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Gluten-free Panic! By Stephanie Karl, Nutritionist at JTS Medical Centre in Jumeirah 1 Going gluten free seems to be a common trend, and a great party conversation topic despite a lack of empirical evidence to identify a true reason behind this action. The list of celebrities whom have gone gluten free make it tempting to dismiss this phenomenon as the latest hysteria of an over diagnosed condition in a bid to maintain a healthy weight and youthful appearance, and feel mentally sharp and physically robust. Weight loss strategies, digestion, autism spectrum, eczema, detoxing and alkalizing diets all tend towards cutting out gluten and bread. Gluten is a tenacious protein found in wheat, rye and barley. Oats are often grown in the same geographical areas and processed in factories alongside wheat and therefore exposure to gluten can allow for cross-contamination. Gluten allows baked products to assert that spongy quality as carbon dioxide is trapped in the protein as it expands allowing for a light and delectable texture. Of all grains, wheat has been altered the most to improve its commercial qualities for the food industry and due to a greater output, became a much cheaper food product per yield to feed populations and give a viable financial return. According to Todays Dietitian, only about 1 in 100 people test positive to true gluten intolerance, the auto-immune disorder Coeliac Disease, via a trans-glutaminase blood test and an endoscopy of the small intestine to view villi damage. This diagnosis confirms a lifetime of gluten free living. It is usually passed on in families and avoidance will guard against aspects of nutrient malnutrition and poor health. CD usually goes hand in hand with herpetiformis dermatitis (gluten rash) and dominant symptoms can be both skin and digestion, one or the other. A dutch paediatrician in the 1950’s realized during a grain shortage that children taken off gluten showed dramatic health improvement otherwise characterized by malnutrition, stunted growth, cancer, neurological and psychiatric illness and even death. Since then, the mainstream view of gluten intolerance has been relatively black or white and patients that suspect they're sensitive to gluten but test negative for CD are told that they're simply imagining an affliction that doesn't exist. To understand the role of gluten-free diets requires untangling the web of three separate problems blamed on gluten: coeliac disease, gluten intolerance and wheat sensitivity. A quick lesson in the biochemistry of wheat and wheat digestion looks at the different classes of proteins in this food. Gliadins and glutenins are the two main components of the gluten fraction of the wheat grain. They give bread the ability to rise properly during baking. Within the gliadin class, there are four different types: alpha-, beta-, gamma- and omega-gliadin. Wheat also contains agglutinins and prodynorphins. Once wheat is consumed, enzymes in the digestive tract called tissue transglutaminases help to break down the wheat compound forming additional proteins, including deamidated gliadin and gliadorphins or gluteomorphins. As the morphin ending translates, they can have a morphine type effect on the brain, mood, anxiety, sleep, cognitive function and depression. Coeliac disease is characterized by an immune response to a specific type of gliadin (alpha-gliadin) and a specific type of transglutaminase (tTG-2). But we now know that people can react to several other components of wheat and gluten, including other gliadin types discussed above. Therefore the conventional lab test for CD and of gluten intolerance screening for antibodies to alpha-gliadin and transglutaminase-2 will come up as negative for CD and gluten intolerance no matter how severely you're reacting to wheat. It is not an auto-immune or allergic reaction but a non-coeliac gluten sensitivity which resolves when gluten is removed from the diet and CD and allergy have been ruled out. It's difficult to estimate the prevalence of gluten sensitivity because of the lack of definitive diagnostic testing and sufferers go for years before diagnosis especially if clinicians are unfamiliar with the symptoms. Instead labels such as irritable bowel syndrome, eating disorders or dietary nutrient deficiencies are diagnosed and gluten avoidance may in fact be underpublicized as a treatment option. My colleague, Dr Suresh Puri,Consultant Pulmonologist at JTS medical centre in Dubai suspects gluten to be under-reported and over looked as having a possible influence on some conditions. “It is assumed that gluten intolerance always causes digestive distress, however a vast number of patients diagnosed with coeliac disease do not have gastrointestinal symptoms” he said during a discussion we had about a patient who has struggled with reoccurring respiratory tract infections, poor immunity and gastrointestinal symptoms for many years. A six month trial period of going gluten-free, however, caused a measureable improvement in his health despite little in the way of digestive symptom Gluten intolerance can affect nearly every tissue in the body, including the brain, skin, endocrine system, stomach, liver, muscles and even the nucleus of cells. Emerging research indicates other associations with diseases, such as asthma, Type 1 diabetes, schizophrenia, epilepsy, arthritis, osteoporosis, dermatitis and psoriasis, Hashimoto's hypothyroidism and peripheral neuropathy can greatly improve by following a gluten free diet and yet is often not suspected. With all of this in mind, the obvious question that arises is what is the best way to test for gluten intolerance? Current laboratory testing remains limited and therefore removing gluten from the diet completely for a period of at least 30 days, and then adding it back in after that may be the best indicator. If symptoms improve during the elimination period, and return when gluten is reintroduced, a diagnosis of non-coeliac gluten sensitivity can be made. For many people a gluten-free diet isn't enough as some grains that don't contain gluten, such as corn, oats and rice, contain proteins that are similar enough in structure to gluten to elicit an immune response in people with sensitivities. Casein, the protein in milk is also often a contributor of unpleasant symptoms due to its sometimes virulent effect on an already compromised digestion and it also has a measureable opiate effect trigger protein called casomorphine. This may explain why many patients continue to have symptoms or clinical signs after adopting a gluten-free diet. For this reason, many medical nutrition treatment plans recommend a completely grain - and dairy-free diet during the gluten challenge period. Symptoms of Gluten Intolerance - • gas, bloating and mouth ulcers, • heartburn and reflux, • slow or fast bowel elimination, • poor growth and development, • depression and mental illness, • failing health, fatigue, pain and premature aging To further obscure this misunderstood diagnosis, this condition is not an auto-immune disorder nor a true IgE allergy such as wheat allergy where reactions are almost immediate and can be severe. This diagnosis simply is subjective feelings of symptoms, possibly bloating, bowel changes, or mental fogginess after eating gluten. Another equally frustrating aspect of removing wheat is improvements in health may not be due to the protein gluten, but the removal of specific sugars or saccharides found in cereals as well as fruits, vegetables, dairy, lentils and pulses. This group of chemicals include fructans, fructose, raffinose, monosaccahrides, disaccharides, oligosaccharices,lactose and poly phenols. Gas from fermentable sugars is going to cause bloating and foods are often already known to the patient. This may be due to bacteria, candida yeast, parasites, an enzyme deficiency, incomplete digestion and low stomach pH. Testing can reveal some causal problems, while an experienced nutritionist will also help. The exciting news is that once these factors are addressed the body absolutely responds by returning to balance, symptoms are reduced and sometimes diseases are totally reversed. In an age where we do not expect malnutrition to be occurring in the western world but rather over nutrition, food sensitivities in fact do lead to malnutrition. Identifying triggers and working to remove offending foods, replace nutrients, re-colonate with good bacteria and restore the integrity of the gut lining is the base for a treatment program. Eating the essential fats is imperative as these are what build’s and nourishes cell membrane fluidity while targeted supplementation with likely single element deficiencies is one of the most difficult areas of clinical nutrition as nutrient corrections are made to restore adequate levels. In the absence of accurate science and testing to identify all types of food intolerance, the best course of action is to eliminate foods that are suspect or might be identified from an intolerance test such as the Cambridge panel, diagnose a treatment plan followed by food challenges after about a month. Elimination diets need to be well planned and supported to avoid further malnutrition and results evaluated to identify likely causal relationships, diagnosis and correct exclusion long term rather than following a fashionable fad. Dr Puri and I support [email protected] founded by Mrs Sarah Decker for those seeking support for themselves or family members with food allergies.