By NATALIE DIGATE MUTH, M.D., M.P.H., R.D.
I don’t have celiac disease, but I’ve cut all gluten-containing products from my diet and feel so much better. Is there anything wrong with adopting a gluten-free diet?
Over the past several years, a growing number of people have experimented with gluten-free diets to help alleviate symptoms like abdominal pain, cramping and generalized fatigue. In some cases, people have adopted the diet in simple protest against the current American culture of overconsumption of heavily processed, nutritionally poor foods as many fresh, wholesome foods like fruits and vegetables are gluten-free. While historically (and scientifically) a gluten-free diet only has been considered necessary for people with a relatively rare, but debilitating disease known as celiac disease (defined as an allergy to gluten-containing products), a lot of people free of celiac disease, or even gluten sensitivity, swear by the benefits of a gluten-free diet. But the question that often arises is: For people who do not have celiac disease, is this restrictive eating regimen worth the inconvenience and risk of nutritional deficiency? And what exactly is ‘gluten sensitivity’? While there’s not a lot of research to fully back up anyone’s assertions one way or the other, familiarity with celiac disease, gluten sensitivity and the body’s nutritional requirements can help a person choose an eating plan for optimal health and well being, whether or not it includes gluten.
Nearly 1 percent of the population suffers from celiac disease; for unknown reasons the prevalence appears to be increasing slightly. Celiac disease is characterized by an autoimmune rejection of gluten-containing foods. Gluten is a protein compound made up of two proteins called gliadin and glutenin that is found joined with starch in the grains wheat, rye and barley. When the body is exposed to gliadin—the “toxic” component of gluten for people with celiac disease—it goes into immunologic overdrive. The gastrointestinal system becomes inflamed and pathologic changes to the small intestine, the body’s main site for nutrient absorption, ensue. When the gut is unable to absorb nutrients, common symptoms like vitamin deficiencies, anemia, weight loss and diarrhea occur. Other symptoms include abdominal pain and distention and in some cases neurologic dysfunction. Celiac disease is very difficult to diagnose and though it begins in childhood, many people do not learn that they have the disease until well into adulthood. The longer a person suffers from undiagnosed and untreated celiac disease, the more likely he or she is to develop complications such as other autoimmune disorders, osteoporosis, infertility, neurologic problems and, in rare cases, cancer. This is why it is very important for anyone who suffers from the symptoms of celiac disease to see a physician immediately for evaluation. Celiac disease can be diagnosed with laboratory testing and biopsy of the small intestine. The only definitive treatment for the disease is strict avoidance of gluten-containing foods.
Gluten sensitivity is much more common, and less understood than celiac disease. This occurs when the body has a pronounced response to gluten-containing foods leading to feelings of tiredness, abdominal pain and other GI symptoms like diarrhea or constipation. Many people report experiencing these symptoms after eating gluten-containing foods (or more commonly, they report these symptoms going away after avoiding gluten), but it is not exactly clear what causes these symptoms or the body’s actual response to the gluten. It is very important for anyone who believes they might have a gluten sensitivity to see a physician and dietitian prior to adopting a gluten-free diet. The doctor can test for celiac disease (the tests are not accurate if done after a person has eliminated gluten from the diet) and the dietitian can help develop a balanced eating plan. Typically people with gluten sensitivity will test negative for celiac disease but still feel that gluten-containing foods make their symptoms worse.
Many foods contain gluten and, without appropriate dietary planning, complete elimination of gluten from the diet can lead to nutritional deficiency. The Dietary Guidelines recommend that most adults get anywhere from six to eight servings of grains per day. Grains are an excellent source of B-vitamins and fiber. Most standard grains such as bread, cereal and pasta contain wheat, rye or barley and thus include gluten. Complete elimination of gluten-containing grains can lead to nutritional deficiencies including B vitamins, calcium, vitamin D, iron, zinc, magnesium and fiber. In fact, a Swedish research study of people with celiac disease who had been gluten-free for 10 years found that half of the patients had vitamin deficiencies, including low levels of vitamin B-6 or folate, or both (Hallert et al, 2002). Likewise, a survey of people on a gluten-free diet in the United States found that over half had inadequate fiber, iron and calcium intake (Thompson et al, 2005). Though it is true that a multivitamin may be able to provide “insurance” and protect from overt nutritional deficiencies, it is always ideal to get the body’s needed nutrients from food sources when possible.
Of course, sticking to a gluten-free diet is no simple feat. Thanks to the 2004 Food Allergen Labeling and Consumer Protection Act, food labels must identify if they contain any of the top eight food allergens, which includes wheat. But a quick glance of ingredient labels at a grocery store reveals that gluten is present in most foods. While it is possible to buy gluten-free bread, pasta, cereal and various other products, these tend to cost substantially more than the gluten-containing counterpart. For people with celiac disease, the difficulty of adhering to a gluten-free diet is the price to pay for good health. The same may hold true for some people with gluten sensitivity.
Anyone considering starting a gluten-free diet should first seek consultation with a physician and dietitian. Most people who have celiac disease are currently undiagnosed and for anyone with symptoms of the disease, a physician will likely want to evaluate for it. If a person sees the doctor, tests negative for celiac disease, and still would like to adopt a gluten-free diet, a registered dietitian can help plan a wholesome diet that is high in gluten-free B-vitamins and fiber-containing foods such as rice, corn, soy, potato, tapioca, beans, quinoa, millet, buckwheat, flax, nut flours and uncontaminated oats. Other naturally gluten-free products include milk, butter, cheese, fruits and vegetables, meat, fish, poultry, eggs, beans and seeds. It is also worth fully exploring whether it is the gluten or some other food, lifestyle behavior or medical problem that is contributing to the gastrointestinal symptoms. Adopting a gluten-free diet is not recommended as a method to lose weight or to “become healthier.” The diet is restrictive and can lead to serious vitamin deficiencies and can contribute to disordered eating behaviors. And, unlike saturated and trans fats, for example, gluten itself is not inherently unhealthy. Perhaps the best way for many people who do not have celiac disease to feel better and adopt an overall healthier way of life is to continue to focus on minimally processed foods (gluten-free or not per individual preference) and a diet rich in wholesome foods like fruits and vegetables.
Natalie Digate Muth, M.D., M.P.H., R.D., is a pediatrics resident at UCLA Mattel Children’s Hospital, a registered dietitian, an ACE-certified Personal Training and Group Fitness Instructor, and spokesperson for the American Council on Exercise.
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Hallert, C, et al. (2002). Evidence of poor vitamin status in celiac patients on a gluten-free diet for 10 years. Alimentary Pharmacolology & Therapeutics, 16, 1333–1339.
Thompson, T., et al. (2005). Gluten-free diet survey: Are Americans with celiac disease consuming recommended amounts of fibre, iron, calcium and grain foods? Journal of Human Nutrition and Dietetics, 18, 163–169.