The problem with leaping into a gluten-free diet

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In recent times, it seems as though every newspaper or magazine with a dedicated health section has a focus on the perils of gluten and the benefits that come along with adhering to a gluten-free diet. Or better yet, each week brings a new celebrity touting the dangers of gluten, and how it is an unhealthy ingredient that should be avoided religiously. Is this truly sound advice?

As a practicing academic gastroenterologist, I do love when my patients are eager and in search of information on the Internet about their intestinal woes, what they may be due to, and how to treat them. What I have also found, unfortunately, is that not only is there so much conflicting information about this pesky little protein called gluten and who will truly benefit from a gluten-free diet, but the internet is also littered with many irresponsible recommendations from health care providers about “going gluten-free” without importantly first ruling out celiac disease, an autoimmune disorder that can cause a whole host of medical conditions affecting both the intestinal tract and other organs.

I have dozens of patients come to me with abdominal pain, bloating, nausea, and the like, and they are not quite sure why. Understandably, they get tips and helpful hints from their friends, friends of friends, and family members of friends about what to do about it. Oftentimes, the recommendation is that it’s all from gluten, and gluten is bad, and that it should be eliminated from the diet entirely. Eventually, such a patient finds his/her way to my door, already on a gluten-free diet. Hooray! Problem solved. Well, actually, just the opposite.

The crucial problem with this approach is that celiac disease has not yet formally been evaluated as a potential cause. The caveat is that in order to properly diagnose the disease, patients need to be consuming gluten. If patients are already adhering to a gluten-free diet, they will need to reintroduce gluten into their diet for a recommended period of about four weeks before the appropriate testing for celiac disease can be done.  Of course, this is frustrating and confusing to patients. And many will ask, “Well what’s the difference if I have celiac disease or not if I just avoid gluten all together?” This is the million-dollar question.

Celiac disease, present in close to 1% of the US population, is an autoimmune disorder where, in the presence of gluten, the lining of the small intestine is eroded, worn down, and inflamed, causing the body to malabsorb essential nutrients. This can lead to diarrhea, weight loss, abdominal pain and bloating, and in severe cases and after many years with the disease, a rare intestinal lymphoma can develop. Studies like the one published in Gastroenterology in 2009 found that when the diagnosis of celiac disease was delayed, or left untreated, these patients had a higher rate of death from all kinds of causes. Because of the many clinical consequences of celiac disease, it is important to systematically diagnose it or eliminate it as a potential cause of a patient’s gastrointestinal problems before all else, because with such patients, even the tiniest consumption of gluten can lead to symptoms or worse.

Importantly, there are other diseases tied to gluten that can give people symptoms very similar to those with celiac disease. Gluten intolerance, or gluten sensitivity, is one of them. With gluten intolerance, though, blood tests suggestive of celiac disease and biopsies of the small intestines where celiac disease does its damage, will be normal. However, patients with gluten intolerance show an improvement of symptoms on a gluten-free or gluten-reduced diet. Whether this is from the gluten itself or the other products contained in foods that also have gluten, specifically those called fructans, is still up for debate.

The good news about gluten intolerance is that although the consequences of gluten consumption may result in a return of symptoms, it will not cause you to be deficient in essential nutrients and vitamins, nor will it give you some other potentially life-threatening or debilitating problems that celiacs suffer from when they eat gluten-containing foods (infertility, early-onset osteoporosis, anemia, skin diseases, and arthritis to name a few).  Patient resources like the NIDDK’s About Celiac Disease and The Celiac Disease Foundation provide helpful information about celiac disease.

So let’s not all be gluten-haters if we don’t need to be. And let’s not forget the importance of being clinically systematic and smart about first ruling out celiac disease before considering gluten intolerance as the root of your GI symptoms. I only wish this underappreciated but crucial point was the first thing that health care providers promoting a gluten-free diet mentioned, instead of last in tiny print, or sometimes not at all.

Sophie M. Balzora is a gastroenterologist.

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