To be gluten free, or not gluten free? That is one of many questions.
9 min read
The ‘free from’ aisle.
At my local supermarket, there is an entire aisle dedicated to ‘free from’ products. The dietary components that are omitted can be dairy, eggs, gluten, wheat and there are some vegan products. Nearly every single product has packaging that suggests this special food is healthy. I never buy a thing. I have no food intolerances or allergies, nor am I a vegan. Yet an increasing number of people are turning to a gluten-free diet, because of this perception of it being healthier, despite themselves never having been diagnosed with a gluten intolerance or allergy. It’s a growing market, with even ‘free from’ exhibitions scheduled throughout the year.
I find this situation interesting because I’ve not met a single person who has to adhere to a gluten free diet say, ‘I love my diet.’ A while back I bought a gluten free sandwich when all other sandwiches had sold out, and I once accidentally ordered a gluten free pizza much to my partner’s disgust. Both were edible but left me with a bad taste in my mouth. It’s hard to fathom why anyone would willingly cut out gluten if they didn’t need to. Gluten free diets are restrictive and aren’t as healthy as most would think. Gluten has little nutritional value, but is often found in foods rich in fibre, vitamins and minerals. There is evidence to suggest that gluten free diets increase a person’s risk for deficiencies for fibre and B vitamins, and iron, with some studies showing that arsenic, mercury, lead, and cadmium blood levels are increased in people following GFDs which could be because of a reduced intake of a variety of foods.
When your life depends on going gluten free.
Some people cannot eat gluten because it triggers an immune response. Celiac disease (CD) is an autoimmune condition where even the tiniest amount of the protein gluten can cause symptoms such as nausea, diarrhoea, abdominal discomfort and bloating, as well as long term damage to the intestinal lining. There is no cure and the only effective treatment is the complete removal of gluten from the diet. Gluten is widely used in food production for texture and as a thickening agent, as the two protein subunits (gliadin and glutenin) form elastic structures and trap air, accounting for the spongy and elastic texture of food products like bread and cakes. For CD patients it can feel like gluten is in everything, because it nearly is. It can be found in bread and crackers, baked goods, soups, pasta, cereals and other breakfast foods, beer, sauces, some seasoning mixtures, and even medication. Upon diagnosis patients are advised to stop consuming gluten-containing products. There is a consensus among scientists that most CD patients can tolerate 20ppm (parts per million) gluten quite safely, but this has as much to do with the food manufacturer’s limit of detection as it does the limit of tolerance. Whilst there are analytical methods that can detect smaller amounts in food products, these are more expensive and would then reflect in the price. Putting this into perspective a gluten-free slice of bread with 20ppm of gluten equates to 48mg gluten. Some people can have reactions even when smaller amounts are ingested, and even breathing in the protein can trigger CD symptoms in some people. Anytime during the food production chain there is a high risk of contamination from gluten-containing foods if this is not controlled for.
Therefore, if you can walk into a bakery and ask for gluten free, your self-diagnosed gluten intolerance is probably a bit iffy.
In truth, your diagnosed intolerance probably is too. There is a growing number of people who are claiming that they are gluten intolerant in the absence of celiac disease. So much so that scientists coined this new phenomenon non-celiac gluten sensitivity (NCGS). This condition is not without controversy and appears to be more chic than clinical in many cases. Little is known about the pathophysiology of NCGS and currently there are no validated biomarkers to aid diagnosis and differentiate from other gluten related disorders. Yet people are self-diagnosing themselves as being gluten intolerant due to their digestive discomfort improving once gluten-containing products are removed from the diet. Doctors don’t always know how to treat such patients. There are probably a few reasons for this. Firstly, doctors in the UK do not study any nutrition modules at university. Secondly many digestive disorder symptoms are quite general and can be experienced by patients with different digestive disorders such as irritable bowel syndrome, irritable bowel disorder, wheat sensitivity, and intolerance to fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs). If blood tests and biopsies come back negative, doctors may not be certain how to treat a patient, when really the most appropriate course of action would be to refer the patient to a dietitian. Thirdly the confusion could be exacerbated by pressure from patients saying they have read x, y, and z on the internet, and upon cutting out gluten-containing food the symptoms improved. BOOM the doctor gives the diagnosis of NCGS – next patient please.
Should NCGS be taken seriously?
Although there is no validated method to diagnose NCGS, researchers have discovered that an innate immune response is involved in NCGS, whereas CD is mediated by both adaptive and innate immune responses, when compared to healthy controls. As interesting as this observation is, it is still unknown if gluten or other food components are to blame for symptoms in NCGS. Recent evidence suggests that it could be FODMAPs and maybe specifically fructans causing the symptoms in NCGS. Also recently implicated in both CD and NCGS are pest resistant molecules α-amylase trypsin inhibitors, present in wheat. Pest resistant wheat is bred to contain more α-amylase trypsin inhibitors which prevent the digestion of wheat from pests, but still allow digestion from the bacteria that lives naturally in your gut, which could explain the surge of digestive discomfort following consumption of wheat products that just so happens to contain gluten. To understand this elusive condition, there need to be larger and better controlled studies, and it is no wonder that GPs are confused with how to treat such patients. In the UK a 2014 survey reported 3.7% of people claimed to be on a GFD, and the recent National Health and Nutrition Examination Survey has reported that the prevalence of GFDs without CD tripled from between 2010 and 2014 from 0.52% to 1.69%. If this trend increases, and people continue to unnecessarily cut out gluten-containing food with no valid medical reason or guidance on how to safely do so, this growing number of people could be at risk for malnutrition.
About 41% of athletes have diagnosed themselves with gluten sensitivity, and have self-reported improvements in stamina and performance, particularly endurance athletes. While this affords confirmation for people who think they may be gluten sensitive that GFDs are the best diet to follow, a study has shown no effect on performance, gastrointestinal symptoms or inflammation when consuming both gluten free and gluten containing diets over 7 days with a washout period in between. This small, short-term study would need to be repeated over a longer period with a greater sample size, but it is interesting that the same authors found that a cohort of 910 athletes get most of their nutritional information from online sources, fellow athletes and coaches, as opposed to qualified nutritionists or dietitians. In the same way athletes may wear lucky underwear for a competition, it appears athletes do not want to take any chances with their diet either. You only have to go onto social media to see how much people are influenced by their favourite athletes and celebrities. Being an athlete or a celebrity does not necessarily mean they are qualified to give nutritional advice.
Apparently, I could be gluten sensitive!
Whilst researching this article I stumbled across a quiz on The Gluten Free Society’s webpage which can tell you if you are gluten sensitive (sarcasm – please don’t get diagnosed here). I ticked more than 4 very generalised symptoms from an extremely long selection of other generalised symptoms, therefore I am likely gluten sensitive. And should buy their book. And their DNA testing service. This is irresponsible by the society and the founder Dr Osbourne. Not only does this fuel the hysteria surrounding the gluten free fad, but DNA testing won’t tell you anything definitive. Even if people carry the genes for CD, it does not mean they currently have CD or will develop it. For NCGS, currently no genetic predisposition or definititive immune response has been identified. There is no blood test, except to rule out CD. I was not shocked when I did a bit of digging on ‘Dr’ Osborne to discover he is not a medical doctor and has a doctorate in pastoral science. He is associated with The Pastoral Medical Association which advocates ‘bible-based’ health care. Sadly there are many Dr Osbornes and celebrities like Gwyneth Paltrow with millions of followers online but without adequate qualifications, preaching about GFDs for health and weight loss reasons. In the UK, Nutritionist is not a protected title, so make sure you seek advice from a nutritionist who is registered with the Association for Nutrition as this means that they must adhere to a strict code of ethics and conduct. For diagnoses and treatment you should always see a dietitian.
What should you do if you think you are sensitive to gluten?
Don’t cut anything out from your diet. Your initial reaction may be to stop eating foods you believe are causing you issues. This won’t help you when you start the process of getting a clinical diagnosis as tests require you to be eating gluten to observe an adverse reaction.
Keep a food diary. This should include not just what and when you are eating, but also how you feel after each meal. This will help you in the diagnostic process.
Get a diagnosis! First step is to visit your doctor. They will need to rule out celiac disease by performing a blood test and maybe a biopsy of the small intestine.
If you test negative for celiac disease make an appointment to discuss the results with your doctor. This is where the food diary is useful. Explain to your doctor that you wish to be referred to your dietitian to determine which dietary component could be causing your symptoms.
A dietitian will prescribe an elimination diet which is the gold standard test for diagnosing allergies and intolerances. This involves the removal of foods associated with symptoms from your diet. The dietitian will then gradually reintroduce each food in a specific order and monitor your body’s response.