Gluten Sensitivity

Considering going gluten-free? Learn about some of the drivers into this booming market.




Here’s a dilemma for you: put together a dinner menu for a few people. Your dinner party includes folks who love seared meats, two vegetarians, a partner with lactose intolerance, and two guests with gluten sensitivity, one of whom really does not like the texture of rice. Now I love to cook but this spur of the moment dinner made my head spin. I’m an omnivore so my mind drew a blank on a main course that can please everyone. I can accommodate the vegetarians and lactose intolerants, but also add gluten sensitivity to the mix? At that moment, the image of a sweet potato chickpea salad with cardboard crumble came to mind. 


This was me- back when everyone around me appeared to suddenly discover that they had gluten sensitivity. Sure, I had recommended gluten free diets for the few celiac patients on my panel, but it puzzled me how gluten free products had boomed into such big business. Back in 2015, it was reported that an estimated 25% of Americans adopted a gluten free diet. Today, it’s estimated that up to a third of Americans report some sort of gluten sensitivity. So why are so many people avoiding the bread aisle, like if you slipped them a piece of whole grain baguette, they’ll blow up into little pieces right in front of your eyes?


To understand this fear, let’s talk about gluten for a minute. Gluten is a group of proteins found in various cereal grains, namely wheat, barley, rye, and oats. It’s what gives bread its chewy texture. Most people have no problem eating gluten, but for some people, eating gluten may make them have abdominal discomfort,  bloating, diarrhea, or even constipation. Gluten, in and by itself, is not toxic, but for folks with celiac disease, their bodies react as if gluten is toxic. In their case, gluten triggers their body’s immune cells to make autoantibodies against cells of their small intestine. Their immune system goes haywire once gluten is dumped into their gut. Celiac disease patient’s T cells make antibodies that attack itself and literally destroy the lining of their small intestine. In fact, besides having a positive blood test with high levels of IgA tissue transglutaminase, the diagnosis of celiac disease is confirmed when tissue sampling of the small intestine shows evidence of destruction of the small intestine lining. I mean, with the abdominal pain, bloating, and diarrhea, it’s no wonder that even pizza looks like poison. 


But the curious thing about celiac disease is that the disease course is reversible. Once the diagnosis is confirmed, the treatment is, you guessed it, a gluten free diet. It’s a challenge to commit to a gluten free diet but strict gluten avoidance will reverse the damages done to the small intestine lining.  


We understand the pathophysiology of celiac disease. We have markers and ways to diagnosis it. We have a treatment for it. But celiac disease only occurs in 1 to 2% of the population. A gluten free lifestyle can be a costly commitment, there may be nutritional holes in a strict gluten free diet, and unless you are like our friend Omer who makes the best gluten free bread on this side of the Atlantic, it’s a challenge to make things tasty without gluten. So why are a quarter of Americans on a gluten free diet? 


Some people maintain a gluten free diet because they have a wheat allergy. In people with wheat allergy, different proteins trigger an immune response that follows a different pathway than celiac disease. This a histamine mediated pathway. Eating wheat may also trigger skin, respiratory, and circulatory symptoms. But remember, wheat contains gluten, so for all practical purposes, the treatment for wheat allergy is also a gluten free diet. Wheat allergy only affects 1 to 4 % of the general population so if we sum up the number of individuals with celiac and the number of people with wheat allergy, we still have not fully accounted for the popularity of gluten free diet. 


That hole in the numbers can be accounted for by a controversial spectrum of gluten-related disorders called "Non Celiac Gluten Sensitivity." In recent years, an increasing number of people have adopted a gluten free diet to improve their gastrointestinal symptoms or simply because they feel better after cutting out gluten from their diet. If you want a heated debate, just put a bunch of gastroenterologists in a room and say the words, “Non Celiac Gluten Sensitivity.” It’s an active area of research and maybe even skepticism because there are no reliable biomarkers for disease, there is no histological evidence of abnormalities that have been identified, but patients will firmly insist that their symptoms go away with a gluten free diet. There’s simply a whole lot we don’t know and a lot to be discovered. In the meantime, it’s best to discuss any symptoms you have with your doctor.


And about that dinner party. Relax, I didn’t serve cardboard crumble. I did, however, serve a memorably bad meal. Thank goodness there are more gluten free options today.