Ask Dr. Pat

Dr. Pat Consults: Gluten-Free Diets—Science or Fad?

Dr. Patricia Yarberry Allen is a collaborative physician who writes a weekly “Medical Monday” column for Women’s Voices for Change. (Search our archives for her posts, calling on the expertise of medical specialists, on topics from angiography to vulvar melanoma.)

This week, Dr. Pat reaches out to Dr. Brian R. Landzberg, Clinical Assistant Professor of Medicine in the Division of Gastroenterology and Hepatology at the Weill Medical College of Cornell University—a gastroenterologist in private practice in New York City and a member of our Medical Advisory Board—for answers to the questions “What is a gluten-free diet?” and “Who should be on one?”

 

Dear Dr. Pat:

I can barely go out to dinner with friends anymore and just enjoy myself with good food. So many of my friends have developed peculiar demands about food that it amazes me. I can understand that people are not able to tolerate dairy, or have an allergy to shellfish or nuts, but now everyone seems to be intolerant to gluten as well. I understand that people who have to avoid gluten have a disease that is genetic. I have Irish-American cousins who have this disease in their family, and it is a nightmare for them; they have to avoid everything with gluten or they’ll get terrible GI symptoms and fatigue. Is gluten sensitivity real?  Is it celiac disease?

Janet

 

Dr. Landzberg Responds: 

540926535_6117cae4b9_bIt seems that every time one opens a magazine or newspaper there is an article touting the benefits of a gluten-free life. Gluten-free products [products free of wheat, rye, or barley flour] that used to occupy a few shelves in a typical supermarket now comprise a whole aisle, offering a wide selection of great options for the celiac disease patient. But does avoiding gluten make one live better or longer, and is it advisable in the absence of bona fide celiac disease? I offer one gastroenterologist’s opinion below.

Celiac disease is an autoimmune disease of the small intestine with a prevalence of approximately 1 in 200 Americans. It results in a wide spectrum of clinical manifestations, from no symptoms to mild irritable bowel syndrome to frank malabsorption. For many celiac patients, associated extra-intestinal manifestations, especially neurological ones, may overshadow intestinal symptoms.

For many years, American physicians and patients often missed the diagnosis of celiac disease in the absence of malabsorptive symptoms (diarrhea, weight loss, anemia), because of a lack of recognition that these are only the “tip of the iceberg” of celiac patients. It might be said now, however, that the pendulum has swung to the other extreme, especially among the general population. It seems that celiac disease and gluten consumption have become the scapegoat for all of society’s ills, including a host of non-specific symptoms including fatigue, headache, depression, irritable bowel syndrome, etc.

Many such patients will say that these non-specific neurological or mild gastrointestinal symptoms improve on a self-imposed gluten free diet. But is this real, or simply a placebo effect akin to a patient’s taking a medicine? The answer is complicated. It is true that celiac disease often presents with such symptoms in the absence of malabsorption. It is also true that carefully obtained data over the last several years shows that a subset of irritable bowel syndrome patients without celiac disease do fare better with gluten restriction.  Some of this may relate to changes in digestive function with aging, osmotic load, enzyme deficiencies, and—most interestingly from a scientific standpoint—intestinal barrier function. Many physicians, if they have a high enough clinical suspicion for celiac disease in the patient, may advocate a gluten-free diet. An excellent medical review on diagnosis and management of celiac disease, prepared by the leading celiac experts in the world, was published this summer—but it was notably silent on the case of gluten sensitive symptoms in the absence of bona fide celiac disease.

So a question I am often posed is, “What is the harm, then, of just staying gluten-free if the patient feels better, without formal blood or endoscopic testing?” The answer is that gluten-free diets are not easy. It is not simply a matter of skipping the bread, pasta, and beer; it is extremely difficult, and can be socially isolating. Most soy sauces contain gluten, thus eliminating most Chinese cuisine.  Many lipsticks, envelope sealants, and myriad other items in the typical American diet and culture are off limits. Dining out involves almost military strategy and a third-degree of the waiter. In a patient with celiac disease, in whom the gluten content of even a fortieth of a slice of bread daily can keep the disease going, a gluten-free diet is important and will often lead to improved well-being and fewer long-term complications of the disease. However, this is not a lifestyle I would want to maintain or feel comfortable advocating for others unless there was clear reason to be on it.

A gluten-reduced diet, however—with general avoidance of pasta, bread, cakes, beer, etc.—may help some patients with non-specific neurological or irritable bowel symptoms, and is far easier to maintain than a gluten-free diet. My suggestion, therefore, is to know where you stand first.  If you have irritable bowel syndrome or non-specific neurological symptoms, by all means see your physician and get tested for celiac disease with simple blood tests BEFORE embarking on a gluten-free diet. If blood tests are positive, see a gastroenterologist, who will rule in or rule out the disease with an endoscopy with biopsies, again BEFORE going gluten-free. It is often difficult to know if the patient has celiac disease after the gluten-free diet has been started, because the blood tests and intestinal biopsies may revert to negative, leaving uncertain whether you have successfully treated the disease or whether you never had it. 

If the tests show that you have celiac disease or gluten-sensitive neurological disease, a gluten-free diet is appropriate and worthwhile. If the workup is negative, then you can try a gluten-reduced diet and see if you feel better, recognizing it may be a real or may be a placebo effect. In this author’s opinion, life is too short to maintain a socially limiting gluten-free diet without good evidence to support its necessity.  

Several helpful resources about the gluten-free diet and celiac disease may be accessed through this NIH site:  http://www.celiac.nih.gov/Materials.aspx  or through these celiac society websites: http://www.csaceliacs.org/ or http://celiac.org/

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