Should gluten be avoided in autoimmune diseases? 

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Over the past ten years the number of people following a gluten-free diet in the western world has increased fivefold, however, the number of diagnosed celiacs has barely changed. Are we simply facing a new trend or is it more of a reflection of a society increasingly concerned about health?

Answering that question straightaway with a simple yes or no is quite a challenging thing to do. So instead, lets analyze the characteristics of gluten, its effects on the body, its pros and cons so we can actually be able to give an opinion.

What is gluten?

Wheat is a cereal with lots of carbohydrates and proteins, amongst which three are considered problematic: gluten, wheat germ agglutinins (WGA) and amylase and trypsin inhibitors.

  • Wheat germ agglutinins are proteins that trigger an inflammatory response in intestinal cells, increasing gut permeability. Normally, since they’re in wheat, they accompany gluten, but it’s possible to have problems only with WGA and not with gluten. This study shows models in which WGA produce inflammatory changes in the intestinal wall as well as the secretion of several inflammatory cytokines and a slight increase in histamine production.
  • Amylase and trypsin inhibitors (ATI) are another family of proteins present in wheat. They are the main suspects behind non-celiac gluten sensitivity. ATI activate immune cells both in the gut and other tissues, worsening symptoms of inflammatory conditions. Here you can read an interesting study on the mechanism through which ATI produce gut inflammation.
  • Lastly, gluten, which is composed of gliadin and glutein, makes up 80% of wheat proteins. It’s a very widely used component in cooking because it provides the elasticity and consistency which are so typical of wheat products. Though gluten always takes the blame, it should be noted that wheat-related issues are often a combination of a reaction to all three proteins mentioned above.

Does gluten only affect celiacs?

The most well-known gluten related health issue is celiac disease. Nowadays, two out of every 100 europeans have been diagnosed with this condition. It’s a disease with an importan genetic factor and, unlike most other autoimmunes, it is perfectly treatable most of the time. A strict gluten-free diet enables remission in over 80% of the cases. Actually, celiac disease is a frankly interesting field of study since, together with atopic dermatitis, it is the first autoimmune disease to be successfully treated through diet and without medication.

Until just a few years ago, celiac disease was the only pathology for which a gluten-free diet was used. However, the concept of non-celiac gluten sensitivity has appeared, especially during the last ten years. It is the case of people who positively respond to a gluten-free diet, although they don’t have disease specific genes or present intestinal damage. It is estimated that up to 25% of europeans suffer non-celiac gluten sensitivity. Also, this condition is more likely in autoimmune disease sufferers than in average population. And as it’s been mentioned previously, it can be several proteins that cause trouble, not just gluten.

Is a gluten-free food necessarily healthy?

Not at all. This is one of the biggest misconceptions nowadays. Many who avoid gluten for health reasons do consume all types of products labeled “gluten-free”, let it be corn cookies or rice drink with added sugar. For a healthy person, the most important thing is for diet to be composed of natural stuff such as fresh vegetables and fruit, fish and meat. That’s why it’s definitely healthier to make your own wholegrain bread than to eat processed corn or rice based junk food.

Is a gluten-free diet dangerous?

The food industry lobby is constantly funding studies for big publishers in which gluten-free diet is regarded as seriously dangerous for health. The truth is that such articles deliberately ignore that the studies analyzed a gluten-free but junk food rich  (corn and rice based, mainly) diet. Once again, it’ll be healthier to eat some brown bread than some pre-made corn or potato starch based pizza. It’s just a question of common sense. Therefore, a well designed gluten-free diet (with plenty of veggies, fruit, some meat and fish and some rice, for example) can only be a healthy choice.

Is gluten-free diet just a passing trend?

Though there are many trying to take advantage of this phenomenon, the truth is that gluten-free diet has increasingly more evidence behind it. This fact put together with the growing number of non-celiac and gluten sensitive people will certainly carry to more people following it. We don’t actually see anything wrong about it, as such a type of diet, if well designed, brings only benefits. Right now the important is to educate people who do need such a diet so they don’t fall into the “gluten-free” products, often expensive and unhealthy.

How are gluten-related issues diagnosed?

There are several interesting tools that enable celiac disease diagnosis. Firstly, the doctor will have a look at symptoms. Abdominal pain, especially foul-smelling diarrhea, eccema or migraines will lead your practitioner to perform a genetic study and testing for blood levels of transglutaminase antibodies. If results are still not conclusive, the doctor will then perform an endoscopy and biopsy of the small intestine, which is the method of diagnosis par excellence. Unfortunately, individuals with non-celiac gluten sensitivity test negative to all of the above and only show physical symptoms. We remind you that in order to perform all the tests correctly you’ll have to continue eating gluten, or otherwise results could come back false.

In the case of all tests coming back negative and other conditions have been ruled out, the doctor could recommend a gluten-free diet, since this is probably the best method of non-celiac gluten sensitivity detection.

Gluten and FODMAPS

Many people with digestive issues report an improvement after removing gluten from their diet. Though there is no doubt about the benefits of this type of diet for most of the patients, the truth is that it’s difficult to understand exactly where the improvement comes from. Wheat contains lots of FODMAPS, therefore its elimination often brings significant improvement to those with digestive issues. As we mentioned earlier, it’s hard to know whether the improvement is due to the elimination of FODMAPS or gluten.

Why can gluten be harmful?

Gluten containing grains have been used by man since the beginning of agriculture. They are cheap and easy growing, and have always provided a great source of food in rough times. In the past 200 years, though, breeding has lead to much higher gluten contents.

When problems with gluten occur, the body synthesizes antibodies against transglutaminase, an enzyme in charge of wound cicatrization. Thus, when transglutaminase is created so to deal with the lesions that gluten causes in the gut, it is recognized and attacked by the immune system. This results in continuous damage to the intestine as long as gluten is consumed.

The mechanism through which wheat proteins damage the organism is quite simple: the body creates not-so-specific antibodies against those proteins and ends up attacking its own intestinal enterocytes. The damage doesn’t lessen while the proteins continue to be consumed, which causes a non-stop inflammatory process. Gluten also stimulates the production of zonulin, a protein which regulates intestinal permeability. Increased permeability of enterocytes enables unwanted particles such as food proteins or bacteria to reach the blood stream. Once in the blood, molecular mimicry theory says the immune system confuses those particles, attacking them.

Therefore, gluten damages the organism in an indirect way: by increasing intestinal permeability.

Should gluten be avoided in autoimmune diseases?

There’s plenty of controversy around this subject. Recommendations from the medical community are that only celiacs and people sensitive to gluten should follow this diet. The truth is there aren’t any studies which prove gluten-free as the best option for autoimmune conditions. Even so, there’s plenty of anecdotal evidente as well as some small studies which show a clear improvement of symptoms when gluten is avoided. It all seems to be linked to the normalization of intestinal permeability:

In a large group of patients with inflammatory bowel diseases, 65% of the ones who started following a gluten-free diet said to feel an improvement. Another interesting study showed how gluten affected the intestinal wall in patients who suffer irritable bowed syndrome and diarrheas. Also, a third of IBS patients respond positively to a gluten-free diet.

It is also known that celiacs have higher risk of suffering other autoimmune diseases than the average population. About one third of patients with thyroid disorders are non-celiac gluten-sensitive. A gluten-free diet improves symptoms in almost half of rheumatoid arthritis patients. In Madrid, Dr Carlos Isasi believes that numerous cases of fibromyalgia or chronic fatigue syndrome are actually untreated cases of non-celiac gluten sensitivity. Here he shows roughly twenty cases of remission after the elimination of gluten. In another paper, published in the Reumatología Clínica journal, Isasi shows several cases of ankylosing spondylitis in remission through a gluten-free diet.

It has been known for a while now that untreated celiac disease can end up causing other autoimmune diseases due to a chronically increased intestinal permeability.  Thus, it’s quite common that refractory celiacs develop lymphocytic colitis. These conditions which are typically treated with high doses of cortisone normally subside when adopting a strict gluten-free diet.

Another interesting study showed that psoriasis patients can reach remission by going gluten-free even though not having shown any obvious gluten sensitivity. On the other hand, atopic dermatitis (a skin condition) is actually a cutaneous manifestation of reaction to gluten and normally eases when steering off gluten.

Even though a thorough revision of all the evidence is still to be performed, we think that nowadays there are good reasons to believe that a large number of autoimmune disease patients would benefit from a strictly gluten-free diet.

Should healthy people follow a gluten-free diet?

Despite having mentioned that a well designed gluten-free diet is perfectly healthy, we don’t think that removing gluten from diet should be a healthy persons biggest priority. We believe that people should worry more about eating real food instead of junk food and processed stuff. If you’re healthy you’ll be just fine eating a quality bread sandwich every now and then. It’ll be much less healthy if you eat lots of pizzas of cookies, even though they’re “gluten-free”. We don’t think it’s necessary for a healthy person to eliminate gluten in order to continue being healthy. Our opinion might change in the future, but with current evidence we don’t think it seems sensible to recommend it to everyone in general. Of course, celiacs, gluten-sensitives and autoimmune disease sufferers are a different story.

Correctly following a gluten-free diet

Nowadays it’s pretty easy to make sure you’re buying gluten-free due to the labels (which typically mention possible traces). However, some things often escape the knowledge of those who decide to go for such a diet. Firstly it should be noted that gluten has an average lifetime within our body of 5 to 8 months, so taking it seriously is important. If you’ve come to the conclusion that you need to be following a gluten-free diet the best thing you can do is to drop by your local celiac association or foundation. There they usually have excellent little booklets which show foods, brands or places to avoid. Generally speaking, have the following in mind:

  • Avoid storing gluten-free foods together with those that do contain it.
  • Never use products of which you don’t know the composition.
  • Cooking space and utensils should be free of gluten. Don’t use cutting boards  or other wooden utensils that have been use to manipulate gluten.
  • Don’t use the same electrical appliances to cook gluten containing and gluten-free foods (toasters, oven, blender, etc.).
  • Don’t fry in oil that has been previously used for gluten containing foods.
  • Avoid sharing spreads: butter, jam, honey, etc.
  • Whenever you eat out, make sure people know what they’re doing at the restaurant.

As you might realize, avoiding gluten isn’t always as easy as it looks. The ideal would be for whoever lives with you to also follow the same diet, in order to simplify things and avoid contamination. Another thing that should be noted is that gluten tolerance varies amongst individuals, so the strictness will vary from one person to another. Even so, it is recommended to follow the diet strictly for the first few months (remember a minimum of 6 months) so to figure out if it works or not.

Summary:

A large percentage of people with autoimmune disorders seem to benefit from eliminating gluten, even if they aren’t sensitive to gluten or celiacs. The improvement appears to be closely linked to the normalization of intestinal permeability. The best way to find out whether it’ll work for you is to follow it strictly for a minimum of 6 months.

 

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