- What is Gluten?
- Gluten Sensitivity & Celiac Disease Aren't that Rare
- If You're Sensitive, Gluten Can Affect Your Health
- Surprising Results from Going Gluten-Free
- Why the Increase in Gluten-Related Health Problems?
- Should You Be On a Gluten Free Diet?
- 3 Ways to Know if Going Gluten Free Could Be Healthy for YOU
- Can I Ever Eat Gluten Again?
I'll admit it. I'm cautious – to the point of skeptical – about buying into health trends for myself, for my family – and for my patients. I've seen many diet fads come and go – at substantial health and financial costs to their devotees. So with gluten free diets becoming the rage and gluten free foods dropping into the market like manna from heaven – gluten-free manna, of course – I’ve had to do my research!
What is Gluten?
Gluten refers to proteins found in wheat, barley, and rye. It’s what gives bread that chewy, elastic quality. It can also be found as an accidental contaminant in other grains and foods processed in the same facilities as the three primary gluten-containing grains.
A surprising number of products including, to name just a few, salad dressings, sauces, soy sauce, and even ketchup, contain gluten, as do beer and a number of other alcoholic beverages. Even many body products and cosmetics – including lipstick – contain gluten.
Gluten Sensitivity & Celiac Disease Aren't that Rare
Historically, it was thought that consuming gluten was only a problem for people with celiac disease (also known as “sprue”), a condition that was, until recently, considered relatively rare.
It is now known that celiac disease is more common than previously believed, affecting more than 1 in 100 Americans. The prevalence has increased 4-fold in the United States in recent years. Many more people than this go undiagnosed, and as many as 40% of Americans could be suffering from non-celiac gluten intolerance.
Celiac disease may occur in only mildly symptomatic forms, leading to a significant amount of under diagnosis. It is now known that testing – including small intestine biopsy, previously considered the gold standard of tests – can be normal even when someone has celiac disease.
Celiac was also previously thought to be a disease that primarily affected only children, but it is now found widely in the adult population. It was also thought to mostly affect whites, especially Northern Europeans, but it is known to occur across races.
Gluten sensitivity, or non-celiac gluten intolerance, can lead to symptoms of varying severity when gluten-containing products are ingested. Though they are generally milder than in patients with full-blown celiac disease, they can dramatically affect health, quality of life, and longevity. There is no definitive test for gluten sensitivity.
Celiac disease and its little cousin, non-celiac gluten intolerance (gluten sensitivity) are clearly widespread!
If You're Sensitive, Gluten Can Affect Your Health
My go-to scientific source for information on celiac disease and non-celiac gluten intolerance is Dr. Allesio Fasano. Fasano is an internationally renowned pediatric gastroenterologist and one of the foremost specialists on celiac disease. He also happened to be my daughter-in-law's professor when she was in her pediatrics residency at Harvard. One day, after a lecture, she asked Dr. Fasano if he ever ate gluten-containing foods.
His response, “Do you ever text while driving?”
Her answer, “Well, it's dangerous so I try not to, but sometimes it happens…”
His reply, “Exactly.”
Digging into the medical literature, I found a 2009 study published in JAMA (Journal of the American Medical Association), which linked an increased risk of death with celiac disease as well as other types of gluten-related inflammation. Heart disease and cancer, both inflammatory conditions, were the primary causes of death, and were a startling 39% greater in people with celiac disease and 72% higher in those with gluten-related inflammation.
There is also a modest body of data connecting gluten proteins with psychiatric problems including depression and suicidality – even psychosis. I am not a stranger to this phenomenon; the first patient I ever saw having a psychotic break was during my medical training. She was 16 years old and some genius older doctor at Yale-New Haven hospital, where I was training, figured out the elusive underlying cause when drug and other obvious testing came back negative – celiac disease with a gluten exposure!
The evidence for me was mounting that some of my patients really might benefit from a gluten free diet.
So I began “Phase 2” of my research: seeing how going on a gluten free diet worked for my patients whose symptoms could be related to undiagnosed celiac disease or gluten sensitivity.
Few patients were unfamiliar with the idea of a gluten free diet. Most had a friend or relative who had tried going gluten free. Some had already started to go “gluten-lite” – cutting out “most” of the gluten in their diet, or doing an 80/20 kind of thing – no gluten at home, but being less strict when eating out.
Many were eager for my guidance in helping them to go 100% gluten free. They found it overwhelming to know exactly what foods they needed to forego, how to know which gluten free products were healthy, and they wanted to make sure they were getting the nutrition they needed from other sources. Some were smartly suspicious of gluten free products, recognizing that they just seemed to be another version of junk food.
Others were completely unsure of what on earth they would eat because their breakfasts, lunches, and dinners all featured gluten!
I was happy to help them sort through the morass of foods and information.
I instructed my patients to eliminate all potentially gluten-containing products from their diet and rather than switching to gluten free bread, pasta, and other gluten free flour products, to introduce healthy whole grains such as quinoa, brown rice, and millet. The nutritionists in my practice helped patients to plan meals and identify healthy, gluten free recipes. This was invaluable for patients, especially those who were just starting out eating a more natural diet.
Surprising Results from Going Gluten-Free
To my surprise and delight, many of my patients began seeing significant improvements in symptoms. I mean to the point that I hardly believed them!
Patients were reporting very noticeable and even complete resolution of symptoms such as “brain fog,” hypothyroidism, and rheumatoid arthritis – just a few short weeks after removing gluten from their diets.
Some of the results were so profound that I implored my patients to tell me the absolute truth – not what they thought I wanted to hear. “Really,” they assured me – they were seeing the improvements they were reporting.
While I do not put every patient on a gluten free diet, it is a commonly effective first-line approach in my medical practice.
Why the Increase in Gluten-Related Health Problems?
Gluten is so ubiquitous in the American diet that some people blame its over-consumption on the recent rise in health problems attributed to it. The story is actually quite a bit more complex than this, and includes:
- Changes in the quality of gluten products available on the market due to hybridization of the grains themselves
- Changes in human gut flora from overexposure to antibiotics throughout our lives and diets devoid of good probiotics leading to “leaky gut syndrome”
- Whether we were breastfed
- Timing of gluten introduction when we were children
- Childhood intestinal infections
- and numerous additional factors we are still discovering.
What we do know is that celiac disease causes inflammatory damage in the small bowel while gluten sensitivity causes the body to mount a more generalized immune response against proteins in the gluten, leading to a host of generalized inflammatory and autoimmune conditions.
The bottom line is that gluten causes inflammation, and inflammation, like an out of control forest fire, is the root cause of many common symptoms and diseases.
Should You Be On a Gluten Free Diet?
Not if you tolerate gluten.
The problem is that millions of people who don’t tolerate gluten don’t know it. Gluten intolerance masquerades as numerous illnesses that most Americans, and even the medical community, just take for granted as facts of life or natural consequences of aging. But chronic disease is neither!
I recommend that my patients try a gluten free diet if they have any of the following gluten intolerance symptoms:
- Chronic nutritional deficiencies, especially iron deficiency anemia, B vitamins, and Vitamin D deficiency
- Digestive problems including diarrhea, constipation, gas, bloating, cramping, or reflux
- Arthritis, or joint pain and swelling without a diagnosis of arthritis
- “Brain fog” (memory and concentration problems)
- Depression, anxiety, irritability, behavioral problems in kids
- Weight gain or difficulty achieving weight loss
- Swelling, for example, rings get tight or there are lines on the ankles after removing your sock off
- Numbness and tingling in the hands and feet
- Autoimmune conditions include Hashimoto’s thyroiditis, inflammatory bowel disease (ulcerative colitis, Crohn’s), rheumatoid arthritis, psoriasis, or vitiligo
- Skin rashes, canker sores, eczema
- Seasonal allergies, chronic sinus problems
- Infertility or certain other gynecologic problems
Of course, numerous other factors can also lead to these symptoms – it’s not only gluten. But a gluten free diet is a relatively easy thing to try, assuming other major medical conditions have been ruled out. While the root causes of illness are often multifactorial for many people, removing gluten – temporarily or permanently – can be a part of the solution.
3 Ways to Know if Going Gluten Free Could Be Healthy for YOU
I don’t recommend that everyone go gluten free. But some people really do benefit.
If you are wondering whether gluten is a problem for you I recommend the following 3 steps:
1. Go Gluten Free: Go 100% gluten free for 4 weeks – no cheats and being really careful to avoid accidental ingestion – while keeping track of your symptoms. If symptoms improve or clear up, this is a pretty good indication that gluten might not be an optimal food for you. Please note it can take months for your system to fully cool down the inflammation caused by gluten – so symptoms should improve though might not clear up all the way during these few weeks. The elimination diet is the gold standard method to test for gluten sensitivity – and it is free and something you can do at home.
2. Do A Gluten Challenge: After 4 weeks on the gluten free diet, do a challenge by reintroducing gluten for a few days. If your symptoms return, or you have a flare, this is further indication that you’d likely benefit from staying on a gluten free diet. (If serious or severe symptoms resolve on the gluten free diet, you might not want to do the challenge – just remain off of gluten).
3. Get Tested for Gluten Intolerance and Celiac Disease: Get tested to see if you are sensitive to gluten. This can be done by having your doctor do some simple blood tests to see if you have genes for gluten sensitivity (HLA DQ2 or HLA DQ8), or antibodies to gluten (anti-gliadin IgG and IgA and tissue transglutaminase antibodies, TTG).
If the genes are positive it doesn’t mean you have or will develop celiac disease; it just means you are at higher risk and may want to avoid gluten indefinitely.
If your antibodies are positive it may just mean you are sensitized to gluten because of a “leaky gut” and healing your gut through diet and some simple supplements may allow you to enjoy gluten containing foods regularly, or on occasion, without symptoms.
Note that the gene testing will be positive whether or not someone has been gluten free for a long time, but if you’ve been gluten free for many months, the antibody testing could be negative – even if you are gluten sensitive. Sometimes testing yields negative results but people still get significant improvement on a gluten elimination diet. In such cases I tell my patients that, “If it walks like a duck and quacks like a duck, it's probably a duck” and I encourage them to stay gluten free while we work on healing their gut to see if this helps.
Also sometimes eliminating other foods that may cross-react with a fraction of the gluten protein, for example, dairy, oats, corn, millet, and even coffee, may lead to improvement when going gluten free alone doesn’t bring dramatic improvements.
Can I Ever Eat Gluten Again?
Some people find that once they’ve been off of gluten for enough time to allow symptoms to resolve, they can safely re-introduce small amounts of gluten into their diets, on occasion, with minimal or no symptoms. However, it is important to keep in mind that even small amounts of gluten leading to slight symptoms translates into inflammation in your body and over time, even little bits of this can lead to bigger problems.
Others find that once they’ve done the work of healing their gut, they can comfortably re-introduce gluten.
My general recommendation is that anyone who has positive celiac genes, and anyone who has had significant symptoms related to consuming gluten, remain 100% gluten free. There are many other wonderful and nutritious foods to choose from!