What To Do if You Suspect Gluten Problems

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Symptoms of gluten sensitivity include irritable bowel type symptoms such as bloating, abdominal pain, and changes in bowel habits, as well as systemic manifestations such as brain fog, headache, fatigue, depression, joint and muscle aches, numbness in the extremities, skin rash, or anemia. I previously discussed why people who suspect they might be gluten sensitive should not go on a gluten-free diet. But if that's true, what should they do?

The first thing is a formal evaluation for celiac disease, which currently involves blood tests and a small intestinal biopsy. If the evaluation is positive, then a gluten-free diet is necessary. If it's negative, it's best to try a healthier diet with more fruits, vegetables, whole grains and beans while avoiding processed junk. In the past, a gluten-free diet had many benefits over the traditional American diet because it required increasing fruit and vegetable intake--so no wonder people felt better eating gluten-free: no more unhealthy bread products, no more fast food restaurants. Now, there is just as much gluten-free junk out there.

If a healthy diet doesn't help, then the next step is to try ruling out other causes of chronic gastrointestinal distress. In a study of 84 people who claim gluten causes them adverse reactions (they're referred to in the literature as"PWAWGs," People Who Avoid Wheat and/or Gluten), highlighted in my video, How to Diagnose Gluten Intolerance, about a third didn't appear to have gluten sensitivity at all. Instead, they either had an overgrowth of bacteria in their small intestine, were fructose or lactose intolerant, or had a neuromuscular disorder like gastroparesis or pelvic floor dysfunction. Only if those are also ruled out, would I suggest people suffering from chronic suspicious symptoms try a gluten-free diet. If symptoms improve, stick with it and maybe re-challenge with gluten periodically.

Unlike the treatment for celiac disease, a gluten-free diet for gluten sensitivity is ideal not only to prevent serious complications from an autoimmune reaction, but to resolve symptoms and try to improve a patient's quality of life. However, a gluten-free diet itself can also reduce quality of life, so it's a matter of trying to continually strike the balance. For example, gluten-free foods can be expensive, averaging about triple the cost. Most people would benefit from buying an extra bunch of kale or blueberries instead.

No current data suggests that that general population should maintain a gluten-free lifestyle, but for those with celiac disease, a wheat allergy, or a sensitivity diagnosis, gluten-free diets can be a lifesaver.

For more on gluten, check out Is Gluten Sensitivity Real? and Gluten-Free Diets: Separating the Wheat from the Chat.

Some food strategies that may help with irritable bowel symptoms are covered in a few of my previous videos, such as Kiwifruit for Irritable Bowel Syndrome and Cayenne Pepper for Irritable Bowel Syndrome and Chronic Indigestion.

In health,

Michael Greger, M.D.

PS: If you haven't yet, you can subscribe to my free videos here and watch my live year-in-review presentations Uprooting the Leading Causes of Death, More Than an Apple a Day, From Table to Able, and Food as Medicine.

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How a Gluten-Free Diet Can Be Harmful

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Until only a few years ago, almost the whole of the scientific world maintained that the wheat protein gluten would provoke negative effects only in people with rare conditions such as celiac disease or wheat allergies. But by the early part of 2013, it was largely becoming accepted that some non-celiac patients could suffer from gluten or wheat sensitivity. Indeed, a consensus panel of experts now officially recognizes three gluten-related conditions, wheat allergy, celiac disease and gluten sensitivity.

What percentage of the population should avoid wheat? About 1 in a 1,000 may have a wheat allergy, and nearly 1 in a 100 may have celiac disease. Celiac disease appears to be on the rise, though there's still less than about a 1 in 10,000 chance an American will be diagnosed with celiac in a given year. Our best estimate for wheat sensitivity is in the same general range as celiac, slightly higher than 1 percent. That's still potentially millions of people who may have been suffering for years who could have been cured by simple dietary means, yet who were unrecognized and unaided by the medical profession.

Although gluten sensitivity continues to gain medical credibility, we still don't know how it works. We don't know how much gluten can be tolerated, if it's reversible or not, or what the long-term complications might be of not sticking to a gluten-free diet. Considering the lack of knowledge, people with gluten sensitivity should consider reintroducing gluten back into their diet every year to see if it's still causing problems.

The reason health professionals don't want to see people on gluten-free diets unless absolutely necessary is that, for the 98 percent of people that don't have gluten issues, whole grains--including the gluten grains wheat, barley and rye--are health promoting, linked to reduced risk of coronary heart disease, cancer, diabetes, obesity and other chronic diseases.

Because some people have a peanut allergy doesn't mean everyone should avoid peanuts. There is no evidence to suggest that following a gluten-free diet has any significant benefits in the general population. Indeed, there is some evidence to suggest that a gluten-free diet may adversely affect gut health in those without celiac disease, gluten sensitivity, or wheat allergy. A study out of Spain, highlighted in my video, Gluten-Free Diets: Separating the Wheat from the Chat, found that a month on a gluten-free diet may hurt our gut flora and immune function, potentially setting those on gluten-free diets up for an overgrowth of harmful bacteria in their intestines. Why? Because the very components wheat sensitive people have problems with, like FODMAP and fructans, may act as prebiotics and feed our good bacteria.

Gluten, itself, may also boost immune function. After less than a week on added gluten protein, subjects experienced significantly increased natural killer cell activity, which could be expected to improve our body's ability to fight cancer and viral infections. Another study found that high gluten bread improved triglyceride levels better than regular gluten bread.

Ironically, one of the greatest threats gluten-free diets pose may be the gluten itself. Self-prescription of gluten withdrawal may undermine our ability to pick up celiac disease, the much more serious form of gluten intolerance. The way we diagnose celiac is by looking for the inflammation caused by gluten in celiac sufferers, but if they haven't been eating a lot of gluten, we might miss the disease. Hence, rather than being on a gluten-free diet, we want celiac suspects to be on a gluten-loaded diet. We're talking 4-6 slices of gluten packed bread every day for at least a month so we can definitively diagnose the disease.

Why does it matter to get a formal diagnosis if you're already on a gluten-free diet? Well, it's a genetic disease, so you'll know to test the family. But most importantly, many people on gluten-free diets are not actually on gluten-free diets. Even 20 parts per million can be toxic to someone with celiac. Many on "gluten-free diets" inadvertently eat gluten. Sometimes gluten-free products are contaminated, so even foods labeled "gluten-free" may still not be safe for celiac sufferers.

As editorialized in the Lancet, the irony of many celiac patients not knowing their diagnosis, while millions of non-sufferers banish gluten from their lives, can be considered a public health farce.


Though the medical profession now recognizes wheat sensitivity as a discrete entity, it's still not clear if it's actually the gluten to which people are reacting. For a review of the controversy, see Is Gluten Sensitivity Real?

In How to Diagnose Gluten Intolerance, I go step by step how someone may want to proceed who suspects they might be sensitive to gluten-containing grains.

More on the benefits of whole grains in general in Whole Grains May Work As Well As Drugs and Alzheimer's Disease: Grain Brain or Meathead?

More on keeping our gut flora happy in videos such as Prebiotics: Tending Our Inner Garden and How to Change Your Enterotype.

In health,
Michael Greger, M.D.

PS: If you haven't yet, you can subscribe to my free videos here and watch my live year-in-review presentations Uprooting the Leading Causes of Death, More Than an Apple a Day, From Table to Able, and Food as Medicine.

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Gluten Sensitivity Put to the Test

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In 1980, researchers in England reported a series of women with no evidence of celiac disease (the autoimmune disorder associated with gluten intolerance), who nevertheless resolved their chronic diarrhea on a gluten-free diet. The medical profession was skeptical at the time that non-celiac gluten sensitivity existed, and even 30 years later, such patients were commonly referred to psychiatrists. Psychological testing of such patients, however, found no evidence that they were suffering from any kind of psychosomatic hysteria.

The medical profession has a history of dismissing diseases as all in people's heads--post-traumatic stress disorder, ulcerative colitis, migraines, ulcers, asthma, Parkinson's disease, and multiple sclerosis. Despite resistance from the prevailing medical community at the time, these health problems have subsequently been confirmed to be credible physiologically-based disorders rather than psychologically-based confabulations.

On the flipside, the internet is rife with unsubstantiated claims about gluten free diets, which has spilled over into the popular press to make gluten the diet villain du jour, with claims like "17 million Americans are gluten sensitive." However, it must be remembered that the gluten-free food industry is a big business. When literally billions are at stake, it's hard to trust anybody. As always, it's best to stick to the science.

What sort of evidence do we have for the existence of a condition presumed to be so widespread? Not much. The evidence base for such claims has been unfortunately very thin because we haven't had randomized controlled trials demonstrating that the entity even exists. The gold-standard for confirming non-celiac gluten sensitivity requires a gluten-free diet, followed by a double-blind, randomized, placebo-controlled food challenge. For example, give people a muffin and don't tell them if it's gluten-free or gluten-filled--to control for placebo effects--and see what happens. The reason this is necessary is because when you actually do this, a number of quote-unquote "gluten-sensitive" patients don't react at all to disguised gluten and instead react to the gluten-free placebo.

We never had that level of evidence until 2011, when a double-blind, randomized placebo-controlled trial was published, which tested to see if patients complaining of irritable bowel symptoms who claimed they felt better on a gluten free diet--despite not having celiac disease--actually could tell if they were given gluten containing bread and muffins or gluten-free bread and muffins.

Subjects started out gluten-free and symptom-free for two weeks and then were challenged with the bread and muffins. In my video, Is Gluten Sensitivity Real?, you can see what happened to the 15 patients who got the placebo, meaning they started out on a gluten-free diet and continued on a gluten-free diet. They got worse. Just the thought that they may be eating something that was bad for them made them feel crampy and bloated. This is what's called the nocebo effect. The placebo effect is when you give someone something useless and they feel better; the nocebo effect is when you give someone something harmless and they feel worse. On the other hand, the small group that got the actual gluten, felt even worse still. The researchers concluded that non-celiac gluten intolerance may therefore indeed exist.

It was a small study, though, and even though the researchers claimed the gluten-free bread and muffins were indistinguishable, maybe at some level the patients could tell which was which. So in 2012, researchers in Italy took 920 patients that had been diagnosed with non-celiac gluten sensitivity and put them to the test with a double-blinded wheat challenge by giving them capsules filled with wheat flour or filled with placebo powder. More than two-thirds failed the test, such as getting worse on the placebo or better on the wheat. But of those that passed, there was a clear benefit to staying on the wheat-free diet. The researchers concluded that their findings confirmed the existence of a non-celiac wheat sensitivity. Note I said "wheat sensitivity," not "gluten sensitivity."

Gluten itself may not be causing gut symptoms at all. Most people with wheat sensitivity have a variety of other food sensitivities. Two thirds are sensitive to cow's milk protein, and many are sensitive to eggs. If we put people on a diet low in common triggers of irritable bowel symptoms, and then challenge them with gluten, there's no effect. We find the same increase in symptoms with high gluten, low gluten, or no gluten diets, calling into question the very existence of non-celiac gluten sensitivity.

Interestingly, despite being informed that avoiding gluten didn't seem to do a thing for their gut symptoms, many participants opted to continue following a gluten-free diet as they subjectively described "feeling better." So researchers wondered if avoiding gluten might improve the mood of those with wheat sensitivity. Indeed, short-term exposure to gluten appeared to induce feelings of depression in these patients. Whether non-celiac gluten sensitivity is a disease of the mind or the gut, it is no longer a condition that can be dismissed.


More than 10,000 articles have been published on gluten in medical journals--intimidating even for me! Combined with the multi-billion dollar financial interests on both sides, it makes for a difficult task. But I think I did it! This is the first of a 3-part series summarizing the best available science on gluten. Also check out: Gluten-Free Diets: Separating the Wheat from the Chat and How to Diagnose Gluten Intolerance.

Why this apparent increase in food sensitivities in recent decades? It could be because of pollutant exposure (see Alkylphenol Endocrine Disruptors and Allergies and Dietary Sources of Alkylphenol Endocrine Disruptors).

What can we do about preventing so-called atopic diseases (like allergies, asthma, and eczema)? See my videos Preventing Allergies in Adulthood and Preventing Allergies in Childhood. The weirdest example of an emerging food sensitivity may be the tick-bite related meat allergy story I review in Alpha Gal and the Lone Star Tick and Tick Bites, Meat Allergies, and Chronic Urticaria.

In health,
Michael Greger, M.D.

PS: If you haven't yet, you can subscribe to my free videos here and watch my live year-in-review presentations Uprooting the Leading Causes of Death, More Than an Apple a Day, From Table to Able, and Food as Medicine.

Image Credit: Guillaume Paumier / Flickr

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