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The Healthy Skeptic: Is Gluten Really so Guilty?
Another factor in grains may account for symptoms; Gluten-free diets can be unnecessary and unhealthy

11/20/2014 By Craig Weatherby
People love to classify foods as villains or heroes.
 
It all began before the Civil War, with America's first “health food” guru.
 
In the 1830's, Sylvester Graham touted whole grain, additive-free bread and vegetarian diets. 
 
He influenced John Kellogg, who, in the 1890's, created whole grain cereal, promoted vegetarian diets and soy foods, and decried foods he believed led to overactive (hence unhealthful) libidos.
 
Then in the late 1960's, Professor Ancel Keys' now-discredited Seven Countries study demonized saturated fat and cholesterol.
 
Two decades later, Americans fearful of weight gain went low-fat … and makers of processed foods compensated by adding more sugar and salt.
 
Today's heroes are antioxidant-rich plant “super foods” like kale and pomegranate, while gluten is blamed for weight gain, digestive problems, and brain fog.
 
The evidence in favor of antioxidant-rich plant foods is very strong … but is the war against gluten justified? 
 
The gluten debate involves two separate questions.
 
Is gluten inherently unhealthful? And, are those who believe they're sensitive to gluten really reacting to that protein, or to something else?
 
What is gluten?
Gluten is a protein that occurs only in rye, barley, wheat, and wheat ancestors like spelt, teff, triticale, and kamut. 
 
Gluten makes dough elastic and helps it rise, lets bread keep its shape, and gives it a chewy texture.
 
Most commercial breads and flours contain added gluten, because there isn't enough in wheat to produce these effects … without skillful handling.
 
Gluten does not occur naturally in oats, rice, corn, quinoa, or buckwheat (which is actually a fruit), and is not normally added to baked goods that contain only these naturally gluten-free grains.
However, many oat, rice, and corn products contain wheat flour, or trace amounts of gluten left on processing equipment after production of wheat, rye, or barley goods.
 
Celiac disease versus gluten sensitivity
Gluten is extremely harmful to people with celiac disease, who must avoid it entirely or suffer severe damage to their intestines.
 
The rates of celiac disease have been rising, from one in 500 Americans in the 1970s, to one in 250 in the mid-1980s, reaching almost one percent (one in 133) in 2000.
 
Alessio Fasano, M.D., is the world's leading researcher of celiac disease, and Director of the Center for Celiac Research at Massachusetts General Hospital.
 
He discovered a major, previously unknown genetic cause of celiac disease and authored Gluten Freedom: The Essential Guide to a Healthy, Gluten-Free Lifestyle.
 
Dr. Fasano says that seven to eight percent of Americans believe they are gluten-sensitive ... and that “non-celiac gluten sensitivity” is a real phenomena in a small but as yet undetermined percentage of the population (Czaja-Bulsa G 2014; Mansueto P et al. 2014).
 
At present, there are no tests that can confirm a diagnosis of non-celiac gluten sensitivity, which in some cases may mask other conditions, such as wheat allergy or sensitivity to other food factors in wheat.
 
The results of small clinical trial from Australia persuaded many skeptics that non-celiac gluten sensitivity does exist, and fueled the gluten-free foods fad (Biesiekierski JR et al. 2011).
 
However, those results have not been repeated, and were seriously undermined by a less-widely reported and better designed study from the same team, consisting of two controlled clinical trials … see “Is gluten always the source of wheat reactions?” below.
 
Dr. Fasano delivered the keynote address at a recent conference of the traditional-foods advocacy group Oldways, titled Whole Grains: Breaking Barriers.
 
As he said there, “When we started this journey 20 years ago, gluten free products were awful in part because there was no market to support” researching and creating good gluten-free foods.
 
“So we started this crusade to increase celiac disease awareness, and we were so darn good at it that it went out of control with some people pulling the science out of context.” 
 
He was referring to assertions and implications that gluten is inherently unhealthful, even to people who do not have celiac disease (which can be diagnosed), or who definitely suffer from non-celiac gluten sensitivity ... a condition that's much harder to diagnose.
 
Why are people going without gluten?
Surveys show that almost one in three American adults (30 percent) follow a gluten-free or gluten-reduced diet … up from 25 percent in 2010.
 
About half (55 percent) of Americans who follow a gluten free diet say they do so because they think it's healthier, while one in four (27 percent) hope it will help them lose weight.
 
Americans cite two other main reasons for following a gluten free diet: a desire to ease stomach problems and/or to clear up a foggy mind.
 
Those motivations originate partly from publicity generated by two bestsellers: Grain Brain by neurologist David Perlmutter, M.D., and Wheat Belly by cardiologist David Williams, M.D.
 
Careful readings of both books reveal that – more than gluten per se – their authors' main concerns are diets high in grains and carbs (Grain Brain) and wheat (Wheat Belly).
 
Dr. Fasano agrees that a gluten-free diet can help people lose weight or become healthier ... but not because of gluten-avoidance.
 
Instead, as he observes, a gluten-free diet may lead people to avoid foods packed with sugar-like, nutrient- and fiber-poor refined carbohydrates (e.g., pizza, pastries, and chips).
 
Sadly, that's often not the case, because gluten-free product lines often feature unhealthy alternatives, and because many folks mistakenly believe that “gluten-free” automatically means “healthy”.
 
Is gluten always the source of wheat reactions?
The available research hasn't confirmed the existence of gluten sensitivity, but some people may suffer from it.
 
However, wheat also contains complex carbohydrates called FODMAPs … an acronym for fermentable oligosaccharides, disaccharides, monosaccharides, and polyols.
 
Most people have no trouble digesting FODMAPs, but some do, because FODMAPs pull water into the gut, which can cause abdominal pain, bloating, gas, and diarrhea.
 
Many other types of foods also contain FODMAPs. These include garlic and onions, foods naturally high in fructose (honey, apples, mangoes, and watermelon), and milk products.
 
In two recent clinical trials, when people who believed they were gluten-sensitive ate diets containing FODMAPs but no gluten, stomach symptoms did not improve for most participants (Biesiekierski JR et al. 2013). 
 
The outcomes of these trials suggest that the real cause of the symptoms in these self-diagnosed gluten-sensitive people was FODMAPs, not gluten.
 
Confirming that suspicion, no biological markers were found in the subjects' blood, feces, or urine to suggest that gluten caused any unusual metabolic response.
 
The authors conclusions are worth quoting at length, because the results of these two trials contradict those of the same authors' 2011 trial. 
 
As they say, the two trials conducted in 2013 were more tightly designed and controlled, to eliminate other dietary factors known to cause stomach upset, making the results much more reliable (Biesiekierski JR et al. 2013):
  • “Generally, NCGS [non-celiac gluten sensitivity] is viewed as a defined illness, much like celiac disease, where gluten is the cause and trigger for symptoms. In such a case, it would be anticipated that removal of gluten from the diet would lead to minimal symptoms and subsequent exposure to gluten would lead to specific triggering of symptoms. The results of the current study have not supported this concept.”
  • “First, some of the patients were not minimally symptomatic, despite apparent adherence to and previous considerable improvement on a GFD [gluten-free diet]. Reduction of FODMAPs in their diets uniformly reduced gastrointestinal symptoms and fatigue in the run-in period, after which they were minimally symptomatic. Secondly, in 2 double-blind, randomized, placebo-controlled, cross-over trials, specific and reproducible induction of symptoms with gluten could not be demonstrated.”
  • Such findings must be reconciled with the results of our recent double-blind, randomized trial, in which gluten induced greater gastrointestinal symptoms and fatigue than did placebo in an identically selected population of patients who fulfilled the criteria for NCGS. Several key differences in study design might have potentially influenced the results ... in contrast to the previous use of supplements with the habitual diet, food intake was carefully controlled … to reduce ‘background noise' and control for changes in participants' usual diet, particularly intake of other potential dietary triggers.”
The Australian team proposed that, for some people who react to foods containing gluten, “gluten might induce symptoms only in the presence of a moderate content of FODMAPs” (Biesiekierski JR et al. 2013).
 
Problems with gluten-free diets
One potential problem is that, as the 2013 Australian trial suggests, many people who believe that they are gluten sensitive may actually be reacting to FODMAPs.
 
Gluten-free foods can be considerably more expensive than their regular counterparts, so mistaking gluten sensitivity for FODMAP intolerance can be a costly error.
 
In addition, following a gluten-free diet for no good reason means that you can't easily join friends and family in meals, and need to request special foods.
 
Last but not least, a gluten-free diet – like a diet that includes gluten – can be nutrient-poor.
 
According to research dietitian Pam Cureton – a colleague of Dr. Fasano's at the Center for Celiac Research – “The gluten-free diet typically is missing some important nutrients … like fiber, iron, B vitamins, calcium and zinc, which can lead to iron deficiencies, osteoporosis and constipation.”
 
She notes that in a study of 47 adults who followed a gluten-free diet, 46 percent of the women didn't get enough fiber, 31 percent didn't consume enough calcium, and 44 percent were short on iron.
 
And the men following a gluten-free diet suffered even deeper deficiencies of each nutrient measured in the study.
 
“There is a solution”, Cureton said. “Use alternative whole grains. Gluten free does not mean grain free.”
 
She noted that buckwheat, brown rice, amaranth, quinoa, teff, and millet can close the nutritional gaps and make gluten-free diets more sustainable for those who really need to avoid gluten.
 
If you are convinced that a gluten-free diet has helped you, by all means trust and follow your experience.
 
Just be aware that the evidence for gluten sensitivity is thin at best, and that you may be going to considerable trouble and cost for no reason!
 
 
Sources
  • Barrett JS, Gibson PR. Fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) and nonallergic food intolerance: FODMAPs or food chemicals? Therap Adv Gastroenterol. 2012 Jul;5(4):261-8. doi: 10.1177/1756283X11436241.
  • Biesiekierski JR, Newnham ED, Irving PM, Barrett JS, Haines M, Doecke JD, Shepherd SJ, Muir JG, Gibson PR. Gluten causes gastrointestinal symptoms in subjects without celiac disease: a double-blind randomized placebo-controlled trial. Am J Gastroenterol. 2011 Mar;106(3):508-14; quiz 515. doi: 10.1038/ajg.2010.487. Epub 2011 Jan 11
  • Biesiekierski JR, Peters SL, Newnham ED, Rosella O, Muir JG, Gibson PR. No effects of gluten in patients with self-reported non-celiac gluten sensitivity after dietary reduction of fermentable, poorly absorbed, short-chain carbohydrates. Gastroenterology. 2013 Aug;145(2):320-8.e1-3. doi: 10.1053/j.gastro.2013.04.051. Epub 2013 May 4.
  • Biesiekierski JR, Peters SL, Newnham ED, Rosella O, Muir JG, Gibson PR. No effects of gluten in patients with self-reported non-celiac gluten sensitivity after dietary reduction of fermentable, poorly absorbed, short-chain carbohydrates. Gastroenterology. 2013 Aug;145(2):320-8.e1-3. doi: 10.1053/j.gastro.2013.04.051. Epub 2013 May 4.
  • Czaja-Bulsa G. Non coeliac gluten sensitivity - A new disease with gluten intolerance. Clin Nutr. 2014 Aug 29. pii: S0261-5614(14)00218-0. doi: 10.1016/j.clnu.2014.08.012. [Epub ahead of print] Review.
  • Mansueto P, Seidita A, D'Alcamo A, Carroccio A. Non-celiac gluten sensitivity: literature review. J Am Coll Nutr. 2014;33(1):39-54. doi: 10.1080/07315724.2014.869996. Review.
  • Fasano A/Oldways. Why Are Celiac Disease and Gluten Sensitivity on a Rise? Accessed at http://wholegrainscouncil.org/files/2014wgcBBconf_Fasano.pdf
  • The New Yorker / Specter M. Against the Grain: Should you go gluten-free? November 3, 2014. Accessed at http://www.newyorker.com/magazine/2014/11/03/grain