I get a lot of questions with regards to grain-free lifestyles and more specifically, gluten. To bakers, gluten is the magical agent that can be manipulated to bind their creations together and create a bold texture like in bagels and pretzels or subtly developed to create form and structure while allowing the product to flake apart like Grandma’s buttermilk biscuits. But to those afflicted with autoimmune conditions like Celiac disease or Crohne’s, the presence of gluten can be a very serious and even life threatening issue.
Gluten sensitivity includes a wide range of disorders from non-celiac gluten intolerance to celiac disease as a result of the body’s inability to properly process gluten from wheat as well as similar proteins in rye and barley (Stepniak et al. 2006). This sensitivity is a systemic autoimmune disease, or more simply, a disease in which exposure to gluten causes the immune system to attack and harm the body’s own tissues. It is important to note that all celiac disease is by definition, a form of gluten sensitivity or intolerance. However, gluten sensitivity itself is not a diagnosis of celiac disease. Many issues present themselves for sufferers of all levels of the disorder from ability and doctors’ willingness to diagnose, lack of education and established support systems, ease of lifestyle transition, cross-contamination during the production of products which would not naturally contain gluten and failure of regulatory bodies to establish specific guidelines for labeling of gluten-free products.
While testing methods for gluten sensitivity have not fully been developed, celiac disease is a genetically inherited disease in which patients will carry one of the two autoimmune response genes, HLA-DQ2 or HLA-DQ8. The carrying of these genes however, does not necessarily signify that the person will develop celiac disease. It is merely a genetic predisposition. This predisposition is carried by about half the population. About 1 in 20 who carry HLA-DQ2 and 1 in 150 who carry HLA-DQ8 will develop the disease (Science Daily 2012 Oct). Actual diagnosis for celiac disease requires the testing for damage to the gut from the presence of gluten. This testing is done through blood analysis and intestinal biopsy. The blood tests look for specific antibodies, and where levels of these antibodies are elevated, more than 95% of these patients will be found to have celiac disease (Ford). The specific antibodies are: tTG (IgA tissue transglutaminase antibody), a specific antibody made against muscle damage to small bowel; DGP (Deaminated Gliadin Peptide), a test to detect an immune response to a specific section of the gluten molecule called gliadin; and EMA (Endomesial Antibodies), an older version of the test to detect gut tissue damage (Ford).
Gluten is defined as a protein found in the prolamin, or storage protein, fraction of wheat (gliadin), rye (secalin) and barley (hordein). When ingested, enzymes in the gastrointestinal tract break down these proteins into peptides. In celiac sufferers, these peptides bind to either the HLA-DQ2 or HLA-DQ8 binding sites and cause an autoimmune T-cell response leading to inflammation of the small intestine (Stepniak et al. 2006).
In the case of celiac patients, this autoimmune response and attack on the small intestine can lead to the inability of the body to absorb nutrients leading to malnutrition that can be life-threatening (Gottesman 2012). The immune response in gluten sensitive individual can result in symptoms such as diarrhea, constipation, gas or bloating, vomiting, nausea, skin irritation, fatigue, muscle cramps, brain fog and depression. In more recent studies evidence has been shown that gluten sensitivity in some individuals appears in the form of neurological dysfunction, most commonly depression and anxiety, but illnesses such as epilepsy, bipolar disorder and schizophrenia may also be affected. (Hadjivassiliou et al. 2010).
Gluten sensitivity affects an estimated 18 million Americans. The prevalence of celiac disease is believed to be as high as 1 in every 133 persons, however only 1 in every 4,700 have been clinically diagnosed (University of Chicago CDC). These rates have been rising since around 1950. The reasons for the increases have not yet been specifically determined however several theories exist.
The most fundamental from an evolutionary point of view is that grains have historically not been in the human diet for very long as a staple food. While grains have always been present and were available to our hunter gather ancestors, their primary diets consisted of fruits, nuts, herbs, tubers and meat if a hunt was successful (Gottesman 2012). It was not until the end of the last ice age around 10,000 years ago that man first discovered how to plant and cultivate crops and later around 8,000 years ago, man began to transition into using efficient methods of farming and eventually learning to use grains in baked goods which further increased gluten intake. An important fact however, is that the grains that were eaten at that time are vastly different from those we currently see today. This is a result of modern farming techniques and biologically engineered strains. These are not to be confused with genetically modified strains. Most of the commercially available wheat is not genetically modified in a laboratory sense. These have been biologically engineered through cross-breeding intervention with the intent of increasing crop yields. As a result, these strains have higher gluten contents than the ancestral crops producing a higher resistance to pests (Gottesman 2012).
Aside from the increase in gluten content of today’s grains and the obvious presence of gluten content in many processed foods, hidden sources of gluten remain a problem for those attempting to live a gluten-free lifestyle. Once determined to be gluten-sensitive, individuals can make the choice to avoid gluten containing products as they wish depending on the severity of their symptoms. For celiac sufferers, this is not an optional choice. They must choose to avoid gluten in all its forms and sources, and in some cases a gluten free lifestyle may not completely alleviate all the complications of the disease (Mayo 2011).
This is not as simple as avoiding common foods known to include gluten. Lack of specific FDA guidelines for labeling further complicates the issue. In 2007, the FDA proposed to allow manufacturers to label their products “gluten-free” if they did not contain any ingredients that are a type, crossbreed or an ingredient derived from wheat, rye or barley unless the derived ingredient has been processed to remove gluten. This proposal that any ingredient derived from these grains must, after processing, contain fewer than 20 parts per million. A 2008 deadline was set to define federal standards, but this deadline was not met and 7 years since the FDA began working to create a regulation and define which products can carry the label, there is no legal requirement that needs to be met for a manufacturer to label a food “gluten-free” (Martin 2008). As of this writing, labeling rules are under final review by White House officials (Enterprise 2013).
Cross-contamination and lesser known gluten containing products are also major factors for those trying to avoid gluten. Most food processing plants produce a variety of products on their production lines. In one evaluation of allergen cleaning procedures for a food production environment, a chicken processing facility was found to produce 140 varieties of chilled, frozen and other processed chicken and turkey products. Of these 140 products, 131 of them contained wheat-derived ingredients (Wang, Young and Karl 2010). An area of higher risk of cross-contamination exists in restaurants, cafeterias and dining facilities. Mostly due to lack of education of the seriousness of the disease, gluten contamination can occur by means of reusing cutting boards, knives, cooking utensils, cooking surfaces, dishes, storage containers and other means that have not been properly cleaned. The higher risk for contamination in these areas compared to food production facilities is that most major facilities have a means of testing for the presence of allergens after equipment and machinery have been cleaned. These testing methods do not exist in most public restaurants or eating facilities.
Hidden sources of gluten can be especially challenging due to the lack of any ingredient labeling on some products. Even food products like seasonings, sauces, milk (if malted), flavorings in beverages and food starches may contain gluten but the presence may not be clearly stated in the labeling. Non-food products ranging from children’s play dough and paints to items like gum, makeup, and pharmaceuticals can contain levels of gluten that are dangerous to celiac patients (Hlywiak 2008).
Although there is no current cure for celiac disease, advancements are being made toward more effective and cost efficient testing and diagnosis as well as the potential for treatment in the future. An exciting program is the CD-Medics project in Slovenia now undergoing clinical trials. The CD-Medics technology will eliminate the need for invasive gut biopsies and delay in diagnosis due to sending blood to a lab for testing. Requiring one drop of blood on a credit card sized “lab-on-a-chip”, the card is inserted into an interface device and tests for both the HLA gene variants as well as gluten antibodies (Science Daily 2012 Jun). Scientists Justin Siegel, Ingrid Swanson Pultz and colleagues are reporting advancements towards a pill that may be able to be developed which would allow celiac patients to eat gluten containing foods much the same as those with lactose intolerance can take for dairy. Current clinical trials are underway by ImmusanT for a blood test and therapeutic vaccine, Nexvax2 which would restore immune tolerance to gluten and allow individuals to return to a gluten containing diet (Stuart 2013). While the mainstream availability of these methods may be years away, it brings hope to those who wish to someday return to a normal life without celiac disease and gluten intolerance.
Stanford University News Service. [cited October 22, 2012].New Stanford analysis provides fuller picture of human expansion from Africa. [Internet]. Available from: http://news.stanford.edu/pr/2012/pr-genetic-human-evolution-102212.html.
Stuart A. 2013. Making Bread Safe for Celiacs. [Internet]. Available from: http://www.immusant.com/wp-content/uploads/2011/60/Race-for-fix-to-celiac-disease-underway-in-Boston-Business-The-Boston-Globe-031113.pdf
Hadjivassiliou M, Sanders DS, Grünewald RA, Woodroofe N, Boscolo S, Aeschlimann D. 2010. Lancet Neurology. 2010 Mar; Vol. 9 (3), pp. 318-30.
Gottesman, N. 2012. Going gluten-free. Natural Health. Jun2012, Vol. 42 Issue 5, p54-56. 3p. In: Health Source – Consumer Edition [database on the Internet]. Available from: http://search.ebscohost.com.
Hlywiak K. 2008 Sep. Hidden Sources of Gluten. Practical Gastroenterology: 27-39.
Wang X, Young O.A., Karl D.P.. 2010. Evaluation of Cleaning Procedures for Allergen Control in a Food Industry Environment. Journal of Food Science. Vol. 75, Nr.9: T149-155.
Doerner T.B., Cleroux C, Poirier C, Cantin I, Alimkulov A, Elamparo H,. 2011 Jun. Gluten contamination in the Canadian commercial oat supply. Food Additives and Contaminants. Vol. 28, No. 6, June 2011, 705-710.
Adams J. . Seven Years and Counting: FDA Drops Ball on Gluten-free Standards [Internet] Celiac.com web site [cited in 2011 Aug 10]. Available from http://www.celiac.com/articles/22628/1/Seven-Years-and-Counting-FDA-DRops-Ball-on-Gluten-free-Standards/Page1.html
Enterprise Labeling staff. 2013. Labeling rules for ‘gluten-free’ products under final review by White House officials [Internet]. Enterprise Labeling web site. [cited in 2013 Mar 28]. Available from: http://enterpriselabeling.com/2013/03/28/labeling -rules-for-gluten-free-products-under-final-review-by-white-house-officials/
Martin C 2011. The FDA Gets Serious About Gluten-Free Labeling Laws [Internet]. Forbes web site. [cited 2011 Aug 18]. Available from: http://www.forbes.com/sites/work-in-progress/2011/08/18/the-fda-gets-serious-about-gluten-free-labeling-laws/
History World staff. [date unknown]. Hunter-Gatherers to Farmers. [Internet] History World website. Available from: http://historyworld.net/wrldhis/PlainTextHistories.asp?historyid=ab63#1864
Davis W. . The Wheat Lobby Smokescreen [Internet]. Wheat Belly web site. [cited in 2012 Mar 21]. Available from: http://www.wheatbellyblog.com/2012/03/the-wheat-lobby-smokescreen/
Stepniak D, Spaenij-Dekking L, Mitea C, Moester M, de Ru A, Baak-Pablo R, van Veelen P, Edens L, Koning F. 2006. Highly efficient gluten degradation with a newly identified prolyl endoprotease: implications for celiac disease. American Journal of Physiology – Gastrointestinal and Liver Physiology. 291:G621-G629.
Irvin D. 2006. Using Analog Assessment Procedures For Determining The Effects Of A Gluten-Free and Casein-Free Diet On Rate Of Problem Behaviors For An Adolescent With Autism. Behavioral Interventions. 21: 281-286.
Roma E, Roubai A, Kolia E, Panayiotou, Zellos A, Syriopoulou V.P.. 2010. Dietary compliance and life style of children with coeliac disease. Journal of Human Nutrition and Dietetics. 23: 176-182.
Ford R. [date unknown]. Gluten blood tests: Recommended blood tests for Gluten/celiac problems. Dr Rodney Ford web site. [date cited unknown]. Available from: http://drrodneyford.com/faq/bloods-tests/gluten-blood-tests.html.
Hershcovici T, Leshno M, Goldin E, Shamir R, Israeli E. 2010. Cost effectiveness of mass screening for coeliac disease is determined by time-delay to diagnosis and quality of life on a gluten-free diet. Alimentary Pharmacology & Therapeutics. 31: 901-910.
Mayo Clinic Staff. 2011. Gluten-free diet: What’s allowed, what’s not. Mayo Clinic web site. [cited in 2011 Dec 20]. Available from: http://www.mayoclinic.com/health/gluten-free-diet/MY01140.
Wilson M. 2013. ‘Gluten-free’ labeling rules head to White House. The Hill web site. [cited 2013 Feb 02]. Available from: http://thehill.com/blogs/regwatch/healthcare/284929-gluten-free-labeling-rules-head-to-white-house.
U.S. Food and Drug Administration staff. 2011. A Glimpse at ‘Gluten-Free’ Food Labeling. FDA Consumer Health Information. Available from: http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm265212.htm.
University of Chicago Celiac Disease Center staff. [date unknown]. University of Chicago Celiac Disease Center web site. Available from: http://uchicago.edu/research/center/university_of_chicago_celiac_disease_center
Science Daily staff. 2013. Can an Increase in Celiac Disease Be Attributed to an Increase in the Gluten Content of Wheat as a Consequence of Wheat Breeding? Science Daily web site. Available from: http://www.sciencedaily.com/releases/2013/02/130206131129.htm.
Science Daily staff. 2013. A Quick, Cheap, Accurate Test for Gluten Intolerance. Science Daily web site. Available from: http://www.sciencedaily.com/releases/2012/06/1206092619.htm.
Science Daily staff. 2012. Toward a Pill to Enable Celiac Patients to Eat Foods Containing Gluten. Science Daily web site. Available from: http://www.sciencedaily.com/releases/2012/12/121219133558.htp.
Science Daily staff. 2012. New Insight Into Celiac Disease. Science Daily web site. Available from: http://www.sciencedaily.com/releases/2012/10/121011124003.htm