VIDEO VERSION here:
What is your opinion about gluten? How have you come to your conclusions? As a functional medicine physician, I find most articles I read in the popular press incomplete. I would like to share what I have learned in my journey from conventional doctor to functional medicine physician.
The basic statistic is this: 1% of Americans have celiac disease, a well-established autoimmune disease. An additional 5-6% of Americans may have non-celiac gluten sensitivity (NCGS), which has very recently been recognized as a real illness by gastroenterologists. Both celiac disease and NCGS can have symptoms that have nothing to do with the gut.
So, why are 10-30% of Americans (depending on the survey) trying to reduce the gluten in their diets? Are most of them fools?
A new disease
First let me point out that until 2011, most gastroenterologists refused to believe that gluten could cause stomach cramps in patients without celiac disease. That is barely 4 years ago. Now many admit that they were missing a lot of people with NCGS. Could they be missing something else? What will they admit to in another 4 years? Would you prefer to get healthier now, or would you like to wait?
I understand the strong drive to prevent our patients from falling prey to expensive scams. I understand our hesitation to recommend a diet that has not been “proven” safe. I also understand that we worry that patients will neglect some other treatable condition and instead do diet experiments we believe are doomed to fail. So I think physicians who don’t believe so many people should be gluten-free have good intentions.
I also know that American agriculture has a strong vested interest in maintaining (increasing, really) our collective consumption of wheat products. And American processed food manufacturing and food retailing has a similar strong vested interest. In the setting of powerful conflicts of interest, mainstream media does not serve us well.
Here is my point of view
As a doctor, I see sick people. I don’t see well people because they don’t seek me out. Out of the sick people I see, many have a problem with gluten. As a quick review, gluten is a protein found in wheat, barley, rye and in contaminated oats. It contains another protein called gliadin, which seems to be the one to cause problems.
Types of problems with gluten
Here’s some of the problems my patients are having, in order of increasing difficulty to diagnose:
o Some people have wheat allergies. When they eat wheat, they get a stuffy nose, or they break out in hives. This is diagnosed with a simple blood test for Wheat IgE.
o Many people have a problem with processing carbohydrates (40% or more, actually). This may show up in the blood as a high Hemoglobin A1C (over 5.6%). People with this problem can easily demonstrate to themselves, by using an inexpensive glucometer (freely available on Amazon) that a meal consisting of cereal, or sandwich, or pasta, results in elevated blood sugar (as opposed to a salad, or a meal consisting of only lean protein plus broccoli).
o Some people have celiac disease. They have the genetics that put them at risk (positive DQ2 or DQ8 genes) and in addition, they have a positive transglutaminase (tTg) IgA antibody, endomysial antibody or deamidated gliadin antibody. Note that testing only for the tTg is not enough to rule out celiac disease. In addition to blood testing, gastroenterologists recommend an intestinal biopsy to officially call it celiac disease, but some argue that positive antibodies are sufficient to recommend a gluten-free diet.
o Some patients have a problem tolerating lectins, which are also in beans and some other foods. A possible test for lectin sensitivity is the wheat germ agglutinin antibody test.
o Some people have a problem with FODMAPs. These are components (fermentable carbohydrates) abundant in certain foods (including wheat) that cause bloating in susceptible individuals. There is a hydrogen breath test that may or may not help with detecting this.
o Some people react to breakdown products of gluten and dairy called gluteomophins and casomorphins. I am not sure these can be measured outside of research labs.
o Some people have non-celiac gluten sensitivity (NCGS). At this time, this is a condition without clear diagnostic criteria. If you say that you feel better off wheat, that makes you a candidate. There are tests for anti-gliadin antibodies, but they are not universally accepted by conventional medicine. There are also biopsy findings but most people with gluten sensitivity do not undergo intestinal biopsies.
The test I use is from Cyrex Laboratories. It finds more people with anti-gliadin antibodies than any other test.
You will see the figure of 3-5% of people having NCGS. This is when you test all the patients in a gastroenterology practice. If you take people with joint pains, or people with balance problems, or people with autoimmune disease, or people in my practice, you will find a different percentage--sometimes lower, sometimes much higher.
Why do I take patients off gluten?
Taking people off gluten is one of my most common initial dietary changes. Here’s why I do it, and why this makes all the articles you read by science journalists who have consulted with conventional medical sources incomplete.
I take anyone off gluten who has significant inflammation. How do I know they have inflammation? I learned that from reading research studies about the medical conditions I treat. Most people who haven’t felt well for months or years (my specialty is chronic illness) have inflammation. In any given person with a health complaint, I actually have to prove it’s not a factor. It is my job to improve this aspect of the immune system in all my patients. It’s the only way I can hope to reverse illness without the use of drugs.
Why is gluten a problem for inflammation?
First, gluten causes increased intestinal permeability in everyone temporarily. For some, this is repaired before the next dose of gluten. For others, it’s not. Leaky gut will cause leakage of large poorly digested proteins from the gut into the bloodstream, and basic immunology tells us that these tend to elicit an immune response (i.e. inflammation). In addition to this, some people are exquisitely sensitive to some undigested proteins from specific foods. Leaky gut also allows gut bacteria to leak into the bloodstream, and these bacteria have a substance on them called lipopolysaccharide (LPS), which is also a strong immune system stimulant (i.e. inflammatory).
It has been hypothesized that a healthy gut microbiome may minimize the issues with intestinal permeability. However, as we well know, our microbiomes have been weakened by our environment and our customs (such as hygiene and antibiotics).
Second, wheat products tend to take the place of healthier products in our diet. They present a number of drawbacks, including the fact that they have a high glycemic index, and the fact that they don’t have as many vitamins and phytonutrients as do fruits, vegetables, seeds and nuts. If you replace your cereal/bread/pasta with a “gluten-free” version, you will not see much of a difference in your nutrient intake. However, this is not what I recommend. Gluten-free products are processed foods, and thus of little use to any person who is trying to overcome a serious medical problem. If you replace your breakfast cereal with a smoothie full of fresh produce, your lunchtime sandwich with a big colorful salad, and your evening noodles or pizza with healthy protein and a vegetable stir-fry—then you will indeed reap the rewards of a healthier diet.
Third, changing your diet changes your beneficial bacteria. As they are in charge of your immune system, of making vitamins for you, of breaking down toxins or causing inflammation, changing them is often beneficial in changing your symptoms.
Traditional vs. updated
The controversy about gluten relates to the different ways in which patients with chronic illness are viewed in the conventional vs. the alternative medicine model. In the conventional model, we seek a single cause—an infectious agent, an injury, a genetic predisposition. In the alternative model (or more precisely in this case, the functional medicine model), the “terrain” or underlying weakness of the individual is the most important factor: the microbiome modulates genetics to create inflammation that results in disease.
Gluten acts almost like a litmus test that reveals significant inflammation and gut microbiome weakness. These preconditions exist before gluten is added but worsen with the addition of gluten. Thus, many people find that they feel better when they transition from a standard diet to a high nutrient, gluten-free diet.
The controversy about gluten might simply be related to our shifting understanding of the underlying drivers of health and disease.
The basic statistic is this: 1% of Americans have celiac disease, a well-established autoimmune disease. An additional 5-6% of Americans may have non-celiac gluten sensitivity (NCGS), which has very recently been recognized as a real illness by gastroenterologists. Both celiac disease and NCGS can have symptoms that have nothing to do with the gut.
So, why are 10-30% of Americans (depending on the survey) trying to reduce the gluten in their diets? Are most of them fools?
A new disease
First let me point out that until 2011, most gastroenterologists refused to believe that gluten could cause stomach cramps in patients without celiac disease. That is barely 4 years ago. Now many admit that they were missing a lot of people with NCGS. Could they be missing something else? What will they admit to in another 4 years? Would you prefer to get healthier now, or would you like to wait?
I understand the strong drive to prevent our patients from falling prey to expensive scams. I understand our hesitation to recommend a diet that has not been “proven” safe. I also understand that we worry that patients will neglect some other treatable condition and instead do diet experiments we believe are doomed to fail. So I think physicians who don’t believe so many people should be gluten-free have good intentions.
I also know that American agriculture has a strong vested interest in maintaining (increasing, really) our collective consumption of wheat products. And American processed food manufacturing and food retailing has a similar strong vested interest. In the setting of powerful conflicts of interest, mainstream media does not serve us well.
Here is my point of view
As a doctor, I see sick people. I don’t see well people because they don’t seek me out. Out of the sick people I see, many have a problem with gluten. As a quick review, gluten is a protein found in wheat, barley, rye and in contaminated oats. It contains another protein called gliadin, which seems to be the one to cause problems.
Types of problems with gluten
Here’s some of the problems my patients are having, in order of increasing difficulty to diagnose:
o Some people have wheat allergies. When they eat wheat, they get a stuffy nose, or they break out in hives. This is diagnosed with a simple blood test for Wheat IgE.
o Many people have a problem with processing carbohydrates (40% or more, actually). This may show up in the blood as a high Hemoglobin A1C (over 5.6%). People with this problem can easily demonstrate to themselves, by using an inexpensive glucometer (freely available on Amazon) that a meal consisting of cereal, or sandwich, or pasta, results in elevated blood sugar (as opposed to a salad, or a meal consisting of only lean protein plus broccoli).
o Some people have celiac disease. They have the genetics that put them at risk (positive DQ2 or DQ8 genes) and in addition, they have a positive transglutaminase (tTg) IgA antibody, endomysial antibody or deamidated gliadin antibody. Note that testing only for the tTg is not enough to rule out celiac disease. In addition to blood testing, gastroenterologists recommend an intestinal biopsy to officially call it celiac disease, but some argue that positive antibodies are sufficient to recommend a gluten-free diet.
o Some patients have a problem tolerating lectins, which are also in beans and some other foods. A possible test for lectin sensitivity is the wheat germ agglutinin antibody test.
o Some people have a problem with FODMAPs. These are components (fermentable carbohydrates) abundant in certain foods (including wheat) that cause bloating in susceptible individuals. There is a hydrogen breath test that may or may not help with detecting this.
o Some people react to breakdown products of gluten and dairy called gluteomophins and casomorphins. I am not sure these can be measured outside of research labs.
o Some people have non-celiac gluten sensitivity (NCGS). At this time, this is a condition without clear diagnostic criteria. If you say that you feel better off wheat, that makes you a candidate. There are tests for anti-gliadin antibodies, but they are not universally accepted by conventional medicine. There are also biopsy findings but most people with gluten sensitivity do not undergo intestinal biopsies.
The test I use is from Cyrex Laboratories. It finds more people with anti-gliadin antibodies than any other test.
You will see the figure of 3-5% of people having NCGS. This is when you test all the patients in a gastroenterology practice. If you take people with joint pains, or people with balance problems, or people with autoimmune disease, or people in my practice, you will find a different percentage--sometimes lower, sometimes much higher.
Why do I take patients off gluten?
Taking people off gluten is one of my most common initial dietary changes. Here’s why I do it, and why this makes all the articles you read by science journalists who have consulted with conventional medical sources incomplete.
I take anyone off gluten who has significant inflammation. How do I know they have inflammation? I learned that from reading research studies about the medical conditions I treat. Most people who haven’t felt well for months or years (my specialty is chronic illness) have inflammation. In any given person with a health complaint, I actually have to prove it’s not a factor. It is my job to improve this aspect of the immune system in all my patients. It’s the only way I can hope to reverse illness without the use of drugs.
Why is gluten a problem for inflammation?
First, gluten causes increased intestinal permeability in everyone temporarily. For some, this is repaired before the next dose of gluten. For others, it’s not. Leaky gut will cause leakage of large poorly digested proteins from the gut into the bloodstream, and basic immunology tells us that these tend to elicit an immune response (i.e. inflammation). In addition to this, some people are exquisitely sensitive to some undigested proteins from specific foods. Leaky gut also allows gut bacteria to leak into the bloodstream, and these bacteria have a substance on them called lipopolysaccharide (LPS), which is also a strong immune system stimulant (i.e. inflammatory).
It has been hypothesized that a healthy gut microbiome may minimize the issues with intestinal permeability. However, as we well know, our microbiomes have been weakened by our environment and our customs (such as hygiene and antibiotics).
Second, wheat products tend to take the place of healthier products in our diet. They present a number of drawbacks, including the fact that they have a high glycemic index, and the fact that they don’t have as many vitamins and phytonutrients as do fruits, vegetables, seeds and nuts. If you replace your cereal/bread/pasta with a “gluten-free” version, you will not see much of a difference in your nutrient intake. However, this is not what I recommend. Gluten-free products are processed foods, and thus of little use to any person who is trying to overcome a serious medical problem. If you replace your breakfast cereal with a smoothie full of fresh produce, your lunchtime sandwich with a big colorful salad, and your evening noodles or pizza with healthy protein and a vegetable stir-fry—then you will indeed reap the rewards of a healthier diet.
Third, changing your diet changes your beneficial bacteria. As they are in charge of your immune system, of making vitamins for you, of breaking down toxins or causing inflammation, changing them is often beneficial in changing your symptoms.
Traditional vs. updated
The controversy about gluten relates to the different ways in which patients with chronic illness are viewed in the conventional vs. the alternative medicine model. In the conventional model, we seek a single cause—an infectious agent, an injury, a genetic predisposition. In the alternative model (or more precisely in this case, the functional medicine model), the “terrain” or underlying weakness of the individual is the most important factor: the microbiome modulates genetics to create inflammation that results in disease.
Gluten acts almost like a litmus test that reveals significant inflammation and gut microbiome weakness. These preconditions exist before gluten is added but worsen with the addition of gluten. Thus, many people find that they feel better when they transition from a standard diet to a high nutrient, gluten-free diet.
The controversy about gluten might simply be related to our shifting understanding of the underlying drivers of health and disease.
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