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Up until recently, most people, whether members of the public or health professionals, thought a gluten free diet was only for the 1% or so of people diagnosed with coeliac disease. As research progresses and results from clinical practice emerge, we now know that gluten (a protein found in some grains) and associated proteins (gliadins and glutenins) can contribute to health issues in a much wider part of the population. The spectrum of gluten-related disorders broadly spans three categories: auto-immune, allergic and non-autoimmune/non-allergic conditions.

Gluten-related disorders

Widely acknowledged as the world’s leading expert on gluten-related disorders, Dr Alessio Fasano MD, along with his former team at the University of Maryland School of Medicine, Baltimore, proposed the following classification of the disorders (Figure 1), which may even be too simplistic.

Figure 1. Source: Sapone et al. BMC Medicine 2012, 10:13.

Included among those affected by gluten are therefore not only coeliacs, but also people who suffer from wheat allergy (Ig-E and non-Ig-E-mediated) and those who have, what is now referred to, as Non-Coeliac Gluten Sensitivity (NCGS). First referred to in the 1980s, NCGS is the term used to describe individuals suffering a range of symptoms, not linked to auto-immune disease, that quickly improve after gluten is removed from the diet, and in which both coeliac disease and wheat allergy were properly ruled out. If gluten exposure is maintained, there is a risk that very serious conditions, such as autoimmune thyroiditis, may occur in around 1% of the NCGS population, itself difficult to estimate given the low rates of reporting and medical diagnosis.

Making matters even more complicated is the scale of under-reporting linked to gluten-mediated type 1 diabetes and cancer, both of which are triggered via autoimmune reactions (Figure 1). These conditions are frequently undiagnosed as being gluten-mediated and being forms of 'silent coeliac disease', they result from years, or decades, of chronic exposure to gluten.

A prevailing view among the medical establishment is that less than 10% of the population would benefit from wheat exclusion. Taking then a conservative estimate of 6% of the population being affected by gluten-related disorders, that still equates to 3.9 million Brits and 19.4 million Americans being affected and unequivocally benefiting from going gluten free. And that’s a conservative view! That’s enough to ensure anyone suggesting gluten free is a fad is either ignorant of the facts or they have no interest in public health.

While insightful nutritional and functional medicine practitioners have for several years witnessed remarkable turnarounds in their patients’ health, more recently many 'celebrities' and ‘healthy eating' gurus have begun to extol the health benefits of not eating gluten containing grains. That’s triggered a push back that one can be certain is supported directly or indirectly by corporations benefiting from our common intolerance or sensitivity to the main Western staple.

In devising our Food4Health guidelines, we looked not only at the most relevant published science, but also at clinical experience, which led to us taking the unprecedented step of offering a plate-based guideline back in January 2015 that was 100% gluten free.

Fasano on gluten

Given last week’s BBC Horizon programme put Dr Fasano in the hot seat as the most credible scientist offering a view on going gluten-free, and somehow, through various tricks of editing, he appeared to say something different, we too look to Dr Fasano for his views. The programme tackled what it called ‘clean eating’, apparently a fad diet being put around by ‘clean eating gurus’ in such places as Britain, the USA and Australia. The centrepiece of the show was an attack on the current 'trend' for removing gluten from a person's diet. It was unfortunate that instead of finding that eating healthily without gluten is scientifically sound Fasano appeared to suggest that gluten was only a problem for those with underlying genetic predisposition, imbalanced gut microbes, faulty immune systems and leaky guts. We now know that gluten can affect our body in multiple ways (Figure 2), but various factors are needed for gluten sensitivity to develop. We explore the science further to see how they influence the way gluten contributes to make a perfect storm and create the conditions for chronic disease to develop.

Figure 2: Factors affecting mucosal immune systems resulting in intestinal barrier dysfunction, autoimmunity and nervous system abnormalities

Genetic Disposition

Coeliac disease develops when a genetically susceptible person is exposed to gluten. It has also been suggested that there is a genetic factor in the development of NCGS. Dr Fasano is clear that having a genetic disposition does not mean you will develop a particular disease, it depends on other factors, most notably the health of our microbiome. It's like playing a piano "you can't change the piano keys, but you can change the notes you play".

Imbalanced microbiome

A healthy gut microbiome (bacterial population) is essential to the development of a healthy immune system (Figure 3).

Figure 3. Alessio Fasano, MD, slide from keynote presentation (IM Network Forum, 2016)

Changes to the health of our microbiome can take place due to antibiotic (or other medication) use, poor eating habits (lack of fruit & veg, high processed foods and sugary foods), stress etc. More and more research is pointing to disruption of our gut microbes as a starting place for the development of disease. Once we develop dysbiosis (damage to gut health) we set the stage for gluten to become a problem, to promote further inflammation and damage to the gut. Dr Fasano tells us that "what happens in the gut does not stay in the gut", in other words inflammation in the gut can spread to the rest of the body (Figure 4).

Figure 4. Alessio Fasano, MD, slide from keynote presentation (IM Network Forum, 2016)

Leaky gut

One of the most important and overlooked functions of the gastrointestinal tract is its role in protecting us from unwanted molecules entering our bloodstream. Back in 2000 Fasano and his team discovered a protein they named zonulin, which regulates the opening and closing of gateways in the gut wall to ensure that what should stay in the gut stays there and what should go into the body does (gut integrity). Further research discovered that gluten, a key protein in most people's diets, changes the way zonulin functions. Zonulin evolved for a very specific purpose. If we ingest some nasty bacteria in our food, the tight junctions in our gut wall open to allow our gut contents to leak into our abdominal cavity so that they can be exposed to our full battery of immune cells. This is something we hope happens occasionally – the less often the better. Eat gluten regularly, perhaps 6 times every day, especially if you lean towards having a greater sensitivity to the ubiquitous grain protein (an affliction probably faced by more than 1 in every 10 of us) and we start to suffer a permanently activated, or ‘upregulated’, immune system.

Impaired immune system

Autoimmune disease is an illness that occurs when our body is attacked by its own immune system and includes diseases like rheumatoid arthritis, lupus, Hashimoto’s and coeliac disease.

Our gut is unable to breakdown gluten-containing grains fully, leaving behind another protein component, gliadin. This activates zonulin, which opens the doors in our gut (tight junctions), and stimulates our immune system to produce antigliadin antibodies leading to inflammation that then spreads through our body in the form of autoimmune illness. Research has found the autoimmune response is damped down if you take gluten out of the diet.

Our Advice

Daily consumption of wheat and wheat products, as well as other cereal grains is not advised as its contribution to chronic inflammation and autoimmune disease manifestation is both well documented and common. Even more importantly, most people have little idea as to where they sit in terms of their overall risk to gluten especially given that some effects, including serious ones, may not manifest clinically for years (e.g. silent coeliac disease).

Going gluten free is no fad, especially when it’s linked to eating real food made mainly at home from fresh ingredients that have yet to see a bar code. It’s about getting in touch with our evolutionary heritage (Evosense), given that anatomically modern humans have spent only around one-tenth of their existence being exposed to gluten-containing grains like wheat (incuding spelt, kamut, farro, durum), barley, rye and triticale. Add to this, our much more recent obsession with refining these grains to within an inch of their lives – and not only is the gun loaded and the trigger pulled – the bullet has been fired. Run as fast as you can – your life — and its quality — depend on it!

For more information on how gluten 'works' and autoimmunity develops along with tips about managing a gluten free diet, we suggest you read Dr Fasano's hugely successful book Gluten Freedom.

Recipes

For recipes, we suggest you look at one or more of the following, tuning into their books, social media outputs or other commentary.

UK-based:

US-based:

Click the infographic below for a comparison between the ANH-Intl Food4Health Guidelines and the UK Eatwell Guide