Do I need to go gluten-free?

In recent years, following a gluten-free diet has become increasingly popular in Western countries. In the United States for example, the estimated population adhering to a gluten-free diet without celiac disease has more than tripled to 1.69% in 2013-2014 compared to only 0.52% in 2009-2010 [1]. Another survey conducted in Australia found 7.3% of the 1184 participants avoided gluten in their diet [2]. Overall, an estimated 6% of the Western population is avoiding gluten [3]. The growing popularity of gluten-free diet is due to the belief that it is healthier; fuelled in part by best-selling books, television talk shows, and celebrity endorsements which portrayed gluten-free diet as the cure to diseases ranging from depression and anxiety to arthritis and autism [4]. Are such claims valid?

What is gluten?

Gluten is a general name for the proteins found in wheat, rye, and barley. With flour from these grains widely used, gluten is commonly found in many food products including breads, pasta, noodles, breakfast cereals, soups, beer, brewer’s yeast, etc. Therefore, food containing gluten is ubiquitously found, especially in regions of the world where wheat is the staple food.

Wheat products like bread and cereals contain gluten.

Who should avoid gluten?

Those with celiac disease

Endoscopy picture of a patient with celiace disease with intestinal inflammation.

Gluten-free diet is the only known effective treatment for people with celiac disease [5]. For people with celiac disease, their immune system will react towards the ingested gluten from food causing inflammation in the intestines. Common symptoms include nausea, vomiting, bloating, constipation or diarrhoea. These symptoms are chronic, that is, they are persistent and recurring. If left untreated, the symptoms can severely affect the quality of life and causing skin rashes, headache, anxiety, and depressed mood. Malabsorption of nutrients is also a serious consequence of celiac disease with many manifestations such as failure to thrive, weight loss, delayed puberty, infertility, iron-deficiency anaemia, anorexia, and osteoporosis. There is also an increased risk of other autoimmune diseases such as type 1 diabetes and autoimmune thyroiditis [5]. Therefore, for anyone with celiac disease, eating gluten food can wreak havoc with the body’s immune system and health, even lead to a higher risk of death [6]. Therefore, lifelong avoidance of gluten food is necessary for people with celiac disease. Nevertheless, celiac disease is a genetically predisposed condition that affects only a small percentage of the population (about 1% in countries mostly populated by individuals of European origin) [7].

Those who are gluten sensitive

Joint pain can be a symptom of gluten sensitivity

Non-celiac gluten sensitive is now an officially recognised medical condition as well [8]. People who has gluten sensitivity may also react to ingested gluten and exhibit similar symptoms of nausea, vomiting, bloating, constipation or diarrhoea, etc. Those with gluten sensitive may also experience other non-specific symptoms such as skin rashes, joint pain, fatigue, foggy mind, anxiety, and depression. In gluten sensitivity, unlike celiac disease, there is no autoimmune mechanisms and intestinal inflammation involved. Like the celiac disease, though, the associated symptoms will generally improve after removal of gluten from the diet [8].
The recognition of non-celiac gluten sensitive is relatively new, although there have been reports over more than 30 years. Much is still unknown about this condition and there is no blood test or biomarker for diagnosis. The gastrointestinal symptoms of gluten sensitivity are common with irritable bowel syndrome (IBS), hence, many people with IBS are in fact gluten sensitive [9]. It is not known whether long-term avoidance of gluten is needed for the case of gluten sensitive.

Are Asians less prone to gluten-related diseases?

While celiac disease has been widely recognised as a disease affecting predominately population of European origin, this is changing in recent years. We now know that celiac disease is also common in North Africa, the Middle East and India; however, due to poor disease awareness and lack of diagnostic facilities, most of the celiac disease cases are undiagnosed [7]. Even in China, especially in the northern area where wheat is the main food, celiac disease might not be uncommon as well, as discovered in a recent study reported by researchers from Zhejiang University, Hangzhou [10]. Furthermore, with the increasing modernization of many Asian countries, the diet of people in Asian cities has become more Westernized. Gluten-based food such as pasta, pizza, bread, and cake has replaced rice in many meals. This may also lead to the increase in the prevalence of celiac disease and gluten sensitivity in Asia [10].

Going gluten-free

Gluten free products are now widely available off the shelves

The claim that gluten is linked to many diseases are not unfounded since it is now recognised that non-celiac gluten sensitivity can lead to a host of non-specific symptoms. Much is still unknown about gluten sensitivity. Since a gluten-free diet is safe and nutritionally comparable to a diet with gluten [10], there is no harm experimenting with gluten-free diet should you feel that you may be gluten sensitive. A sensible approach to go gluten-free is to avoid gluten for a few weeks (e.g. 6-8 weeks) and observe any improvement in symptoms. After which, you can reintroduce gluten food in small amounts to verify whether your symptoms reappear. Most people can tolerate a certain amount of gluten food, even if they are gluten sensitive. The key is to find the balance.

Conclusion

People with celiac disease need to avoid gluten for life. Most people who reacted to gluten food, however, are merely gluten sensitive. Going for a gluten-free diet may help to improve gastrointestinal symptoms such as nausea, vomiting, bloating, constipation or diarrhoea in gluten sensitive individuals. Other non-specific symptoms such as skin rashes, joint pain, fatigue, foggy mind, anxiety, and depression in gluten sensitive individuals may also be alleviated after adoption of a gluten-free diet. Hence, adopting a gluten-free diet can possibly help to improve the health of gluten sensitive individuals.

Common digestive symptoms including bloating and diarrhoea can be due to gluten sensitive. Try gluten free. 

References

[1] K. Hyun-seok, P. Kalpesh G., O. Evan, K. Neil, D. Michael F., P. Nikolaos, A. Sushil K., Time Trends in the Prevalence of Celiac Disease and Gluten-Free Diet in the US Population : Results From the National Health and Nutrition Examination Surveys 2009-2014, JAMA Intern. Med. 176 (2016) 1716–7. doi:10.1001/jamainternmed.2016.5254.
[2] N. Corsini, P. Mohr, Motivations for avoiding wheat consumption in Australia : Results from a population survey Motivations for avoiding wheat consumption in Australia : results, Public Health Nutr. 18 (2015) 490–9. doi:10.1017/S1368980014000652.
[3] K.E.A. Lundin, Non-celiac gluten sensitivity – why worry?, BMC Med. 12 (2014) 86. doi:10.1186/1741-7015-12-86.
[4] D.T. Nash, A.R. Slutzky, Gluten sensitivity: new epidemic or new myth?, Baylor Univ. Med. Cent. Proc. 27 (2014) 377–378.
[5] D. Schuppan, K. Zimmer, The Diagnosis and Treatment of Celiac Disease, Dtsch. Arztebl. Int. 110 (2013) 835–46. doi:10.3238/arztebl.2013.0835.
[6] F. Biagi, G.R. Corazza, Mortality in celiac disease, Nat. Rev. Gastroenterol. Hepatol. 7 (2010) 158–162. doi:10.1038/nrgastro.2010.2.
[7] C. Catassi, S. Gatti, E. Lionetti, World Perspective and Celiac Disease Epidemiology, Dig. Dis. 33 (2015) 141–146. doi:10.1159/000369518.
[8] A. Sapone, J.C. Bai, C. Ciacci, J. Dolinsek, P.H.R. Green, M. Hadjivassiliou, K. Kaukinen, K. Rostami, D.S. Sanders, M. Schumann, R. Ullrich, D. Villalta, U. Volta, C. Catassi, S. Fasano, Spectrum of gluten-related disorders: consensus on new nomenclature and classification, BMC Med. 10 (2012). doi:10.1186/1741-7015-10-13.
[9] J.R. Biesiekierski, J. Iven, Non-coeliac gluten sensitivity: piecing the puzzle together, United Eur. Gastroenterol. J. 3 (2015) 160–165. doi:10.1177/2050640615578388.
[10] L. Jiang, B. Zhang, Y. Liu, Is adult celiac disease really uncommon in Chinese?, J. Zhejiang Univ. Sci. B. 10 (2009) 168–71. doi:10.1631/jzus.B0820164.

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