Gut Instincts: The Fact and Fiction Behind the Gluten-Free Movement

By Aimee Lee Ball

Recently a market research group called Mintel International did a study about gluten-free foods and beverages, noting a need for innovation. Few Americans have been diagnosed with celiac disease, an immune response to a protein in wheat and other grains that precipitates an inflammatory condition in less than one percent of the population. Yet the phenomenon of adopting a gluten-free diet is so widespread—Mintel estimated sales of gluten-free products would reach $10.5 billion in 2013, with a 50 percent increase expected over the next two years—that the research group’s admonition to the food industry was: Keep up the pace—there’s gold in those gluten-free cookies.

The study neatly joins two seemingly incompatible but indisputable truths about this moment in our common culture: There aren’t a whole lot of people who have a diagnosed medical reason for avoiding gluten. But suddenly a whole lot of people have decided that they’re better off without it. The gluten-free diet has reached the popularity of Game of Thrones and Downton Abbey combined (with a fair amount of absurdity—perhaps you’ve seen “gluten-free water” in the market).

Which begs two questions: Why gluten? And why now?

The writers of two popular books on the subject believe they know: David Perlmutter, M.D., a neurologist in Naples, Florida, and author of Grain Brain, calls wheat the brain’s silent killer and turns the classic American food pyramid upside down. Gluten, he says, is our generation’s tobacco—virtually everybody’s problem—and there is no such thing as healthy whole grains. “Gluten sensitivity is perceived as an intestinal illness, but to think that it has nothing to do with the brain is silliness,” he says. “If your gut is sensitive, that will be directly related to the brain. Celiac disease, Alzheimer’s, Parkinson’s, and multiple sclerosis are all things that hang their hats on the mechanism of inflammation. When the gut develops inflammation, it’s traumatizing to the brain.”

William Davis, M.D., a cardiologist in Milwaukee, Wisconsin, and author of Wheat Belly, says that wheat isn’t even wheat any more—it’s a monstrosity created by genetic research so that it will yield more grain per acre. He proposes that wheat is unique among foods in its addictive properties, somewhat similar to heroin (although it makes us hungry instead of high), and leading to similar disastrous consequences, from mood swings and mental fog to delusions and hallucinations. Modern wheat, he says, is a “perfect chronic poison.”

There is no doubt that celiac disease is on the rise, doubling every twenty years or so. It’s rather astonishing to note that twenty years ago, when the U.S. Department of Health and Human Services and the National Institutes of Health published an 800-page report on digestive diseases, the words “celiac disease” did not appear. But the leading researchers in the field dispel the trendy theories about what’s causing that spike:

Genetically modified wheat is not commercially available. “There is not a single grain of wheat sold anywhere in the world that comes from genetically modified gluten,” says Stefano Guandalini, M.D., founder and medical director of the University of Chicago Celiac Disease Center. How come? Part of the answer has to do with government oversight: In the United States, the Food and Drug Administration controls foods from genetically engineered crops in conjunction with the Department of Agriculture and the Environmental Protection Agency under the Coordinated Framework for the Regulation of Biotechnology. The name itself is a mouthful, suggesting a lot of red tape; approval for commercial use is a complicated—some would say draconian—process.

Animals aren’t eating Frankenwheat either. “There is no genetically modified wheat commercially produced in the U.S., regardless of whether it is fed to humans, cows, or pets,” says Jayson Lusk, Ph.D., a food and agriculture economist at Oklahoma State University. “The only genetically modified wheat in the U.S. is the tiny amount grown for research purposes, typically indoors in greenhouses; it is highly regulated and is not released in the food supply, human or otherwise.”

Lusk cites two reasons that wheat farmers don’t pursue genetic modification, both related, unsurprisingly, to profit: Europe and Japan buy huge amounts of American wheat (there’s a good chance that the delicious fettuccine in Rome is made with amber waves of grain from Kansas), but they’ve been antagonistic to genetic engineering. So there’s concern about the impact on international trade. Corn farmers do create modified breeds, and they’re accustomed to buying new seed every year because seed that is saved from the previous crop doesn’t reproduce well. “But wheat is a different beast,” explains Lusk. “The seeds don’t lose their productivity when the farmers replant, so they balk at the expense—‘What, you want me to buy new seed?’”

But perhaps the most salient facts are these: It’s hard to alter wheat. “The genetic makeup is really complicated,” says Brett F. Carver, Ph.D., professor of wheat breeding and genetics at Oklahoma State. “Up to 300,000 genes may be expressed in the plant until it’s harvested, which makes it difficult to judge the effectiveness of any single gene. Most of what’s inside the wheat kernel is starch, so it’s hard to improve productivity and also increase the protein content, which is what gluten is. In that sense it is unrealistic to say that the protein in wheat has reached unprecedented levels. We’re trying to preserve the gluten content and properties in the wheat to maintain its traditional function in a multitude of food products.”

In the early 1900s, wheat’s gluten content varied between 14 and 18 percent of the wheat, according to Guandalini. Currently it’s between 13 and 16 percent, thus essentially unchanged. Some manufacturers add gluten to make various foods more chewy, stretchy, spongy, or palatable—for instance, to increase elasticity in bagels—and it’s the major component of the ersatz “meat” called seitan or the “mock duck” at a Chinese restaurant. (It’s also in “thickening” shampoos, “volumizing” mascaras, and the kind of postage stamps you have to lick.) But we are not eating more wheat. “Nothing could be farther from the truth,” says Guandalini. “The amount of wheat consumed per capita in the early 1900s was almost twice as much as the amount currently being consumed. It used to be 240 pounds per person; now it’s 120 to 130 pounds.”

The thinking about celiac disease changed dramatically in 2003 when the Center for Celiac Research at the University of Maryland published a study in Annals of Internal Medicine showing that one in 133 people in the United States were affected by the disease, which damages the lining of the small intestine, where almost all nutrients are absorbed. “That put it on the map,” says Amy Burkhart, M.D., R.D., who, as her designatory initials attest, is both a physician and registered dietician in Napa, California, specializing in digestive health. “The incidence of celiac disease was not one in 10,000 as we were taught in medical school.” Screening got better too: An older test, called EMA, was expensive and technically difficult; the new test, called tTG, is less expensive, easier to perform, and more sensitive, with fewer false negatives, although Burkhart points out that a true diagnosis must include a biopsy of the small intestine, done endoscopically, plus genetic testing to confirm the presence or absence of specific genes associated with the disease.

That groundbreaking study a dozen years ago was led by Alessio Fasano, M.D.; he’s now director of the Center for Celiac Research at Massachusetts General Hospital for Children in Boston, and jokingly blames himself for the public confusion about gluten. “There are a lot of fantasies and very few facts,” he says. “Gluten is the only protein that we cannot completely digest, and there is some scientific evidence that we as a species did not evolve to deal with it. For two and a half million years, humankind was 99.9 percent gluten-free. When our ancestors changed from a nomadic lifestyle to being settlers, they started to generate grains containing gluten. Gluten is like a pearl necklace: We break the necklace and peel the pearls—amino acids—with digestive enzymes, but we can’t completely digest gluten because the composition is so weird.”

Fasano has written a book called Gluten Freedom that he calls “the voice of common sense,” and he does not share the “wheat belly” and “grain brain” exhortation for a gluten-free world. “These books say that because nobody can digest this stuff, everybody needs to go gluten-free. That’s a stretch of imagination. Since we didn’t evolve to deal with this molecule, the immune system deploys the same kind of weaponry as when we’re under attack from bacteria. We engage in war with many bacteria every day, but we rarely lose this battle and develop infection. Same with gluten—we all engage in this fight, but very rarely do we lose the battle.”

Fasano and other leading researchers in celiac disease concede that they don’t know why there’s been an uptick, but there are some good theories: One has to do with the microbiome, the collection of microorganisms and bacteria that inhabit the human body. “Man used to be born in a non-sterile environment,” says Guandalini. “That kind of exposure would direct the development of a healthy immune system. We have lots of cells that happily live in our gut. It’s like having Riccardo Muti of the Chicago Symphony, ensuring a nice harmonious play of all the elements.” But various aspects of life in the developed world, like the use of antibiotics and the increase of cesarean births, change the composition of our healthy bacteria and have a profound impact on development of immune system.”

The microbiome definitely influences how carbohydrates in food are fermented. “We know that the genes associated with celiac haven’t changed, and gluten hasn’t changed,” says Peter H. R. Green, M.D., director of the Celiac Disease Center at Columbia University in New York. “We have billions of bugs in our bodies, and they vary with the seasons. They may or may not be involved, but it’s tantalizing to think they might be.”

In 2011, Peter Gibson, M.D., a professor at Monash University in Australia, published a study showing that gluten caused gastrointestinal distress in people who did not have an autoimmune disease, and an international consensus conference gave credence to the concept of “non-celiac gluten sensitivity” (NCGS). But when Gibson decided to repeat the study with more rigorous controls, he reversed his own findings and said so in the journal Gastroenterology. The study was small but shone light on an odd acronym that may soon become part of the common parlance. FODMAP (an abbreviation for Fermentable, Oligo-, Di-, Mono-saccharides and Polyols) is a group of sugars found in some foods such as apples, watermelon, onions, garlic, and, yes, wheat. They are poorly absorbed by the small intestine, and the fermentation process from all that bacteria in the digestive system can create symptoms such as gas, bloating, diarrhea, and fatigue. (Sound familiar?) When people eliminate bread products from their diet and feel better, Gibson posited, it may be because they’re unwittingly cutting out FODMAP. The Australian Government has already taken the step of creating a “FODMAP-friendly certification program” with logos to identify low-FODMAP foods. It may not be long before we’re hearing about celebrity-endorsed FODMAP-free diets.

“The problem is that for celiac disease, we have biomarkers—exact lab data that can tell us for sure, you have this condition,” says Guandalini. “In NCGS, there are no biomarkers, so we must rely on the patient’s report. The symptoms could be due to FODMAP. But I add another consideration. There is emerging evidence in animals that a protein in wheat called amylase-trypsin-inhibitor (ati) is very capable of causing some degree of intestinal inflammation. The jury is still out for humans. But the point is that at present we have absolutely no proof that gluten has anything to do with so called ‘non-celiac gluten sensitivity.’”

Those who condemn the new varieties of wheat argue that too much experimentation took place before government guidelines were set. It’s perfectly true that hybridization has been pursued for years in the name of increasing crop strength, maximizing profit, and feeding the world. Norman Borlaug won the Nobel Peace Prize and was known as “the man who saved a billion lives” in recognition of his work toward ending world hunger by developing high-yield, disease-resistant varieties of wheat. “Wheat that the Romans and Greeks were eating was different,” says Fasano, “but wheat changed over millennia, not decades. Hybridization doesn’t explain the recent numbers for celiac disease. I believe we’re in the midst of an epidemic not because we changed the content of gluten in wheat but because something changed that made people lose their tolerance to gluten. And probably the most influential change is the composition of bacteria that live within us, the microbiome.”

Not having simple answers to questions about gluten is as wearisome to those studying it as it is for those suffering from it. “What’s happening now is frustrating for people who have a true medical issue because the fad component is taking over,” says Burkhart, who has a personal as well as professional interest—she and seven family members have celiac disease. “It’s a challenging path for most people. They turn to the Internet, and it’s a myriad of confusion.”

But you may take heart from a prediction. “We’re close to finding a cure for celiac disease,” says Guandalini. “We’re working actively on the idea of restoring tolerance to gluten by interacting with the immune system in different ways, and we’re confident this will come to fruition.”
And as for the mixed messages and misinformation, be assured that for everyone it’s hard to separate the wheat from the chaff.

Photo credit: Maren Caruso