Gluten-free

Gluten is a composite protein found in wheat and related cereal grain species. It is highly similar to the protein avenin, found in oats.[1] The protein is useful for giving elasticity to dough which helps it rise and keep its shape along with providing a chewy texture. Cereals containing gluten have been a staple in many cultures since the start of agriculture and its effects are well known. For the vast majority of people gluten is useful addition to a healthy diet. Gluten-free commonly refers to a diet that excludes sources of gluten and may also refer to a diet excluding sources of avenin.

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Gluten is the product of the combination of two storage proteins in wheat and related grasses: glutenin and gliadin. Gliadin (and occasionally analogous proteins in other grains, called prolamins as they're rich in proline and glutamine) is the offender; in certain people with a genetic predisposition, its metabolites can trigger a false-alarm immune response, attacking the small intestine and causing the symptoms of celiac.

The gluten-free diet (GFD) can be adopted as a treatment for legitimate medical conditions, most notably celiac disease, which is estimated to affect around 1 in 70 people.[note 1][4] Other medical conditions for which a GFD may be appropriate are wheat allergy, nonceliac gluten/wheat sensitivity (NCGS).[5] It has also been embraced as a fad diet, weight-loss gimmick, and purported autism cure, mostly by people who don't actually know what gluten is and can't define it when asked. [6]

Evidence-based reasons for adoption

While you may have heard of the no-good reasons, there are a few very valid reasons people may choose a gluten-free diet.

If you ever serve food to someone who says they're gluten-free, please take it seriously and be careful not to give them gluten. Some people get sick from eating gluten (and, in extreme cases, can feel horribly ill after coming in contact with traces). Remember, poisoning other people is bad.

Celiac disease

Celiac disease (or coeliac outside of the US) is an autoimmune disorder which interferes with digestion. The immune system responds to gluten peptides absorbed in the small intestine, causing inflammation and damage to the gut and a variety of unpleasant symptoms. Celiac disease is also triggered in about 75% of patients by avenin, a molecularly similar protein found in oats. There are also long-term effects primarily related to malabsorption, including failure to thrive (in children), chronic diarrhoea and digestive problems, osteoporosis, anaemia (generally iron, vitamin D and folic acid), a characteristic form of blistering eczema and a significant increase in risk of cancer, especially in the stomach or bowel. Even a small amount of gluten (e.g. a small crumb, a dusting of flour, or a microscopic remnant on a surface) can trigger an attack. Symptoms of being "glutened" range from person to person, as do the amount of gluten needed to cause a reaction; and typically include lethargy, nausea, bloating, vomiting, and either constipation or diarrhea.

The condition has been recognized since at least the first century CE, and was described by Aretaeus of Cappadocia ("celiac" is of ancient Greek origin).[7] The connection between gluten and celiac disease was discovered by a Dutch pediatrician, Willem Karel Dicke.File:Wikipedia's W.svg[8] During the Dutch famine during the end of World War II when wheat bread was unavailable, he noticed that death from celiac dropped to zero.[8] Later, in 1952, he and colleagues discovered that gluten was the trigger for celiac disease, which then led to the development of the gluten-free diet.[8]

Like autism, this has led some people to think that celiac is a modern disease. The reality is that even ancient forms of wheat such as spelt and kamut trigger an attack as easily as any modern wheat variety. It is more likely that better recognition of the symptoms, and understanding the etiology, accounts for the higher rates of diagnosis. It is still widely considered to be under-diagnosed with an estimated prevalence in the population as high as one percent.[9]

It is not possible to self-diagnose celiac disease, not least because the symptoms are generally indistinguishable from conditions such as irritable bowel syndrome. Diagnosis normally consists of a blood test for the genetic marker (HLA-DQ2/8) and the antibody tTG-IgA; followed by a duodenal biopsy that examines the intestine lining for villous atrophy (erosion of the villi, structures which increase the surface area of the gut wall to improve absorption). In extreme cases the gut wall may become completely smooth. The blood test is very accurate with a false negative rate of less than 5% and a much lower false positive rate, leading some specialists to dispute the need for a (mildly distressing) biopsy in clear-cut cases.

The only current proven treatment is a completely gluten-free diet which allows the intestine to heal, absorb nutrients and function normally.[10] (While the intestine is healing, the patient might also need to avoid dairy products, as the damaged intestines might be unable to cope with milk proteins; but most of the time dairy can be resumed afterward.) However, there are some early vaccine trials that are attempting to desensitize the body's immune response to gluten peptides.[11][12] There has also been some preliminary evidence that helminthic therapy might be an effective treatment.

Dermatitis Herpetiformis

Dermatitis herpetiformisFile:Wikipedia's W.svg is another autoimmune disorder triggered by gluten. Dermatitis Herpetiformis is related to Celiac disease[13] and affects the skin.[14] Dematitis Herpetiformis is rarer than Celiac Disease with a prevalence between 1 in 3,300 to 1 in 10,000.[14][15]

Dermatitis Herpetiformis can be treated using the drug Dapsone, however prolonged use of Dapsone can lead to side effects and the recommended treatment is as per Celiac Disease a lifelong avoidence of gluten in the diet.[14][15]

Wheat allergy or gluten sensitivity

Aside from celiac disease, many people have a less-intense but still real (maybe[16]) sensitivity to gluten. Levels of sensitivity can vary from person to person. Still other people have a wheat allergy, which is not the same as celiac disease or gluten sensitivity. Because of the lifestyle changes that a gluten-free diet imposes, and because advanced cases of celiac disease sometimes need additional immunosuppressant or steroid treatments, it's important to be examined by a competent medical professional when someone has concerns about their intake of gluten.

Not all sensitivites to gluten are real, though.[17][18][19] What may actually be going on are so-called FODMAPs (Fermentable Oligo-Di-Monosaccharides and Polyols)[20], short-chain carbohydrates akin to the ones in beans that are digested by gut bacteria and cause flatulence; although they generally aren't terribly digestible, some people react to the fermentation products worse than others, producing gastrointestinal symptoms akin to irritable bowel syndrome. This however is not nearly as damaging as celiac.

An "elimination" low-FODMAP diet[21], includes no wheat, so that could explain why many people mistakenly think that they are gluten-intolerant when in fact it has nothing to do with gluten and everything to do with FODMAPs.

Interestingly, one component of FODMAPs, polyols, can be properly digested by 0% of the human population — so in a sense, everyone is FODMAP-intolerant to a greater or lesser degree.

Hypothyroidism

A correlation exists between patients suffering from autoimmune hypothyroidism and celiac disease.[22] This association is on the order of a tenfold increase in the odds of having celiac disease if you have Hashimoto's thyroiditis, as compared with the incidence of celiac disease in the general population. One possible mechanism is a similarity between gliadin and one or more thyroid tissues.

This, of course, leads to inevitable overreaction, such as claiming that all hypothyroid patients should go gluten-free, whether they've been tested for celiac disease or not.[23]

Woo-based reasons for adoption

Gluten has become a new food woo, with fad diets popping up touting themselves gluten-free, including products that are not even grain such as gluten-free salt. This is usually done because people will pay larger amounts of cash for things perceived as better for you. These products have arisen due to the mistaken belief that gluten is somehow responsible for many bowel problems in non-celiacs and that better health can be achieved by abstaining from it. Some quacks have gone so far as to "link" gluten to a myriad of diseases such as autism in a similar way that quacks "linked" vaccines to autism.

Because of the constraints the diet imposes, doing so may be detrimental to their health.[24]

Autism quackery
See the main article on this topic: Autism

Gluten-free diets are sometimes promoted by anti-vaccination types such as Jenny McCarthy as a means to treat or "cure" autism.[25][26] There is no known basis for this assertion, and in fact a gluten-free diet can make you worse off if you aren't somehow making up for lost nutrients.[27]

ABC News reported in 2010 on a study that showed a gluten-free, casein-free diet had no effect on autism.[28][29]

A study presented at the International Meeting for Autism Research showed that 18% of children with autism, Asperger disorder, or PDD-NOS had been put on a "special diet" advocated by alternative medicine, and among those, 47-50% had been put on a gluten-free diet. Families discontinued the use of special diets at a rate of only 5-10% per year, indicating a strong adherence to the idea despite a lack of results.[30]

Weight loss quackery

Diet woo for weight loss has jumped on this one! Here is the reason you're fat: it's gluten.[31] Few medical experts or professional dieticians have ever found any reason to suggest a gluten-free diet aids in weight loss, but seemingly it fits so well into the "low-carb" "paleo diet" world. Early in the trend, going "gluten-free" was likely to lead to weight loss, because it necessarily cut out a number of foods which are calorie dense, such as pastas, breads, and other baked goods. However, since the trend has grown, it is now easy to find gluten-free varieties of these items, as well as a large number of gluten-free junk food items, thus making it just as easy to be obese without gluten as it is with.

Discussions about gluten-free diets are found in the comment sections of many weight loss sites, even when the diet doesn't specifically blame gluten for weight gain.[32][33]

In reality, the onset of a GFD has been shown to cause weight gain and obesity, and also new-onset insulin resistance and metabolic syndrome.[5]

Athletics quackery

A 2015 study of 1,000 competitive athletes in Australia found that 41% of those surveyed were following a gluten-free diet.[34] The prevailing belief was that eating gluten-free would reduce the symptoms of digestive disease, which affects athletes disproportionately.[35] A follow-up study in which athletes followed a gluten-free diet combined with either a gluten-free or glutinous "energy bar" found that the gluten-free diet had no effect on their overall health whatsoever.[36]

Alleged toxicity
See the main article on this topic: Toxin

(Again with the "toxins"!) It has been claimed by some paleo diet webshites that gluten is toxic.[37][38] In fact, there is no data to support the idea that gluten is toxic to healthy, asymptomatic adults or children.[5]

Conspiracy!

A number of gluten-free advocates also buy into GMO hysteria and claim that the presence of gluten in food is essentially food adulteration for profit; there are numerous related memes among such people, including that GMO wheat has increased gluten (there was no GMO wheat on the market as of 2014), or that gluten is an expendable filler, or such things. Monsanto pops up a lot in the discussion, as do various aspects of the paleo diet and the "golden age" thinking that implies.

What's the harm in a fad diet?
See the main article on this topic: What's the harm

A danger to genuine celiacs is that if gluten-free is perceived as a "lifestyle" choice then many food preparers may not educate themselves or treat the condition with the seriousness that it deserves, e.g. not bother to separate food from sources of contamination that won't harm people on some GF fad diet, but can cause serious harm to a celiac sufferer. Because of this, gluten-free labeling is regulated in many parts of the world. In addition if the fad implodes as it did with the Atkins diet, then genuine sufferers are back to square one and left to deal with the misinformation fallout.

For people without celiac disease, there may be risks to going on a gluten-free diet, including "potential for obesity, new-onset insulin resistance, and deficiencies of B vitamins, folate, iron, and other nutrients."[39][5] Celiac disease is hereditary, so going on a gluten-free diet will not prevent you from having celiac disease.[39][5] "Obesity, overweight, and new-onset insulin resistance and metabolic syndrome have been identified after initiation of a GFD."[5] This may be due to GFD packaged foods containing a higher density of fat and sugar than non-GFD packaged foods.[5] GFD packaged foods are also rarely fortified with vitamins, leading to the potential for B vitamin and iron deficiency.[5]

In 2017, two parents in Belgium were convicted in the death of their 7-month old child.[40] The parents had self-diagnosed that the baby had gluten intolerance and fed him a gluten- and lactose-free diet of quinoa milk (Chenopodium quinoa).[40] The baby had never been taken to a medical doctor but the parents took him to a homeopathic "doctor" when they realized the baby was ill.[40]

As with many restrictive diets, the gluten-free diet is moderately tiresome to stick with, and unless you are medically required to, you probably shouldn't bother.[41]

If you have a partner who is highly sensitive to cross-contamination, you may end up on a gluten-free diet yourself, depending on their sensitivity. Learn to love rice pasta, millet bread, and sorghum beer.[42] Wine, cider, and distilled alcoholic beverages are safe too. See? Healthy!

Safe and unsafe foods

At its most basic, the diet means cutting out any source of gluten, primarily wheat, barley and rye. Kamut and spelt are "ancient" forms of wheat that still contain gluten. As oats contain avenin, a similar protein, many choose to also avoid oats.

The most obvious sources of gluten would be bread, biscuits and some cakes. But many foods have unexpected gluten.[43] Wheat flour is often used as a thickener and starch, meaning that most restaurant soups and many sauces will contain gluten. Pseudo-grains such as millet, buckwheat, quinoa are fine, as are potatoes, rice and corn. Oats are frequently contaminated due to being processed on machinery also used to process wheat, but there are brands which are tested and certified free from contamination. Wheat gluten is often used in meat substitutes, and sausages may contain biscuit rusk. For those with celiac, cross-contamination in the manufacturing process can also be a source of hidden gluten so it's important to check packaging for shared equipment warnings.

Some foods or food ingredients, commonly monosodium glutamate, or "glutinous rice", are safe (or at any rate, gluten-free) despite their similar names.[44]

Highly-processed grain derived products such as maltodextrin, glucose syrup, caramel coloring, grain alcohol (yay) and malt vinegar are usually gluten-free. Some gluten-free products will use highly processed wheat starch which is also gluten-free.

In short it is vital to inspect the ingredients extremely carefully and if in any doubt, don't buy. It is common to find that one brand of a product (e.g. ketchup) is safe while another brand is not.

Gluten-free alternatives

Many gluten-free substitute foods are available, such as bread and pasta made from rice & corn flour;[45] some products also use balsa wood and styrofoam, or at least taste as if they do. The quality of bread varies widely based on the ingredients and preparation involved. The biggest problem is that bread tends to fall apart or squash because it is not elastic. Some gluten-free mixes use additives to preserve the shelf life of the product, with cellulose being a common ingredient.

Grocery shopping outlets such as QFC and Fred Meyer,[46] and home-delivery services such as Amazon Fresh,[47] have special sections for gluten-free foods. Many restaurants have a gluten-free alternate menu, or mark gluten-free items on the menu itself or in a nutrition guide.

Coeliac UK has a website with an online food database that includes many supermarket brands, and UK residents can also get gluten-free staples on prescription through the NHS. The additional cost of gluten-free foods is tax-deductible for US residents with a true coeliac diagnosis (as opposed to "thinking that gluten is bad for them").

Food regulation

Europe

European food regulations require food advertised as gluten-free to possess 20 parts per million (ppm) or less of gluten. A second category of food possessing 21-100ppm may be advertised as very low gluten. [48] Some products may be "naturally gluten-free" which means there is nothing to imply gluten (e.g. a bag of carrots is naturally gluten-free) but no formal testing has been done to know for sure and in the case of some grains occasional contamination does occur.

A product must highlight allergens including gluten in its list of ingredients e.g. by putting them in bold. A separate allergens box is optional. Many products will state they "may" contain traces of gluten due to their manufacturing process.

There is no standard logo for gluten-free products however the UK Coeliac Society's "crossed grain" symbol has become the most commonly used throughout the EU and elsewhere [49]. Other products might use a similar motif or just the words "gluten-free" somewhere on their packaging.

United States

As of August 2014, the U.S. FDA requires all food labelled as "gluten-free" to contain 20 parts per million (ppm) or less of gluten, and to not be made with any unprocessed gluten-containing grain.[50]

Australia

Food Standards Australia and New Zealand (FSANZ) in collaboration with Coeliac Australia requires that for a product to be declared 'Gluten Free' it must be made on seperate equipment to any gluten containing products and contain no gluten (0ppm) or avenin. Unlike in the UK, products containing oats can not be marked Gluten Free in Australia.

Gluten-free makeup

No, we're not making this up.[51] Since a lot of cosmetics use wheat starch as a cheap filler, several cosmetic companies now sell gluten-free product lines.

It is possible, depending on where the makeup in question is applied, that a little of it could be ingested. This could trigger a reaction in a celiac sufferer. But there's no evidence that gluten can be absorbed through your skin. So you probably shouldn't worry about gluten in your eye shadow, unless your celiac bedmate likes to nibble on your eyeballs.

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See also

Notes
  1. In Australia. There are varying rates around the world: for instance, 1/100 in the UK and an estimated 1/100 worldwide[2][3]

References
  1. What Is Gluten? by Alina Bradford (December 23, 2015 03:23pm ET) Live Science.
  2. Coeliac Disease in the UK Patient Info
  3. Celiac Disease, Celiac Disease Foundation
  4. Statistics About Coeliac Disease, Coeliac Australia
  5. The Gluten-Free Diet: Recognizing Fact, Fiction, and Fad by Norelle R. Reilly (2016) The Journal of Pediatrics.
  6. Pedestrian Question, What is Gluten?
  7. The Extant works of Aretaeus, the Cappadocian.
  8. Doctors Once Thought Bananas Cured Celiac Disease. They Saved Kids' Lives — At A Cost by Jill Neimark (May 24, 20171:43 PM ET) The Salt (NPR).
  9. Coeliac prevalence and screening, Coeliac UK
  10. WebMD: Celiac Disease — Topic Overview
  11. Pioneer in the gluten-free diet: Willem-Karel Dicke 1905-1962, over 50 years of gluten-free diet
  12. Nexvax2® – Lead therapeutic
  16. … or is it? Does gluten sensitivity in the absence of coeliac disease exist?, Imran Aziz et al., British Medical Journal, 30-Nov-2012
  17. What if your gluten intolerance is all in your head?, New Scientist, 11-July-2013
  18. Non-Celiac Gluten Sensitivity May Not Exist, RealClearScience blog, 14-May-2014
  19. Biesiekierski et al., 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 (August 2013), pp. 320-328
  20. Fermentable Oligo-, Di-, and Mono-saccharides And Polyols. See FODMAP.File:Wikipedia's W.svg
  21. the one that low-FODMAP dieters are encouraged to follow for 2-6 weeks before easing off a bit to see what they can cope with
  22. Risk of thyroid disease in individuals with celiac disease, J. Clin. Endocrinol. Metab. 2008 Oct
  23. e.g. Chris Kresser (a licensed acupuncturist and practitioner of integrative medicine), The Gluten-Thyroid Connection
  24. WebMD: The Truth About Gluten
  25. The GFCF (Gluten-Free, Casein-Free) Diet for Autism Spectrum Disorders
  26. GlutenFreeHelp.info: Louder Than Words by Jenny McCarthy
  27. WebMD: Gluten-Free/Casein-Free Diets for Autism
  28. ABC News: A Gluten-Free, Casein-Free Diet No Remedy for Autism
  29. Evaluation, Diagnosis, and Treatment of Gastrointestinal Disorders in Individuals With ASDs: A Consensus Report
  30. INSAR: Persistence of Complementary and Alternative Medicine (CAM) Use In ASD
  31. example
  32. SparkPeople: Celiac Disease and Gluten-Free Group
  33. Weight Watchers: Gluten-Free Main Dishes
  34. http://www.ncbi.nlm.nih.gov/pubmed/24901744
  35. http://well.blogs.nytimes.com/2016/01/20/when-athletes-go-gluten-free/
  36. http://www.ncbi.nlm.nih.gov/pubmed/25970665
  37. Chris Kresser: 9 Steps To Perfect Health – #1: Don’t Eat Toxins
  38. PaleoLeap: 11 Ways Gluten And Wheat Can Damage Your Health
  39. Gluten-free diet may not be good for healthy kids by Cristela Guerra (May 14, 2016) Boston Globe.
  40. Baby fed 'alternative' diet weighed less than 10lbs when he died with a totally empty stomach: Mother and father tried to give baby son products like quinoa milk despite warnings it was unsuitable by May Bulman (17 May 2017 10:14 BST) The Independent.
  41. If people want to add a few gluten-free products to a normal diet including, for example, regular bread with gluten, this is a best a harmless, expensive placebo.
  42. Kill me now. — PintofStout
  43. WebMD: Hidden Gluten — Topic Overview
  44. Celiac.com's list of safe ingredients
  45. Udi's Gluten Free Bread
  46. Archive copy at the Wayback Machine
  47. Amazon: Learn How to Shop for Gluten Free
  48. concerning the composition and labelling of foodstuffs suitable for people intolerant to gluten
  50. Gluten-Free Labeling of Foods, FDA, last retrieved 8-Oct-2015
  51. Are Gluten-Free Cosmetics Necessary?, U.S. News and World Report, 11-September-2012
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