What is Gluten? | Why so Common? | Why Should I Care? | Am I Sensitive? | My Tests are Negative... | Now What?? | I Feel Worse...WTF? | Cross-Sensitivity | Resources for Gluten-free Living | References

What is Gluten?

Gluten (from Latin gluten "glue") is a protein found in wheat and related grain species including barley and rye. It gives elasticity to dough, helping it to rise and to keep its shape, and it is what gives bread a chewy texture.  Gluten is comprised of two proteins, gliadin and glutenin. All wheat-based bread and pasta products contain gluten, as do foods containing rye, spelt, triticale, faro, and barley. But these are not the only gluten-containing foods. Gluten makes a fabulous stabilizer for other food items such as salad dressing, and is a common “hidden” ingredient in most processed foods.

A person with gluten sensitivity has an immune system response when he or she is exposed to gluten. This immune response can cause a variety of symptoms, and leads to a stress response in the body. The most well-known gluten-sensitivity is Celiac Disease, which causes stomach and intestinal irritation in many patients. Many people who complain of “irritable bowels” have undiagnosed gluten sensitivity and it is estimated that incidence of Celiac Disease has increased from one in 700 to one in 100 over the past 50 years.  (11) However, less than one out of three people with gluten sensitivity have gastrointestinal symptoms. (5) The majority of gluten sensitivity symptoms are neurological. (6)
Common symptoms of gluten sensitivity include:

1. Upset stomach or cramping after eating gluten products
2. Muscle or joint pain
3. Headache
4. Brain fog or difficulty thinking straight
5. Runny or stuffy nose
6. Increased phlegm in the throat
7. Gait abnormalities and balance disturbances
8. Hearing loss
9. Depression or anxiety

Symptoms occur minutes or hours after eating something containing gluten, and can last for a few hours or for months. It is estimated that for a typical gluten-sensitive patient with Hashimoto’s disease, a single gluten exposure leads to thyroid gland irritation for eight months!

Because gluten sensitivity leads to an immune system response, ANY chronic illness can have a gluten-related link. Even if gluten sensitivity is not a CAUSE, gluten can make it worse. back to top

Why is Gluten Sensitivity so much more prevalent than it used to be?

Many people I talk to think that gluten sensitivity is a fad, the latest hokey medical myth crafted to generate need for special gluten-free foods. They see more and more people claiming gluten sensitivity, and wonder why there seems to be so much of it these days. The answer is complicated, and involves a variety of factors. (1)

1. Genetically modified foods can lead to chronic inflammation in the gut and blood vessels which make the body more likely to react to other foods. Our immune systems are designed to treat foreign proteins as a threat. Since genetically modified foods have a different genetic structure than other food we eat, our bodies may consider these foods to be foreign invaders and launch an attack against them, leading to increased inflammation.
   
   
2. Gluten deamidation is a process that makes gluten more water soluble, allowing it to be used as an inexpensive emulsifier and stabilizer in a variety of processed foods. Deamidated gluten is more inflammatory than “regular” gluten and is often hidden in sauces, soups, clarifying agents in red wine, and gelling agents. It is difficult to identify on an ingredient list.
   
   
3. Grains from many farms are brought together into large holding silos, and may be stored for long periods of time before making it to market. Wheat and wheat family grains are susceptible to a variety of molds and other toxins, which have more opportunity to grow when grains are stored for longer periods of time. It is impossible to know if you are eating flour from this season’s wheat or from wheat which has been stored for a year or more, unless you buy grains directly from the farmer.
   
   
4. Increased prevalence of leaky gut syndrome. Leaky gut syndrome is a condition in which the lining of the small intestine becomes inflamed. This lining is responsible for keeping waste products from returning to the blood stream. When it becomes inflamed, it becomes more permeable than it should be, allowing waste molecules to "leak" back into the body. People with leaky guts are more likely to have inflammatory responses to a variety of foods.
   
   
5. Chronic stress can lead to immune system dysregulation and heightened immune response.
   
   
6. Enzyme deficiency can lead to incomplete digestion of proteins.
   
   
7. Genetic predisposition. One third of the US population has the HLA-DQ gene, and these people are at least 90% likely to develop sensitivity to gluten sometime during their lives.

Many people who are gluten sensitive also react to a variety of other foods including casein (a protein in dairy products), chocolate, coffee, buckwheat, sorghum, millet, tapioca, amaranth, quinoa, yeast, sesame, corn, rice, and potatoes. (2,8,10) back to top

Why should I care?

If you are sensitive to gluten, every time you eat something containing gluten it is like rubbing poison oak on your arm. Instead of the skin getting irritated, it is the lining of your digestive tract (Celiac Disease), your nerve endings, your joints, your thyroid, or some other affected tissue.
Chronic irritation of the intestines leads to a "leaky gut". Molecules that should be excreted are able to return to the blood stream, leading to overall increased toxicity and tissue irritation. Nerve cells are particularly susceptible to irritation, leading to muscle pain and weakness, altered gait, and other neurological symptoms. Even more concerning, when the gut barrier is compromised the blood-brain barrier is almost always compromised. This means that things that can’t usually get into the brain are able to get into the brain, leading to inflammation in the brain itself. Brain inflammation can cause brain fog, confused thinking, seizures, depression, anxiety, hallucinations, and other neurological symptoms. back to top

How do I know if I’m sensitive?

The “gold standard” for establishing gluten sensitivity is the elimination diet. Stop eating all sources of gluten for about three weeks, then have a big hunk of bread and see how you feel. If you find all the low-grade annoying things you experience gradually lessen as you get farther away from gluten, and then you feel awful after eating it again, you know you are sensitive.

You can also establish sensitivity through testing for antibodies in the blood, saliva, or stool. back to top

My tests are negative. Does that mean I’m NOT sensitive?

In my practice, I see a number of patients who swear they have been tested for gluten sensitivity and the tests were negative. But, clinically, their presentations are practically screaming gluten sensitivity. Across the board, if I have been able to convince these individuals to do a trial period without gluten, their symptoms have significantly decreased. More importantly, when they tried eating pizza after a few weeks without gluten, they felt horrible. The question always then arises: how can I be sensitive if the tests are negative?? The answer is somewhat complicated.

There are 17 different proteins in gluten, and a variety of pathways for immune system response to it.
Historically, gluten sensitivity tests have looked only at alpha gliadin, and then only at the IgA response to it. The only people who will have an IgA response to alpha gliadin are people with “true” Celiac Disease. Remember, this makes up only a small percentage of people with gluten sensitivity.

Complicating the issue further, if you have been experimenting with a gluten-free diet for a while, you may no longer be making antibodies to gliadin. We only make antibodies when our bodies are actively under attack, and once the exposure is stopped, antibody production stops.

Another complicating factor is that a side effect of chronic inflammation is immune system suppression. Many people have decreased ability to produce antibodies once their systems become chronically inflamed. In these cases, the tissue which is most affected by the irritant demonstrates more antibodies than other tissue such as the blood stream. For this reason, sometimes saliva or stool antibody tests show positive results when blood tests do not. Antibodies stick around the intestines longer than other tissues, so stool tests may show positive results where saliva does not.

There is now one lab in the US which tests for IgA and IgG antibody response to each of the 17 gliadin proteins. The test costs approximately $300, and is a viable alternative to the elimination diet for determining true gluten sensitivity in a person who does not have Celiac Disease. back to top

So I’m gluten sensitive. Now what??

The ONLY answer to relieving gluten sensitivity is to eliminate all exposure to gluten. This means eliminating all the wheat and wheat-family grains from your diet, including barley, spelt, kamut, and rye.

While oats do not contain gluten, nearly all oats in the US are stored and transported with wheat or barley. This means they are very likely to be contaminated. If you purchase oats directly from the farm, or from a company such as Bob’s Red Mill who makes a point of keeping their oats separate from other grains during harvest, storage, and shipping, oats are OK to eat.

There are many hidden sources of gluten because of its use as a food stabilizer and emulsifier. Some common hidden sources include salad dressings, soy sauce, beer, malt extract and flavoring, food starch, lechtin (unless it specifically comes from soy), and most commercially processed “foods”. A great resource for the latest information about hidden sources of gluten can be found at www.celiac.com. back to top

I stopped eating gluten, and now I feel worse.  WTF???   
    
Congratulations, you have just discovered gluteomorphin. Gluteomorphin is a compound your body makes during the breakdown and metabolism of gluten. It is similar in chemical structure to the opioids found in codeine or heroin, and plays a similar role in the body. (8) This is part of the reason we crave foods like bread and pasta.

Unfortunately, for some of us, our bodies become addicted to gluteomorphin. When we stop eating gluten, we actually experience withdrawal symptoms. If you experience constipation, nausea, shakiness, irritability, difficulty sleeping, and/or flu-like symptoms when you stop eating gluten, in absence of an actual flu you are probably experiencing withdrawal. It is unpleasant, but it will pass. Symptoms typically go away on their own within a week or two, and your body will thank you for sticking with it. back to top

OK. I’ve done it all, but I still keep getting sick. Now what?

You’re probably experiencing “accidental” exposure. In other words, something you are eating contains gluten you don’t know is there. Or, you are also reacting to other foods in your diet.

It is very common for people with sensitivity to gluten to also be sensitive to foods such as corn, soy, coffee, chocolate, lactose, casein, and other starches found in potatoes and other non-gluten grains. You can try eliminating all of these foods from your diet (this is easier to do while following a program such as the Clearvite diet). It is also possible to do a blood test to test for cross reactions. (10) (2)

In the case of accidental exposure, brush border enzymes such as DPP IV Protease, (9) amylase, cellulase, and invertase can help to more quickly break down the gliadin proteins and get them out of your body. Apex Energetics makes a product called Gluten-Flam that contains all of these enzymes. Health Concerns makes a similar product which includes a mixture of enzymes and Chinese herbs. Use of these products is for accidental exposure only. They are not strong enough to stand up to the damage done by a big pizza and garlic bread binge!

In addition, flavonoids including lycopene, quercetin, and luteolin can help reduce inflammatory responses to foods. (3 ) Probiotics support the normal gut flora, which helps to minimize irritation from offending foods. Vitamin D is needed for normal immune system function, and most people are deficient.

Gluten-free living requires a change in lifestyle. You can no longer eat anything anywhere, and you need to be much more conscious about your food choices. However, for the person who is truly gluten sensitive the change in overall health with elimination of gluten is enormous. back to top

Resources for Gluten-free Living

1. www.celiac.com Awesome resource for everything gluten-free, including lists of gluten-safe and gluten-unsafe foods.
   
   
2. www.glutenfreegirl.com Blog about gluten-free living, including great recipes and suggestions for preferred brands of gluten-free products.
   
   
3. www.elenaspantry.com Blog and recipes for gluten-free foods. Elena is into to the Paleo diet, so her recipes are gluten-free, dairy-free, and mostly grain-free.
   
   
4. www.glutenfreeeasy.com Recipes, resources for gluten-free foods, grocery lists, etc.    
                 
5. www.glutenfreeliving.com Magazine for gluten-free living. Also has a monthly newsletter, recipes from top chefs, and  resources for finding gluten-free foods.
   
   
6. www.glutenfreeinsd.com Resources including support groups, meet-ups, restaurants with gluten-free options, gluten-free bakeries, etc. in the San Diego area.
   
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References

1) Armstrong MJ, Robins GG, Howdle PD. Recent advances in celiac disease. Curr Opin Gastroenterol. 2009 Mar;25(2):100-9.

2) Craig, L et al. The role of structure in antibody cross-reactivity between peptides and folded proteins. J Mol Biol, 1998; 281:183-201.

3) DeStefano D, et al. Lycopene, quercetin and tyrosol prevent macrophage activation induced by gliadin and IFN-gamma. Eur J pharmacol. 2007;566(1-3):192-9.

4) Duggan, Jm. Celiac disease: the great imitator. Med J Aust. 2004 May17;180(10):524-6. Review.

5) Fasano, A. Current approaches to diagnosis and treatment of celiac disease: an evolving spectrum. Gastroenterology, 2001; 120:636-651.

6) Hadjivassiliou M, Grünewald RA, Davies-Jones GA. Gluten sensitivity as a neurological illness. J Neurol Neurosurg Psychiatry, 2007:72:560-563.

7) Howdle. PD. Gliadin, glutenin or both? The search for the Holy Grail in celiac disease. Eur J Gastroenterol Hepatol. 2006 Jul;18(7):703-6.

8) Kharrazian, D. Understanding the complexity of gluten sensitivity. Class notes, copyright 2010.

9) Kozáková H, et al.Brush border enzyme activities in the small intesting after long-term gliadin feeding in animal models of human celiac disease. Folia Microbial (Phraha). 1998;43(5):497-500.

10) Kristjánsson G, Venge P, Hällgren R.  Mucosal reactivity to cow's milk protein in coeliac disease.Clin Exp Immunol, 2007; 147:449-455.

11) Rubio-Tapia, A. Increased prevalence and mortality in undiagnosed celiac disease. Gastroenterology. 2009 Jul;137(1):88-93. Epub 2009 Apr 10.
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