Volume 11  Number 1  March 14, 2014
Second Opinions


Part of the secret of success in life is to eat what you like and let the food fight it out inside.

Mark Twain

I respect faith, but doubt is what gets you an education.

Wilson Mizener

Over 840 million people in the world are hungry – most of these in sub Sahara Africa and parts of Asia. (But don't forget the Middle East: Syria, Iraq and other areas of civil wars.) Yet for millions of Americans obsessed with food phobias, gluten – if you'll pardon the expression – takes the cake. Time magazine, in its survey of Americans' food eating habits, labeled the gluten-free movement number 2 out of its top 10 list of food trends in 2012. A recent market research report by the NPD Group states that of 1000 respondents one third are cutting back on dietary gluten big time.

Gluten (from Latin gluten or glue) is a composite protein in wheat, barley, and rye and thus found in foods processed from these grains, such as bread, cakes and other baked goods, as well as breakfast cereal and pasta. Pure oatmeal does not contain gluten, though some oatmeal may contain bits of wheat or barley from cross-contamination during manufacture. Rice, including "sticky rice" and corn are gluten-free.

What's so Frightful about Gluten?

Celiac disease is an uncommon autoimmune disorder of the small intestine which occurs in genetically predisposed people of all ages from middle infancy onward. Symptoms, most classically in children, include abdominal pain and discomfort, chronic constipation, diarrhea, vomiting, pale, foul-smelling stools, weight loss, and growth failure and anemia due to malabsorption. In adults some of these complaints may be absent, and symptoms in other organ systems have been described. Increasingly, diagnoses are being made in asymptomatic persons as a result of various, if controversial screening tests for certain antibodies.

True celiac disease, according to The University of Chicago's Celiac Disease Center affects about 0.75% of Americans, about 1 in 133, but some figures quoted in Wikipedia suggest a much lower prevalence. Prevalence in other countries may vary. Yet, despite these statistics, gluten fright has captured the public mind, becoming a "dietarily" correct food phobia on a level with the usual suspects: sugar, salt, saturated and trans fats, carbs, and cholesterol.

Researchers are studying the reasons celiac disease affects people differently. The length of time a person was breastfed, the age a person started eating gluten-containing foods, and the amount of gluten consumed are factors thought to play a role in when and how celiac disease appears. While adults are less likely to have digestive symptoms, according to some self-styled "experts" celiac disease may also present with one or more of the following: Fatigue, iron-deficiency anemia, bone or joint pain, osteoporosis, arthritis, depression, anxiety, tingling in the extremities, seizures, missed menstrual periods, infertility, canker sores, liver problems, even intestinal cancer (sic!) These symptoms and conditions in toto are experienced by most of the population at one time or another. Indeed, there exist an unknown number of Americans with non-celiac gluten sensitivity, but could this number reach 18 million Americans as this site claims?

Gluten is Often not the Culprit

Why celiac disease symptoms, especially in adults, are so varied and why gluten may not be the culprit in non-celiac gluten sensitivity are discussed in this important article in the journal Gastorenterology. The authors reported results of various gluten challenge diets and compared them with reversion to a normal diet in 37 patients. Only 6 patients responded to pure gluten challenge. Although the study was limited, it raises vital questions about the oft-reported improvement on gluten free diets by the public. The researchers concluded that the large majority of people with self-reported gluten sensitivity didn't experience symptoms after a gluten challenge when they had eliminated foods high in certain carbohydrates from their diets. *

The truth, however, could be much more complicated. "This study does not mean gluten sensitivity doesn't exist," Dr. Alessio Fasano, head of Massachusetts General's Center for Celiac Research told Jane Anderson in an interview. "But it may show that the symptoms are not due to the gluten component in wheat." See her excellent article, which includes suggestions for self-administered limited gluten challenge.

It gets even more complicated. For example, some researchers have speculated that symptoms in irritable bowel syndrome can be triggered by foods high in FODMAPs.* Wheat contains moderate amounts of FODMAP carbohydrates, but many other foods – notably, many common fruits and vegetables like apples, peaches, asparagus and broccoli – contain higher amounts. This probably explains why some people with irritable bowel syndrome (IBS) or other similar symptoms, but not celiac disease, report improvement on a gluten free diet.

Shopping for Gluten-Free and Your Grocery Bill

Another excellent article by Martha C. White, says it all: "Why We're Wasting Billions on Gluten-Free Food". Ms. White points out that, as food fads go, we're paying an enormous premium to avoid gluten without any legitimate medical reason. In effect, we are hypnotized by urban myths, advertising, and the profusion of gluten-free grocery shelves. The "99%" imagine they'll feel better, attain good health, and who knows, longevity-by shelling out huge bucks for gluten free-food they probably don't need.

Foody nonsense and fad diets along with their accompanying phobias masquerading as dietary theology, go back to the 70s, when sugar became the bête noir of foods. Then, as mentioned above, it was fat, salt, carbs, cholesterol-and finally the latest pariah ingredient, gluten. People who have bad reactions to common gluten-containing foods – pasta, breads, baked goods and breakfast cereal – may actually be sensitive to something else. It's also probable that some people develop gastrointestinal or other symptoms simply because they believe they're food-sensitive.

As White continues, "None of this would be a huge problem, except that this is an exceptionally pricey food fad. Producing gluten-free items, especially baked goods, are more expensive because manufacturers have to come up with alternatives that will give the finished product the same light, chewy texture that gluten imparts."

Researchers from Dalhousie Medical School at Dalhousie University in Canada compared the prices of 56 ordinary grocery items that contain gluten with their gluten-free counterparts. All of the gluten-free ones were more expensive, and some were much more expensive. The average unit cost of the gluten-free product was $1.71 while the average unit cost of the regular gluten-containing product was $ 0.61. This translates to gluten free products costing 242% more than the "real thing."

The challenge has been met by an increasing number of food manufacturers who have happily entered this highly profitable growth industry. The market research company Packaged Facts said in a report last fall the gluten-free market in the United States was $4.2 billion last year. It predicts that the category will grow to $6.6 billion by 2017.

Stay tuned.

* FODMAPs is an acronym for Fermentable, Oligo-, Di-, Monosaccharides and Polyols, various sugars of varying chain length or sugar alcohols.

Martin F. Sturman, MD, FACP

Copyright 2014, Mathemedics, Inc.

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