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Elizabeth A. Reid, MD Gluten Free: Not Just a Fad


cery stores, coffee shops, and bakeries offer shelves of gluten- free muffins, cookies, and pas- tas. Even European hotels, usu- ally above catering to American food fads, add trays of gluten- free breads and rolls to their breakfast buffets to accommo- date an apparently increasing number of people who seek to avoid wheat—or, more specifi- cally, the gluten in wheat. Among some people, there is grumbling suspicion that gluten is yet an- other overhyped health concern, but among the gluten intolerant, there are evangelists who warn their bread- and pasta-eating friends that gluten may be si- lently damaging their intestines. Who is right? What going on?


G is actually


The first task is to understand what we are talking about. Glu- ten is a core protein in wheat and to a lesser extent in barley and rye and possibly oats. It gives baked products structure and pli- ability. The mushy carbohydrate fraction of these grains causes no problems in people whose in- testines do not


tolerate gluten,


but since the carbohydrates in grains are hard to separate from the proteins, the easiest way to avoid gluten is to avoid most grains and the products made from them.


10


LUTEN-FREE PROD- ucts are popping up in many places. Gro-


Reasons to Test for Gluten Intolerance


• Unexplained, chronic diarrhea, nausea, and cramping abdomi- nal pain


• Anemia and/or osteoporosis secondary to poor vitamin and mineral absorption


• Autoimmune diseases: thyroiditis, type 1 diabetes, and derma- titis herpetiformis*


• Family history of gluten intolerance


• Neuropathy, seizures, mental illness, hepatitis, psoriasis, alope- cia, or infertility in patients with any of the above


*Dermatitis herpetiformis is an intensely itchy rash combining tiny red bumps and watery blisters, usually on the elbows, knees, low back, and buttocks.


Though grains have been di-


etary staples for thousands of years, some people have a ge- netic pattern that makes their in- testines see gluten as an alien worthy of attack. Many people, perhaps 30 to 40 percent of the Western population, have this ge-


netic makeup, but most have no trouble eating grain products that contain gluten. This means that other, nongenetic factors, as yet unknown, are setting off the im- mune response to gluten. In people who do react nega- tively to dietary grains, gluten


Type of Gluten Intolerance


Symptoms Classical*


(No GI symptoms, may have other autoimmune diseases) Latent


(No GI symptoms, may have other autoimmune problems) *still referred to by many as celiac disease


Antibodies Against Small Intestine Gluten Fragments


Biopsy Positive


(Gastrointestinal, with or without other autoimmune disease) Silent


Positive Positive Abnormal May be abnormal Normal


fragments act like bacterial or vi- ral invaders, stimulating immune cells in the small intestine’s lining to attack them. In the process, inflammation damages the villi, which are little fingerlike projec- tions in the lining. Normally, mil- lions of villi make the surface area of the small intestine hun- dreds of times larger than it would be if the lining cells were smooth and flat. This huge surface area increases the ability of the intes- tine to absorb food.


In a chronic battle between the


immune cells and gluten, the villi flatten out and disappear. Food, fat, minerals, and vitamins slip by, passing out of the body as waste. In other words, they are malabsorbed. This malabsorption produces gas, bloating, and nau- sea, the typical symptoms seen in someone whose digestive sys- tem fails to tolerate gluten. Less (Continued on page 60)


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