Should I quite Gluten?

Avoiding wheat and other gluten-containing grains is certainly a popular dietary trend, but is it necessary?

Coeliac disease and wheat allergy

It is well known that sufferers of coeliac disease must adhere to a strict gluten free diet to control symptoms and manage the condition. Individuals with coeliac disease react to the gluten protein found in wheat, rye, barley, spelt and oats and an autoimmune process causes damage to the intestinal wall. This damage results in a myriad of digestive and other related symptoms [1].

Wheat allergy is different from coeliac disease in that individuals react to a number of the proteins found in wheat, not just the gluten, and exhibit symptoms of a typical allergy such as itching and swelling of the eyes, nose and mouth and in severe cases, life threatening anaphylaxis. Gastrointestinal symptoms are also present such as cramping bloating and diarrhoea [1].

Non-coeliac gluten sensitivity

Still, many people without a diagnosis of coeliac disease or wheat allergy find that avoidance of gluten or wheat relieves a number of their uncomfortable or distressing symptoms [2]. This phenomenon, which is receiving increasing attention in the scientific literature, is a reaction that is termed non-coeliac gluten sensitivity (NCGS). The symptoms of NCGS are varied and include irritable-bowel-like digestive upset, fatigue, headaches, joint or muscle pain, brain fog, skin eruptions, depression, anxiety and anaemia. The symptom onset can be rapid but improves within hours to days after gluten withdrawal, and then relapses after reintroduction [3].

Ongoing research is identifying the possible mechanisms by which gluten-containing grains may pose a problem to non-coealics. The likely mechanisms are outlined below,

• In some individuals, the proteins found in cereal grains may evoke an immune response and contribute to inflammation in the gastrointestinal tract without causing full blown coeliac disease [4]. Coeliac disease and gluten sensitivity can be thought of as provoking different aspects of the immune system with coeliac disease being the more serious of the two [5].
• The carbohydrate fraction of certain grains may be difficult for some to digest. These carbohydrates are called short-chain fructans and avoidance of similar types of carbohydrates found in other fruits and vegetables concomitantly has shown dramatic symptom improvement [3]. These carbohydrates fall under a category called FODMAP’s. In one study, researchers compared the response to the removal of gluten to the total removal of all FODMAPS from the diet in individuals with Irritable-bowel-syndrome. It was found that many patients with NCGS were also sensitive to the carbohydrates found in the FODMAP foods. Only a small percentage of the participants were sensitive to the gluten alone [6]. Put simply gluten free diet alone may not be sufficient to control symptoms in some people, particularly those with IBS.
• Non-coeliac gluten sensitivity may relate to a condition called ‘leaky gut’, where the integrity of the lining of the digestive tract is compromised triggering an inflammatory response upon exposure to gluten or other components of gluten containing grains [7].
• Bowel infections may also account for some cases of transient NCGS [8].

Problems with a gluten free diet

So are there any problems with initiating gluten free or low gluten diet? The answer is, possibly…  The issue with following a self-initiated gluten free diet unnecessarily raises two main concerns. Firstly, as consumption of gluten is needed for accurate diagnosis of coeliac disease, its voluntary removal before consulting a health practitioner may result in misdiagnosis. This may then be associated with poor management and result in future complications such as poor bone health, anaemia [3] and other autoimmune diseases [7].  Secondly, the restrictive nature of a gluten free diet itself poses a potential problem, particularly where whole grains are replaced with nutritionally poor and often refined gluten free grains. These gluten-free replacements are often lacking in fibre, b vitamins and other beneficial phytonutrients [3].

Naturopathic approach

So whilst much is known about the clinical picture and possible mechanisms of NCGS, distinguishing NCGS from other gastrointestinal disorders is difficult due to the overlap with Irritable Bowel Syndrome, immune dysfunctions and the FODMAP picture. This is perhaps a situation in which naturopathic care is ideally suited because of the holistic approach that is taken. A naturopathic approach to treatment is to treat the whole of the individual rather than distinct disease states, identifying where possible the possible underlying causes.  For example, many of the above listed mechanisms associated with NCGS can be driven or initiated by chronic stress [9] [3]. A holistic treatment plan would therefore incorporate the necessary tools to address both the stress and the effects the stress has had on the body (inflammation, leaky-gut, bacterial overgrowth etc). In other words, rather than removing gluten forever, the preferred option would be to attempt to correct the underlying dysfunctions.

[1]      F. Tovoli, C. Masi, E. Guidetti, G. Negrini, P. Paterini, and L. Bolondi, “Clinical and diagnostic aspects of gluten related disorders.,” World J. Clin. cases, vol. 3, no. 3, pp. 275–84, Mar. 2015.

[2]      M. Pietzak, “Celiac disease, wheat allergy, and gluten sensitivity: when gluten free is not a fad.,” JPEN. J. Parenter. Enteral Nutr., vol. 36, no. 1 Suppl, p. 68S–75S, Jan. 2012.

[3]      J. R. Biesiekierski and J. Iven, “Non-coeliac gluten sensitivity: piecing the puzzle together,” United Eur. Gastroenterol. J., vol. 3, no. 2, pp. 160–165, Mar. 2015.

[4]      K. de Punder and L. Pruimboom, “The dietary intake of wheat and other cereal grains and their role in inflammation.,” Nutrients, vol. 5, no. 3, pp. 771–87, Mar. 2013.

[5]      A. Sapone, K. M. Lammers, V. Casolaro, M. Cammarota, M. T. Giuliano, M. De Rosa, R. Stefanile, G. Mazzarella, C. Tolone, M. I. Russo, P. Esposito, F. Ferraraccio, M. Cartenì, G. Riegler, L. de Magistris, and A. Fasano, “Divergence of gut permeability and mucosal immune gene expression in two gluten-associated conditions: celiac disease and gluten sensitivity.,” BMC Med., vol. 9, p. 23, Jan. 2011.

[6]      J. R. Biesiekierski, S. L. Peters, E. D. Newnham, O. Rosella, J. G. Muir, and P. R. Gibson, “No effects of gluten in patients with self-reported non-celiac gluten sensitivity after dietary reduction of fermentable, poorly absorbed, short-chain carbohydrates.,” Gastroenterology, vol. 145, no. 2, pp. 320–8.e1–3, Aug. 2013.

[7]      C. Catassi, J. C. Bai, B. Bonaz, G. Bouma, A. Calabrò, A. Carroccio, G. Castillejo, C. Ciacci, F. Cristofori, J. Dolinsek, R. Francavilla, L. Elli, P. Green, W. Holtmeier, P. Koehler, S. Koletzko, C. Meinhold, D. Sanders, M. Schumann, D. Schuppan, R. Ullrich, A. Vécsei, U. Volta, V. Zevallos, A. Sapone, and A. Fasano, “Non-Celiac Gluten sensitivity: the new frontier of gluten related disorders.,” Nutrients, vol. 5, no. 10, pp. 3839–53, Oct. 2013.

[8]      G. Holmes, “Non coeliac gluten sensitivity.,” Gastroenterol. Hepatol. from bed to bench, vol. 6, no. 3, pp. 115–9, Jan. 2013.

[9]      K. de Punder and L. Pruimboom, “Stress induces endotoxemia and low-grade inflammation by increasing barrier permeability.,” Front. Immunol., vol. 6, p. 223, Jan. 2015.