Two small but explosive words that are sure to trigger the passions and convictions of anyone with an interest in food and wellness. That's one of the things I've learned in researching this blog: it's a really emotional topic. I was asked to write about it by customers who'd enjoyed my last post on gut health and wanted the same flavour of insights on gluten free (GF). Sure, I thought, that should be pretty straightforward. After all, it's quite open and closed; we have those who absolutely must adhere to GF diets for medical reasons, and those who opt for GF because it makes them feel better.
I'd been sourcing GF foods for a couple of years for my coeliac and wheat allergic customers, so I felt I was reasonably well informed ... eh, until I began my deep dive, which quickly downgraded my "informed" status to "bewildered". Little did I know just how much I had to learn, but the hoops and loops in doing so have been difficult, not least because of the sheer volume of conflicting content out there. I hope this post will save you some time and give you a well-resourced overview on the current thinking so you can make up your own mind, informed by the facts.
I was not alone in my confusion. Many friends and customers find it really difficult to get to the heart of this muddy debate, primarily due to the plethora of so-called information available, the media hype and the lack of readily available evidence-based science on the subject. I am not an expert, so my observations here are personal but carefully sourced to provide a balance that's rooted in science. Personally, I hold no strong opinions either way - I don't follow a GF diet myself, although I do eat some of the GF products I sell simply because they taste fantastic and I know they are high quality with no additives. So, I was an open book ready to learn.
I preface my comments at the outset by saying I've been looking at three distinct communities within the broad GF consumer audience for this blog: (1) those who suffer with diagnosed coeliac disease (CD) for which there are no ifs or buts - GF is absolutely mandatory, (2) those who have a wheat/gluten allergy for which there are also standardised tests and the requirement to exclude gluten of every variety, and (3) those with a wheat/gluten 'sensitivity' who fall into the Non-Coeliac Gluten Sensitivity (NCGS) definition. This latter group is generally where most controversy lies - individuals who are not coeliac or allergic, but appear to react to gluten resulting in digestive and IBS-type symptoms, though many are drawn to the diet simply because they believe it makes them feel better or will help with weight management.
What I wasn't prepared for in my research was the scale of sharp medical, ethical and social divisions between the GF converts in the NCGS group, and those who are outright rejecters of what's seen as a trendy lifestyle choice rather than a medical imperative. The rejecters see GF as a canny attempt by the food industry to dupe fickle consumers into needlessly buying expensive, unnecessary products. Both sides of this debate are equally passionate, with the science scales currently falling more towards the naysayers as there are just not enough evidence-based studies yet to properly define, diagnose and treat those with NCSD. Media hype is also largely responsible for feeding confusion.
GF is Big Business - it's a huge money maker for long-standing food brands who have the opportunity to create entirely new product ranges to sit alongside traditional ones (breakfast cereals, pasta, beer etc), and newer players who spot opportunities to make money on the fringes with supplements, cook books, blogs and a plethora of platforms and products aligned to the GF lifestyle. The GF food market alone was reported to have made in excess of $15bn worth of global sales in 2017, and the industry wheels will continue to churn, with or without science on its side. It's simply following the money, with intense marketing practices that encourage consumers to believe that GF is healthiest/most natural etc, a notion that is refuted by experts, scientists and dieticians.
What Exactly Is Gluten?
So, what exactly is this villain called gluten? Simply put, it’s a naturally occurring protein found in wheat, rye, and barley. It’s present in bread, pasta, cereals and a host of sauces and regular cooking ingredients found in every kitchen and supermarket. For most, gluten is a non-issue, consumed by billions of people every day with zero adverse effect. For about 1% of the population, gluten is highly toxic and has a detrimental effect on health. This is called coeliac disease.
Coeliac disease (CD) is an autoimmune condition where the immune system – the body's defence against infection – mistakenly attacks healthy tissue. In coeliac disease, the immune system mistakes substances found inside gluten as a threat to the body and attacks them. This damages the surface of the small bowel (intestines), disrupting the body's ability to absorb nutrients from food.
Eating products with gluten causes chronic inflammation and damage to the intestines, leading to crippling health problems and often serious medical conditions. The list of symptoms is a long roll call of everything miserable that can compromise wellbeing and long-term health, so for CD sufferers, a GF diet is not optional, it's a must. For this group, the recent surge in the availability and range of GF products is welcome news.
Wheat allergies are a reaction to proteins found in wheat, triggered by the immune system and usually occurring within minutes of eating. The body perceives it as an enemy and sends out antibodies to combat it. This reaction results in symptoms, which can be life threatening. Anaphylaxis caused by the gluten protein requires emergency care. The condition, like a lot of other allergies, does not have a cure but can be managed with the right diet, notably the removal of all wheat, which again makes GF products mandatory.
NCGS - also known as wheat or gluten sensitivity - is when symptoms similar to coeliac disease are experienced, but there are no associated antibodies and no damage to the lining of the gut. There is no routine test available, so any proper investigation requires a medical doctor, allergist or gastroenterologist to assess and diagnose NCGS. However, it seems there is no standardised test or treatment for NCGS, so in the absence of recognised criteria, it's Open Day for all manner of misunderstanding and mismanagement.
By and large, I found this is where things get tricky, and we enter the grey zone of magazine covers and celebrity cook books, anecdotes shared on social media, and media hype that's poorly supported by hard science and research.
The headlines compound this characterisation, as any stroll past a newsstand or a celeb Twitter feed will demonstrate. Novak Djoković’s book is a classic example of the broad stroke PR that GF cures all ills and can propel you to the top of your game, whatever that might be. Pick any A-lister, and you'll probably find a card-carrying member of the GF army: airbrushed, thin, glowing, and citing GF as the source of all things feel-good ... it's easy to see the populist appeal.
That said, NCGS is recognised as a set of real conditions, defined by Professor Umberto Volta, Professor of Diagnostic Immunopathology, University of Bologna as a "syndrome characterised by symptoms occurring a few hours or days after the ingestion of gluten and wheat in patients testing negative for coeliac disease and wheat allergy". NCGS is also described as "a 're-discovered' clinical entity distinct from CD for which there is very little certainty and many knowledge black holes. There is no routine test or medical cure for NCGS, so in terms of knowledge, we are with NCGS now where we were with CD 40 years ago", say the authors of the Salerno Experts Group who are working towards defining criteria to standardise and diagnose NCGS.
So, we know that there is a grouping of "syndromes" called NCGS that can look like CD but are not CD, and for which there seems to be no routine test or standardised treatment, nor is there scientific consensus on what actually causes these symptoms. As I was to learn, gluten may not, in fact, be the enemy after all.
There is a group of names that tend to recur in the field of coeliac and gluten research, so it wasn't difficult to find these committed scientists when I began to look for peer-reviewed studies.
Prof. Peter Gibson and team at Monash University who now cite FODMAPs (mainly carbohydrates), not gluten, as the cause of digestive/gut problems commonly known as NCGS
Enter one the most pre-eminent specialists, Professor Peter Gibson of Monash University in Australia and his team who have performed extensive research into the cause and triggers of NCGS. Known as the "father of gluten free", his first report in 2011 set the entire GF craze into full swing after he announced his research had identified that gluten was the trigger for NCSD. With that, a whole industry was born and millions jumped on board the GF train.
However, just as I thought I was getting a clear picture, I discovered that Prof. Gibson and his team had, in fact, reversed their position on gluten in an updated report in 2013, two years after the original ground-breaking study appeared, which now pointed the guilty finger at FODMAPs, a group of carbs in wheat, as the culprits causing the horrible IBS-type symptoms of NCGS - gluten, it appears, was no longer the prime suspect.
Following the publication of the second report, the headline in Science Alert perfectly demonstrated the moving feast and transient science that exists when it comes to nailing jelly to the NCGS wall. The news that gluten wasn't the single issue previously thought was greeted by disbelief in headlines all over the world (see this Good Morning America TV report). Unfortunately, the dominant GF genie was out of the bottle and has been impossible to stop since, despite the new FODMAPs research (I found this short video from Monash University really helpful in explaining FODMAPs if this is a new angle to you).
Confused yet? Well, I certainly was, not least when I watched Dr. Alessio Fasano's superbly engaging presentation on why GF is unequivocally the best dietary decision anyone could/should make. Yet another expert to scramble my thoughts just a little bit more! Dr. Fasano is director of the Center for Celiac Research and Treatment at Massachusetts General Hospital and one of the top researchers in the world. If his video is anything to go by, I imagine he's also an incredible teacher.
Dr. Fasano believes gluten is a trigger for almost every illness imaginable, from MS to cancer, but he recognises the GF craze may have gone too far, "... the pendulum is all the way to the right, where this is a fashionable diet ... I think that in the future, we will see a readjustment of the pendulum and hopefully we’ll go back to where it belongs".
All this ambiguity leaves the barn door open, through which today's already confused consumers are passing into the shopping aisles, websites and book stores in the hope of piecing together some sort of understanding. Many seek advice from nutritionists and allergists who try to identify common links in foods consumed and subsequent symptoms displayed, but this can be tricky as elimination diets alone are complex to manage in the new world order of gluten and FODMAPs.
Many people turn to a GF diet in the belief it'll help them lose weight. Serious health decisions are made every day on the turn of a celeb tweet or red-carpet soundbite, claiming svelte silhouettes and glowing skin are all magically down to a GF diet.
The big problem with this? There is absolutely no evidence to support that belief, says Dr. Glenn Gaesser, director of the Healthy Lifestyles Research Centre at Arizona State University in his paper Gluten-Free Diet: Imprudent Dietary Advice for the General Population published in the Journal of the Academy of Nutrition and Dietetics. This is supported by many others, including Dr. Peter Green who heads the Celiac Disease Center at Columbia University. In his book Gluten Exposed, he states, "There is a desire to search for some sort of magic bullet that's going to solve a lot of their health problems ... but we couldn't find a single study published that supports a weight-loss claim for a gluten-free diet ... Manufacturers have to add in more things to counteract the loss of flavor and texture from the gluten. And some of those replacement items are calorically dense."
Some people may lose weight by going GF, but this has little to do with gluten and everything to do with cutting out the high calories hidden in bread, pasta, cereals, cakes, beer etc. Cutting out a huge swath of carb-heavy foods under any circumstances will result in weight loss, but popular belief supported by media representations has conflated the two. The Harvard School of Public Health review of Gluten-Free Diets concurs with Dr. Green and Dr. Gaesser, going one step further and observing that many people actually gain weight on a GF diet.
Well, this is actually easier to dispel than I'd expected! Dr. Rosalind Fallaize, Research Fellow in Nutrition and Dietetics at the University of Hertfordshire published an extensive new study a few weeks ago in the Journal of Human Nutrition and Dietetics. Key findings highlight that:
- Gluten-free groups had a higher percentage of high- and medium-fat products, with the exception of crackers.
- The median total fat contents for GF brown bread and white bread were more than double those of regular products.
- The costs of GF products are significantly higher across all food categories; the median cost of GF brown and white bread and white and wholegrain flour was over four times the price of regular equivalents, which may impact on adherence to a GF diet for individuals with coeliac disease.
- GF products were found to have significantly lower protein content than regular equivalents across nine of 10 food categories.
- GF foods were 159% more expensive than their regular food equivalents.
Dr. Fallaize states, "It’s also clear from our research that gluten-free foods don’t offer any nutritional advantages over regular foods, so are not a healthier alternative for people who do not require a gluten free diet."
This is pretty compelling for those who do not actually need a GF diet, and equally unfortunate for CD sufferers who absolutely require GF products.
These findings are strongly supported by the British Dietetic Association, with Sioned Quirke, a dietician and spokesperson stating in an article in The Guardian “I’m seeing an increase of people coming to the clinic saying, 'I buy this gluten-free bread to help me lose weight’ or ‘it’s better for me’. If you have coeliac disease, then it’s essential that you have gluten-free products, but if you don’t have an intolerance, for the general population, gluten-free products are really not required and they won’t help you lose weight."
The Health Risks in Self-Prescribing a Gluten-Free Diet
It seems that many people choosing a GF diet do so under their own steam, often using online tools or self-help books to make a decision. One of the major downsides of going gluten free on your own (as opposed to under a doctor's supervision) is that your GF diet might actually be masking an entirely different condition, such as allergies or a sensitivity to FODMAPs. In 2015 an Australian national survey reported "When asked if they had any formal diagnosis, including that of an intolerance, allergy or coeliac disease, which required them to avoid wheat, most (84%) of these symptomatic individuals said no".
Dr. Peter H.R. Green is director of the Celiac Disease Center at Columbia University, one of the few centres in the US devoted solely to diagnosing people with CD. As for going GF without medical advice, he comments, "It may mask another condition," says Green. "If you're going to pick a diet that treats a specific condition, you should be tested for that condition first." He's also the author of the book Gluten Exposed, which makes the case that for the vast majority of us, eating gluten is just fine.
My Own Conclusion - To Go Gluten Free or Not?
It's been a real eye-opener writing this blog. Non-coeliac illnesses are very real, no question, but the jury is out on whether gluten or FODMAPs (or an as-yet undiscovered constituent) are the problem. For every scientist that advocates a GF diet, there's one that holds the opposite opinion. It is, however, clear that the medical world is researching like crazy, and whilst findings may currently differ, I hope consensus will ultimately be reached. More time, more research dollars and lots of patience are required.
Regardless, wheat remains firmly in the frame, but the dial is shifting away from gluten as the exclusive cause of many bowel and digestive health problems as we learn more about FODMAPs. When you consider it's less than a decade since gluten entered our daily dietary vocabulary, I'm optimistic we will see more clarity emerge in the next decade.
While we wait for a more rigorous, consistent and science-based methodology in diagnosing and treating NCGS, self-diagnosis is extremely dangerous (especially for children), so seeking medical advice is a must, especially in determining what type of diet will help.
I was surprised to learn about the lower quality of so many GF products, which tend to be enhanced with unhealthy artificial additives and fats to enhance the taste. That said, I had personal experience of this when I received some GF bread samples from a potential supplier, which tasted great, but the additives were so horrendous that I politely declined. The fact that GF diets alone won't help you lose weight makes sense to me, and I'm surprised so many people have fallen for the weight-loss story.
In closing, I can only recommend that if you're considering or have made the move to GF, do so under proper medical supervision having first tested for other possible illness. Keep abreast of the research and source your information from reputable, ideally science-based sources. Read the labels as you chose your products and buy the best quality, additive-free GF products you can.
If you are looking for tasty, exceptional quality GF ingredients, you can find all of our gluten-free products here. If you are looking for some recommendations, why not start with one of the following, each of which is a top-seller for us:
I do hope this blog has been useful to anyone looking for a balanced view. Please feel free to share if you know someone who, like me, has been puzzled by the subject. Now that I'm more informed (at last!) I will continue to keep you up to speed as research develops.