Who Should Eat a Gluten-Free Diet?
Whole Wheat: Friend or Foe? Image: FreeDigitalPhotos.net
*Warning: A long post, but please stick with me here and let me know what you think.
Gluten-free foods have become all the rage the past five years, from quinoa pasta to rice-based crackers. Many people swear by eating gluten-free: more focus, weight loss, greater energy, you name it. But do you really need to give up gluten entirely? Understanding the causes of and differences (or lack thereof) between gluten intolerance, wheat/gluten allergy, gluten sensitivity and celiac disease is crucial, and that’s what this article sets out to explain, in laymen’s terms. I will be citing a few references, but will also be providing a few personal “logical extensions” of what we currently know. If you agree with me, great. If you don’t, I’d love to know why (with appropriate competing references and rationale) because it helps me learn more. But before we delve in too deeply I want to know: do you know what gluten is?
According to Wikipedia (they have a good definition!), “gluten is a protein composite found in foods processed from wheat and related grain species, including barley and rye” (and kamut). So, gluten is one of the primary proteins in wheat. Sometimes you will see oats on the “avoid” list for gluten-free diets as well because many grain-processing facilities in the U.S. process wheat and oats in/near similar machines, so cross contamination can occur. However oats themselves do not contain the gluten protein that those with gluten intolerances are sensitive to.
On the Internet and throughout the media these days the words “gluten sensitivity,” “gluten intolerance” and “wheat/gluten allergy” are used quite interchangeably. Researchers, on the other hand, use these terms to refer to specific reactions and levels of severity.
Wheat/gluten allergy: Creates a systemic allergic reaction similar to other food allergies like hives, nausea, congestion and even anaphylactic shock in severe cases. Low prevalence, only about 1% of children (many grow out of it) and a few adults.
Celiac Disease: A severe form of gluten sensitivity. When someone with true celiac disease eats a food with gluten, the body’s immune system attacks the gluten in their digestive tract and causes the destruction of many of the cells that are responsible for food and nutrient absorption into the body (properly called villi/microvilli). The resulting inflammation and gastro-intestinal distress (i.e. diarrhea, bloating, cramps, etc.) is largely dependent on the severity of the celiac disease. Other symptoms may include malnutrition and increased risk of osteoporosis and cancer. There are specific tests to determine whether you have celiac disease, and those with the diagnosis require gluten-free diets to remain symptom-free.
Considering how many people out there are swearing by gluten-free diets, you’d think that a huge portion of the population has celiac disease. What percent of the American population do you think has celiac disease? 20%? 10%? 5%? According to a recent study of nearly 7,800 people in the American Journal of Gastroenterology in July 2012, the prevalence of celiac disease in the U.S. is 0.71%. Less than three quarters of one percent. Interestingly, 29 of the 35 people who had celiac disease were undiagnosed until the study! Non-Hispanic whites were the highest sub-group with a rate of 1.01%.
And this is not limited to the U.S. In Europe here are some percentages (people 30-64 years old):
In total, across 29,212 participants: 1%
2.4% in Finland
0.3% in Germany
0.7% in Italy
Interestingly, another study showed that prevalence of celiac disease has increased four-fold in the past 50 years, from 0.2% to 0.8%. However, is this a result of changes to our diets or more sophisticated detection processes? Either way, celiac disease is relatively uncommon. The conclusion of the first study says it all: “Most persons who were following a gluten-free diet did not have a diagnosis of celiac disease.”
So why are so many people eating gluten-free diets? Are there other types of people sensitive to gluten that do not have celiac disease? It seems like there may be.
Undefined/Un-diagnosable Gluten Sensitivity: According to an interesting article in the Wall Street Journal, about 6% of the U.S. population may suffer from “gluten sensitivity,” resulting in stomach discomfort, headaches/migraines, balance problems and more. But these sensitivities cannot currently be diagnosed. So how can we tell the difference between this kind of gluten sensitivity and celiac disease? The author of the article provides a great distinction:
“Their immune reactions were different, too. In the gluten-sensitive group, the response came from innate immunity, a primitive system with which the body sets up barriers to repel invaders. The subjects with celiac disease rallied adaptive immunity, a more sophisticated system that develops specific cells to fight foreign bodies.”
In other words, gluten-sensitive people have a more generalized inflammatory response to deal with the presence of gluten (i.e. the entire body gets pissed off) compared to those with celiac disease, where the body specifically attacks the gluten and the parts of the body immediately surrounding it (i.e. the body attacks the GI tract where the gluten is located).
Here’s my breakdown of the current information/research:
The body is designed to protect against foreign invaders. Those invaders typically carry particularly identifiable “proteins” that our body can sense. In celiac disease, there is a very specific auto-immune response (there is a direct, measurable cause-and-effect of eating gluten and getting sick) where a person’s body attacks itself when they consume gluten. Therefore they should follow a gluten-free diet.
For gluten sensitivity, however, the issue is much more murky. There’s no particular measurable antibody response, although people do tend to feel better when they no longer eat gluten-based foods. This “primitive immunity” results in an increase in general inflammatory proteins, that are impacted by many other factors besides gluten (to be discussed below). So what’s going on? Maybe we’re just getting too much of a good thing?
This is where I take a logical leap, follow me for a minute and let me know your thoughts:
About 40 years ago the U.S. (and in some ways the world) went on a HUGE whole-grain kick when people realized that eating white bread and white rice all day wasn’t the best thing. The fiber, vitamins and minerals from the bran and germ portions of the grain were important. So we started eating more whole grains. And what type of grain did the U.S. have an abundance of? Wheat! Fields and fields of wheat (points if you got the Woody Allen reference!).
So we started having wheat cereal for breakfast, wheat-bread with our sandwiches at lunch, wheat crackers as a part of our snacks and eventually whole wheat pasta for dinner. We couldn’t get enough wheat. In general, the more we expose our bodies to a particular stimulus without giving it a chance to recover (even good stimuli), the more potential we have for a negative response from the body.
Take running, for example. Going for a run a couple times a week is good. Our body gets the stimulus, recovers and then is ready for the next run. Now imagine going for two or three runs a day, every day for half your life. Do you think your body will wear out and get pissed off and inflamed? Now consider how often we eat wheat each day.
Is it just possible that we’ve eaten too much wheat and need to reduce how much of it we’re eating? This is the essence of most food sensitivities. Your body gets pissed off because you’ve had too much of a particular food over and over again (consider dairy as another one). If you’ve eaten a ton of it you may need to greatly reduce or cut it out to allow your body to “calm down.” But then you can probably add it back in reasonable portions. How much you have is up to you and your body’s reaction, but you could probably have it at least a few times a week, maybe even once a day. Just not three times a day.
I would also like to mention that since the inflammatory response in gluten sensitivity is non-specific, it is affected by many other factors such as stress (mental or physical), exercise, consumption of other inflammatory foods, drinking alcohol, heat and more.
Non-specific inflammation (which is what occurs in non-celiac gluten sensitivity) is very much like a pool filling with water. There’s a drain at the bottom of the pool which is our body’s natural ability to process and deal with inflammation. However, causes of this inflammation (i.e. non-specific gluten sensitivity, stress, etc.) are streams of water pouring in. The body is able to handle a certain amount of inflammation based on our ability to process it. Healthier habits such as sleep, staying active, drinking water and stress management tend to slow the flow of water in and increase the size of the drain allowing water to flow out. On the other hand, unhealthy habits tend to make the water flow in faster and make the drain smaller. We only show symptoms when the pool reaches a critical point where the water is filling in so fast that it begins to spill over the edges, since the drain cannot clear it out fast enough.
In those with gluten sensitivity, gluten is one of the things that causes the water to flow into the pool faster. So unless you want to go the rest of your life without pasta or bread, the key is to determine how much gluten you can eat without having your pool spill over (a tip: do lots of other things that help increase the size of the drain at the bottom of the pool to keep inflammation levels down).
If you have celiac disease or a true wheat allergy, then you should consult a Registered Dietitian and doctor for nutrition counseling before making any significant changes to your diet.
Beck, M. (2011). Clues to gluten sensitivity. Wall St. Journal, Health Journal, March 15, 2011. Accessed on 8/16/12 at: http://online.wsj.com/article/SB10001424052748704893604576200393522456636.html#
Hadjivassiliou, M. et al. (2010). Gluten sensitivity: from gut to brain. The Lancet: Neurology. 9, 318-330.
Mustalahti, K. et al. (2010). The prevalence of celiac disease in Europe: Results of a centralized, international mass screening project. Annals of Medicine. 42(8), 587-595. Accessed on 8/16/12 at: http://informahealthcare.com/doi/abs/10.3109/07853890.2010.505931
Rubio-Tapia, A. et al. (2009). Increased prevalence and mortality in undiagnosed celiac disease. Gastroenterology. 137(1), 88-93. Accessed on 8/16/12 at: http://www.gastrojournal.org/article/S0016-5085%2809%2900523-X/abstract?referrer=http%3A%2F%2Fscholar.google.com%2Fscholar%3Fq%3Dceliac+disease+prevalence
Rubio-Tapia, A. et al. (2012). The prevalence of celiac disease in the United States. American Journal of Gastroenterology. July 31, 2012 edition. Accessed on 8/16/12 at: http://www.nature.com/ajg/journal/vaop/ncurrent/full/ajg2012219a.html
Sapone, A. et al. (2011). Divergence of gut permeability and mucosal immune gene expression in two gluten-associated conditions: celiac disease and gluten sensitivity. BMC Medicine. 9(23). Accessed on 8/16/12 at: charlotteceliacconnection.com/files/Divergence_of_Gut_Permeability_and_Mucosal_Immune_Gene_Expression_in_Two_Gluten_Associated_conditions_-_BMC_Medicine_-_March_2011.pdf