When going gluten free makes sense
By Shannon Lewis, M.D., gastroenterologist, The Oregon Clinic, and Niki Strealy, RD, LD, outpatient dietitian, Providence Nutrition Services.
Sitting on top of the “hot” list of today’s diet fads is the gluten-free diet. People with certain medical conditions have very good reasons to avoid gluten, the gluey, chewy protein found in wheat, kamut, spelt, rye, barley, triticale and malt. But there are equally good reasons not to go gluten free if you don’t have to. Here are the top three reasons on each side of the issue.
Three good reasons to go gluten free
- To manage celiac disease. In people with this autoimmune disease, gluten triggers the immune system to attack the small intestine. Even trace amounts of gluten can cause significant damage. With repeated attacks, the small intestine loses its ability to absorb vital nutrients, such as calcium and iron. Over time, people with untreated celiac disease can develop severe nutritional deficiencies, such as osteoporosis and iron-deficiency anemia, as well as other autoimmune disorders, extreme fatigue, infertility, neurological problems and, in a very small percentage of cases, lymphoma of the small intestine. If you have been diagnosed with celiac disease, the treatment is to adopt a strict, gluten-free diet. This allows the small intestine to heal so it can absorb nutrients properly, and reduces the risk of associated problems.
- To control dermatitis herpetiformis (DH). DH is a form of celiac disease that triggers the immune system to attack the skin, rather than the small intestine. It causes a chronic itchy, bumpy rash that can be quite painful. A telltale sign of DH, besides the fact that it shows up after eating gluten, is that the rash is usually symmetrical – if you develop a rash on your left elbow, you’ll most likely have a similar rash on the right elbow. If people with DH continue to eat gluten, they also may run an increased risk of developing intestinal cancer. Once diagnosed, however, people with DH are usually highly motivated to stick with a gluten-free diet to steer clear of these painful rashes.
- To reduce symptoms of gluten sensitivity. Unlike celiac disease and DH, gluten sensitivity is not an autoimmune disease. It’s more like lactose intolerance – the inability to process or metabolize lactose – except that it’s gluten that can’t be metabolized. People with gluten sensitivity experience gastrointestinal distress – ranging from diarrhea, gas and bloating to constipation and irritable bowel symptoms – when they eat gluten. (People with celiac disease, on the other hand, may experience these symptoms, or may have no symptoms at all.) With gluten sensitivity, it doesn’t appear to be as critical to long-term health to avoid gluten – it’s more a matter of choice to avoid symptoms. The occasional slice of pizza may cause some short-term digestive discomfort, but it isn’t believed to increase the risk of serious long-term consequences. Future studies may reveal more about this relatively new diagnosis and its potential risks.
Three good reasons not to go gluten free
- To eat healthier. Don’t give up gluten because you think it’s a healthier way to eat. Unless you have to go gluten free to manage a medical condition, it isn’t. Carbohydrates should make up 55 to 60 percent of a healthy diet, and that’s where gluten is found. Cutting out wheat, rye, barley and the other grains that provide gluten eliminates some of the key sources of complex carbohydrates needed in a balanced diet. Also lost are the fiber, B vitamins and folate found in carbohydrates, as well as the iron, calcium and vitamin D provided by fortified breads and cereals. Gluten-free breads, cereals and crackers may help you fill the void, but they tend to be lower in fiber, are generally not fortified, and often contain more sugar and fat to make up for the texture and flavor that are lost when gluten is left out. Yes, you can take supplements to replace some of the lost nutrients, but people tend to absorb nutrients best when they come from food.
- To lose weight. A desire to lose weight is the wrong reason to go gluten free. As we’ve seen with numerous fad diets, anyone can lose weight when cutting an entire food group from his diet – the trick is how to keep it off once the food restriction gets old. A gluten-free diet is not easy to stick with, it’s expensive and, as mentioned above, it puts you at risk of missing out on important nutrients. There are far healthier and easier ways to lose weight than going gluten free. Start by making fruits and vegetables half of every meal, using a smaller plate, and reducing the number of calories you sip in the form of sodas, coffee drinks, sports drinks and juices. These are healthy weight habits that you can adopt easily and maintain for life.
- To try to diagnose your own symptoms. If you think you may have celiac disease, DH or gluten sensitivity, don’t go gluten free on your own to try to find out. It’s important to see a doctor for an accurate diagnosis while you are still eating a normal diet. The blood test used to help diagnose celiac disease and DH depends on finding an antibody to gluten in your blood. If you have been avoiding gluten, the antibodies may not show up in your blood test, which could yield a false negative.
You might ask, if I go gluten free and I feel better, why does it matter what my specific diagnosis might be? It matters for a couple of reasons. One is that a strict gluten-free diet goes way beyond simply avoiding bread, pasta and pizza – gluten hides, in trace amounts, in some surprising products. The small slip-ups that won’t do much harm if you have gluten sensitivity can damage your intestine if you have celiac disease. It’s important to know how strict you need to be, and what the consequences are if you let the diet slide a little. The second reason is that people with celiac disease need to be followed by a physician to monitor for signs of long-term associated problems. So find out first – then go gluten free.
In the next issue of Health Balance® News, we’ll share our best advice for adopting a gluten-free diet to manage celiac disease, DH and gluten sensitivity.
If you think you may have one of these conditions, see your health care provider for a complete evaluation. And if you are simply looking for ways to eat healthier or to lose weight, Providence’s registered dietitians can help.