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Where you get your medical information will ultimately determine your long-term health.
Ask yourself if you are seeking alternative sources of medical information mainly to justify a gluten-free diet as the answer for ongoing symptoms. As 19th-century French physiologist Claude Bernard said, “It is what we think we know already that often prevents us from learning.”
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Does a Gluten-Free Diet Work for You? (#ulink_9e5d6e22-6081-5f09-81f3-a5cb4de1a40c)
You have to decide that food is no longer the focus of your life.
(DINA, 28)
It’s harming people with celiac disease because people are choosing the “diet of the month,” and it’s really impacting the people who medically are on a restricted diet.
(JEAN, 37)
Are You a PWAG?
PWAGs (pronounced pee-wags) stands for people who avoid wheat and gluten. It is a term coined by a group of gastroenterologists to encompass the huge numbers of patients they have been seeing who go on a gluten-free diet because of what they describe as an intolerance to wheat products in the absence of celiac disease.
Many of these patients have a higher prevalence of the genes associated with celiac disease (the HLA-DQ typing). And one study showed that PWAGs had a higher number of medical diagnoses for other food intolerances and small intestine bacterial overgrowth (SIBO).
If you are a PWAG, there are many reasons you made this decision—disease treatment, symptoms relief, perception of a healthier way to be, recommended by a health care professional, etc. And an equal variation in its success.
First and Foremost—What Is Gluten?
Gluten is the general term used to describe the storage protein of wheat. Wheat is approximately 10 to 15 percent protein—the remainder is starch. Gluten is what remains after the starch granules are washed from wheat flour. The gluten fraction that is most studied in celiac disease is gliadin, but there are other proteins that chemically resemble gliadin in rye (secalins) and barley (hordeins). These proteins are not strictly glutens, but are generally included in the term. There are other proteins in wheat (See chapter 11 (#u65d45adf-1a4c-5d09-a0f6-f794bbfe7288), “Gluten and Nongluten Grains”) that may also be problematic for PWAGs and are part of the complex reason why the diet works for some, only partially for others, or not at all.
Why a Gluten-Free Diet Works
You have celiac disease and the diet fixes the inflamed intestine.
A gluten-free diet is a lifesaver for those with celiac disease and is a proven medical treatment. If followed carefully, it resolves symptoms, rebuilds nutritional stores depleted by a damaged intestinal lining, and, in children, rebuilds bone loss caused by malabsorption of calcium. (See chapter 17 (#u447e315a-7f60-59e4-a27b-078768998d26), “Celiac Disease.”)
You have nonceliac gluten sensitivity (NCGS) and the diet relieves symptoms (neurological, skin, gastrointestinal).
Many individuals who feel or have been told that they have NCGS—again, there are currently no diagnostic tests for this condition—find relief with gluten withdrawal for neurological disorders, skin rashes, and GI symptoms such as gas and bloating. (See chapter 18 (#u5ed481d4-4820-560c-9fb1-35266fbb5144), “Gluten Sensitivity.”)
You have irritable bowel syndrome (IBS), and elimination diets have resolved some or all of the gas, bloating, and pain.
IBS may be due to a sensitivity to a food that most tolerate without problems. It is a diagnosis of exclusion—other tests having proven negative—and dietary restriction can be successful, often only partially, for those patients with carbohydrate intolerances. (See chapter 12 (#u24c2036b-6f5c-5feb-b338-80112af267a8), “Carbohydrates and FODMAPs,” and chapter 19, “Irritable Bowel Syndrome.”)
You just think it works so it does.
A placebo is not only the archetypal sugar pill but anything that impacts a patient’s expectations.
Why a Gluten-Free Diet Does Not Work
The main reason a gluten-free diet does not work is that gluten is not the issue and/or you may be missing treatment for another disease.
This may include:
SIBO
Fructose intolerance
Lactose intolerance
Other food intolerances
Microscopic colitis
Gastroparesis (a condition where the stomach cannot empty properly)
Pelvic floor dysfunction (weak muscles in the pelvic floor, often caused by childbirth)
A problem related to a medication you are taking
After a thorough medical evaluation, we find that many PWAGs have a variety of conditions and may, in fact, be able to eat gluten again, symptom free, with proper diagnosis and treatment.
You may be on a gluten-free diet but other types of carbohydrates, e.g., fructose, are the problem. (See chapter 12 (#u24c2036b-6f5c-5feb-b338-80112af267a8), “Carbohydrates and FODMAPs.”)
You’re under the impression that the diet is a cure-all for many health-related ailments.
A survey by Consumer Reports showed that 63 percent of North Americans think that a gluten-free diet improves physical or mental health, and 33 percent buy gluten-free products because they believe these foods will improve digestion and gastrointestinal function. Unless you have celiac disease or a specific carbohydrate intolerance, a gluten-free diet will not work for either of these issues.
The diet does not work to lower cholesterol or strengthen your immune system, even though many people believe it does.
The diet is disrupting your intestinal flora—the microbiome—and causing symptoms.
Restrictive diets—gluten-free, low-FODMAP—have been shown to reduce the richness and diversity of our intestinal microbiota, which in turn may cause persistent symptoms in patients with celiac disease and possibly other conditions. While it is unclear exactly what this disruption means or the long-term effects, it is generally believed that a diverse microbiome is healthier. While there is no one “healthy” microbiome, the studies on this should be watched. (For more, See chapter 9 (#uada19a92-979d-53bb-abaa-9b6112cad3c6), “The Microbiome.”)
People should make every effort to diversify their diets. This may be particularly important as people age. Aging is known to be associated with a reduced diversity of the gut microbiome, and this may lead to a compromised intestinal barrier and increased susceptibility to infectious diseases and infections.
If a disrupted microbiome is a side effect of a gluten-free diet, these consequences should be considered before you embark on a gluten-free regimen unless you have celiac disease.
Will It Work in Other Ways?
Can I lose weight on a gluten-free diet?
Some go on a gluten-free diet to lose weight. This works if you exclude but do not replace wheat as the main carbohydrate. In animal studies a gluten-free diet prevented the development of obesity and metabolic disorders. BUT, while gluten was eliminated from the diet, the mice were not fed replacements with gluten-free products. The no–white food or Atkins diet (no bread, pasta, potatoes, rice, cake, or cookies) will usually ensure weight loss but can be nutritionally inadequate if enough fruit and vegetables are not substituted for those carbohydrates. It is also hard to sustain.
Will I have more energy?
Unfortunately, if you do not have celiac disease, a gluten-free diet is not likely to make you the Energizer Bunny. Although many people insist that they feel logy or tired after eating gluten, there is little scientific evidence to support this. Postprandial fatigue (which occurs after eating) is common, especially after a large meal, when various hormones are released to aid digestion. These hormones act on the brain when released in the gut and cause the fatigue many report.
Will I become a world-class athlete—or will thinking so make it better?
The use of a gluten-free diet by famous people has enhanced its appeal. Publicized by Hollywood stars, it has also been endorsed by several high-profile athletes. The reasons behind this speak to our infatuations with celebrities and fad diets, and wanting to believe something enough to think it works—the placebo effect.
An Australian study of nonceliac athletes, including eighteen world and/or Olympic medalists who followed a gluten-free diet 50 to 100 percent of the time, reported that self-diagnosed gluten sensitivity was the primary reason for adopting the diet. The leading sources of information on the gluten-free diet were online, a trainer/coach, and other athletes. Neither the diagnosis nor treatment was based on medical rationale, merely the perception that removing gluten provided “health benefits” and an “ergogenic edge.”
If you do not have chronic symptoms that require medical treatment, the gluten-free diet can be both placebo and minefield. We advise staying tuned to your local news for updates—the latest dietary trend may be announced on Entertainment Tonight.
If you are looking for more realistic scientific advice, the following chapters will explore what taking gluten and other foods out of your diet will really do to and for your body.
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Picky Eaters—Orthorexia and the Hygiene Hypothesis (#ulink_6ccce85b-6e9c-53b5-a9c3-eb1ecb2e3ee8)
Water surges, only to overflow.
—CHINESE PROVERB
Things turn into their opposites when they reach their extremes. And “healthy” eating is moving in that direction.
There are good reasons that we have food on our minds. According to the U.S. Centers for Disease Control and Prevention (CDC), half of all Americans have a chronic disease or condition such as high blood pressure, heart disease, or type 2 diabetes and have been instructed to think about fat, sugar, and/or salt. More than 9 percent have diabetes and must monitor their sugar/glucose intake multiple times every day. At least 35 percent of Americans are obese and cycle through different diets, gaining and losing weight every year. About 1 percent has celiac disease and avoids gluten. Up to 15 million people in the U.S. have a food allergy, estimated to affect 1 in every 13 children under the age of 18. A study by the World Health Organization reported that noncommunicable diseases were responsible for 86 percent of all deaths and 77 percent of the disease burden in the European Region and noted that this primarily included conditions caused by high blood pressure and cardiovascular diseases. Three of the priority interventions recommended were dietary.
Unfortunately, the National Eating Disorders Association notes that 20 million women and 10 million men suffered from a clinically significant eating disorder at some point in their life, including anorexia nervosa, bulimia, binge eating, or an eating disorder not otherwise specified. In the UK, a National Health Service (NHS) study estimated that more than 725,000 people are affected by an eating disorder and that eating disorders can affect people of any age.
The current obsession with food is not surprising; mankind has been on some kind of restricted diet—by need or choice—since the beginning of time (see Appendix A (#u38ca89cb-57e2-5013-b66f-99de071e46b6)), but for some it has taken a turn into the obsessively unhealthy.
Orthorexia Nervosa—Healthy Eating as a Disease
Food is an important part of a balanced diet.
—FRAN LEBOWITZ
I don’t like anything “lite”—that’s not my thing. I have one friend who goes to a chiropractor who tests you, and they take one thing after another out of your diet. He evaluates what you eat and decides what foods your body is not tolerating. She’s currently living on kale.
(ILYSSA, 39)
The focus of the press and social media on “healthy eating” as the source of, or cure for, disease has taken hold to the point of creating a new condition termed orthorexia nervosa. Individuals eliminate one healthy food after another (gluten, corn, soy, meat, dairy, all fats, carbohydrates, etc.) in the belief that these foods are “unhealthy”—until they are barely receiving adequate nourishment. It can reach the point of anemia, bone loss, vitamin depletion, and malnutrition.
The condition is not as yet recognized in the DSM-V (the Diagnostic and Statistical Manual of Mental Disorders, used professionally to diagnose psychiatric disorders) but is being seen by many doctors evaluating patients for symptoms related to nutritional deficiencies.
The term orthorexia was coined by Dr. Steven Bratman from the Greek ortho (correct or proper) and orexis (hunger or appetite). Unlike in anorexia, those with orthorexia focus on the quality rather than the quantity of food eaten. They start removing foods because they do not feel well, and when they do not feel better, they remove more and more until they are on an overly restricted and generally unhealthy diet.
Are You Orthorexic?
Have you eliminated entire food groups from your diet? (Gluten, dairy, corn, and soy are the usual suspects as well as red meat, carbohydrates, etc.)
Three or more food groups?
Do you constantly worry about which foods may be unhealthy?
Do you feel guilty when you eat food you consider unsafe?
Do you have problems finding healthy foods?
Do you have ritualized eating patterns?
Are you anxious when eating out or traveling?
Have you started avoiding lunches, dinner dates, and catered parties?
Do you lecture your friends and family about unhealthy eating?
Do you read medical journal articles about digestion, carbohydrates, protein, etc.?
Do you challenge others who disagree with your food choices?
Do you wish that you could just eat and not worry about the quality of foods?
Do you have symptoms that do not fit any medical diagnostic category for which you blame gluten, dairy, or a specific food?
Orthorexia affects a small percentage of individuals, but is yet another food-related disorder that has evolved from the increased focus on food as cause and/or cure for symptoms and disease.
The Hygiene Hypothesis—Are We Too Clean for Our Own Immunological Good?
My daughter-in-law sterilizes everything that goes into my grandson’s mouth. I raised four children on the 10-second rule—if it’s been on the floor for less than 10 seconds, pick it up and eat it—and not one had an allergy or food issue. Now we’re boiling the baby’s fork and spoon after it comes out of the dishwasher, and every other person’s child is allergic to peanuts or dairy or gluten. Something’s wacky here.
(GERI, 64)
The diagnosis of allergies and autoimmune diseases has risen dramatically in the last few decades. While there are many underlying and complex mechanisms at work, a great deal of scientific interest is being focused on the “hygiene hypothesis.” This states that childhood exposure to germs and certain infections helps the immune system develop normally, and that excessive cleanliness interrupts this process.
In other words, the young child’s environment can be too clean to effectively challenge a maturing immune system. Frequent and repeated exposure to a variety of microbial antigens and infections may lead to a more robust, i.e., healthier immune system.
While it is well documented that avoiding germs helps prevent the spread of infections, the hygiene hypothesis suggests that we have taken this too far. And with the advent of antibiotics and the great public health efforts of the last century, the immune system is no longer required to fight germs as actively as in the past.
Scientists based this hypothesis in part on the observation that, before birth, the fetal immune system’s “default setting” is suppressed to prevent it from rejecting the mother’s tissue. This is necessary before birth—when the mother is providing the fetus with her own antibodies. After birth the child’s own immune system must take over and learn how to fend for itself. But the extremely clean household environments often found in the developed world do not provide the necessary exposure to germs required to “educate” the immune system so that it can learn to launch its defense responses to infectious organisms.
A critical part of this evolution is orchestrated by a child’s developing microbiome, and a lack of diversity—reduced by exposure to fewer germs and infections—derails the period of immune growth after birth.
The hygiene hypothesis has been implicated in the growing number of people with allergies, autism, and autoimmune diseases.
MacDonald’s Farm Had the Right Idea?
Since the hypothesis was first proposed by epidemiologist Dr. David Strachan in 1989, several studies have revealed a reduction in the sensitivity to allergens and atopic (skin) disease in children exposed to farm environments, those who have animals in their homes, and in those who have attended day care at an early age and were exposed to other children’s infections.
Several lessons have come from studies comparing populations in Russian Karelia and neighboring Finland. These two populations live in completely different socioeconomic circumstances—they have one of the largest socioeconomic discrepancies in the world—yet share similar diets and genetic backgrounds.
The researchers determined that the children in Karelia are exposed to a large variety of different microbial infections that are significantly less frequent in Finnish children. Starting in 1999, numerous studies on autoimmune and allergic diseases show an incidence of type 1 diabetes that is six times lower in Russian Karelia. The incidence of celiac disease is 1 in 496 in Karelia and 1 in 107 in Finland using identical criteria. These studies appear to indicate that environmental factors play a role in our immune reaction to microbes and in the development of allergies and autoimmune conditions. While all of the factors initiating these conditions have not been identified, the hygiene hypothesis offers an intriguing approach.
The mechanisms by which microbes can reduce the development of autoimmune disease are not well understood. They are only part of a larger autoimmune and allergic response that is also affected by your genetic makeup, and a variety of factors that occur over a person’s lifetime. It cannot be considered the sole determinant of a disease.
Before people start feeding their children from the floor or allowing them to share the dog’s bowl, it should be stressed that many researchers feel that the hygiene hypothesis is far too simplistic an approach to understanding the causes of celiac disease or any other autoimmune disease.
This hypothesis does focus attention on the impact of microbes on disease, hopefully without discouraging good hygiene practices.
