Gluten Sensitivity: Does Everyone Need to Avoid Gluten?
Gluten, a protein composite found in wheat, barley, and rye, has become a dietary buzzword in recent years. While some individuals swear by the benefits of a gluten-free diet, others find the restrictions unnecessary. The reality lies in a nuanced spectrum, where individual responses to gluten vary considerably. Does everyone need to be avoiding gluten in order to be healthy?!?
Understanding the Nuances of Gluten Sensitivity, Gluten Allergy, and Celiac Disease
Before having a discussion about wheat, gluten, and the potential harm it causes, it’s crucial to differentiate between a few conditions that are often used interchangeably: celiac disease, non-celiac gluten sensitivity (NCGS), and wheat allergy.
Celiac disease is an autoimmune disorder triggered by gluten, resulting in damage to the small intestine. It is diagnosed through specific laboratory blood tests, and is confirmed with a biopsy of the small intestines. It is the most severe of the wheat/gluten related conditions, and often accompanies other autoimmune conditions. It necessitates a strict, lifelong adherence to a gluten-free diet. Individuals with celiac disease are strongly encouraged to ensure that the food they consume are certified gluten free. Occasionally, individuals with celiac disease also benefit from avoiding all grains (even the gluten free ones) if their immune system is overactive and cross-reacting to non-gluten containing foods. Diagnostic blood tests (in addition to the ones used to diagnose celiac disease) can be used to see if the person’s immune system is generating a “molecular mimicry” response and targeting gluten free foods as if they contained gluten.
Wheat allergy is an immune response to wheat proteins, manifesting in symptoms like hives or difficulty breathing. Even though a wheat allergy generates an immune response for individuals with this condition, it is a different type of response than the autoimmune reaction that individuals with celiac disease produce. A wheat allergy is more likely to induce an anaphylactic reaction (similar to someone that may be allergic to shellfish or peanuts). Additionally, wheat-dependent exercise induced anaphylaxis in a concern with people that accidently consume wheat prior to physical activity. This wheat reaction is strongly connected to the omega-5-gliadin immune trigger.
Non-celiac gluten sensitivity is the most mysterious of the three, and the most difficult to diagnose. Characterized by symptoms such as bloating, fatigue, headaches, anxiety, poor sleep, digestive discomfort, and a variety of other overlapping symptoms that alleviate upon gluten elimination, NCGS lacks a definitive diagnostic test. Even though laboratory blood tests that evaluate IgG levels of wheat/gluten antibodies can help with identifying potential gluten related reactions, these tests are not definitive for NCGS, and do not guarantee that an individual will feel better by avoiding gluten. The ultimate test for non-celiac gluten sensitivity is an elimination diet, wherein an individual avoids all gluten containing foods for a predetermined time, and then slowly reintroduces gluten back into the diet, assessing for symptomatic change.
The Importance of Strictly Avoiding Gluten
For individuals with celiac disease, a rigorous gluten-free diet is non-negotiable. Even minuscule gluten exposure can inflict substantial damage to the small intestine. Long-term consequences of untreated celiac disease encompass an elevated risk of certain cancers, malnutrition, osteoporosis, and infertility. Adhering to a strict dietary regimen is paramount in preventing these health complications.
A subset of individuals with NCGS may also discover that a stringent gluten-free diet is essential for effectively managing their symptoms. If removing gluten significantly enhances their quality of life, maintaining a gluten-free lifestyle might be worthwhile.
In addition to strict gluten avoidance for individuals that have celiac disease, and experience a significant improvement in their NCGS symptoms, adding specific digestive enzymes that help break down the gluten molecule can help mitigate symptoms when accidental consumption of gluten occurs. Aspergillo-pepsin (ASP) and dipeptidyl peptidase IV (DPP IV) are commonly seen in digestive support products that help to target the breakdown of the gluten protein. Our office frequently recommends GlutenFlam from Apex Energetics as a supportive aid while avoiding gluten for reactive individuals.
Is There A More Flexible Perspective to Managing Gluten
Conversely, some people find that a more permissive approach to gluten suffices. Emerging research suggests that the prevalence of NCGS might be overstated, and certain symptoms attributed to gluten sensitivity could stem from other factors, such as irritable bowel syndrome (IBS) or food intolerances that are frequently consumed with gluten.
Researchers debate on the most appropriate approach to managing NCGS. Since it is an umbrella term that has been associated with a wide range of both gastrointestinal and non-gastrointestinal symptoms that respond to gluten restriction and recur with gluten ingestion. These symptoms may include bloating, abdominal discomfort and pain, altered bowel habits, flatulence, rash, fatigue, headaches, mental disturbances, irritability, depression, bone and joint pain, and even attention deficit disorder.
Multiple studies have investigated the need for a gluten free diet for individuals that do not express celiac disease, wheat allergy, or NCGS, but conclusion are difficult to come by. Some proponents of a gluten free lifestyle believe that gluten can never be included in a healthy lifestyle, and therefore should be avoiding by all people, all of the time. This conclusion is a result of how devastating gluten can be, when it is a problem for people. For example, one double blind, placebo controlled study showed celiac disease patients that were in remission (ie. symptom free) and then subsequently challenged with 50 mg of gluten developed a 20% decrease in intestinal villi height/crypt death (ie. a ton of inflammation, and wearing away of the intestinal lining, which leads to malabsorption). For context, a typical slice of bread contains anywhere between 2000 – 4000 milligrams of gluten. On the low end, 50 mg of gluten, in a slice of bread that contains 4000 mg of gluten, means you only need to eat 1/80th of a piece of bread to create an extreme reaction (1/40th of a slice of bread if it only contains 2000 mg of gluten). These findings indicate that minor amounts of gluten have the potential to cause chronic mucosal damage, which in some people, is irreversible. It is no wonder that some people place gluten and the devil in the same sentence.
Others believe that gluten intolerance or sensitivities are a myth, and that no one should attempt to avoid gluten with the exception of individuals with known celiac disease. Even though these individuals are ignoring the body of evidence that supports the known condition of non-celiac gluten sensitivity, there is research that indicates patients with NCGS may not be responding to gluten after all. For individuals that appear to be unresponsive to gluten, yet have been identified as NCGS, FODMAPs may play a larger roll in their symptomatic expression. Even though it may sound nitpicky to place the blame on FODMAPs for NCGS, since wheat contains both FODMAPs and gluten, research seems to indicated that individuals with NCGS do better with limiting FODMAPs over gluten. So what is a FODMAP anyways? The Cleveland Clinic describes FODMAPs in this way, “FODMAP is an acronym for a certain class of carbohydrates, called fermentable short-chain carbohydrates, which are more difficult for people to digest. (The full acronym stands for Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols.)” There are established guidelines for clinicians to be able to diagnose NCGS which can help individuals to find the answers the need.
Whether an individual appears to be reacting to gluten, FODMAPs, or another portion of the wheat molecule, the most important thing we can do is try to mitigate the patient symptoms, regardless of the diagnoses. For many people, avoiding wheat based foods, and staying far away from gluten is a good step. On the other hand, some people may be better served by addressing their symptomatic presentation in a different way, which in turn allows their body to no longer react to the gluten containing foods that once created so much havoc in their lives.
Navigating the Middle Ground of Gluten Related Symptoms
Determining the optimal approach to gluten for each individual necessitates careful deliberation. If you suspect gluten sensitivity, there are a variety of ways to attempt to diagnose the suspected reaction. As mentioned previously, certain laboratory tests can be used to confirm the presence of celiac disease. A simple blood test from LabCorp for celiac antibodies can provide an accurate diagnoses. An other test from LabCorp is able to analyze the immune system for wheat allergy (which as discussed previously is a separate and distinct presentation from celiac disease). In our office, we use a test from Cyrex Labs to screen for NGCS, which analyses a variety of of the wheat related proteins, peptides, opiates, enzymes, and lectins that commonly trigger immune based reactions. Even though these tests are not all inclusive for every patient, they provide an excellent objective criteria for identifying the associated imbalance.
The most cost effective way to experience relief when potentially reacting to gluten (or any other potential food trigger) is through an elimination diet. By systematically excluding gluten from your diet and subsequently reintroducing it, you can ascertain if gluten is indeed the underlying cause. Maintaining a food diary can also prove beneficial in tracking symptoms and recognizing patterns. Ultimately, the decision to embrace a strict or flexible gluten-free diet is a personal one. It’s crucial to listen to your body and select an approach that fosters overall health and well-being. Using laboratory tests can assist in identifying the severity of some gluten related conditions, and in some situations, justify the need for strict avoidance.
