'll bet they are the same.

Wrong again.  Have you ever actually looked  anything up before posting?
 As it happens, I test my blood with a glucose meter after meals; I can
eat a dinner plate full of veggies and/or salad without a rise, but only
a spoonful or two of potato or rice or wheat shoots it up badly.

>>It doesn't matter that veggies are carbs
>
[quoted text clipped - 5 lines]
> I think your wording will be to confusing to people ("even though they are
> carbs they are low carb") .

You're the only person trying to confuse the issue, or who's so easily
confused.  Here's the reality: I eat boatloads of veggies, yet my diet
is between 15-20% carbohydrate, much of which is metabolically inactive
(unmetabolized) fiber, making it much lower in calories and insulin
requirements.

Susan
Don Brady - 13 Mar 2006 18:57 GMT
>> You are evidently using a different definition of starches.  Veggies are
>> largely starches.
>
>You are evidently having a problem with reality.

http://ebooks.palm.com/product/book/excerpt/16631
"Most plant foods, including cereals, whole grains, pasta, fruits, and
vegetables, are starches, also known as complex carbohydrates."

But I think  that what you mean by starches is something different from the
scientific sense.  That's ok

>>>>Anyway starches (complex carbohydrates) are the predominant component of
>>>>"veggies"   http://www.carbohydrateaddicts.com/kinds.html   
[quoted text clipped - 5 lines]
>
>Wrong again.  Have you ever actually looked  anything up before posting?

You'd be better off leaving off the insults.

>  As it happens, I test my blood with a glucose meter after meals; I can
>eat a dinner plate full of veggies and/or salad without a rise, but only
>a spoonful or two of potato or rice or wheat shoots it up badly.

http://www.lowglycemicdiet.com/

I do not know what "veggies" are specfically but here are some numbers:

Potatoes 37-85 (interestingly yams are quite low).

Converted White Rice 38 (instant white 87)

Carrots 49
Parsnips 97
Peas 48

So it is all over the place.  

Now, a few leaves of salad are practically zero calories and essentially zero
everything so obviously they are not going to raise anyones blood sugar.   They
are also completely valueless nutritionally

>You're the only person trying to confuse the issue, or who's so easily
>confused.  Here's the reality: I eat boatloads of veggies, yet my diet
>is between 15-20% carbohydrate, much of which is metabolically inactive
>(unmetabolized) fiber, making it much lower in calories and insulin
>requirements.

There's nothing wrong with (the right) carbohydrates as such.  They are
essential.  That's the point I was trying to make originally.  You actually
agree with it but I could not tell that from your original posts.

If people post "avoid carbs" then I am going to follow up because it is wrong.
No, it turns out that they usually mean something else entirely, but people
need to understand a little more than "go on a low carb diet".
Susan - 13 Mar 2006 19:35 GMT
> http://ebooks.palm.com/product/book/excerpt/16631
> "Most plant foods, including cereals, whole grains, pasta, fruits, and
> vegetables, are starches, also known as complex carbohydrates."
>
> But I think  that what you mean by starches is something different from the
> scientific sense.  That's ok

That is an absurdly simplified, or dumbed down reference.

http://www.whatislife.com/glossary/c.htm

Carbohydrates
Biochemical name for sugar containing molecules including single sugar
(monosaccharides) like glucose and galactose, but also polysaccharides
(complex carbohydrates) like starch (poly-glucose), cellulose (plant
fiber material, also poly-glucose with a different chemical bond
structure linking glucose units than those found in starch/glycogen and
enzymatically indigestible by humans), chitin (hard shells of insects),
and more complex carbohydrate components part of lipids and proteins
such as blood serum glycoproteins (antibodies and blood group
determinants A, O, B, rhesus positive or negative). All microorganisms
(bacteria, viruses) contain carbohydrate surfaces (glycolipids) being
the major determinants of immunogenic reactions during infections.

http://www.ndif.org/Terms/carbohydrate.html

DEFINITION:

Any of various neutral compounds of carbon, hydrogen, and oxygen (as
sugars, starches, and celluloses) most of which are formed by green
plants and which constitute a major class of animal foods.

The definitions used in this glossary of terminology either have been
provided by the authors of the articles, or have been extracted wholly
or in part, or paraphrased from the following sources: The American
Medical Association Encyclopedia of Medicine, Charles B. Clayman, MD,
Medical Editor, Random House, New York, 1989; Dorland's Illustrated
Medical Dictionary, 28th Edition, W. B. Saunders Company, Philadelphia,
1994; The Random House Dictionary of the English Language, Unabridged
Edition, 1966; Webster's Ninth New Collegiate Dictionary, 1991.

> You'd be better off leaving off the insults.

I simply stated fact; it is very clear that you have confused "starch*
for "carbohydrate" as if they are one and the same.

>> As it happens, I test my blood with a glucose meter after meals; I can
>>eat a dinner plate full of veggies and/or salad without a rise, but only
[quoted text clipped - 13 lines]
>
> So it is all over the place.  

Carrots, parsnips and peas are not eaten on a modified carbohydrate diet
 because of their starchiness and resultant high glycemic impact.

Non starchy vegetables are high in fiber and nutrients, low in calories.

> Now, a few leaves of salad are practically zero calories and essentially zero
> everything so obviously they are not going to raise anyones blood sugar.   They
> are also completely valueless nutritionally

You and I must shop and eat on different planets.  I eat enormous
servings of mixed baby greens with almost no bg impact, and they are
loaded with nutrients; you must pass these on your way to buying iceberg
lettuce.

> There's nothing wrong with (the right) carbohydrates as such.

Exactly.  I eat lots and lots of the right ones, which aren't potatoes,
rice, pasta, cereal, bread, parsnips, cooked carrots.

  They are
> essential.

Wrong.  There is no such thing in human nutrition as essential
carbohydrates.  Biochemically speaking (check a textbook, any textbook),
essentials are those things we cannot manufacture ourselves.  There are
only essential fats and proteins in human nutrition; without them, you
will die.  You can live forever without eating carbohydrates.  Protein
supplies ample glucose.  Fat can,too, in a pinch.

 > That's the point I was trying to make originally.  You actually
> agree with it but I could not tell that from your original posts.

No, you never made the same point, you don't distinguish between starch
and carbohydrate, and you have zilch understanding of nutrition.

> If people post "avoid carbs" then I am going to follow up because it is wrong.

You confused "carbs" with "starch."   You still don't know that there's
a difference in content in different foods.  You also don't know that
carbohydrate is a non-essential macronutrient.

> No, it turns out that they usually mean something else entirely, but people
> need to understand a little more than "go on a low carb diet".

People need to understand what a carbohydrate is and does before they
spout off a bunch of incorrect nonsense about nutrition and dietary needs.

Susan
Don Brady - 13 Mar 2006 21:29 GMT
>No, you never made the same point, you don't distinguish between starch
>and carbohydrate, and you have zilch understanding of nutrition.

Ok I'm done since I do not care for the totally unjustified personal insults.

Too bad since it is was a  very interesting discussion....
Susan - 13 Mar 2006 21:41 GMT
> Ok I'm done since I do not care for the totally unjustified personal insults.

You're done, alright, but it's got nothing to do with anything
unjustified. You misrepresented every statement I made and contradicted
all the scientific literature, then had the noive to call my definitions
unscientific.

> Too bad since it is was a  very interesting discussion....

Only to you, I'm afraid.

Susan
Susan - 13 Mar 2006 18:42 GMT
>>Because if one is getting carbs from high fiber and leafy veggies, one
>>is eating low carb, even if eating a very large volume of them.  If one
[quoted text clipped - 10 lines]
>
> Have ytou checked veggies?  I'll bet they are the same.

Don, are you failing to distinguish between starches and carbohydrates?

From your statements, it appears that you are.

Susan
Shirley Ann - 12 Mar 2006 13:02 GMT
I am allergic to wheat and gluten (Celiac disease).

My sinus' have not improved but have gotten worse over the last 3 years.

shirleyann
tyshock - 12 Mar 2006 17:27 GMT
Did it take 8 days before you noticed any effects in regards to your
sinuses?  I am preparing to begin a series of food elimination trials
to identify any allergens/irritants.

Tyler
JohnD - 12 Mar 2006 20:39 GMT
> Did it take 8 days before you noticed any effects in regards to your
> sinuses?  I am preparing to begin a series of food elimination trials
> to identify any allergens/irritants.
>
> Tyler

Yes Tyler, but I stopped choking on phlegm after 2 days without bread and
pasta.
I was eating 6 to 8 slices of bread per day and pasta for my evening meal.
One thing I find is that I don't want bread or pasta
anymore. Even the wheat free products bloat me.
Now, I'm eating better, nuts, fruit, dried fruit etc.
I'm sort of adjusting my diet as I go. The first couple of day's, I coudn't
think what to eat but I soon got the hang of things. Just anything but
bread. :-)
Less bulky food  is making me feel a lot better but I will keep eating rice
and a few potatoes as I don't get any indigestion from them and I feel I
need them in my diet.
I think I am wheat and gluten intolerant.

Best of Luck
Tony
 
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