The takeaway first

The last five years or so the gluten-free diet has been the most popular way of eating. Even the recent Wimbledon winner Djokavic and the New York Yankees slugger Mark Teixeira have adopted this new way of eating, which excludes wheat, rye and barley. While there is a real, clinical disease called celiac disease, where eating gluten products cause severe gastric problems, the type I’m talking about today is non-celiac gluten sensitivity. Most importantly, I want to know whether the whole thing is…BS.

By the way, Mark Teixieria hit a game winning homerun (update 8/10/15: 30 HR’s) this weekend. Not bad for a 35 year-old baseball player coming out of a year of injuries. He is having one of his best years at an age where most baseball players steadily decline. (I’m a NY Yankees fan)

Just saying…

What is celiac disease?

This disease is an autoimmune disease where your immune system attacks your intestines—but only when there is gluten in your diet. The fancy medical term for the process is small intestinal immune-mediated enteropathy (just in case you want to sound smart at your next cocktail party). Celiac disease occurs in 1% of the population, and the main symptoms include abdominal bloating and pain , chronic diarrhea , pale, foul-smelling, or fatty stool and rapid weight loss . Other common symptoms like chronic fatigue and irritability occur as a result of poor absorption of nutrients.

What is gluten?

Gluten is a protein made out of glutenin and gliadin. The elasticity created when the pizza man kneads dough before throwing it in the air is made from glutenin and gliadin combination. That’s the same molecule that gives bread its chewy texture. Gluten also traps carbon dioxide, which, as it ferments, adds volume to the loaf.

Why would non-celiac people want be on a gluten-free diet?

About 20% of Americans want gluten-free foods (I too choose gluten-free often). The reason why non-celiacs want to eat gluten-free is because they just simply feel great when they’re not eating glutinous grains. Symptoms like gastric bloating, irregular bowel movements and even headaches and joint aches have been relieved just by excluding gluten from the diet. These people suffer from what’s called non-celiac gluten sensitivity. The very first case of non-celiac gluten sensitivity was reported in the mid-1970s where a few young women reported gastric distention

and irregular bowel movements (Cooper et al., 1976) and experienced great relief when they cut gluten out of their diets. Only when gluten was re-introduced did the symptoms return (Ellis et al. 1978).

The science behind a gluten-free diet

Many would say there isn’t any science behind it at all. 

They just haven’t looked.

In one study, 920 adults without celiac disease and with irritable bowel syndrome (IBS) who self-reported gluten-based sensitivity were asked to maintain a gluten-free diet for 4 weeks. After about two weeks, one group was introduced again to wheat where 30% of them (the wheat group) developed IBS symptoms: abdominal pain, bloating and altered stool consistency (Carroccio et al., 2012).

Another study looked at 34 patients with IBS who self-reported gluten sensitivity and whose non-celiac status was confirmed by expert investigators. They received 16g of gluten per day or placebo for up to 6 weeks. Within the gluten group, 68% reported irritable bowel symptoms, such as abdominal pain, bloating, and stool inconsistencies, compared with 40% in the placebo group.

When comparing baseline parameters, patients with non-celiac gluten sensitivity are generally more likely to have nutritional deficiencies, another autoimmune disease, a lower mean BMI, and weaker bones than the general population; however, non-celiac gluten-sensitive people usually don’t have these extra problems.

In a case series of 1,000 patients with progressive ataxia (loss of control of body movements), 18% of patients were found to be sensitive to gluten consumption (Hadjivassiliou et al., 2013). This doesn’t mean that gluten gives you ataxia, though.

Small studies have even associated gluten consumption to depression (Peters et al. 2014) and psychotic, schizophrenic events (Kalaydjian et al. 2006). While these studies to not prove cause and effect, the association is pretty compelling.

For non-celiac endurance athletes, a short-term gluten-free diet had no overall effect on performance. It didn’t help gastrointestinal symptoms, wellbeing, or indicators of intestinal injury or inflammatory markers (Lis et al., 2015). Of course, this study was performed for about one week and to truly see benefit from a gluten-free diet it take about 90 days of complete abstinence from glutinous consumption.

Criticism of gluten-free diets

One Consumer Reports video makes several claims against the gluten-free label. I have problems with this video.

For example, the video claims, “Fat and sugar are sometimes used to replace the oomph in foods that gluten usually fulfills.” Yes, this may be true, but this claim has just as much oomph as saying that we shouldn’t be vegan because some donuts are vegan.

Sure, some foods marketed as gluten-free are crap, but that’s the worst way to be gluten-free.

The Consumer Reports video also claims that gluten-free foods are “not fortified with the same nutrients that foods with gluten [are fortified with].” Folic acid and iron are two examples given. My response? You can get folic acid, iron, and every other nutrient from foods that naturally contain them. Countless foods that are gluten-free are not marketed as such. Green leafy vegetables, for example, have all the folate and iron you could ever dream of, but nobody is calling them gluten-free.

There are two other big criticisms of gluten-free diets. Some say that gluten-free foods are expensive, but I reply that only the gluten-free label is expensive. All fresh produce is gluten-free, but it lacks the label. Why? Because produce has enough nutritional value on its own that it doesn’t need help from the gluten-free marketing campaign.

My take on gluten-free diets, and what you should do

I prescribe a gluten-free diet to all of my patients because it seems to relieve pain and inflammation. This is my experience, and I do whatever solves my patients’ problems.

Therefore, if you have pain or inflammation, I would suggest you try a gluten-free diet for 90 days. This doesn’t mean you have to buy gluten-free products or offer up your wallet as a ritual sacrifice to the gluten-free gods. All it means is that you cut out bread and pasta.

Same goes for my prostate cancer patients – they go mostly gluten-free as gluten wrecks the gut of most people and promote inflammation. In order to beat cancer you must have a strong gastro-intestinal system

If going gluten-free, follow these simple tips:

All fruits are naturally gluten-free. Eat those that have a low-glycemic index

All vegetables are naturally gluten-free. Eat plenty.

All meat, unless it’s processed, is naturally gluten-free. Go for the best fish (my

favorite is vital choice). Also go for grass-fed, organic meats.

Eggs are naturally gluten-free too, and very good for you. Get those from farms or farmers markets where the chickens roam freely and eat naturally (including worms.)

Many grains like quinoa and buckwheat are gluten-free. Eat them too.

As always, don’t eat processed foods or crappy gluten-free foods. But if you want a treat and will do a 90 day test, then eat a gluten-free treat.

Go easy on the alcohol, even if it’s “gluten-free.” By the way, tequila is gluten-free (wink, wink)

I suspect Djokovic’s and Teixeria’s gluten-free dietary benefits is mainly quicker recovery from the stress induced from playing their respective sport.

I know when I am 100% gluten-free, I can play long games of basketball or train for hours without feeling much pain afterwards.

If you have not done so, try going gluten-free. If anything, you will enjoy the challenge. OK maybe “enjoy” is an overstatement.

References

Carroccio, A. et al. Non-celiac wheat sensitivity diagnosed by double-blind placebo-controlled challenge: exploring a new clinical entity. Am. J. Gastroenterol. 107, 1898–1906 (2012).

Cooper, B. T., Holmes, G. K., Ferguson, R., Thompson, R. & Cooke, W. T. Proceedings: Chronic diarrhoea and gluten sensitivity. Gut 17, 398 (1976).

Ellis, A. & Linaker, B. D. Non-coeliac gluten sensitivity? Lancet 1, 1358–1359 (1978).

Kalaydjian, A. E., Eaton, W., Cascella, N. & Fasano, A. The gluten connection: the association between schizophrenia and celiac disease. Acta Psychiatr. Scand. 113, 82–90 (2006).

Hadjivassiliou, M. et al. Transglutaminase 6 antibodies in the diagnosis of gluten ataxia. Neurology 80, 1740–1745 (2013).

Lis D, Stellingwerff T, Kitic CM, Ahuja KD, Fell J. No Effects of a Short-Term Gluten-free Diet on Performance in Nonceliac Athletes. Med Sci Sports Exerc. 2015 May 12.

Lis DM, Stellingwerff T, Shing CM, Ahuja KD, Fell JW. Exploring the popularity,

experiences, and beliefs surrounding gluten-free diets in nonceliac athletes. Int J Sport Nutr Exerc Metab. 2015 Feb;25(1):37-45.

Peters, S. L., Biesiekierski, J. R., Yelland, G. W., Muir, J. G. & Gibson, P. R. Randomised clinical trial: gluten may cause depression in subjects with non-coeliac gluten sensitivity—an exploratory clinical study. Aliment. Pharmacol. Ther. 39, 1104–1112 (2014).