KBW | Is Gluten REALLY Bad For You? A Review of Celiac and NGCS

A 2020 study by Transparency Market Research reports that the Gluten-free market is expected to reach $4.9 billion by 2021! Gluten-free is a BIG trend. But why? Is gluten bad for you? Or is it just hype? 

 What Is Gluten

 Gluten is a protein found in some grains like wheat and spelt. This protein substance helps foods maintain their shape, acting as a glue that holds food together. There are foods that naturally contain gluten and foods that do not naturally contain gluten but are commonly cross-contaminated with gluten due to processing.

 In fact, A study by Columbia University published in the American Journal of Gastroenterology in 2019 found that up to 50% of foods labeled as “gluten-free” actually contained gluten.  Why does this matter? Even tiny amounts cause problems for those that are reactive to gluten or have celiac disease (Lerner et al., 2019).  

Gluten-containing grains: 

• wheatberries
• durum
• emmer
• semolina
• spelt
• farina
• farro
• graham
• KAMUT® khorasan wheat
• einkorn wheat
• Rye
• Barley
• Triticale
• Malt in various forms, including malted barley flour, malted milk or milkshakes, malt extract, malt syrup, malt flavoring, malt vinegar
• Brewer’s Yeast
• Wheat Starch that has not been processed to remove the presence of gluten to below 20ppm and adhere to the FDA Labeling Law

 Top Gluten cross contamination sources:

• Oats – that are not specifically labeled gluten-free
• Pizza – even pizzerias that offer gluten-free crusts sometimes do not control for cross-contact with their wheat-based doughs
• French fries - these are often fried in the same oil as gluten-containing foods like wheat-breaded chicken fingers 
• Non-certified baked goods – e.g., “gluten-free” goods from otherwise gluten-containing bakeries

Why Go Gluten-Free?

There are two disorders in which you would NEED to be gluten-free. Those are celiac disease and non-celiac gluten sensitivity (NCGS). Outside of those two diagnoses, you might not “need” to be gluten-free, but many people feel markedly better doing so. I’ve had countless clients see mysterious symptoms like eczema, anxiety, acne, and insomnia disappear when going gluten-free. 

 If you are going to go gluten-free, due to a diagnosis, or not, there are certain things you do need to know to ensure your overall health and safety. Stay tuned for more on that in a moment. But first, let’s discuss the difference between celiac and NCGS, including symptoms and diagnoses. 

Celiac Disease

Celiac is more common than you might think.  A landmark study by one of the most prolific gluten researchers, Dr. Alessio Fasano out of Harvard, found the incidence of Celiac Disease in people donating blood to be 1 out of every 133. If someone is symptomatic or has a celiac-related disorder such as anemia, or osteoporosis, the incidence of CD increases to 1/25.  If there is a first-degree relative with CD, the incidence increases further to 1/22 (Fasano et al., 2003). 

Celiac Disease is an autoimmune, genetic, lifelong condition that can present at any age. When someone with celiac ingests gluten it triggers an immune reaction that results in damage to the villi of the intestinal mucosa. Over time, with continued ingestion of gluten, a person with celiac develops malabsorption and complications from this malabsorption, including anemia, severe vitamin deficiencies, heart disease, osteoporosis, infertility, and neurologic symptoms as well. 

There are more than 300 known symptoms of celiac disease! Some of the more common are: 

Testing for celiac disease:

Basic screening for celiac disease includes a serum TTG IgA and total serum IgA. Some providers will also include a DGP-IGA, AGA, and EMA in their celiac screen/panel or do these tests as a reflex. Genetic testing for human leukocyte antigens (HLA-DQ2 and HLA-DQ8) can also be used to rule out celiac disease, and the confirmatory “gold standard” test for celiac disease is an endoscopic biopsy. This biopsy is indicated if tests are positive and are required for diagnosis.

**Unfortunately, according to current estimates, only 17% of American patients with CD are actually diagnosed!! When I work with clients with mystery symptoms that won’t go away despite making positive diet and lifestyle changes, I will often encourage them to look into testing for Celiac disease. 

Non-Celiac Gluten Sensitivity 

 What is NCGS? 

It was originally thought that people with Non Celiac Gluten Sensitivity (NCGS)  only experienced symptoms and did not have any intestinal damage. However, in July 2016, a team of researchers at Columbia University Medical Center, published a study confirming that wheat exposure in this group is, in fact, triggering a systemic immune reaction and accompanying intestinal cell damage. This response is believed to be immune in nature, but not autoimmune in nature as with celiac disease. 

Surprisingly, it is estimated that the impacted population is equal to or even exceeds the number of individuals with celiac disease! 

Those with NCGS often experience symptoms similar to those found in celiac disease, such as brain fog, anxiety, depression, ADHD-like behavior, abdominal pain, bloating, diarrhea, constipation, headaches, pain, and chronic fatigue when they have gluten in their diet, yet they do not test positive for celiac disease. In these populations, when they fully remove gluten from their diet, their symptoms resolve. 

 How do you diagnose NCGS?

Unfortunately, while some labs offer blood, saliva, or stool tests for gluten sensitivity, there is currently no consensus on a validated test to diagnose NCGS. Diagnosis is typically made by ruling out CD and wheat allergy while the patient is on a gluten-containing diet. Once both are ruled out, a gluten-elimination diet is prescribed. If symptoms improve, the patient is deemed to have NCGS. 

The Dangers of Going Gluten Free

 First of all, there is no physiological need for gluten in the body. It is not an essential vitamin, mineral, or nutrient of any sort. If you don’t get enough Vitamin C, you can contract scurvy. If you don’t get enough thiamin you can contract Beriberi disease. There is no disease that comes with skipping out on gluten. 

However, many gluten-containing grains are fortified with vitamins and minerals, and many gluten-containing grains are high in fiber, and this is where we need to use caution when embarking on a gluten-free diet. Here are the most common nutrients found in gluten-containing foods, both naturally occurring, and fortified: Folic Acid, Niacin, Thiamin, Riboflavin, Pantothenic acid, Iron, Zinc, Calcium, Phosphorus. If you were previously receiving these nutrients from consuming a lot of processed foods and grains (ex: cereal for breakfast, sandwiches for lunch, and rice, pasta, and cookies at dinner time), you’ll need to carefully ensure you’re replacing these missing nutrients with gluten-free sources. 

It is entirely possible to eat a healthy, gluten-free diet that is rich in fiber, niacin, thiamin, and more, but it does need conscious effort. I have all of my gluten-free clients work with my Registered Dietitians on staff to ensure they are eating a well-designed, nutrient-dense diet with plenty of fiber so they can safely be gluten-free with no ill effects. 

So What Should YOU Do?

Remember, it’s estimated that 1/133 people have celiac disease, and a similar number have NCGS and yet the vast majority of both are UNDIAGNOSED. If you think gluten may be a problem for you, and you experience symptoms when eating it, talk to your medical healthcare provider about your symptoms and testing to get started. And if you end up deciding to go gluten-free, make sure you are eating a well-designed, healthy, gluten-free diet with the proper amounts of fiber, vitamins, and minerals.