Gluten is a group of proteins called gliadin and glutenin. Wheat, barley, rye, and triticale all contain gluten. There are several forms of wheat including:
- Khorasan wheat
WHY CAN’T I EAT GLUTEN?
Good news: gluten may not be a problem food for you! There are three different disease presentations associated with wheat and gluten. Celiac disease (also known as non-tropical sprue) is an autoimmune disorder in which the affected individual’s body processes the gluten proteins in such a way that the body identifies the molecules as pathogenic, thereby triggering an inappropriate inflammatory immune response. Only about 1% of the population is affected by celiac disease, but up to 80% of people who have it might not be diagnosed with it yet. The clues that may point to celiac disease include the following:
- Digestive problems
- IBS (Irritable Bowel Syndrome) symptoms: constipation, diarrhea, abdominal pain/cramping/bloating/distension
- Bacterial overgrowth of the small intestine
- Mouth ulcers and damaged dental enamel
- Increased risk of adenocarcinoma and lymphoma of the small bowel
- Ulcerative jejunitis
- Bowel strictures
- Headaches, fatigue, and weight loss due to reduced ability to absorb carbohydrates
- Joint pain
- Acid reflux & heartburn
- Dermatitis herpetiformis: itchy, blistering skin rash due to presence of transglutaminase enzyme in the skin
- Osteoporosis or osteomalacia: decreased bone density or bone softening, respectively, due to calcium and vitamin D malabsorption
- Anemia: iron deficiency or megaloblastic (B12 and folic acid deficiency)
- Hyposplenism: low functioning spleen
- Nervous system & cognitive problems
- Numbness & tingling of the hands and feet
- Balance problems
- Learning disability
- Lack of muscle coordination
- Abnormal liver function tests
- Pregnancy complications
There appears to be a genetic component to celiac disease, but NCGS—the next type of disease presentation—has not demonstrated a genetic component. Little peer-reviewed research (PRR) exists on the topic of NCGS—most articles link back to about 3 PRR articles. However, the body of informal and anecdotal research continues to increase as the popularity of the gluten-free diet grows. Many of the same symptoms of celiac disease may manifest with NCGS, but the symptoms are often less severe. There is frequently a cumulative effect in that an adverse reaction only occurs after long-term, repetitive exposure to gluten.
The last disease process is the wheat allergy or sensitivity. Wheat allergy is due to the activation of the IgE response—Type I Immediate Hypersensitivity Reaction—to one or more wheat proteins including albumin, globulin, gliadin, and/or gluten. The following symptoms may occur:
- Swelling, itching, irritation of the mouth or throat
- Hives, itchy rash, swelling of the skin
- Nasal congestion
- Itchy, watery eyes
- Difficulty breathing
- Cramps, nausea, vomiting
- Anaphylaxis: dial 911 and seek immediate medical care in the case of anaphylaxis
Wheat sensitivity is often due to an IgA or IgG reaction to the fructans in the wheat, which means that it’s necessary to avoid wheat products but not necessarily all gluten-containing products. Some people that feel great after going gluten-free actually just feel better because they aren't exposing themselves to wheat fructans.
HOW DO I KNOW IF I HAVE A GLUTEN PROBLEM?
Celiac disease is typically verified by a blood test called the tTG-IgA (tissue transglutaminase antibody) test. The lab that I use for this test reports 90% sensitivity (the percentage of celiacs who are correctly identified as having celiac disease) and 95% specificity (the percentage of non-celiacs who are correctly identified as not having celiac disease) for this test. Total IgA Antibody is also performed to screen for IgA deficiency, and if IgA deficiency is present there are two other tests (IgG-tTG antibody or DGP antibody) that can screen for celiac disease. If the blood tests come back positive, an esophagogastroduodenoscopy (EGD) and biopsy will be performed by a gastroenterologist, and genetic tests may be performed. If the blood tests come back negative, but the individual still has symptoms, he or she be checked for other disease processes depending on the presenting symptoms. If those tests come back negative, the two most popular diagnoses of exclusion (meaning the doctor has ruled out everything else) are IBS and NCGS.
BUT I DON’T WANT TO SPEND ALL THAT TIME MONEY ON DIAGNOSTIC TESTING!
Don’t get me wrong, seeking the advice and diagnostic expertise of a qualified health professional is ideal—especially since some of these disease processes can result in serious health consequences (cancer, for example) the further that they progress. However, you’re not alone in wanting to avoid spending lots of time and money on diagnostic studies since some health insurance plans do not cover all (or any) lab tests, some people do not have health insurance, and almost everyone is busy, busy, busy. This is one reason that I believe the gluten-free diet trend has become so popular. Since you have to buy food and other products anyway, it is merely a matter of making different purchasing decisions, which may take a little extra time at first.
SO YOU’VE DECIDED TO GO GLUTEN-FREE
In the case of any of the disease processes discussed, total abstinence from gluten or wheat (depending on the process) is the standard treatment. I am still advocating testing, and I definitely recommend talking to your doctor before going gluten-free. If you choose to proceed without any testing, there are a few guidelines that you should follow:
DURATION OF TRIAL: Everyone is different in terms of how long it takes to notice positive changes from a gluten-free diet. It can take 6 months to 1 year for your gut to heal and for your symptoms to resolve, although some people may notice immediate changes. Most Complementary and Alternative Medicine (CAM) practitioners recommend a 6-month trial of a totally gluten-free, no-cheating lifestyle.
- GLUTEN-FREE LIFESTYLE: Going gluten-free is a lifestyle, not just a diet. There are four primary routes that substances may enter the body. This includes breathing it (inhalation), eating it (ingestion), injecting it, or absorbing it through the skin (dermal/topical). The main way that gluten enters the body is via ingestion, but it may also be absorbed through non-digestive membranes and through the skin. That’s why you’ve seen gluten-free shampoos and cosmetics in addition to gluten-free foods. You’ll need to become an persistent label reader. Here’s a resource for identifying gluten-containing foods and products, and here’s a good article about it.
- EAT GLUTEN-FREE BUT NOT GLUTEN-FREE FOODS: This is a concept that I learned from Dr. William Davis’s book Wheat Belly. The best gluten-free foods are whole foods including organic fruits, veggies, and proteins (fish, fowl, meat, beans); raw nuts; healthy oils; and herbs & spices. Avoiding foods that are labeled gluten-free will allow you to avoid substances that increase blood sugar. High blood sugar can lead to “weight gain, diabetes, cataracts, arthritis, cancer, dementia, heart disease, and belly fat,” according to Dr. Davis. You should think of foods that are labeled “gluten-free” such as gluten-free muffins as “sometimes foods” or occasional indulgences, otherwise you might as well be snorting Pixie Sticks.
- DOCUMENTATION: Take an inventory of your symptoms before you start your gluten-free lifestyle, and then document your symptoms again at least once a month. If you fall off the wagon one day, that’s an opportunity to document any changes you may have noticed after exposing yourself to gluten.
- OTHER ALLERGIES, AUTOIMMUNITIES, AND SENSITIVITIES: Realize that if you do have a problem with gluten, there is a higher likelihood that you have problems with other foods and/or substances. The easiest way to identify these problems is by visiting your doctor. However, you could try eliminating suspected offenders in the same way that you’ve eliminated gluten. If these suspects are things that you eat, you might try an elimination diet in which you eliminate all suspects for a trial period and then add the offenders back one at a time, checking for reactions as you go. Here’s an example of an elimination diet, and here's one more example.
Do you still have unanswered questions about gluten? Contact me. Are you interested in diagnostic testing? I’m happy to help. Are you gluten-free or have you tried it before? Share your experiences with others.