With more Americans eating a gluten-free diet than ever before, it’s hard not to wonder whether you should be following in their footsteps. Gluten-free advocates praise the positive effect this diet has had on their lives, crediting it with curing everything from gastrointestinal issues to skin rashes and migraines. But is a gluten-free diet all it’s cracked up to be? The answer depends on several factors, including the presence of celiac disease or non-celiac gluten sensitivity, and what a gluten-free diet allows (and forbids) in terms of what you can regularly eat.
What is gluten?
Gluten is a protein found in wheat, barley, oats, spelt, and rye. Gluten is a very elastic protein, and when those proteins connect with one another they become very stretchy. Slice into a loaf of bread and you’re likely to see plenty of air bubbles; these are a result of gluten proteins stretching and then hardening as the bread is baked. There are two groups of proteins that make up gluten as a whole: gliadins and glutenins. Gliadins are a type of protein found specifically in the grass genus Triticum and are the active compound needed to make bread stretch and rise. Unfortunately, people who suffer from celiac disease are most sensitive to gliadins and are unable to tolerate them in even the smallest amounts. Glutenins are another type of protein found in gluten. When water is added to wheat flour and kneaded, the glutenin and gliadin come together to produce cross-links of proteins that grow and become stronger the more the dough is worked. When yeast is added to wheat flour it creates gas bubbles that form holes in the bread as it bakes. Because wheat gluten plays such an integral role in how bread is structured and baked, it can be extremely difficult to make things like bread, cake, and even muffins gluten-free without sacrificing a light texture.
Types of Gluten Intolerances and Sensitivities
Gluten issues fall into one of two categories, celiac disease and non-celiac gluten sensitivity (NCGS).
Celiac disease is an autoimmune disorder in which any gluten that is eaten attacks the small intestine by damaging the villi, the small finger-like structures that line the intestine and encourage nutrient absorption. If left untreated, celiac disease can eventually lead to serious health problems such as epilepsy or migraines, anemia, intestinal cancer, infertility, type 1 diabetes, multiple sclerosis, skin conditions, osteoporosis, and leaky gut syndrome (wherein toxins, peptides, and antibodies found in the intestine end up in your bloodstream). The World Gastroenterology Organization has recognized three different kinds of celiac disease: classical, non-classical, and silent. Classical celiac disease in adults is accompanied by symptoms such as diarrhea and foul-smelling stools that stem from nutrient malabsorption. Non-classical celiac disease may be accompanied by the above malabsorption symptoms and less obvious symptoms such as anemia, persistent fatigue, tingling or numbness in the extremities, osteoporosis, vitamin deficiency, depression, anxiety, and itchy skin. Silent celiac disease (also known as asymptomatic celiac disease) is much more difficult to diagnose because there are no overt symptoms to report even if there is significant damage to the small intestine. The Celiac Disease Foundation recommends first-degree relatives be tested if there is silent celiac disease present in a family, as there is a 1:10 chance it could be passed down through family members.
Symptoms of Celiac Disease
It’s important to note that symptoms of celiac disease can present themselves differently in children from the way they do in adults. Sue Newell is the operations manager for Education and Special Projects at the Canadian Celiac Association, and she notes that symptoms once thought of as a “classic” for adults—such as diarrhea and weight loss—are actually more likely to be seen in children suffering from celiac disease. In fact, only one-third of adults are likely to experience diarrhea and will instead experience symptoms that are less clearly identifiable as celiac disease, such as anemia, fatigue, bone or joint pain, arthritis, liver disorders, depression, anxiety, canker sores, and missed periods.
Incidence of Celiac Disease: A Worldwide Health Issue
Studies have shown that there is a definite rise in the incidence of celiac disease during the last half of the 20th century, although medical experts aren’t in total agreement as to how this has happened. One aspect of this phenomenon that experts can agree on is that celiac is actually a global issue. [pullquote align=”center”]“One of the biggest barriers is getting celiac disease onto the radar of primary care physicians, including the fact that the classic presentation they might be thinking about is not the most common presentation today.” —Sue Newell[/pullquote] Celiac disease used to be attributed to the gluten found in Western cuisine, but Newell says “that researchers found celiac all over the world once they started looking for it. Originally [it was] thought to be a European disease, [but] North Africa has the highest rate of disease. Celiac disease is also common in some areas of Pakistan, India, and China based on the amount of gluten present in the typical diets.”
Changes in Wheat Processing
Changes in how wheat is grown in the United States have been hypothesized as a possible cause for the rise in celiac disease over the last 50 years. The theory is that wheat breeding—the practice of refining and developing wheat so that it has a larger crop yield and is more resistant to disease and pests—has created wheat with a higher gluten content than in the past. But recent studies have disproven this idea, and researchers have hypothesized that an increase in wheat and gluten consumption over the past half-century is more likely to be the culprit.
A New Kind of Testing Method
Testing for celiac disease used to mean undergoing a biopsy of the small intestine, an invasive procedure that would determine whether the individual had celiac disease. There is now a celiac screening blood test that can determine whether a biopsy is needed (although a biopsy of the small intestine is often recommended still because of a 10 percent possibility of a false-positive result with the blood test). Newell offers this advice for anyone contemplating a screening test:
If someone thinks they have a problem with gluten, their first step should be a screening test for celiac disease. This test is only valid if someone is eating a normal gluten diet. It measures antibodies produced when someone with celiac disease eats gluten. People who go gluten-free first must go back on gluten for a period of weeks to months to be screened. This gluten challenge is frequently an extremely uncomfortable experience.
Although celiac disease screening has often improved the lives of those who have undergone the test, it’s been an uphill battle to increase public awareness about the disease. Newell says there is still a long way to go:
I think there is no question that the rise in awareness has made diagnosis more likely, but it appears that more than 80 percent of the people with celiac disease remain undiagnosed. One of the biggest barriers is getting celiac disease onto the radar of primary care physicians, including the fact that the classic presentation they might be thinking about is not the most common presentation today.
Who should be screened for celiac disease?
If you have a first-degree relative (such as a parent, child, or sibling) who suffers from celiac disease, it’s definitely a wise decision to get screened, even if you don’t have any noticeable symptoms. Whereas the general public has about a 1 in 100 chance of developing celiac disease, a first-degree relative has a 10 percent likelihood of developing the disease. Other risk factors that make someone a good candidate for screening include a lingering and unexplained ongoing illness or an autoimmune disorder such as type 1 diabetes or arthritis. Children with Down syndrome, Turner syndrome, and Williams syndrome have also shown a greater likelihood of having celiac disease.
Non-Celiac Gluten Sensitivity
Some people may notice unpleasant physical side effects after eating gluten, including the more obvious symptoms of gastrointestinal distress and less recognizable symptoms such as headaches, fatigue, and itchy skin. An important difference between celiac disease and NCGS is that NCGS does not involve the damage to the small intestine that is found in celiac disease. Cases of NCGS appear to be on the rise, although Newell stresses that they “remain a diagnosis of exclusion because there are no reliable biomarkers, despite extensive research into the matter. Studies are suggesting that there NCGS may be caused by several distinct issues, including sensitivity to a different component of wheat and an issue with FODMAPs. Both of those conditions can be improved with a gluten-free diet.” (FODMAPs, by the way, are a series of short-chain carbohydrates that can be difficult for your gut to digest and can potentially cause irritable bowel symptoms to flare up.)
How should you treat NCGS?
Getting screened for celiac disease should be the first step when seeking treatment options for NCGS. If your results come back negative, specialists do not recommend a gluten-free diet but instead suggest discussing further dietary options with your doctor or a dietician. NCGS is still relatively misunderstood by the medical community, which means that treatment plans are often complex and may have nothing to do with the inclusion of gluten in your diet.
Why Cutting out Gluten Isn’t Always the Best Solution
Cutting out gluten may seem like an easy fix for what ails you, but it may actually do more harm to your body than good. Newell explains that “the primary risk of harm comes from the nature of a gluten-free diet. Gluten-free flour is rarely enriched, unlike wheat flour. Many of the common flours are not whole grain and contain low fiber. In order to make a product that has a reasonable taste and mouthfeel, manufacturers often need to add extra eggs, fat, and sugar. Since the products are frequently much smaller than their wheat counterparts, people tend to overeat.” She adds that “some people eliminate grain-based and highly processed foods from their diet to make it gluten-free. If they don’t add gluten-free equivalents, then they may end up with a healthier diet, but this not the most common form of a ‘gluten-free diet.’”
If you’re convinced gluten-free is the way to go, just what should you be eating?
Quinoa is a naturally gluten-free seed that comes from a grass and can be made into flour and used to make pasta and bread or as the base for pilafs or grain salads. The Gluten Free Society recommends quinoa for its taste and versatility but cautions those with celiac disease to be extra careful when reading food packaging to make sure it hasn’t come in contact with other gluten-containing grains.
Beans are a fantastic source of dietary fiber and are also naturally gluten-free, which makes them a fantastic option for salads, soups, and more. Make sure you read the labels, though, as some beans may contain traces of wheat or soy due to cross-contamination. Beyond Celiac also cautions against buying dried beans from bulk food stores.
Fruits and Vegetables
Fruits and vegetables are fair game for those eating a gluten-free diet and are recommended for their high amounts of fiber, vitamins, and minerals. Make sure to read the labels on frozen or prepared produce and avoid buying dried fruit from bulk stores to avoid cross-contamination.
If you’re a home baker, you might feel frustrated by the differences between flour containing gluten and flour without it. Gluten-free flours can’t replicate the real thing very closely, but there are gluten-free options you can experiment with. White rice flour, chickpea flour, and buckwheat flour are all great flours to begin experimenting with.
Xanthan gum might sound like an exotic ingredient, but chances are you’ve eaten this common gluten-free food additive many, many times. Xanthan gum can be used as a thickener, binder, and stabilizer in gluten-free baking in an effort to avoid a rock-hard texture and an overly dense crumb. Xanthan gum can be purchased in specialty shops, natural food stores, and online.
Sneaky Foods to Avoid When Eating Gluten-Free
Soy sauce is made from fermented black beans and wheat, which makes it unsafe for people with celiac disease. Reach for tamari instead (always checking the label to make sure it’s gluten-free), which has such a similar taste to soy sauce that you might not even notice the difference.
Nicknamed “wheat meat,” this meat analogue is literally made of wheat. Stick to tofu if you’re in the mood for vegetarian protein, and as always, read the label.
Most beer is made from wheat and barley, which sadly makes it a bad choice for those suffering from celiac disease. The good news? Gluten-free beers are now widely available, and some small craft beer breweries have gone completely gluten-free in production and processing.
The Bottom Line
Experts agree that going gluten-free isn’t a great option unless you suffer from celiac disease. If you’re unsure or worried about the potential implications of this chronic disease, it’s important to talk to your doctor about getting screened. By embarking on an unnecessary gluten-free diet, you risk eliminating major nutrients from the foods you would normally enjoy—as well as paying more for products specifically labeled as gluten-free. Make an appointment to talk with your doctor if you’re worried about gluten, and you can move forward with your treatment confident that you’re working with a professional.