Doctors and dietitians often use an open hand and a closed fist to explain how people with celiac disease respond to gluten. An open hand with digits extended represents a normal, healthy intestine where the finger-like villi sponge up the nutrients when the tuna casserole you had for dinner flows by.
The closed fist, however, represents the surface of an intestine of a celiac patient that's been damaged by an autoimmune response caused by ingesting gluten. The villi experience atrophy, and with the "fingers" gone, it results in a relatively smooth-surfaced intestine with less surface area with which to absorb nutrients. The short-term result of anyone with celiac disease ingesting some gluten is cramping, nausea, a particularly malodorous diarrhea, headaches, intestinal bleeding, and an all-round malaise often called a "full-body flu." The long-term effects are mostly associated with those seen with standard malnutrition like problems with growth, delayed puberty, skin diseases, a small spleen, and a failure to thrive in general.
While people with legitimate gluten sensitivity don't actually experience any damage to their villi from eating gluten, they can still manifest many of the same symptoms as someone suffering from celiac disease. Nonetheless, the open hand/closed fist terminology is also useful in another context. When people with celiac disease or legitimate gluten sensitivity see schmucks appropriating their disease because it's trendy and spouting off about things they know little about, they want to either use a closed fist to punch them in the forehead or an open hand with exposed fingers so they can poke them in the eyes and hear that boink sound you hear in Three Stooges movies.
True celiac disease or serious gluten sensitivity is a nightmare. Just to give you a little taste of what they have to deal with, simply going out to eat at a restaurant can turn into a crapshoot where one mistake on the part of the waiter or chef can trigger an autoimmune or gastrointestinal free fall. Celiac or gluten sensitive diners have to grill the waiter with questions about how the food was prepared, asking if the soup or salad dressing is canned or made from scratch, and if it's the latter, does the chef's secret ingredient include gluten? Because egg omelets often do, and so do baked potatoes because they're sometimes dusted with flour to make them crispy.
And are there artificial bacon bits on the salad? Can't have those because they're made with soy and soy is usually housed in the same facilities as wheat. Is the oil used to fry the French fries used to cook anything else? Is the seafood in the salad made with imitation crabmeat? Because almost all of the fake stuff has gluten in it. How about the green tea, for crissake? Does it have barley in it? Green tea sometimes does. And are you absolutely positive, waiter-boy, that the food will be prepared on a clean cooking surface with pristine utensils, lest any cross-contamination occur?
So when people with legitimate health issues see that seemingly half of America is suddenly anti-gluten because they think it's the secret to weight loss, droning on about it with zealous fervor to any unfortunate soul they can corner and acting all uppity about it because they think it's somehow emblematic of enlightened eating, it understandably makes the stomachs of true celiac sufferers or gluten-sensitive folks gurgle a little more than usual.
How did this gluten hate-fest happen? And more importantly, is it legitimate? Clearly, a lot of people feel better when they stop eating bread and various gluten products, but is gluten to blame, or is something else? Walter Voegtlin, a gastroenterologist from the 1970's, made a name for himself by suggesting that human genetics hadn't changed that much since Paleolithic times so we'd do best eating foods that were available 10,000 years ago, which pretty much rules out anything from the Jimmy Dean line of fine frozen foods. Hence was born the Paleo movement where followers began to eschew most modern, processed foods. Even so, Paleo people didn't bear any particular grudges against gluten, at least not until 2011 when two pivotal events caused them to bring out their dietary pitchforks.
One event was the publication of the book, Wheat Belly, by William Davis, which makes the claim that eating wheat causes obesity instead of the usual culprits like sloth or eating buckets of pork rinds. Davis made at least three powerful claims against wheat and gluten that caused pupils everywhere to dilate. First, Davis pointed out that modern wheat contains a protein known as gliadin, which was supposedly created by genetic research in 60's and 70's. Gliadin, he writes, is a problem because it binds to opiate receptors in the brain and thus stimulates appetite, so much so that on average, wheat-eating Americans were eating 440 extra calories each and every day.
Then there's the supposed problem with the starch found in wheat. Davis wrote that wheat amylopectin is different than that found in other carb-rich foods like potatoes and vegetables in that its structure allows it to be converted into sugars very quickly. Eat if often enough, and it drop kicks blood sugar levels again and again until you develop type II diabetes.
Davis then put on his statistical analysis hat and pointed out that the proliferation of wheat products paralleled the increase in the national waist size. It was all hugely compelling. Bread futures plummeted. The Earl of Sandwich rolled over in his pumpernickel-loaf grave and Paleo followers pulled out their talking drums to spread the news of this bad juju grain.
About the same time, Peter Gibson, a professor of gastroenterology at Monash University in Australia, published a double blinded, randomized, and placebo-controlled experiment that found gluten to be the cause of gastrointestinal distress in people without celiac disease, a condition known as non-celiac gluten sensitivity (NCGS). Gibson's study had any remaining doubters swearing off their breads, waffles, and pancakes. Fans of Wheat Belly developed blisters from pointing to the study emphatically over and over again and saying, "See?"
The one-two punch was so effective that recent surveys indicate that about 30% of Americans would like to eat less gluten. Accordingly, sales of gluten-free products are estimated to hit $15 billion by 2016, an increase of 50% over 2013's figures. Manufacturers are so worried about the anti-gluten shopper that the term, "gluten free" is now commonly affixed to products that never contained gluten in the first place.
But is gluten really the problem? Maybe not. If you start to tease apart the assertions made in Wheat Belly, they start to crumble. Is gliadin a genetically modified protein that binds to opiate receptors and causes us to have bread cravings? Well, for one thing, gliadins are present in all grain lines, and some seeds of ancient strains contained more gliadin than modern grains. Consider, too, that there's no historical record of any GM wheat being grown or marketed commercially, despite what Davis said about modern wheat's nefarious origins.
As far as gliadin's purported opioid properties, the concept itself might be a hallucination. Gluten can be divided into two protein fractions, gliadin and glutenin, and it's true that gliadin (called gliadorphin), when injected directly into the blood of rats, acts like an opiate. However, research says the human intestine can't absorb gliadorphin, so with apologies to Alan Ginsberg, unless you're hysterical, naked, dragging yourself though the streets looking for an angry injectable gluten fix, you're not going to have any opiate-like effects from eating bread or gluten products in general.
Let's look at the assertion that the starch in wheat is different than that found in other starchy foods and how it supposedly has a dramatic effect on blood sugar. In fact, there are only two types of starches found in plant tissue, amylose and amylopectin, and most foods, wheat included, have a ratio of about 25% amylose and 75% amylopectin. Clearly, the amylopectin in wheat is no different or more prevalent than any other carb food. Consider, too, that bread has a lower GI than the same amount of potatoes or rice, which are two foods that most anti-gluten people eat freely.
What about the math that shows that the collective waist size of Americans corresponds with the rise in wheat consumption? Well, I suppose that's true, but the extra fattiness also parallels the rise of fructose consumption, or junk food consumption in general. It also parallels the rise in ownership of smart phones, but those all seem to be causal relationships, especially when you consider that even though there have been dramatic downturns in the consumption of both bread and fructose, waistlines have continued to grow.
And it's difficult to overlook the preponderance of evidence that shows wheat or grain consumption in general is associated with a lower body mass index, a lower risk or cancer, diabetes, and heart disease. Further, it's a great source of fiber, which is unequivocally the one thing the American diet is sorely lacking, other than sound judgment.
And that brings us back to the Australian study, the one that supposedly proved the existence of NCGS and gave doughy ammo to the anti-gluten people. The results didn't sit right with the guy who did the study. Gibson hadn't figured out what it was about gluten that could be causing problems in people. Also, there were so many variables that he worried that there might be something he wasn't controlling or taking into consideration, so he decided to repeat the experiment, this time taking extra precautions that are rarely seen in any nutritional research. He found 37 subjects, none of which had celiac disease but all of whose gastrointestinal problems had improved on a gluten-free diet. He provided all their meals so there was no chance of subjects making midnight runs to Al's Donut and Taco Cabana.
He eliminated any potential dietary trigger for gastrointestinal problems, including certain preservatives, lactose, and poorly absorbed short-chain carbohydrates known as FODMAPS (Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols). And, in an effort to leave no stone unturned, he collected everyone's urine and fecal matter for analysis. He also had them all cycle through different diets. They were first put on a low-FODMAPS for two weeks to establish a baseline. In the following days, they were given either a diet high in gluten, one with 2 grams of gluten and 14 grams of whey protein isolate (the low-gluten diet), or one with 16 gram of whey protein isolate (the placebo diet). No one ever knew what diet he or she was on. When he looked at the results, he found that all the diets worsened gastrointestinal symptoms to a similar degree! He concluded that it was psychological and since participants expected to feel worse, they did.
Gibson was forced to conclude that, "In contrast to our first study...we could find absolutely no specific response to gluten." But before you anti-gluten people wail and gnash your teeth in anger and disbelief, Gibson and his co-researcher, Jessica Biesierkierski, did find a culprit. Their study showed that it was far more likely that it was the FODMAPS were causing the gastrointestinal problem previously attributed to gluten. Remember that I wrote that the subjects were first put on a low-FODMAP diet to establish a baseline? Well, according to Biesierkierski, "Reduction of FODMAPS in their diets uniformly reduced gastrointestinal symptoms and fatigue in the run-in period, after which they were minimally symptomatic."
And get this, when you stop eating bread products, as is the most universal attribute of the low-gluten diet, you automatically remove some of the largest dietary sources of FODMAPs. That could well explain why so many people claim to feel better when they go on gluten-free diets. FODMAPS are poorly absorbed by pretty much all us human types, and any that aren't absorbed by the small intestine pass onto the large intestine where they're fermented by bacteria. The resultant gas formation causes some people, probably those with an overpopulation of certain bacteria and an under population of others, to experience symptoms similar to that of irritable bowel syndrome, which could easily be misconstrued as gluten sensitivity.
So what we're left with is this: Despite the musings of Walter Voegtlin, the father of Paleo, the dire Chicken Little allegations of Wheat Belly author William Davis, and the apparently legitimate gastrointestinal symptoms reported by thousands of Paleo followers and gluten-phobes in general, the problem may well lie elsewhere. Gluten may be totally innocent.
There's strong evidence that those who are avoiding gluten because they think it's addictive and causing them to gain weight are wrong, and many of those that think they're having gluten problems are actually having FODMAP problems. Gibson and Biesierkierski themselves say that there's "definitely something going on, but true NCGS may only affect a very small number of people..." There are also those that are suffering from a psychological condition known as the "nocebo" effect where people who take a harmless substance experience harmful effects.
From what I can see, people who are suspicious of gluten have 5 things to consider:
- You can look at the evidence and at least be open to the idea that some cases of alleged gluten insensitivity are actually psychological and the result of the "nocebo" effect.
- If being gluten-free has allowed you to lose weight, consider that it's probably not because you're now free of the opioid-like effects of a mysterious wheat protein, but because most people start to lose weight whenever they start following any diet where they're forced to pay attention to what they're eating. Not only that, but gluten-free diets are pretty restrictive, so you're bound to lose weight.
- If you suffer legitimate gastrointestinal problems that seem to disappear after going gluten-free, consider that it might be related to FODMAPs and not gluten. After all, low or no-gluten diets are also low in FODMAPs.
- If you suspect that FODMAPs might be a problem for you, information on low-FODMAP diets is widely available. People with FODMAPs sensitivities might also want to start taking probiotics and eating probiotic foods to see if they have any benefit.
- If you truly are gluten sensitive, then you should probably stay the course.