A gluten free diet excludes foods that contain the gluten proteins found primarily in wheat, barley, and rye and is necessary for people with gluten intolerance or celiac disease.

Gluten is a generic name for the plant storage proteins found in the seeds of cereal grains.  Although all grains contain gluten proteins, only the gluten in wheat, barley, and rye appear to be problematic for the health of sensitive individuals.  Studies have shown pure oats do not appear to cause harm, but they are typically contaminated in the process of growing, handling, storing, processing, and transporting them alongside other gluten containing grains.  It is possible to find gluten-free oats on supermarket shelves that have been handled so as to prevent cross-contamination and have been certified as gluten free by private testing organizations.

Common foods that should not be eaten on a gluten free diet include:

• Bread
• Beer
• Pasta
• Soy Sauce

Gluten is used in many processed foods and as an ingredient in many common dishes. The widespread use of gluten-containing ingredients requires vigilance when making food choices, whether at the grocery store or when eating at restaurants. Reading food labels to ensure gluten does not make it into a gluten free diet is a skill that all people with gluten intolerance or celiac disease must have.

Gluten Intolerance & Celiac Disease

Gluten intolerance and celiac disease are the names given to conditions caused by the consumption of gluten in sensitive individuals.  Both conditions lie on a spectrum of sensitivity ranging from an immune response (gluten intolerance) to an autoimmune response (celiac disease).

Celiac disease is an autoimmune response to gluten in which the body’s immune system cannot distinguish between gluten and bodily tissue.  In trying to protect itself from gluten the immune system attacks the bodily tissue in the small intestine.  With continued consumption of gluten the body eats away at the lining of the small intestine and the tissues responsible for absorbing nutrients from digested food are damaged.  This leads to malabsorption of vitamins and minerals, in turn causing malnutrition in those in with celiac disease.  The following vitamins and minerals are most likely to be malabsorbed in those with celiac disease:

• Vitamin D
• Iron
• Folate
• Fiber
• Vitamin B12
• Calcium

Malnutrition caused by celiac disease can cause other symptoms in the body including osteoporosis.

Celiac disease is now thought to occur in up to 1 percent of the world’s population and continues to be underdiagnosed as the condition is not well known in the United States.  The disease was previously thought to be restricted to certain world populations, but new information shows the incidence rate to be relatively stable in countries throughout the world.  Many doctors are still unaware of the symptoms of celiac disease which leads to an average time to diagnosis of 12 years.  A staggering 99-percent of gluten sensitive individuals are not aware of their sensitivity.

Much of what is known regarding celiac disease was learned only recently due in large part to the work of Alessio Fasano. Though the disease was first identified hundreds of years ago giving celiac disease its name, it was only in the 1940′s when bread shortages caused by World War II allowed for the identification of groups of children that saw their symptoms disappear when bread was unavailable, only to return when bread was reintroduced to their diet. Since then we have learned that celiac disease is largely associated with HLA-DQ2 and HLA-DQ8 genes. Nearly 100 percent of celiac positive individuals have one of these two genes, however, the prevalence of these genes in the non-celiac populace indicates their presence is not sufficient for a positive diagnosis.

An endoscopic biopsy of the small intestine used to be considered the “gold standard” of celiac diagnosis, and still is to many medical professionals. However, the prevalence of non-intestinal symptoms caused by gluten consumption has led to a revision of diagnostic criteria. Since extraintestinal symptoms now account for a majority of symptoms, many have begun to question the usefulness of biopsy for diagnosis.

Dr. Fasano, though previously championing the necessity of biopsy, has reversed his position and endorsed a “4 out of 5″ rule in which a positive result for four of five diagnostic criteria is sufficient for a celiac disease diagnosis, despite the absence of one condition, including a positive biopsy. According to the new rule, a patient should be considered to have celiac disease when showing a positive result for four of the following criteria:

• Symptoms related to celiac disease
• Positive blood test for celiac antibodies
• Presence of HLA-DQ2 or HLA-DQ8 genes
• Positive biopsy
• Response to gluten free diet

The Marsh scale was developed to classify the progression of damage to the intestine caused by celiac disease.  According to the Marsh scale, only complete atrophy of the intestinal villi may be used as a basis for a formal diagnosis of celiac disease.  This level of damage is known as Marsh IV.  Anything short of a Marsh IV level of damage to the villi is not considered celiac disease despite the fact that, left untreated, an individual classified as Marsh I-III will develop Marsh IV levels of damage.  The Marsh scale was developed by M.N. Marsh in 1992 and subsequently revised to include three levels of Marsh III (a-c) to account for the progression of villous atrophy seen in celiac patients, with Marsh IIIa referring to partial villous atrophy and Marsh IIIc being the step just short of complete villous atrophy. According to Dr. Sonia S. Kupfer in “Making Sense of Marsh” published by the University of Chicago Celiac Disease Center, 50 to 60 percent of celiac patients are classified as Marsh III.

The only treatment of celiac disease is a lifelong gluten free diet. With strict adherence to the gluten free diet it is possible to reverse the damage and regress from Marsh IV to Marsh I-III as the villi are restored, though for reasons that are not entirely known, not all celiacs will fully recover on a gluten free diet.

Although it is not known for sure why not all individuals with celiac disease on a gluten free diet will restore intestinal villi to full working order, the difficulty of maintaining a gluten free diet and the likelihood of inadvertent consumption or cross-contamination, is suspected.  Even minute levels of daily gluten consumption, as little as 10 mg or less than a crumb of bread, will continue to provoke an immune response that damages the intestinal lining. Most studies conclude that a majority of celiac patients will not react to less than 50 mg/day of gluten. With this baseline established, the Federal Drug Administration has proposed food products labeled “gluten free” require a certification of less than 20 ppm gluten.

Gluten intolerance is not as well understood as celiac disease and there are no formal criteria for defining the condition as there is with celiac disease.  Most research to date has centered around celiac disease and the damage caused to the small intestine. Until recently, the consensus in the medical community denied the role of gluten in causing disease in non-celiac individuals, but recent studies conducted by Dr. Allesio Fasano and others have shown this to be untrue.  Specifically, these studies show how the enzyme zonulin, which exists throughout the body, is targeted by the immune system in gluten-sensitive individuals.

Gluten intolerance is typically associated with raised levels of antibodies to gluten, though this may not occur in all sensitive individuals.  Whereas celiac disease is typically associated with damage to the small intestine, gluten intolerance primarily has extraintestinal manifestations.  The most common symptom of non-celiac gluten sensitivity is now recognized to be dermatitis herpetiformis, a condition in which itchy, rash-like lesions form primarily on the skin of the elbows, knees, face, back, and buttocks. The condition, which has no relation to herpes, is often confused with acne and may cause afflicted individuals to seek treatment for the wrong disease.

Gluten Free Foods

Although only the gluten proteins in wheat, barley, rye, and some close relatives of each grain have been shown to cause gluten intolerance and celiac disease, avoiding gluten is a challenge for those that follow a gluten free diet.  Wheat is a staple grain in many societies and wheat flour is a common ingredient in most processed foods.  Beer is also a prized beverage in many cultures and is typically made from barley or wheat making it unfit for inclusion in a gluten free diet.  Thus, vigilance is required when making food choices and a detailed understanding of food additives is necessary if one is to avoid gluten when consuming processed foods or eating food prepared by others.

Gluten toxicity is specific to the proline-rich grasses of the Gramineae family.

Symptoms of Gluten Intolerance

Most individuals with either gluten intolerance or celiac disease are not aware of their condition, despite exhibiting some of the common symptoms associated with the disease.  Common symptoms include, but are not limited to acne, fatigue, neuropathy (tingly sensation in the fingers or toes), skin rashes, dry skin, depression, mood swings, headaches, migraines, irritability, joint pain, bloating, constipation, diarrhea, and general gastrointestinal discomfort. 

The list is long and varied, and the symptoms are shared by many other conditions which make it hard to single out gluten as the cause.  In some cases known as silent celiac disease individuals may not exhibit any related symptoms despite ongoing inflammation and damage to the small intestines.

Related Diseases

A positive diagnosis for celiac disease increases the risk of developing a number of autoimmune diseases and individuals with these conditions are more likely to also have celiac disease. In 2007, The New England Journal of Medicine listed 55 diseases that can be caused by consuming gluten. Among the diseases listed were multiple sclerosis, rheumatoid arthritis, osteoporosis, cancer, schizophrenia, and depression.

It can affect every organ in the body from the skin (dermatitis herpetiformis, psoriasis, eczema) to the brain (migraines, depression, schizophrenia) to the thyroid (Hashimoto’s). The seriousness of gluten intolerance cannot be overstated. Failing to comply with a gluten free diet in individuals with celiac disease increases the risk of death from all causes by 600 percent.

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