If you’ve noticed a steady increase in the number of people swearing off gluten, a protein found in wheat, rye, barley, and tritcale (a wheat-rye hybrid), you’re not imagining things.
Based on what I see in my practice, plenty of patients are having a hard time tolerating gluten. But why the surge in gluten reactivity?
What does it mean to be “sensitive” or “intolerant” to gluten?
First of all, it’s important to understand the difference between celiac disease and gluten sensitivity or intolerance. Celiac disease is an autoimmune condition affecting up to 1 percent of the general population. The reaction that takes place in the case of celiac is quite severe: The body produces antibodies to itself in the presence of gluten that can lead to gastrointestinal symptoms, malabsorption, increased risk of malignancy, and higher overall mortality than the general population.
Unlike celiac disease, gluten sensitivity and intolerance are not autoimmune reactions. So although a person with a gluten sensitivity or intolerance may experience discomfort when exposed to the protein, the reaction is not as detrimental.
Fortunately, we have reliable diagnostic tests for celiac disease, and it is quite rare in the general population. Gluten sensitivity and intolerance, on the other hand, are quite common.
What is a gluten “sensitivity” or “allergy” versus an “intolerance”?
Many people throw around the phrase “food allergy,” but this can often be a misnomer. A true food allergy (also referred to as a food sensitivity) refers to an atypical immune system response to a dietary trigger. An example of a true allergy/sensitivity is when someone eats a peanut and goes into anaphylactic shock. This type of reaction is mediated by a specific antibody called IgE (the immune system can also produce non-IgE-mediated reactions to foods that can be classified as “allergies” or “sensitivities,” but these reactions are milder and are difficult to test for).
Another type of food reaction is a food intolerance. This reaction is not initiated by the immune system and often results from the absence of specific chemicals or enzymes needed to digest a dietary substance.
The difference between allergies/sensitivities and intolerances is the biochemical mechanisms that drive them. In my practice, as long as I’ve ruled out an anaphylactic or life-threatening response, I place greater emphasis on my patient’s experience when exposed to a food than the biochemical mechanism driving the reaction. Why? Because regardless of the type of reaction, the treatment is the same!
What are the signs and symptoms of gluten sensitivity/intolerance?
Reactions to gluten are quite variable. Some typical symptoms include digestive issues like IBS, bloating, flatulence, constipation or diarrhea, and acid reflux.
Often these symptoms are accompanied by other complaints, such as joint pain, skin issues, asthma, mood problems , and/or fatigue. When this is the case, and any suspicion of a serious pathology like Crohn’s disease or ulcerative colitis has been ruled out, I consider suggesting a trial of food eliminations. Plenty of foods can trigger reactions, but gluten and dairy are among the most common.
Can an elimination diet help?
The gold standard test for a food reaction is called an elimination diet, which involves completely removing the presumed cause of the reaction. I typically recommend patients avoid a potential trigger food for a full month, evaluate how they feel, and then try reintroducing it to see if it brings on symptoms.
The true elimination diet excludes more than just gluten, but it can be modified to test for a specific food in question. In the case of gluten, I advise patients to read labels carefully and to become familiar with hidden sources of the protein before diving into a gluten-free month.
With that said, I often see people respond well to a wheat-free diet that is not 100 percent gluten free. Because food reactions and intolerances are so variable, it is helpful to work with an experienced naturopathic doctor or nutritionist for guidance with food eliminations.
What about FODMAPs?
Earlier this year, a study came out suggesting that something else besides gluten may be the reason many people are suffering from gastrointestinal issues. According to the study, FODMAPs, which are poorly absorbed short-chain carbohydrates and alcohols, could be the culprit.
In my practice, I find that different diets are therapeutic for different people. I often consider a low-FODMAP diet for conditions dominated by gas and bloating. The diet is low in fermentable foods, and if someone is experiencing a lot of gas and bloating, staying away from foods that ferment in the gut is usually beneficial.
But therapeutic efficacy doesn’t necessarily reveal the underlying cause of symptoms, which could be a bacterial overgrowth, food intolerances, or other GI conditions. And although we don’t have diagnostic tests for every possible cause of gas and bloating, diagnostic tools do exist and should be employed when appropriate.
I also find that the low-FODMAPs diet can be very difficult to maintain. It’s very restrictive and can dramatically impact one’s quality of life. With that said, I encourage anyone interested in therapeutic diets to work with a health care practitioner to select the most appropriate diet for them—a diet that promotes feeling well while enjoying life!
The One Medical blog is published by One Medical, an innovative primary care practice with offices in Boston, Chicago, Los Angeles, New York, Phoenix, the San Francisco Bay Area, Seattle, and Washington, DC.
Any general advice posted on our blog, website, or app is for informational purposes only and is not intended to replace or substitute for any medical or other advice. The One Medical Group entities and 1Life Healthcare, Inc. make no representations or warranties and expressly disclaim any and all liability concerning any treatment, action by, or effect on any person following the general information offered or provided within or through the blog, website, or app. If you have specific concerns or a situation arises in which you require medical advice, you should consult with an appropriately trained and qualified medical services provider.