Background

I used to think gluten was an over-hyped health fad that would soon pass.  I’m not talking about Celiac Disease (CD), where the immune system actually physically damages the intestinal lining, but rather individuals who are gluten sensitive without CD.  We refer to these folks as having Non-Celiac Gluten Sensitivity (NCGS).

Now after reviewing the research in further detail and observing the remarkable results when our patients with gluten sensitivity go gluten-free, I’ve become a believer.  

Our immune system is a highly selective defense system that targets the protein segment of foreign invaders (viruses, toxins, etc.) that enter our body. However, it is an imperfect system that is susceptible to “friendly fire.”  This means certain food-based proteins (like gluten) that we ingest may share enough similarity to infections or other foreign invaders, inciting a false alarm that activates our immune system to attack our own body.

For example, exposure to gluten in someone with NCGS or celiac disease may cause their immune system to attack their thyroid gland, which is why there is a strong association between CD and autoimmune thyroid conditions.  

I’m also concerned how the food industry is turning “gluten-free” into the new “fat-free” by producing packaged, processed foods that are indeed “gluten-free,” but still raise the risk of obesity and chronic disease by using other addictive, unhealthy ingredients.

As you can see there are a lot of complexities with gluten and I’m calling upon our nutrition expert, Prerna Uppal, to help you navigate.

Prerna Talks Gluten

Research has indicated that celiac disease has been on the rise and has increased almost fourfold in the past sixty years. 

Ron and I used to wonder why so many of our patients complain about abdominal bloating and painful cramping. We have several patients who come in to see us for prediabetes or heart disease and during the consult will invariably end up reporting a host of digestive problems. Several of them have difficulty losing weight even though they are exercising daily and eating a low carb diet, often even a self-imposed, partially-gluten restricted one. It is not uncommon for us to have a patient say “But I have stopped eating bread”.  Yet their symptoms don’t seem to abate.

Why so many of us are experiencing this discomfort is a hotly debated topic. Do we have a celiac disease epidemic or are we all following yet another fad diet?

Could it be the advanced testing methods that increase detection and/or the overall increased awareness about gluten? Is it that we have over-abused antibiotics and damaged the composition of our healthy gut bacteria (aka “gut microflora” or “microbiome”)…or is the real culprit the genetically hybridized variety of wheat grain that is far different than the wheat our ancestors consumed? It may be a combination of these factors.

Then of course, there is the speculation that our heavily processed modern day diets are to blame as they have altered our gut microbiome. There is scientific evidence to support that the composition of our diets can induce changes in our gut flora. Gut microbes do undergo a rapid shift when switched from a wholesome plant based diet to a more “western” or processed foods diet.

I tend to agree with this hypothesis.  Our overly-processed diets and stressful lifestyles are most likely impacting our gut microbiota (80 % of our immune system lies in our gut and the many bacterial species inhabiting our gut can have a significant impact on our health) and wreaking havoc with our gut health.

Our immune systems may have been more gluten tolerant in the past when they were supported by a healthier diet and lifestyle, but today our modern lifestyles in combination with a higher intake of gluten from genetically hybridized wheat may have created an imperfect storm that is causing immune system overactivation.

What is Gluten?

Gluten is a protein found in wheat, rye, barley and related cereal grains such as spelt, triticale and kamut. Gluten is formed when two proteins, glutenin and gliadin come together to form a bond when flour is kneaded into dough. This bond is elastic in nature and traps air during the kneading process, thereby giving the finished product that contains gluten, a chewy texture.

It is the gliadin that is implicated in the pathophysiology of celiac disease.

CD vs NCGS

Just to clarify again Celiac Disease (CD) from Non-Celiac Gluten Sensitivity (NCGS), CD is autoimmune damage to the surface of the small intestine that can be diagnosed using antibody tests and possibly a confirmatory biopsy of the small intestine if the antibody test is positive.  The treatment is to go on a complete gluten-free diet (GFD).  Please go to this link for more information on CD.

NCGS is not reliably detected by any blood test or diagnostic test other than going completely gluten-free and noticing if any of your symptoms have improved or reversed.  Symptoms range from digestive (bloating, gas, abdominal cramping, etc.) to non-digestive (skin rashes, fatigue, migraines, thyroid disease, etc.) conditions often triggered by inflammation.

What to do for NCGS?

Nutritional management is the cornerstone for NCGS.  Some patients need to be on a completely gluten-free diet (GFD), some do well by eliminating most but not all gluten sources, and others have to go on a low FODMAPs diet which can often be more beneficial than a GFD.  Let’s talk about these options:

1. Gluten-free diet (GFD)-this is the treatment for CD, but it is also necessary in many of our NCGS patients:

  • Avoid gluten containing grains such as wheat, rye, barley and their derivatives
  • Include gluten-free grains such as rice, corn, amaranth, millet, quinoa, teff, buckwheat, sorghum and tapioca
  • Have a gluten-free pantry to make navigating through your kitchen easier
  • Avoid  cross-contaminated foods:
    • Read food labels carefully-manufacturers can only claim their food products are gluten free if they meet the FDA’s proposed federal standard limit of < 20 ppm (parts per million) of gluten/serving. Be aware that gluten-free products may be manufactured in the same facility and share an equipment with gluten containing products and so cross-contamination can occur.
  • Watch out for hidden sources of gluten.
    • A food label making inaccurate claims of being gluten-free can be detrimental for those on a strict GFD. Wheat has become a hidden ingredient in thousands of products such as thickeners, gravies, soups, dressings and spreads.
  • Stock up on healthy gluten-free snacks
    • Although supermarket shelves are overflowing with every imaginable product labeled “gluten-free”, make wise choices and steer clear of heavily processed foods and choose naturally gluten-free snacks/foods to ensure a nutrient dense diet.

2. The Low-FODMAPs diet

  • The acronym stands for Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols.
  • These carbohydrates are:
    • Fructose- found in honey and fruit such as apricots, apples, figs, cherries, watermelon, mangoes and nectarines
    • Lactose- found in dairy products such as milk and ice cream
    • Fructans- found in wheat, onions and garlic
    • Galactans- found in legumes
    • Polyols- found in sugar-free sweeteners
  • Not all carbohydrates are FODMAPs but as you can see many types of foods contain them.These carbohydrates are also osmotic in nature which means they draw water into the intestinal tract causing abdominal pain, bloating and diarrhea.
  • Low-FODMAP diets are complicated so you will need to consult with a dietitian who can plan a balanced diet for you.

Clearing the confusion on oats

When I started practicing dietetics way back in the late 80’s, oats were always excluded on a GFD. I still remember telling my patients to avoid oats on the GFD. We now know that the protein in oats do not appear to be toxic in CD and that the problem was one of cross-contamination. Due to oats being processed on equipment that they shared with gluten containing foods, patients with gluten intolerance were reacting to them. By themselves, when processed in a gluten-free facility, oats are tolerated fine on a GFD. Thankfully, due to more stringent regulations we can find oats made in a gluten-free facility and therefore current nutrition recommendations do not restrict oats on the GFD.

My Tips for Planning your GFD

As we mentioned, going on a GFD is not a simple matter and can be harmful if the right foods are not chosen. Some guidelines are below:

  1. Many gluten-free foods aren’t enriched or fortified with nutrients such as B-Complex vitamins and iron, like wheat products usually are. Ingredients like rice starch, cornstarch, potato starch and tapioca starch are usually used to replace wheat flour. Although some of these starches may be beneficial to health when taken separately (tapioca and potato starch) in moderation, the effect in packaged GF foods is usually one that raises blood glucose and possibly body weight.
  2. Eliminating gluten can increase your chances of eating a less healthy diet, especially if your diet is heavy in processed or packaged foods. To compensate for the lack of taste, gluten-free foods usually have extra sugar, fat or sodium added. This can increase body weight and inflammation.
  3. Instead, focus on naturally gluten-free foods such as vegetables, fruits, good quality meats, fish, poultry, eggs and dairy, legumes and lentils (in moderation) gluten-free whole grains, nuts, nut butters, seeds and healthy fats.
  4. Certain starches in wheat such as “fructans” support healthy bacteria in your digestive tract which promotes gut health and keeps inflammation in check. Talk to a dietitian about other foods such as prebiotics and probiotics that can help maintain gut integrity

Closing Thoughts by Dr.Ron

I realize it’s hard to fathom that even a morsel of wheat on a regular basis can contribute to immune system activation and chronic health problems, but this is a real phenomenon.  It’s important for you to be aware of this if you are struggling with persistent health issues that have not responded to standard treatments.  This can be digestive or non-digestive (rashes, aches/pains, fatigue, migraines, difficulty losing weight, etc.).

As you can see from Prerna’s write-up, this is a complex issue, but when the right diet is implemented correctly it can potentially reverse years of symptoms and chronic conditions.  It is possible for highly motivated and well informed individuals to implement a GFD and/or Low FODMAPs diet on their own, but in our experience we highly recommend patients seek out an experienced dietitian for support.  As Prerna mentioned, you might be worsening insulin resistance and inflammation if you are not selecting the right foods in addition to balancing other lifestyle factors like sleep, stress, and activity.

The good news is that many of our patients can bring back some traditional grains in moderation, including rice.  If you want to know how to eat rice the healthier way, be sure to check out our popular prior post on rice.   There are many diverse ancient foods and cuisines with an abundance of gluten-free foods.  Japanese is one of my favorite gluten-free options since it’s a wonderful combination of seafood, cold rice (a resistant starch-read our rice post!), vegetables and fermented foods that are great for gut health.

So use gluten-free as an excuse to not limit, but broaden your culinary horizons and see if it has a beneficial impact on your overall health.