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If you've been oblivious to the surge of gluten-free products over the past decade, you might have been residing on another planet. The prevalence of gluten-free options raises questions: What's the issue with gluten? Is the gluten-free trend merely a passing fad?
While Coeliac disease (CD) is a familiar term, have you considered non-coeliac gluten sensitivity (NCGS)? Could gluten be a hidden culprit compromising your well-being? Let's explore the gluten conundrum and decipher whether it's a friend, foe, or just a passing trend.
What is gluten?
Gluten is a mixture of proteins found in all grains. There are thousands of different forms of gluten with 400 new ones discovered as recently as 2010. The most studied gluten protein is alpha-gliadin because of its relationship to Coeliac disease. Gliadin is found naturally in wheat, barley and rye. Combined with the glutenin protein the two together make dough sticky and flexible.
What is Coeliac disease (CD)?
Coeliac disease (CD), is a serious chronic autoimmune disorder that, in those genetically susceptible, results in inflammation and damage to the gut (small intestine) when they are exposed to even a tiny amount of gluten.
It is estimated that 1 in 70 to 1 in 100 New Zealanders and Australians have Coeliac disease. Though this is likely to be well underestimated. Some studies suggest it is more like 1 in 30.
The underestimation is due to the inaccuracy of blood tests and the late diagnosis. One study found it took an average of 5 or more visits to doctors and 5 to 10 years after presentation before they were diagnosed.
What is non-coeliac gluten sensitivity (NCGS)?
Gluten sensitivity or non-coeliac gluten sensitivity (NCGS) is an immune reaction to the gluten protein found in wheat, barley and rye. If ignored, it can trigger coeliac disease in genetically susceptible individuals.
The gliadin protein of gluten has been found to activate a hormone called zonulin. Zonulin opens the tight junctions of the gut, increasing the permeability of the gut wall. Gluten can then enter the blood stream resulting in an immune & inflammatory response. The immune system views gluten like a virus, attacking it.
A bacterial or fungal overgrowth, or a parasite infection can similarly increase zonulin and lead to a “leaky" gut.
It is also important to note that vitamin D helps keep these tight junctions tight, and a lot of these “bugs” switch off the vitamin D receptor further depleting vitamin D.
Six percent of the population are estimated to have NCGS, but this is probably way underestimated, due to it being a diagnosis of exclusion.
Many who find a gluten free diet beneficial also do not consult their GPs or have an official diagnosis of NCGS.
What is a gluten allergy or gluten intolerance?
An allergy is typically considered to be an acute IgE immune response by the body to gluten or wheat. The reaction may occur within seconds to one hour after exposure. But a ‘late phase’ reaction can occur 4 – 6 hours after the initial reaction and persist for days causing swelling and inflammation.
Symptoms can include hives, itching, burning and swelling, eczema, vomiting, asthma, coughing, sneezing, diarrhea, colic, reflux, regurgitation, and even bronchitis. An allergy can also be true or acquired. Acquired meaning that the reaction developed due to a break down in gut function.
A gluten intolerance is an inability to tolerate and digest gluten. It can be mediated by the immune system or not. Often it is due to insufficient digestive enzymes to break down the gluten protein and/or a leaky gut. However it can also be a cause of a leaky gut or gut dysbiosis (microbial imbalance).
Unpublished data from Dr Kenneth Fine, the laboratory director at Enterolab in the US, speculates that as many as 1 in 3 have some degree of gluten intolerance or sensitivity!
What are the symptoms of gluten sensitivity or coeliac disease?
Both conditions can have similar symptoms, such as intestinal bloating and cramping, diarrhea or chronic constipation, nausea, or vomiting. But also symptoms outside the digestive tract, such as chronic fatigue, weakness, and brain fog are common. Even depression has been linked to CD and gluten sensitivity.
It has to be noted that some may be asymptomatic or only present with malabsorption symptoms and frequent nutritional deficiencies. But, it is recommended that those with the following should be tested for CD:
short stature
unexplained anemia / low iron
nutritional deficiencies
delayed puberty
osteoporosis or low bone density
frequent dental cavities
frequent dermatitis or rashes (including keratosis pilaris or "chicken skin", little bumps often found on the upper arms)
high liver markers
neurological disease (such as MS) or peripheral neuropathy (tingling/pain/altered sensation in extremities)
infertility and miscarriages
autoimmune disease (e.g. diabetes type 1, thyroid disease, psoriasis, vitiligo)
ataxia (coordination & balance issues)
psychological or mood disorders (eg. depression)
Scarily, in a recent study published in the journal, BMC Gastroenterology, Iranian researchers found that recurrent mouth sores (recurrent aphthous stomatitis, or RAS) can be the only symptom of coeliac disease.
How is Coeliac disease or Non-coeliac gluten sensitivity diagnosed?
Blood tests looking for auto-antibodies are most commonly used for diagnosis of CD. However, they are typically only present in the late stages of the disease when the villi of the gut have been destroyed.
Intestinal biopsy is another test used to diagnose CD. The test looks for atrophy (loss of or damage to) the villi that project from the gut that are involved in nutrient absorption.
However the damage to the villi may be patchy, so the biopsy may miss an area of atrophy, resulting in a false negative diagnosis. Plus inflammation can be present without villous atrophy and is then often ignored, despite those with inflammation possibly having a worse prognosis (JAMA, Sept 16, 2009, Vol 302, No 11).
The tests are also only accurate if the body is currently responding to gluten. This means the test may deliver a false negative for patients who have already reduced or eliminated gluten exposure.
A blood test to look for the "coeliac gene" (HLA- DQ2 and DQ8) is possible, but this does not confirm if you have CD, just that you are at risk. However if it is negative, it does rule out CD.
NCGS is usually diagnosed once CD has been excluded and if improvements in symptoms are noticed on a gluten free diet of at least 4 weeks or more.
How serious is Coeliac disease?
CD increases your risk of mortality by 35-72%!! The most common cause of death is cardiovascular disease, followed by malignancy (cancer). (JAMA, Sept 16, 2009, Vol 302, No 11).
Undiagnosed CD resulted in a nearly 4-fold increased risk of death (Gastroenterology. 2009 Jul;137).
Non adherence to a gluten free diet (defined as eating gluten once per month) increased the relative risk of death 6-fold!! (Lancet, vol 358, August 4, 2001).
But even a gluten sensitivity can be highly detrimental to your health, due to the inflammatory effects. (JAMA, Sept 16, 2009, Vol 302, No 11). Some neurologists even believe that gluten has an impact on our brain and that it may contribute to Alzheimer's or dementia. (See "Grain Brain" by neurologist David Perlmutter).
Why the sensitivity to gluten? What influences gut sensitivity?
In the United States, one study found that the prevalence of CD has increased 4-fold in the last 50 years. This was not due to increased diagnosis, but a true increase in disease prevalence. Why the massive increase? No one knows for sure, but there are a number of factors thought to have had an impact on our ability to tolerate gluten.
Changed milling techniques - roller milling vs stone milling and bleaching. (Also whole wheat is not necessarily better as the outer wheat component is put back in often days later, leaving it rancid and less nutritious).
Changed eating habits - gluten was introduced only 10,000 years ago with the advent of agriculture.
Hybridization of wheat - changed the structure of wheat
Bread baked differently now - the shorter time frame means more gluten is present in the bread (was 2%, now more like 20%).
Poor gut health or an unhealthy microbiome - destroyed by antibiotic use, medications, environmental toxins, poor food choices and more. For more info on the importance of a healthy gut and microbiome, click here.
Chemical and pesticide exposure - such as glyphosate or roundup use on our wheat and most agricultural products. A graph plotting the rising incidence of coeliac disease over a 10 year period, also showed an almost identical rise in glyphosate use on wheat.
Think gluten may be an issue for you?
Then speak to your GP or functional medicine / health practitioner. With the seriousness of both CD and NCGS I'd recommend ruling it out in anyone with gut issues, growth or behavioural issues, depression, neurological symptoms and chronic or autoimmune diseases.
NCGS can be just as detrimental to your health with ongoing exposure to gluten resulting in inflammation to the gut, and possibly even the brain. Nutrient deficiencies are also common if a "leaky gut" occurs, which can lead to a host of other problems.
Please be aware that if you thinking of trying a gluten free diet, ruling out CD first is a good idea to reduce the likelihood of a false negative diagnosis. A positive gene test for CD does not mean you have the disease, but the potential for it. A negative means that you cannot develop CD, but can still have a gluten sensitivity, allergy or intolerance.
Simply replacing gluten containing foods with gluten free packaged foods is also not recommended and may not be any healthier.
Gluten free products often contain more sugar and other questionable ingredients. Choosing a whole foods diet, rich in real fruit and vegetables and good quality protein is the better way to go. You are less likely to miss vital nutrients essential to good health.
Gluten can also be "hidden" in many packaged foods. See below for some sources of hidden gluten you might not be aware of.
One other important note: Dairy and other grains may be problematic too.
Gluten free products also often contain other grain based glutens such as corn (zein gluten protein), rice (orzenin protein) and oats (avenin protein). It is possible that the body's reaction is not just to the alpha gliadin gluten protein, and unfortunately standard lab tests do not look at these other types. These foods are considered to be cross-reactive. The body can confuse them with gluten because of their similar protein structure. Other common cross-reactive foods include dairy, millet and yeast. In my practice I find dairy to be the most common and those with CD appear to respond better when avoiding both dairy and gluten.
It appears that gluten is definitely NOT a friend to a rather large percentage of the population. Continued exposure to gluten in a sensitive individual can be extremely dangerous to their health. It took me at least 8 years from the start of my irritable bowel symptoms to discover that gluten was a major culprit. If you have any of the symptoms or disorders mentioned above, please don't wait as long as I did to discover if gluten is detrimental to your health.