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Fad or Fact – Gluten-Free?

Gluten free

The question of whether to adopt a gluten-free diet is especially timely, given its impressive increase in popularity over the past decade. In fact, gluten avoidance has become the most popular dietary trend in the United States, with approximately 100 million Americans consuming gluten-free products last year. In the UK, the pollster YouGov reports that 60% of adults have bought a gluten-free product and 10% of households contain someone who believes gluten is bad for them. The estimate is that 2.6 million homes in the UK use GF products. In the US Sales of GF products are $8.8bn,the value of the gluten-free market in the US in 2014 and the projected value is $14.2bn by 2017.

Presently, there are at least three proposed clinical syndromes related to gluten ingestion: coeliac disease, an autoimmune-mediated disorder; wheat allergy, an immunoglobulin E (IgE)-mediated entity; and gluten sensitivity, in which coeliac disease and wheat allergy have been ruled out. Therefore, the decision to “go gluten-free” is either a must or a free choice; a gluten-free diet is a must for those individuals with appropriately diagnosed coeliac disease and possibly wheat allergy. However, many individuals elect to follow a gluten-free diet because of a presumed sensitivity. While approximately 1% of the population are believed to have coeliac disease, it is estimated that as many as 60% of Americans believe that a gluten-free diet will improve their physical and/or mental health.[1-4] It is their choice to follow a gluten-free diet in the hopes of improving digestion and bolstering their immune system, while also enabling enhanced performance and weight loss.

Coeliac disease is quite common but it isn’t enough to explain the burgeoning popularity of the gluten-free diet. According to Mintel, 7% of UK adults say they avoid gluten because of an “allergy” or “intolerance” (strictly speaking, coeliac disease is neither of those), and a further 8% avoid it as part of a general “healthy lifestyle”.

Unlike wheat allergy and coeliac disease, gluten sensitivity does not have a known set of biomarkers – as doctors we can’t tell if a patient is suffering from it by examination (although there is a blood test, it doesn’t give accurate results for many patients). So it can only be diagnosed by first ruling out other diseases and then trying out a gluten-free diet.

Although gluten has no nutritional value in itself, making a radical change to one’s diet without the supervision of dietetic help. Going gluten-free may deprive you of many key elements of the diet, like vitamins and fibres that need to be supplemented in order to maintain balanced nutrition..

Part of the controversy surrounding gluten sensitivity stems from the fact that it is difficult to disentangle any benefits someone may experience by adopting a gluten-free diet from the placebo effect – the power of a patient’s expectation that a treatment will lead to a cure.

If you go on a gluten-free diet, taking substitutes like gluten-free beer, pasta, cookies and so on, if anything you gain weight. If you take a regular ‘cookie’ it’s 70 calories. The same ‘cookie’ gluten-free, can go as high as 210 calories.

Most experts agree that eating gluten poses no risk to people who fall outside the spectrum of gluten-related disorders

But author of The Gluten Lie, Levinovitz, strongly believes that the gluten-free fad is not risk-free. Many patients with eating disorders, he says, began their downward journey with exclusion diets. For the vast majority, this is not an issue, but cutting out gluten remains difficult, and potentially expensive and harmful to our relationship with food. In fact, there is some evidence to suggest that extreme anxiety about what we eat can lead to symptoms that are not unlike those of gluten sensitivity.

A survey done by Lis and colleagues of 910 world-class athletes and Olympic medallists found that 41% followed a gluten-free diet, the majority because of a self-diagnosis of “sensitivity to gluten”

However, there are barriers to going gluten-free, including the cost and long-term safety of gluten-free foods and the potential for gluten cross-contamination of products. In addition, a gluten-free diet could present social restrictions, possibly leading to nonadherence.

They propose a working definition as follows: “a clinical entity induced by ingestion of gluten leading to intestinal and/or extra-intestinal symptoms that resolve once gluten is eliminated.” This definition requires that celiac disease and wheat allergy have been ruled out.

In a survey of more than 1000 Australians, 7% reported adverse effects when ingesting wheat products, although the majority had not undergone formal assessment for celiac disease or wheat allergy

Fasano and colleagues emphasized a need for better understanding of the role of gluten and wheat in irritable bowel syndrome (IBS), chronic fatigue syndrome, and autoimmunity, with precise nomenclature and definitions. In the absence of intestinal injury, specific antibodies, or any other biomarker, there is a clear need for an optimal diagnostic algorithm and consensus-based diagnostic criteria.

Gluten: Guilty?

While some studies seem to convincingly support gluten’s role in causing a wide variety of ailments, recent studies have suggested that there is more to the story, casting doubt on whether NCGS is a distinct clinical entity.

Several authors have suggested that the improvement in symptomatology may be due to a placebo effect or to the fact that other nongluten components of wheat, such as fibre and wheat itself, are removed from the diet during adherence to a gluten-free diet.

FODMAPs

Several investigators have proposed a role for poorly absorbed carbohydrates in the genesis of the clinical symptoms. Intake of fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) can trigger gastrointestinal distress.

Nonceliac Wheat Sensitivity

To date, it is not known what component of wheat actually causes the symptoms.

Researchers suggest use of the term “wheat intolerance syndrome,” as this reflects the objective elements: the causative role is wheat and not gluten; the symptoms are best described as intolerance, a term which does not imply a specific mechanism as “sensitivity” does; and the series of reported symptoms may be due to various causes. Therefore, they argue, this is a syndrome.

The current clinical approach involves ruling out celiac disease and wheat allergy, testing for additional food intolerances or gastrointestinal conditions, and providing the latest data on the benefit/unintended consequences of gluten avoidance and these evolving entities. It is also important to inform patients and their families about what is not known. It may also be effective to individualize the recommended dietary strategy by eliminating certain components of the FODMAP class, wheat products, and/or gluten sequentially.

Remaining Questions

As stated by Fasano and colleagues a better understanding of the clinical presentation of NCGS is needed, as well as its pathogenesis, epidemiology, management, and role in conditions such as IBS, chronic fatigue, and autoimmunity. There also must be agreement on the nomenclature and definition of gluten/wheat-related disorders based on proper peer-reviewed scientific information.

It is hoped that in the future, the terms NCGS, NCWS, and wheat intolerance syndrome will be replaced by well-defined nosology, that the phenotypes and mechanisms of syndromes responsive to gluten withdrawal will be better defined, and that there will be biomarkers and definitive therapy for distinct entities.

Partly sourced from Should We All Go Gluten-Free? Medscape. Feb 04, 2016.

What is not mentioned here is the role of the Gut Microbiome but we know that Probiotics are very influential in the disease areas mentioned by Fasano. And I wonder which raising agents in bread and flour may be part of the problem.  If you are into bread – maybe seek out the sourdoughs.

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