“To (eat gluten) or not to (eat gluten)? That is the question”
Celiac Disease and Non-Celiac Gluten Sensitivity
The gluten protein has gotten a lot of press lately. The question is how to decide if gluten is a problem for you or not. Gluten containing grains are widely consumed and provide an estimated 50% of caloric intake worldwide. 1 Gluten is a family of toxic proteins found in wheat, barley, rye, and grains such as oats, barley, spelt, kamut and triticale. 1 Given the widespread use of gluten containing foods, it is of no surprise that in the past 20 years there is an increase in not only celiac disease, but other gluten related disorders. Although this was once thought to be a rare illness and mostly ignored, it is now becoming more widespread worldwide especially as other countries adopt the Standard American Diet.
We will explore a little deeper in hopes that you may be able to make a decision for yourself. For me personally, my allopathic training as a physical therapist drives my interest in how the gluten protein affects the neuromusculoskeletal system, one I treat regularly. This is a fancy word combining the nervous system (brain and nerves), muscular system (muscles and connective tissue), and the skeletal system (bones and joints). Although my clinical focus is peripheral joints (like shoulder and knee) and central joints (like spine) it does not exclude ANY joint in the body. As I have continued my personal paleo-whole-foods inspired journey into health, I continue to be fascinated about how seemingly unrelated systems, like the digestive system, could actually impact our neuromusculoskeletal health and recovery. The further I delve into the research the further I am supported when I say, “No system operates in isolation. It is an impossibility.” Our digestive health is paramount to the health of each and every one of our systems including the neuromusculoskeletal system.
To begin, let’s define the difference between Celiac Disease (CD) and Non-Celiac Gluten Sensitivity (GS). CD is an allergic reaction to gluten that is mediated by the immune system by T-cell activation in the gastrointestinal mucosa. 2 Although CD affects only 1% of the population officially, it is associated with many autoimmune comorbidities of the neuromusculoskletal systems like myesthenia gravis, multiple sclerosis, peripheral neuropathy, cerebellar ataxia, myalgia (muscle pain), multiple myoclonus, depression, anxiety, psychiatric disease, and many others. 2 A hallmark symptom is digestive distress. Official diagnosis of CD is confirmed with genetic testing (for one or both genes, HLA-DQ2 and/or HLA-DQ8) or serological screening of antibodies (IgA tissue transglutaminase anitbodies (tTGA) or endomysial antibodies (EmA), antigliadin antibodies (AGA)). These serological tests must be completed while gluten is a part of your diet. Diagnostic accuracy and risk estimates vary, but is good between 75-98% accurate in determining CD. 2 More information about tests for CD and GS can be found at www.LabCorp.com.
If you don’t test positive in the CD category, gluten may still be impacting your health. Non-Celiac Gluten Sensitivity (GS) is determined by a lack of one or more of the CD criteria of above listed testing criteria. 2 Sounds simple enough, yet the symptomatology of gluten-related disorders (GS) is varied across many systems, not just digestive in nature.
Gluten sensitivity (GS) has been associated with neurological illness like ataxia3 (loss of control of bodily movements). Studies done in 2010 showed a link to gluten sensitivity and psychiatric brain disorders like schizophrenia, 3 acute mania, 4 and bipolar disorders 5 without celiac disease (gluten allergy). A few studies have linked gluten allergy or sensitivity to diseases like systemic lupus erythematous, 6 connective tissue diseases, 7 back pain, 8 rheumatoid arthritis, 9 and ankylosing spondylitis. 10 One author described a case study of a forty-year-old woman with a three-week history of left-knee pain and swelling that responded to a gluten-free diet, stretching, and strengthening, demonstrating the potential role of gluten in joint inflammation. 11
Given the broad symptomology of GS, what happens when you lack confirmation of the diagnostic tests? Turns out that the primary diagnostic criteria are improved symptoms in response to a gluten-free diet. For me personally, I fall into the category of GS without digestive issues. My symptoms of gluten exposure are depression and anxiety a few days after ingestion. I never completed further testing because I had already removed gluten and did not want to go back to eating gluten given how good I felt without. Yet, without the verified “test” many people comment that gluten-free diets are a fad, unnecessary and even unsafe.
Let’s debunk that myth starting with Terry Wahls, MD, who reversed her progressive-multiple sclerosis (MS) using a specific nutrient dense and naturally gluten-free diet. She is now involved with clinical case series to confirm her findings. 12 In order to carry out studies on patients, you must first demonstrate no harm. Her results are promising in improving symptoms of MS. A gluten free diet has even been shown to improve symptoms of a common disorder called reflux or GERD. 13 An additional study showed that there were no ill-effects on performance in athletes with gluten free diets. 14
In both cases, CD and GS, besides the obvious symptoms of abdominal cramps, bloating, diarrhea, gas and other GI disturbances, are often associated with malabsorption secondary to the disruption of the lining of the gut due to the inflammatory response in the presence of gluten. The primary treatment for both disorders is eating a gluten-free diet.
It is important to note, that to optimize recovery or improve your health, that does not mean eating processed foods labeled “gluten-free.”
The precedent to CD and GS is not only presence gluten, but likely a habit of eating heavily refined and nutrient deficient food products for years which disrupt the absorptive cellular lining of the small intestines as well as disrupting the gut microbiome.
In order to recover health following either CD or GS, one must first remove the irritating component, which in this case is gluten. The next step is to replace the diet with whole nutrient rich fruits, vegetables and protein (all of which are naturally gluten-free). This may also include supplementation of probiotics to restore the microbiome. Further integrative testing with a comprehensive nutrient evaluation may be necessary to determine any other supplemental needs based on any nutrient deficiencies found. Restoration of health takes time. Sustaining this lifestyle will allow the gut to heal and begin absorbing nutrients in order to restore your health.
To eat gluten or not to eat gluten? How do you decide?
If you have clear digestive distress, then get tested for CD. If your tests are not confirmative then look further into GS. Yet, if you have ANY symptoms anywhere in your body (mental, physical, digestive or otherwise), then it doesn’t HURT to try going whole-foods naturally gluten free for 30-90 days and see where that takes you. You don’t require any fancy or expensive testing for that. Reintroduce gluten and see how your body responds. Yes, it may be challenging to live naturally gluten free, but it is a simple strategy that can potentially empower you to recover your health. In the end, there is seemingly nothing to lose without gluten in your life. Eating nutrient rich whole foods is by far healthier for you compared to pasta, gluten-free or not.
For me, it resolved many health issues that I had considered “normal.” It’s a lifestyle of eating nutrient rich whole foods that are naturally gluten free.
Simple as that.
Remove. Replace. Restore.
Remove refined and gluten containing grains for 30-90 days or life if you are CD.
Replace with whole organic fruits , vegetables, protein and healthy fats from grass- fed organic meat, butter, olive oil, fish oil. Include probiotic rich fermented foods like kimchi or sauerkraut. If grains need to be a part of your life, choose naturally gluten-free, organic and from California grains like rice or quinoa and prepare traditionally.Think outside the "cracker/pasta box." Sliced vegetables can replace crackers easily and spaghetti squash is a great replacement for pasta. Read the ingredients list on anything in a package, gluten can be hidden even in soy sauce. Seek assistance from a professional if you are struggling to regain your health.
Restore a healthy intestinal lining, nutrient absorption, and a normal inflammatory response.
Eat well. Move well. Sleep well. Soar on.
1. Tovoli F, Masi C, Guidetti E, Negrini G, Paterini P, Bolondi L. Clinical and diagnostic aspects of gluten related disorders. World J Clin Cases. 2015;3(3):275-284.
2. Kohlstadt I, ed. Advancing medicine with food and nutrients. Second ed. Voca Raton, FL: Taylor and Francis Group, LLC; 2013.
3. Dickerson F, Stallings C, Origoni A, et al. Markers of gluten sensitivity and celiac disease in recent-onset psychosis and multi-episode schizophrenia. Biol Psychiatry. 2010;68(1):100-104.
4. Dickerson F, Stallings C, Origoni A, Vaughan C, Khushalani S, Yolken R. Markers of gluten sensitivity in acute mania: A longitudinal study. Psychiatry Res. 2012;196(1):68-71.
5. Dickerson F, Stallings C, Origoni A, et al. Markers of gluten sensitivity and celiac disease in bipolar disorder. Bipolar Disord. 2011;13(1):52-58.
6. Ben Abdelghani K, Mouelhi L, Hriz A, et al. Systemic lupus erythematosus and celiac disease. Joint Bone Spine. 2012;79(2):202-203.
7. Conti V, Leone MC, Casato M, Nicoli M, Granata G, Carlesimo M. High prevalence of gluten sensitivity in a cohort of patients with undifferentiated connective tissue disease. Eur Ann Allergy Clin Immunol. 2015;47(2):54-57.
8. Efe C, Purnak T, Ozaslan E, Ozbalkan Z. Back pain and sacroiliitis in long-standing adult celiac disease: A cross-sectional and follow-up study. Rheumatol Int. 2011;31(2):279-010-1375-8. Epub 2010 Feb 20.
9. Lerner A, Matthias T. Rheumatoid arthritis-celiac disease relationship: Joints get that gut feeling. Autoimmun Rev. 2015.
10. Togrol RE, Nalbant S, Solmazgul E, et al. The significance of coeliac disease antibodies in patients with ankylosing spondylitis: A case-controlled study. J Int Med Res. 2009;37(1):220-226.
11. Ozyemisci-Taskiran O, Cengiz M, Atalay F. Celiac disease of the joint. Rheumatol Int. 2011;31(5):573-576.
12. Bisht B, Darling WG, Grossmann RE, et al. A multimodal intervention for patients with secondary progressive multiple sclerosis: Feasibility and effect on fatigue. J Altern Complement Med. 2014;20(5):347-355.
13. Nachman F, Vazquez H, Gonzalez A, et al. Gastroesophageal reflux symptoms in patients with celiac disease and the effects of a gluten-free diet. Clin Gastroenterol Hepatol. 2011;9(3):214-219.
14. Lis D, Stellingwerff T, Kitic CM, Ahuja KD, Fell J. No effects of a short-term gluten-free diet on performance in nonceliac athletes. Med Sci Sports Exerc. 2015;47(12):2563-2570.
15. Lipski, Elizabeth PhD CCn CHN. Digestive wellness. 4th Edition ed. United States of America: Mc GRaw Hill; 2012.
16. Lieberman S, Bruning N. The real vitamin and mineral book. New York, New York: The Penguin Group; 2007.
Dr Carolyn Dolan DPT, Cert MDT, MSHN
Where physical therapy, nutrition and lifestyle meet, because how you live your life determines whether or not you soar. Inspiring action with information so you can reduce pain, optimize healing and improve function naturally during recovery from injury, surgery or painful condition. This is a website for the open-minded; obstinate need not apply.