Gluten Free Diets: Fad vs Fact

You know a food fad has really made it mainstream when the local mom and pop Italian restaurant here in the heart of rural Pennsylvania starts serving gluten free pasta. I asked the server what was the deal with the new type of pasta, and she told me it was something that was supposed to be better for you. Of course, it costs more than the regular stuff.

Medical science has established that gluten free diets are a godsend for persons with celiac disease (CD), also known as gluten-sensitive enteropathy (GSE). Certain other conditions such as a wheat allergy, gluten sensitive idiopathic neuropathy and gluten ataxia have been shown to benefit from gluten free diets as well.

As many as 1 in 100 people in the US meet the diagnostic criteria for CD. There is a strong genetic component to the condition. Relatives of those with CD are at greater risk of getting the condition themselves. More than 90% of people proven to have celiac disease carry one or both of two white blood cell protein patterns, or human leukocyte antigen (HLA) patterns HLA DQ2 and/or DQ8. However, so do 35-45% of the general U.S. population, especially those of Northern European ancestry.

Most celiac experts agree upon and feel comfortable advising people who meet the strict criteria for the diagnosis of celiac disease: they need to follow a life-long gluten free diet. Controversy and confusion arises when the strict diagnostic criteria are not met, yet either patient and/or doctor believe that gluten is the cause of their symptoms and illness.

Celiac disease is characterized by a huge variety of clinical forms ranging from classical ones to silent forms, and to an increased number of cases of gluten-sensitivity. The latter is an abnormal non-allergic sensitivity to gluten. Clinical manifestations can be very different from CD and this condition seems to benefit from a gluten free diet. Researchers into cases of gluten-sensitivity search for histological markers with elevated specificity, which are able to identify slight and early gluten dependent enteropathy, especially in at risk patients for celiac disease even before classical autoantibodies appear. There are studies that are investigating transglutaminase isoenzymes that can be identified in patients with gluten dependent symptoms without classical autoantibodies.

Forms of gluten allergy have a different pathogenesis from celiac disease and are represented by "backer's asthma" or by classical allergy to wheat proteins. Clinical manifestations can vary from anaphylactic reactions to dermatological, respiratory and intestinal symptoms. Also, in these cases, the therapeutic approach is based on a gluten free diet.

My main concern in writing today is not to discuss the necessity of a gluten free diet in cases of CD or related conditions, but rather the necessity of maintaining a gluten free lifestyle as a matter of general wellness. Undertaking a gluten free diet is no small feat. What is gluten? Gluten is the general name for one of the proteins found in wheat, rye, and barley. It is the substance in flour that forms the structure of dough, the “glue” that holds the product together. When these proteins are present in the diet of someone with CD, they become toxic and cause damage to the intestine. This damage leads to decreased absorption of essential nutrients and, if left untreated, can lead to nutrient deficiency and subsequent disease (i.e. iron deficiency anemia, decreased bone density, unintentional weight loss, folate and vitamin B12 deficiency).

A couple months ago I posted a question on Robb Wolf’s site asking if everyone would benefit from a gluten free diet. For those of you who do not know of Mr. Wolf's work, he is the Paleo Diet guy who says his diet will make you "Lose fat. Look younger. Feel great. Avoid cancer, diabetes, heart disease, Parkinson’s, and Alzheimers". Here are the replies I received:

“Given that gluten (well, grains) strip your gut and do all manner of other nasty things to you, I think everyone does benefit from a gluten-free diet. Cutting out things that damage you can only be beneficial.”

“The answer is YES! Read Healthier Without Wheat by Dr. Stephen Wangen. It's amazing all the problems that can be linked back to gluten. Robb's book is also a must read as he has some great information on what gluten does to the body.”

I wasn’t trying to trick anybody, and I didn’t ask a leading question. I just wanted to get a general consensus.

Just how prevalent are the various forms of gluten intolerance? Alessio Fasano, M.D., director of the Center for Celiac Research at the University of Maryland School of Medicine, estimates some 6% of Americans have some degree of sensitivity to gluten. That is approximately 18 million people in the US alone.

According to marketing firm NPD’s Dieting Monitor, nearly a quarter of American adults are working towards reducing or cutting gluten from their diets. The gluten-free diet has become a sign of enlightened eating. Some see it as a science backed diet supported by a slew of studies and a passionate cadre of celebrity supporters. Jenny McCarthy professes gluten contributed to her son’s autism.

What other signs do we see that gluten free is becoming big business? For one, Amazon.com has added a whopping 178 new gluten-related titles since January of this year, including several children’s books. An additional 25 titles are already on pre-order for coming months. According to CNBC and EuroMonitor, gluten free foods racked up $2.5 billion in global sales in 2010 and are predicted to continue to grow as high as $3.4 billion by 2015. General Mills currently has 300 gluten free products on shelves. That’s big business, my friends.

Some of us might be tempted to say, “Where’s the harm in all of this? So what if a bunch of people try gluten free dieting for a while? Diets always come and go.” On the surface this might be true, but dig a little deeper and you’ll find more.

According to a slew of pro-ana (or Pro Anorexia) sites online, a gluten free diet is an ideal cover for “restrictive eating.” A commenter with the handle Ima_Be_Thin on Pro Ana Angels puts it as bluntly as possible in a thread called “best diet trick ever:” Stacey Rosenfeld, Ph.D., a psychologist who specializes in eating disorders, is in the camp of those who believe that using medical or pseudo-medical reasons for restrictive diets is often a cover-up for disordered eating. “Nobody wants to be called out on an eating disorder or obsessive eating,” she says, “so anything they can do to hide it, they will.” The gluten free lifestyle, while life-saving for the minority of Americans who suffer real consequences from grains, can be a slippery slope (or simply a means of denial) for some.

Fears of gluten, in addition to spawning a booming industry of mediocre gluten free breads, pasta, cakes and cookies, has spurred interest in another option: enzyme supplements that supposedly break down gluten into harmless byproducts before it has a chance to do any damage.

For $30 US one can buy 60 tablets of GlutenEase from a company called Enzymedica, Inc. The pill is supposed to include a blend of enzymes - including amylase, glucoamylase and dipeptidyl peptidase-4 (DDP-IV) - that are intended to digest both casein (a protein found in milk) and gluten. To be fair, the web site does state “GlutenEase is not formulated to prevent celiac symptoms”. It is designed to “support people suffering with gluten or casein intolerance”. “Support”, to me, is one of those weasel words that doesn’t really say anything but the reader often interprets it as being important. Users of GlutenEase are instructed to take one pill with each meal that contains casein or gluten. It can be found in many health food stores as well as online.

Gluten Defense, made by Enzymatic Therapy Inc., contains a similar blend of enzymes that includes DDP-IV, lactase and amylase. Their website says the pills are supposed to “defend against hidden gluten”. The site goes on to say that “the right digestive enzymes can make a difference when trying to support a gluten free and casein free lifestyle”. There is that word “support” again. In fine print at the bottom of the page is the standard FDA statement that says statements on the page have not been evaluated by that organization. Users are instructed to "take two capsules with each meal or as directed by your healthcare practitioner." A bottle of 120 capsules, available online and at many health food stores, costs about $30.

“Over-the-counter enzymes may be able to break down a few molecules of gluten here and there, but it would be downright dangerous for anyone with celiac disease to think that a supplement would make it possible for them to eat gluten again”, says Dr. Stefano Guandalini, a professor of pediatrics and director of the University of Chicago Celiac Disease Center. "The amount of gluten that these would be able to digest is ridiculously low," he says. "For people with celiac disease, these are something to completely avoid."

Dr. Peter Green, director of the Celiac Disease Center at Columbia University in New York City, agrees that current enzyme supplements would digest only a small percentage of gluten molecules. But, he adds, “The basic concept isn't completely far-fetched”. Pharmaceutical companies are currently spending hundreds of millions of dollars to develop an enzyme-based drug that could allow people with celiac disease to eat gluten. However, he adds,” if over-the-counter products already did the job, companies wouldn't be investing such big bucks to reinvent the wheel”.

According to Dr. Guandalini, “some people without CD seem to be more likely to suffer from headaches, indigestion or other problems after eating gluten”. Even for them, he adds,” an enzyme supplement wouldn't break down enough gluten to do any good”. Dr. Green is baffled that so many people want to avoid gluten in the first place. ” If a person doesn't have celiac disease”, he explains, "there's no evidence that the protein can do any lasting harm". "A gluten-free diet isn't necessarily a healthy diet," he adds. He points out that gluten-free products made with rice flour or potato flour tend to be relatively low in iron, B vitamins, folic acid and other nutrients often found in fortified grains.

“For the vast majority of Americans”, says Dr. Guandalini (who you’ll recall is the director of The Celiac Disease Center at the University of Chicago) “there’s no reason to avoid gluten. A lot of people are on gluten free diets that don’t need to be.”

And that is my point precisely. Lots of people out there, some of them who probably cannot afford to do so, are wasting money on gluten free goods when there is no scientifically proven reason to do so. Someone has to be available to act as their advocate so that they may choose more wisely how to make use of their resources. If I’ve made just one well person rethink their need to try a gluten free diet, then I’ve achieved my goal.