So the short answer is, yes, you probably should. At minimum, most people need to start dealing with gut issues by trying an elimination diet, and gluten is the primary thing to eliminate. Dairy, soy, added sugar, corn, alcohol, processed seed oils and processed foods with many ingredients (which are pretty much out if you’re already eliminating corn and soy) are other really common problem foods. So that’s a good place to start.
So let’s talk a little bit about what gluten is. Briefly, it is the protein found in wheat, barley, rye, spelt and triticale, which is a cross between wheat and rye. And because of cross contamination, it can also often be found in oats.
Alpha gliadin is the protein fragment that most research focuses on as the main culprit in gluten sensitivity or celiac disease. But all grains contain proteins that are similar to gluten and may also cause problems. So a heads up that if you have already eliminated gluten and other problem foods, and you’re still having problems, there is a whole school of thought led in part by Peter Osborne who wrote “No Grain, No Pain”, that all grains need to be eliminated. In that case, because you may be having problems or cross-reactivity with other grains, you may want to get a test through Cyrex labs of 24 other foods that have typical cross-reactivity with gluten. One surprising cross-reactive food is instant coffee because there’s a high rate of contamination with gluten.
It’s also possible that what you think is just a sensitivity to gluten may be undiagnosed celiac disease. Celiac is an autoimmune disease in which the villi in your small intestine are actually destroyed by eating gluten. That impairs nutrient absorption, which leads to intestinal symptoms, typically diarrhea, but also fatigue and many other things. So the gold standard for testing for celiac is an intestinal biopsy, but there are also blood tests for Immunoglobulin A (IgA) antibodies, which will be found in about 80% of people with celiac disease. Cyrex lab can also test blood more extensively to catch false negatives for IgA. The problem with the testing for celiac is that you have to eat gluten about twice a day for four weeks prior to the test. Nevertheless, there is real value in actually getting a diagnosis. Imagine you have accidentally discovered that you don’t do well with gluten, but you’re kind of cheating, eating gluten every week or every couple of weeks, and you’re just not really taking it seriously because you don’t have an official celiac diagnosis. You could really be putting your health in danger. Getting that celiac diagnosis is going to lead to a lot better compliance because you’re going to realize what the stakes are for eating gluten. People with celiac disease have increased chances of other autoimmune diseases and the sooner it’s discovered and a very strict gluten-free diet is followed, the better.
I actually had a client who had suffered from extreme fatigue his entire life, but up until more recently, he hadn’t had the gastrointestinal symptoms. At the age of 60, he finally got his celiac diagnosis. So the fatigue comes from a lack of nutrient absorption. You’re basically running on nothing because your villi normally absorb nutrients but they’re getting progressively more destroyed.
It’s estimated that about 1% of people have celiac disease in the U.S. and it is hereditary. If you have a first degree relative with celiac disease, you have a one in 10 risk of having it as well. So if you find out that someone in your family has celiac, or if you find out that you have celiac, you should encourage your relatives to get tested. If you are diagnosed over the age of 20, there’s a 34% risk of another autoimmune disorder. Celiacs do have to eat a strict gluten-free diet for the rest their lives.
In addition to that, for about 8% of celiacs, even gluten-free oats are problematic and cross-reactive. Let me also mention that dairy is also frequently problematic to people who have celiac because it is digested with the top of the villi. But once you go off the gluten and the villi start to heal, which can actually happen relatively rapidly, possibly in a matter of months, then you may regain your ability to digest dairy. So you may want to retest dairy after some time has passed.
Symptoms of celiac disease are unexplained iron deficiency, anemia, fatigue, bone or joint pain, arthritis, osteoporosis, or osteopenia, liver and biliary tract disorders, depression or anxiety, peripheral neuropathy, which is tingling or numbness or pain in your hands and feet, seizures or migraines, amenorrhea (loss of your period), infertility, canker sores, and an itchy skin rash.
Non-Celiac Gluten Sensitivity
Now, let’s talk a bit about non-celiac gluten sensitivity (NCGS), because a lot of people think that if you’re not celiac, then the rest is just kind of made up. That is not true. It is a real diagnosis. In the U.S., somewhere between 0.6% and 6% of people are gluten sensitive. But I have seen in at least one article that as many as 33% of Americans are currently trying to avoid gluten (so restaurant owners, how about more gluten-free options?) One study in Italy of about 12,000 people found that there is about a rate of 3% of gluten sensitivity.
The official way to diagnose NCGS is to test negative for celiac, but have both gastrointestinal and non-gastrointestinal symptoms. The gastrointestinal symptoms would be the kind of symptoms you’d see with IBS, like cramping, bloating, diarrhea, stomach rumbling, constipation and foul-smelling stool. The non-gastrointestinal symptoms are brain fog, trouble concentrating, memory problems, frequent headaches, mood-related changes like anxiety and depression, low energy, chronic fatigue, muscle and joint pains, numbness and tingling in the arms and legs, reproductive problems and infertility, skin issues like dermatitis, eczema, rosacea and rashes, nutrient deficiencies including anemia, and just generally increased inflammation in the body. Having non-celiac gluten sensitivity also puts you at a higher risk of autism, ADHD, Alzheimer’s, dementia, neurological and psychiatric diseases and leads to autoimmune disease.
SIBO and Low FODMAPs
Now, let me also mention that for some people, gluten sensitivity is not in fact sensitivity to gluten, but an intolerance to FODMAPs, which are fermentable oligosaccharides, disaccharides, monosaccharides, and polyols, which are a component of gluten-containing grains. So if you are reacting to foods like onion and garlic as well, it may be that what you need is a low FODMAP diet, not just a gluten-free diet. FODMAPs are in a lot of foods, including lots of fruits and vegetables, and of course in gluten and in dairy. If you do well on a low FODMAPs diet, then that is probably indicative of the fact that you have SIBO or Small Intestine Bacterial Overgrowth, a primary cause of Irritable Bowel Syndrome (IBS).
One of the potential origins of SIBO is an autoimmune attack on the villi in your small intestine, which can come from an episode of food poisoning. And now there’s a test called the IBS Smart Test that is starting to be covered by some insurance and by Medicare and Medicaid, although your doctor may not have heard of it. It can test you for the antibodies that could be hurting your villi, which damages your migrating motor complex (MMC), the movement of your intestines that pushes food through. If you have the autoimmune type of SIBO, you’ll need to get treated for SIBO, but also go on a prokinetic, or something that helps your MMC do its job of peristalsis, or moving food through the intestines. So if you are reacting to onions and garlic, it may be SIBO. Look in that direction for healing rather than just eliminating gluten.
Let me also mention that just going on a low FODMAPs diet will not be sufficient to heal your SIBO. It will help you with the symptoms, but it’s not a good, long-term diet because it is deficient in a lot of nutrients and fiber that are important for your gut microbiome. So you want to get the diagnosis, heal the SIBO (which can be through a prescription drug called Rifaximin or herbal anti-microbials), then you might need to go on a prokinetic to get that small intestine moving again in order to keep the gut motility up and your MMC functioning in the long-term. So you need to see someone (like me) who can help you get the testing and educate you on antimicrobial options.
Why Gluten is Problematic in General
Now let’s talk a bit about why gluten is problematic in general. Gluten, for all people, triggers the release of a chemical called zonulin. And zonulin opens up the tight junctions in your intestines, causing what is known as intestinal permeability or in lay parlance, leaky gut. And the thing is, when those tight junctions open, gluten is a large, hard-to-digest protein that can then slip out those cracks and cause an immune response. So what they have found is that in celiac disease, the opening time for zonulin is much longer, so a good bit of undigested food, toxins and bacteria can slip out.
For people who have NCGS, there may be two things at play. One may be that the barrier is held open for a longer period of time, and then you’ll have increased leakage of undigested proteins and the immune response. But the second is that there may be changes in the gut microbiome that lead to gut dysbiosis, which then leads to increased intestinal permeability, gut symptoms and systemic inflammation, which is your immune immune response.
Gluten and Autoimmune Disease
In both celiac and NCGS, the real danger is molecular mimicry, which means that when that gluten escapes, the gluten protein looks like your own cells. When your immune system sees your own cells that look the same, it attacks those as well, which is one of the origins of autoimmune disease. That’s why Hashimoto’s thyroiditis is so common: the cells in your thyroid resemble the gluten protein. At this point, they say that one in five of American women will have Hashimoto’s or another thyroid disorder in their lifetime. Other autoimmune diseases besides Hashimoto’s that are most frequently mentioned in conjunction with non-celiac gluten sensitivity are dermatitis herpetiformis, psoriasis and rheumatologic diseases like rheumatoid arthritis, which is another one of the very common autoimmune diseases.
So to have that autoimmune reaction, you basically have to have three factors at play. Number one, you have to be genetically predisposed to gluten sensitivity or celiac, you have to have an environmental factor that’s the instigator of the immune response (in this case, gluten), and then at the same time, you have to have that breach of the intestinal barrier so that the genetic predisposition to the food sensitivity can interplay with the protein from that food entering the body.
I should also mention that casein, one of proteins in dairy, also looks like gluten to the body, and about 50% of the people who are sensitive to gluten are also sensitive to dairy. So that’s a big one. I’ve heard clients say to me, well, I went off gluten for X amount of time and didn’t get better. Well, you may be deep into it. First of all, it may take more than a month or two of elimination. But also, you may not be eliminating all the foods that you need to eliminate to really get at the root of your problem. And if you’ve not done that, then you’re still going to have the symptoms.
Elimination Diets and the AIP
So let’s talk about an elimination diet. The ideal elimination diet is going to last at least 30 days and eliminate gluten, dairy, soy, added sugar, alcohol and processed foods, at minimum. Six weeks would be even better. Then you should reintroduce each food individually for a week at a time, eating it a couple of times a day so you can really gauge the effects. It’s important to leave enough time to make sure that food is really non-reactive, then remove that food again as you test something else and then slowly add the non-reactive foods back in at the end.
Now if you are dealing with an autoimmune disease and not just gut symptoms, the autoimmune protocol (AIP) is a much more strict elimination diet that you could try. That also eliminates nightshades, which are tomatoes, peppers, potatoes and eggplant, legumes, eggs, coffee, all grains, nuts and seeds, seed spices, every spice in the pepper family, and chocolate! Tragic, I know. But I wanted to caution you that if you are going to go that route, there’s something that can happen when you go on elimination diets like the AIP. You may end up eating the same things every day and reducing your diet to so few foods that you get to the point where you can basically eat nothing without getting sick. So a word of warning, if you’re just starting to plan to go on the AIP, it is essential to eat a variety of foods, especially fresh produce and the starchy vegetables that are allowed on it, to keep up the diversity of your gut bacteria during that time. Otherwise, you may risk losing oral tolerance for many foods, which is what I hear from a lot of people who have gone on strict elimination diets and kept them going for too long.
(To hear more about loss of oral tolerance, listen to the second part of my podcast on this topic: “Should I give up gluten to help my gut issues?”)
So I know that the big question for a lot of people who are considering going off gluten is, “Does this mean no more pizza for life? Will I always have to be gluten-free?” So if you’re celiac, of course you will always have to be gluten-free. For those who have non-celiac gluten sensitivity, the research at this point is not conclusive. For now, the expert recommendation is that you should follow a gluten-free diet for one to two years and then retest by eating gluten. In my experience, I have had autoimmune conditions (which I described in my January podcast episode: “How I Reversed My Autoimmune Diseases and Got Interested in Gut Health”). During the 5-year process of bringing my antibodies to normal through among other things, staying off of the foods I’m sensitive to (gluten, dairy and soy), I have been able to cheat with gluten about four to six times a year without really throwing myself off track. However, autoimmune experts warn that even eating it once every 6 months could be problematic. That has not been my personal experience.
And there’s no question that I’m gluten sensitive because my stomach bloats up with a food baby every time I eat it, among other problems. But I can still get away with it by taking gluten and dairy digestants and lactose pills. And yet I have been able to continue to reduce my antibodies. Of course I’ll be a little bloated the next day, and I’ll have a sore throat, mostly from the dairy, but I make it worth it. If I’m going to cheat, I’m not having a couple of saltines or frozen pizza. I’m going out for Neapolitan pizza and a chunk of fresh mozzarella or burrata and a nice tiramisu. I’m making the most of it. So I would say that if you’re going to cheat, be purposeful and make the most of it. Don’t just cheat on something stupid because it’s sitting there at some church potluck.
I’ve been thinking that when my Thyroglobulin antibodies for Hashimoto’s are normal (which is under 0.9; mine were last 2.4 ) I may try eating gluten more frequently and see if I can get away with it. But honestly, bread has always made me feel bloated and gross, and it takes up stomach space and calories that really could be filled with more nutrient-dense foods, and it leads to weight gain. (Update 6/3/20: my antibodies were completely normal at my last lab tests in April and I have begun having pizza again every 3 weeks or so with no obvious ill effects. I haven’t retested my antibodies but I’ll update you when I get that chance.)
So in general, I’m not really trying to find more ways to include gluten in my diet, because I don’t think that ultimately it’s the food I most want to reintroduce and take up space with. I have to say that being gluten sensitive has given me a lot of freedom and ease in limiting sugar. I was such a sugar addict before, and the vast majority of desserts out there that you don’t make yourself are going to have gluten in them. So that just means they’re off limits. So it’s really given me the freedom to say “no” to so many foods without even being tempted because they’re just on the no fly list. They’re just never going to be a possibility for me. So I feel like giving up gluten has led to a healthier life overall. So I don’t actually really want to go back on gluten for good. Gluten-free has been a pro in my life.
So if you are struggling with gut issues and haven’t yet taken the plunge and gotten off gluten, this may be the time.
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And I do one-hour consultations as well as longer-term health coaching programs (starting with a free, 1-hour breakthrough session) to help with gut issues, autoimmune disease reversal and weight loss, so don’t hesitate to sign up for a Breakthrough Session.
Happy gut healing!