Healthy Food & Healthy Living by Dr. Ayala

The gluten-free health fad: the good and the bad-part 2

In the previous post I reflected on the rapid expansion of the gluten-free market share and the rising popularity of the gluten-free diet, and said I'm glad to see the growing awareness of celiac disease, and also happy that keeping a gluten-free diet is becoming easier.

But is there a downside of the gluten-free fad? Are we replacing lack of awareness of celiac disease with confusion?

There are now several categories of gluten-free people: Genuine celiac patients, people who suspect they may have celiac and have gone gluten-free without a doctor’s diagnosis, and gluten-free lifestyle adopters, who joined in for perceived health benefits or as treatment for ailments that are not proven to be aided by a gluten-free diet.

The first group, celiac patients, needs to adhere to a very strict gluten-free diet for life. How strict? Very! Even small amounts are forbidden. Gluten sometimes hides in unexpected places, and can cross contaminate food. Although many celiac patients will not experience discomfort after eating some gluten their bowel will feel it and there are long-term consequences to non-adherence.

The second group needs to be evaluated by a doctor, and the diagnosis of celiac confirmed or excluded. Without a clear diagnosis and treatment plan they may be doing themselves harm, or alternately, putting themselves through unnecessary restrictions.

As to the third group they may adhere to the gluten free regimen loosely or strictly, and may feel better on it--we cannot argue with success. But the different degrees of adherence to gluten avoidance is a source of much confusion as we’ll cease to identify a gluten free diet as the extremely strict--not a bread crumb to touch that food--that a celiac patient needs.

Perhaps it's time to give the diet concentrating on gluten avoidance of those without celiac a unique name, such as "low-gluten" or "reduced-gluten" diet. This way it will be clear both to those on it and those cooking for them that they don't have to be extremely strict, and on the other hand it'll be clear to the public that unlike other diets and food preferences a celiac patient's shouldn't be on just a low-gluten diet, but rather on a truly a gluten-free one.

If we don’t understand gluten-free as a medical entity, we won’t treat is with the seriousness it deserves. Gluten-free will have more than one meaning, and there will be gluten-free for celiac and for hobbyists.

Who’s making gluten-free food?

The FDA has a proposed draft that will allow the “gluten-free” claim for voluntary use on products if:

“food does not contain any of the following: An ingredient that is any species of the grains wheat, rye, barley, or a crossbred hybrid of these grains (all noted grains are collectively referred to as ”prohibited grains”); an ingredient that is derived from a prohibited grain and that has not been processed to remove gluten (e.g., wheat flour); an ingredient that is derived from a prohibited grain and that has been processed to remove gluten (e.g., wheat starch), if the use of that ingredient results in the presence of 20 parts per million (ppm) or more gluten in the food; or 20 ppm or more gluten.”

The amount of gluten accepted in a gluten-free product is minute: 20 parts per million, so you can see that contamination by even tiny amounts of wheat flour, which has about 80,000 ppm, brings a gluten-free food to unacceptable levels.

At this point it’s up to the manufacturers of gluten-free food items to guarantee such a claim.

Now it’s one thing to manufacture gluten-free packaged goods in a controlled production facility, and quite another to offer gluten-free options in a busy restaurant.

The growing gluten-free demand is encouraging many restaurants to offer gluten-free options. I believe they mean well, but could they really guarantee a meal is gluten-free? It takes much more than using special gluten-free pasta to make a meal fit for a celiac patient.

My daughter has a close friend who has celiac disease. When I cook a meal for her and her family I will usually skip any gluten-containing food for the entire meal for everyone because it makes cross contamination less likely. If I’m going to still make bread or use any other flour-based recipe, I will do so hours before making the rest of the meal, then completely clean-up the kitchen, store the flour, put my apron in the wash, and cook gluten-free.

Many parents of kids with celiac opt for a gluten-free kitchen because it’s so difficult to avoid contamination. I find it quite hard to imagine that a restaurant kitchen—with many people working under intense pressure using lots of shared equipment—can really make sure the flour from the pasta maker doesn’t touch the rice and that the spoon stirring the gluten-free soup didn’t also go into the barley soup. I think that, try as a restaurant might, it’s very hard to keep menu items truely gluten-free, and the best advice to patients with celiac is to eat at restaurants as little as possible.

Gluten-free junk

While there are a few really wonderful and innovative new gluten-free foods, there’s also a proliferation of gluten-free junk. One of the advantages celiac patients used to have was that they were somewhat protected from our fast- and junk-food environment, and ate home-made naturally gluten-free foods. Do they really need dozens of new processed foods reformulated without gluten?

The take-home message about the gluten-free label

Gluten-free should not read as “healthy” or “pure.” Gluten-free should be read like allergen information (celiac is not an allergy to gluten, but in terms of how strictly the diet needs to be kept, a serious nut allergy is a good comparison) and just like nut-free is information for those allergic to nuts, not signifying good or bad attributes, so it is with gluten: Gluten-free means it’s food that's acceptable to those with celiac; it can be nutritious or pure junk—you’ll have to read the ingredients.

If you don’t have celiac, and are ready to make a change for better health, why not spend your time, energy and money on strategies that make more sense, and reduce (not necessarily eliminate) more serious offenders, such as fast and highly processed foods, or resolve to follow the age old advice of eating more fruits and veggies?

What I hope we’ll all get from the gluten-free boom (before it busts) is greater awareness of celiac disease (along with timely diagnosis) and some great tasting gluten-free breads and pastas, which are no small feats.

What do you think of the popularization of gluten-free foods?

Dr. Ayala

The gluten-free health fad: the good and the bad - part 1

Have you noticed the gluten-free food explosion? I have the privilege of attending many food shows, and I’m stunned by the proliferation of grain based foods—prepared meals, cookies, snacks bread and crackers—developed for the benefit of those on a gluten-free diet and with “gluten-free” as a marketing proposition.

Gluten-free foods are a necessity for people with celiac disease, a disorder resulting from an immune reaction to gluten. But are these foods good for everyone else?

While the precise prevalence of celiac disease isn’t known, it’s estimated to range from about 0.4 percent to about one percent of the general population in the U.S. (up to three million Americans). The number of Americans with physician-diagnosed celiac however, although growing, is still not very large, and estimated anywhere in the range of 40,000-110,000 cases.

Not to sound cynical, but even a one percent consumer base wouldn’t drive manufacturers and retailers to the accelerated expansion of the gluten-free options we’re seeing. The reason food manufacturers have jumped in full force into this market is because gluten-free products are now favored not only by celiac patients, but by many people without the diagnosis—gluten free is indeed the latest food fad—and it’s a huge opportunity to make money. Research firm Mintel estimates that nearly 10 percent of shoppers currently seek gluten-free foods; they forecast 15- 25-percent growth in gluten-free product sales in coming years.

I’m glad to see the growing awareness of celiac, and also happy to see that keeping a gluten-free diet is becoming easier, more acceptable, and requires less sacrifice on taste.

On the other hand, the “fad” aspect of the gluten-free boom worries me quite a bit.

Is gluten bad for you?

Gluten is a protein found in wheat or related grains. It's a remarkably large molecule that’s quite central to the structure and texture of dough.

Gluten is definitely not an evil food component for those not afflicted by celiac. Gluten is part of whole-wheat flours and whole wheat, barley and rye grains—parts of a healthy diet. Although many junk foods contain gluten, gluten isn’t what makes these foods not nutritious—it’s the other ingredients or the processing of the grains that makes them so. If going gluten-free means choosing from the gluten-free menu at Wendy’s or Dairy Queen, or replacing wheat based snacks with corn based ones, you haven’t done yourself much good.

What’s a gluten-free diet good for?

There are only two established medical reasons to avoid gluten: celiac disease and dermatitis herpetiformis, a very itchy chronic skin rash of bumps and blisters, frequently linked to celiac. In celiac disease, complete removal of gluten from the diet is necessary for life, and results in complete resolution of symptoms. Non-adherence to a gluten-free diet can have dire consequences (even if the person is asymptomatic), including poor growth, infertility, osteoporosis, anemia, bowel narrowing and bowel cancer.

A gluten free diet is now touted for many other conditions, from autism to attention-deficit disorder, irritated bowel syndrome, multiple sclerosis and now even weight loss.

Although there are anecdotal stories about gluten-free diets making a difference for these conditions, there's really no good evidence to support such advice.

Autism

The gluten-free casein (milk protein)-free diet is a very common treatment attempt for autism.

A Cochrane review did an extensive literature search to identify randomized controlled studies of gluten-free or casein-free diets as an intervention in autistic features. They found only two small randomized controlled studies, with a total of 35 patients between them. The results of one of these studies indicated that a combined gluten- and casein-free diet reduced autistic behavior, but the second study showed no significant difference in outcome measures between the diet group and the control group.

The researchers concluded (emphasis is mine):

“Research has shown of high rates of use of complementary and alternative therapies (CAM) for children with autism including gluten and/or casein exclusion diets. Current evidence for efficacy of these diets is poor. Large scale, good quality randomised controlled trials are needed.”

Weight loss

There's no logical reason why adopting a gluten-free regimen should result in weight loss. Unless you have a strategy of reducing caloric intake on what just happens to be a gluten-free regimen, I can’t see how gluten-free for weight reduction makes any sense.

In fact, patients with celiac often gain weight once they start a gluten-free regimen. The reason is that while they’re eating gluten, many suffer abdominal pain, malabsorption and other symptoms that lead to reduced consumption or utilization of food. Once they’re on the gluten-free diet they thrive, eat well and gain weight.

Perhaps paying more attention to food—no matter what the regimen—can anecdotally lead to weight loss, but there’s nothing inherently low calorie or healthy about a gluten-free diet.

I learned from nutritionist Janet Helm about Elisabeth Hasselbeck’s book “The G free diet,” which Janet criticizes for inaccuracies, and also for “glorifying gluten-free and making it appear to be the best thing since, um, sliced bread.”

In the introduction to her book, Hasselbeck (who has celiac disease, and therefore greatly benefited from going gluten-free) writes:

“But a gluten-free lifestyle can help countless others as well. People suffering from a wide range of diseases—from autism to osteoporosis, from diabetes to rheumatoid arthritis—can often benefit from this change in diet. Even people with no health issues have a great deal to gain by giving up gluten. The G-free diet can help with weight management. It can elevate your energy levels, improve your attention span, and speed up your digestion.”

To which all I have to say is: Show us the proof! I searched Medline (the online computer database for biomedical journals) and couldn't find it.

But is there a downside to giving gluten-free a try? I'll get to that on the next post, in the meantime, your comments as always are welcome.

Dr. Ayala