Well, the answer is if you are sick, going gluten-free might be worth a try. Just be prepared to do it for beyond 30 days. Let’s look at this nuanced answer in a lot more detail.
It doesn’t take too many consultations into my practice day to have what I call the “gluten conversation.” I don’t think I’m overstating things when I suggest that it might be the most hotly contested dietary conversation of the last decade. Apologies to my low carb twitter crusaders out there who feel slighted by that, but you know I’m right.
Uptake of a gluten-free diet seems not to show any signs of slowing, with a financial times article stating that the global gluten-free retail market has grown from US$1.7 billion in 2011 to US$3.5 billion in 2016[i], growing to an estimated US$6.5 billion in 2022.[ii]
In this article, I’m going to introduce gluten, how it might affect you, and some of the disadvantages of a gluten-free diet, of which there are some apparent risks!
What exactly is gluten?
Gluten (from Latin gluten, meaning glue) is the main form of protein found in wheat, rye and barley, amongst other grains. It is a complex of over a hundred different types of similar but distinct proteins, the main ones called gliadin and glutenin. There are similar proteins in rye, barley, and oats also referred to as “gluten.”[iii]
Gluten is extremely popular in the food industry because it is heat stable and an excellent binder. Its use as an additive is also common in processed foods, mainly to improve flavour and texture and retain moisture.[iv]
Foods that contain gluten
For people living with Celiac’s disease, the removal of gluten is necessary to prevent a dangerous progression, and according to the Celiac disease foundation here is a comprehensive list of gluten-containing grains and their derivatives:[v]
- Wheat
- Varieties and derivatives of wheat include wheatberries, durum, emmer, semolina, spelt, farina, farro, graham, KAMUT, and einkorn wheat.
- Rye
- Barley
- Triticale
- Malt in various forms, including malted barley flour, milk and milkshakes with malt added, malt extract, malt flavouring, malt vinegar, and malt syrup.
- Brewers Yeast
- Wheat Starch
Quite the exhaustive list, don’t you think?. It can be difficult if you are Celiac, especially in Hong Kong. There are other ways you can come into contact with gluten, and they might not be entirely obvious.
Some unexpected sources of gluten you may not be aware of maybe in your bathroom.
Here is the list of potential unexpected sources of gluten:
- Medications; a common way this happens is via wheat derivatives in excipients. It’s essential to define the excipients, as often starch from wheat can be a component.
- Vitamins and Nutritional Supplements
- Pickles (sometimes they can contain malt vinegar)
- Gravy (often flour is used in the production process)
- Soy Sauce
- Miso (made with barley)
- Beer (I always feel like I have to apologise to people for this one)
- Beauty products such as toothpaste, shampoo, lip balms and lipsticks!
Yep, although over the years preceding me writing this, the problem has largely been remedied, there was a period when many beauty products had gluten in them! In fact, in a study released in 2010, a survey conducted in Australian supermarkets found gluten in approximately 2,000 different items, ranging from sauces to processed meats, as well as shampoos and pain relief medications.[vi]
Typically, I’ve seen patients who have developed urticaria based symptoms after trying some new skincare products with hydrolysed wheat proteins in them. Although once again, the extent that these can cause issues for people living with gluten issues is, for the most part, not a problem.[vii]
What makes gluten a problem for people living with Celiac disease
The gliadin protein we discussed above contains small chains of amino acids (amino acids are the parts that link up to form protein), called peptides. These peptides are highly resistant to being broken down by gastric, pancreatic and intestinal digestive functions.[viii] It’s here that the problems can start.
This resistance to absorption is just the tip of the iceberg for those living with Celiac’s disease. When someone with the genetic tendency encounters the proteins in gluten, the immune system causes a varying degree of damage to the small intestine.
This damage becomes severe and chronic over time. The small intestinal damage causes malabsorption symptoms (the inability to digest your vitamins and minerals), abdominal pain and bowel symptoms, such as diarrhoea. Other symptoms include weight loss, iron deficiency anaemia, steatorrhea (an inability to absorb fats) and fatigue.[ix]
Interestingly, it seems that “non-classical” symptoms such as bloating and osteoporosis occur in 66 per cent of cases studied over fifteen years.[x] This non-classical presentation suggests that Celiac disease presentations may vary quite a lot, meaning that consulting with a healthcare professional for proper testing is vital to find out for sure.
My Celiac test was negative. Will gluten still affect me?
It seems it can and comes in the form of a wheat allergy and a newer condition you may not have heard of called “Non-Celiac Gluten Sensitivity.” Other than Celiac’s disease, which we reviewed above, a wheat allergy, mediated by the IgE immunoglobulins in the immune system, can cause very different symptoms. These symptoms include:
- Urticaria or angioedema (swelling of the lower parts of the skin)
- Asthma
- Allergic Rhinitis
- Abdominal pain
- Vomiting
- Worsening of dermatitis symptoms
- Exercise-induced Anaphylaxis.[xi]
These symptoms need to occur within two hours after the exposure to wheat to be considered a wheat allergy, along with other testing. Non-Celiac Gluten Sensitivity (NCGS) is a little difficult to diagnose.
NCGS is only diagnosed when wheat allergy and Celiac disease are ruled out, and it’s essential to get tested first before going on a gluten-free diet; otherwise, the results may gleam a false negative.
There have already been comprehensive discussions around the overlap between symptoms of IBS and NCGS, presenting a somewhat chicken and egg situation between the two.[xii] In fact, gluten is one of the potential triggers of IBS symptoms aside from NCGS.[xiii]
Gluten is implicated in depression and other mental health conditions. You may not experience digestive symptoms at all.
Studies investigating the neurological complications of Celiac’s disease have found that the most common area of non-digestive manifestation of gluten sensitivity is in the brain and nervous system.[xiv] This connection goes all the back to 1956, with a paper named “Bread and tears; naughtiness, depression and fits due to wheat sensitivity.”[xv]
This connection is further substantiated with a compelling paper that expresses that gluten can cause neurological harm without Celiac’s disease being present via direct toxicity, inflammation and other immune flare-ups. This scenario was called “gluten syndrome” at the time. The author suggests that developmental delays in children, depression, migraine, and headaches were prominent elements of how gluten can affect the nervous system.[xvi]
More recently, clinical studies have found increased gluten-related antibodies (immune cells reacting to gluten) in patients with bipolar, major depressive disorder, and schizophrenia.[xvii] [xviii] [xix]
There are so many interactions with the brain and gluten that they deserve a complete article, so watch this space.
Be clear about the risks surrounding a gluten-free diet.
I’m hoping this article serves as an introduction to how gluten may play a role in your digestive or mental health symptoms. Other studies suggest that a gluten-free diet may also assist with autoimmune conditions[xx], such as Hashimoto’s disease, [xxi] and assist with metabolic syndromes such as diabetes.[xxii]
It’s clear that a few more articles need to be written to examine the interactions further here, but let’s say by reading this, you’re feeling like it’s worth investigating further. Perhaps it’s time to finally try that gluten-free diet you’ve heard about as a solution.
Before you do, though, let’s look at some of the risks you’re exposed to when going gluten-free. Long-term gluten restriction can lead to nutritional deficiencies, which we will look at in the next section of this article, increased cardiovascular risk,[xxiii] and an accumulation of heavy metals[xxiv], in particular, mercury, lead and cadmium. Already a significant consideration if you live in Hong Kong.
A gluten-free diet can cause nutritional deficiencies as well.
Whilst grains seem to be worth removing for a more significant subset of unwell people, the fact remains, they are densely nutritious, and their removal will have consequences to the nutritional content of the diet.
There has been some analysis of gluten-free diets. One particular study showed that the recommended amount of calcium, iron and fibre was consumed by 31 per cent, 44 per cent, 46 per cent of women, and 63 per cent, 100 per cent and 88 per cent of men, respectively.[xxv]
Other studies have looked into gluten-free food options, revealing that these products have a higher level of fats, trans fat, protein, and salt than their gluten-containing counterparts.[xxvi]
But don’t despair…
If you’re a regular reader here, you’ll know that it’s these types of situations that are precisely where supplements can help you. It’s also important to talk about the shift towards a whole food diet when gluten-free. This shift to whole foods can mean getting better acquainted with your kitchen and dusting off those recipe books that you bought with good intentions at the time.
Another critical point is to commit. If you feel that you are a candidate for the gluten-free diet, then your trial must be 30 days long at the minimum (long enough to notice your brain changing) and must also be the same as a Celiac’s gluten-free diet. The immune system can be extremely sensitive; in fact, we want it that way, so if you are sensitive to gluten, then just one exposure will be enough to set you back for seventy-two hours from an immune point of view. Keep this in mind when you are planning it all out; it’s not easy initially!
So do you need to care about gluten?
If you are unwell with a gut or mental health issue or a chronic autoimmune issue, I would say yes. As we’ve explored here, it is essential to define what’s going on in a personalised fashion. People living with Celiac disease become very ill when they eat gluten. Their avoidance of it has long-term ramifications on the state of their digestive systems and their whole body. Therefore, it’s essential to know what you are dealing with to act accordingly.
In saying all this, I hope if you are new to this subject, you’ve been able to understand how gluten might be playing a role for you.
Hope it helps.
References
[i] https://www.ft.com/content/4ec0f2f2-2c0a-11e7-9ec8-168383da43b7, viewed 21st December 2021.
[ii] https://www.statista.com/statistics/248467/global-gluten-free-food-market-size/, viewed 21st December 2021.
[iii] Biesiekierski JR. What is gluten?. J Gastroenterol Hepatol. 2017;32 Suppl 1:78-81. doi:10.1111/jgh.13703
[iv] Biesiekierski JR. What is gluten?. J Gastroenterol Hepatol. 2017;32 Suppl 1:78-81. doi:10.1111/jgh.13703
[v] https://celiac.org/gluten-free-living/what-is-gluten/sources-of-gluten/, viewed 21st December 2021
[vi] Jennifer Atchison, Lesley Head, Alison Gates, Wheat as food, wheat as industrial substance; comparative geographies of transformation and mobility, Geoforum, Volume 41, Issue 2, 2010, Pages 236-246, ISSN 0016 7185, https://doi.org/10.1016/j.geoforum.2009.09.006.
[vii] Hall SW, Shaoul R, Day AS. The Contribution of Non-Food-Based Exposure to Gluten on the Management of Coeliac Disease. Gastrointestinal Disorders. 2020; 2(2):140-143. https://doi.org/10.3390/gidisord2020014
[viii] Biesiekierski JR. What is gluten?. J Gastroenterol Hepatol. 2017;32 Suppl 1:78-81. doi:10.1111/jgh.13703
[ix] Ludvigsson JF, Leffler DA, Bai JC, et al. The Oslo definitions for coeliac disease and related terms. Gut. 2013;62(1):43-52. doi:10.1136/gutjnl-2011-301346
[x] Welstead L. The Gluten-Free Diet in the 3rd Millennium: Rules, Risks and Opportunities. Diseases. 2015;3(3):136-149. Published 2015 Jul 13. doi:10.3390/diseases3030136
[xi] Cianferoni A. Wheat allergy: diagnosis and management. J Asthma Allergy. 2016;9:13-25. Published 2016 Jan 29. doi:10.2147/JAA.S81550
[xii] Catassi C, Alaedini A, Bojarski C, et al. The Overlapping Area of Non-Celiac Gluten Sensitivity (NCGS) and Wheat-Sensitive Irritable Bowel Syndrome (IBS): An Update. Nutrients. 2017;9(11):1268. Published 2017 Nov 21. doi:10.3390/nu9111268
[xiii] De Giorgio R, Volta U, Gibson PR. Sensitivity to wheat, gluten and FODMAPs in IBS: facts or fiction?. Gut. 2016;65(1):169-178. doi:10.1136/gutjnl-2015-309757
[xiv] Grossman G. Neurological complications of coeliac disease: what is the evidence?. Pract Neurol. 2008;8(2):77-89. doi:10.1136/jnnp.2007.139717
[xv] DAYNES G. Bread and tears; naughtiness, depression and fits due to wheat sensitivity. Proc R Soc Med. 1956;49(7):391-394.
[xvi] Ford RP. The gluten syndrome: a neurological disease. Med Hypotheses. 2009;73(3):438-440. doi:10.1016/j.mehy.2009.03.037
[xvii] Porcelli B, Verdino V, Ferretti F, et al. A study on the association of mood disorders and gluten-related diseases. Psychiatry Res. 2018;260:366-370. doi:10.1016/j.psychres.2017.12.008
[xviii] Karakula-Juchnowicz H, Gałęcka M, Rog J, et al. The Food-Specific Serum IgG Reactivity in Major Depressive Disorder Patients, Irritable Bowel Syndrome Patients and Healthy Controls. Nutrients. 2018;10(5):548. Published 2018 Apr 28. doi:10.3390/nu10050548
[xix] Jackson J, Eaton W, Cascella N, et al. Gluten sensitivity and relationship to psychiatric symptoms in people with schizophrenia. Schizophr Res. 2014;159(2-3):539-542. doi:10.1016/j.schres.2014.09.023
[xx] Talaie R. Does gluten free diet have more implications than treatment of celiac disease?. Gastroenterol Hepatol Bed Bench. 2015;8(2):160-166.
[xxi] Krysiak R, Szkróbka W, Okopień B. The Effect of Gluten-Free Diet on Thyroid Autoimmunity in Drug-Naïve Women with Hashimoto’s Thyroiditis: A Pilot Study. Exp Clin Endocrinol Diabetes. 2019;127(7):417-422. doi:10.1055/a-0653-7108
[xxii] Haupt-Jorgensen M, Holm LJ, Josefsen K, Buschard K. Possible Prevention of Diabetes with a Gluten-Free Diet. Nutrients. 2018;10(11):1746. Published 2018 Nov 13. doi:10.3390/nu10111746
[xxiii] Potter MDE, Brienesse SC, Walker MM, Boyle A, Talley NJ. Effect of the gluten-free diet on cardiovascular risk factors in patients with coeliac disease: A systematic review. J Gastroenterol Hepatol. 2018;33(4):781-791. doi:10.1111/jgh.14039
[xxiv] Raehsler SL, Choung RS, Marietta EV, Murray JA. Accumulation of Heavy Metals in People on a Gluten-Free Diet. Clin Gastroenterol Hepatol. 2018;16(2):244-251. doi:10.1016/j.cgh.2017.01.034
[xxv] Thompson T, Dennis M, Higgins LA, Lee AR, Sharrett MK. Gluten-free diet survey: are Americans with coeliac disease consuming recommended amounts of fibre, iron, calcium and grain foods?. J Hum Nutr Diet. 2005;18(3):163-169. doi:10.1111/j.1365-277X.2005.00607.x
[xxvi] Niland B, Cash BD. Health Benefits and Adverse Effects of a Gluten-Free Diet in Non-Celiac Disease Patients. Gastroenterol Hepatol (N Y). 2018;14(2):82-91.
