Does everyone need to be gluten-free?

Is gluten-free actually healthier or just a fad?

Hi again,

My apologies (or maybe you’re welcome?) for not publishing in a while. I know your inboxes are full and you likely didn’t notice, but I don’t take for granted you letting me show up in your inbox every so often. I always want to make sure that when you hear from me, the information can:

1. Help you better understand nutrition and the gray areas of its changing landscape, and/or

2. Make your life easier when it comes to eating for your (and your family’s) health.

Today, I’m chatting about gluten. People ask me about it all the time, so I thought you might also wonder:

What’s the deal with gluten?

I’ve received a version of this question from friends, family, clients, and even strangers over the years, and I wish I had a quick and easy answer.

Does everyone need to avoid gluten?

If I had to give a yes or no answer to this question, I would probably say…

Ugh. I honestly don’t know.

It really does depend on the person eating the gluten. Some people can digest it without issue, while others—not just people with celiac disease—cannot.

First thing’s first. What even is gluten?

Gluten is a protein found in some grains (wheat, barley, rye, spelt, and a few others). Most of the gluten we eat in the United States is as wheat. So, it’s in foods like breads, pastas, cereals, crackers, and baked goods. It’s also a less prominent ingredient in countless other foods like sauces, deli meats, granola bars, seasonings, condiments, and others.

Gluten isn’t inherently bad for everyone, but celiac disease isn’t the only reason someone might avoid gluten. Some people have an intolerance to gluten that shows up primarily as bloating and gas. There’s a specific type of carbohydrate in gluten-containing foods (fructans) that, for some people, can be easily fermented (aka: cause gas to form) in the intestinal tract. Fructan-containing wheat is also in the same family of carbs as garlic, onions, and other foods. This leads into the low FODMAP diet conversation, but I’m trying to keep this newsletter concise, and FODMAPs are a whole different can of worms that I don’t want to open today.

Gluten intolerance doesn’t have the severe health risks that someone has with celiac disease or a wheat allergy. While the symptoms from these foods are annoying and absolutely make life harder—Gas on a date? Diarrhea during a big meeting? Stomach puffing out in a new pair of jeans?—their presence doesn’t increase someone’s risk of disease or death (as far as we know now). They are, however, uncomfortable and inconvenient and absolutely can be a reason someone might want to avoid gluten.

Non-celiac gluten or wheat sensitivity or gluten intolerance also warrants a gluten-free diet. People who experience symptoms tied to eating gluten who don’t have celiac disease or wheat allergy typically fall into the category of non-celiac gluten or wheat sensitivity or gluten intolerance. I won’t get into the weeds any further than I already have (or will), but just know that these very real symptoms that are alleviated by following a gluten free diet. While a gluten-free diet is important, are there potential downsides to following a gluten-free diet in someone without celiac disease? We don’t know for sure. Some investigators are looking at the impact a gluten-free diet has on the intestinal microbiota. We don’t know enough to know whether the changes to the microbiota are good or bad, but we do know there is likely a difference in the gut microbiota between someone is or isn’t eating gluten.

Celiac disease increases risk for other diseases. People with celiac disease (an autoimmune condition), have an increased risk for nutritional deficiencies like iron-deficiency other nutrients. They are also at a higher risk for osteoporosis and, thus, bone breaks. People with celiac disease have an increased risk for being diagnosed with another autoimmune disease and for certain cancers.

The only treatment for celiac disease is a gluten free diet (medications can’t fix it). This is why it’s critical to figure out whether someone has celiac disease or whether their reaction is an intolerance or sensitivity. So, when I work with someone with symptoms they’ve dealt with as “normal” their whole life, it’s important to know how flexible they can actually be with their diet. The amount of gluten that can damage the intestine of someone with celiac disease is 350th of a slice of bread—barely a crumb.

Gluten-containing foods are primarily processed foods. Like seed oils, foods made with gluten (primarily wheat) include breads, pastas, crackers, cereals, chips, cookies, cakes, baked goods, etc. Of course, not all of these foods are inherently unhealthy, but they are part of a dietary pattern we refer to as the Standard American Diet (or “SAD Diet”). Eating a diet filled with primarily processed foods is associated with increased risk of chronic diseases like diabetes, heart disease, and cancers. However, whether a diet is free of gluten doesn’t make it a whole and healthy diet.

A gluten-free diet isn’t inherently healthy. Going “gluten-free” isn’t the same from person to person. Some people stop eating gluten and pare down their diet to naturally gluten-free foods: fish, seafood, poultry, meat, eggs, beans, gluten-free whole grains (e.g. wild rice, quinoa, oats), vegetables, fruit, nuts, seeds, etc. This is a whole food-based diet that would likely be the type of diet that has been shown to lower risk of chronic disease.

Now, though, it’s very easy—much easier than when I first started practicing nutrition in 2010—to eat gluten-free. There are gluten-free breads, pastas, crackers, cereals, chips, cookies, cakes, baked goods, etc. Recognize this list? Again, even though they’re gluten free, they’re still highly processed and can comprise a standard American diet that poses health risks.

There are other reasons someone might avoid gluten. As I’ve already discussed, gluten intolerance and non-celiac gluten sensitivity can be good reasons for someone to significantly decrease or completely avoid gluten. Other symptoms or conditions triggered by gluten include gluten ataxia, which is an autoimmune condition that can cause loss of coordination, trouble speaking, and difficulty using one’s hands, arms or legs. This is likely tricker to figure out (uncommon), but I recall a client I worked with many years ago (collaborating with a physician) whose main health improvement was that she was eventually able to walk without a cain! (I’m dead serious this is a true story. It was incredible.)

Autoimmune hypothyroidism (Hashimoto’s thyroiditis) may warrant a gluten-free diet. While it’s still debated in the literature, some research (a meta analysis) suggests that a gluten free diet improves thyroid function in people with Hashimoto’s. I typically encourage clients with Hashimoto’s to try a gluten free diet if they aren’t already following one themselves. And, full disclosure, one of the reasons I’m primarily gluten-free is because 12 years ago I went gluten-free with my mother who was diagnosed with Hashimoto’s. Interestingly, it resolved some digestive symptoms for each of us that we’d dealt with for years. For those curious, her thyroid antibodies did decrease by about 1500 points, but we can’t say for sure that gluten avoidance was the only reason her antibodies went down.

While gluten avoidance outside of celiac disease and wheat allergy is debated, most gluten-containing foods are in ultra-processed foods, and eating a lot of highly processed foods doesn’t promote health. There are absolutely scenarios I work with clients where gluten avoidance can help alleviate symptoms, but I don’t recommend a gluten-free diet to everyone.

Rapid fire Q&A that I didn’t fully dive into:

1. Is wheat different now than in the past, and could that be why people have trouble with it? Yes wheat is different, but whether or how that difference is affecting health outcomes isn’t totally clear.

2. Is there anything someone can take to better digest gluten? For some, maybe but definitely not for people with wheat allergy or celiac disease.

3. Can someone who doesn’t tolerate gluten ever eat it again? It depends, but sometimes, yes! (Per my experience after 14 years of practice)

4. Do people just think they’re going to have a bad reaction to gluten, so they do have a bad reaction to eating gluten? Not completely, but definitely somewhat! Here’s a cool study published in the Lancet asking exactly that!

There are so many more aspects of the gluten conversation I left out. What questions do you have about gluten?

Leigh

P.S. Thanks for sticking with me as I continue to navigate Substack writing outside of my other work seeing clients and volunteer work with organizations like Food Equality Initiative that do life-changing work.