Respectful Insolence

Gluten-free ≠ healthier

One of the more annoying health crazes going around right now is the gluten-free diet. While it’s a boon to the very small proportion of the population who have real celiac disease and thus truly cannot tolerate gluten, at the same time gluten has become the health demon that is touted as the cause of virtually all health problems, be they major or minor, with the cure—of course!—being the now nearly ubiquitous gluten-free diet. The gluten-free diet has become so popular that restaurants and food manufacturers ignore it at their financial peril. Indeed, restaurants that don’t have some gluten-free offerings are becoming increasingly rare. The gluten-free craze has become such so embedded in the culture that it’s considered a fit subject for comedy and parody, for example:

Heheh. “Being gluten intolerant used to be limited only to those who are actually intolerant to gluten” and “being gluten intolerant is a fantastic opportunity for you to assert your dominance on the lives of everyone around you, which helps improve your life.” So true, so true.

So what? you might ask. So did I for a while. After all, what’s the harm, right? The wide availability of gluten-free diets has made the lives of the approximately one in a hundred people with actual celiac disease much better by making it possible for them to have access to a wider variety of foods and to eat in many more restaurants than they used to be able to. If the price is that the rest of us have to put up with a lot of gluten-free woo and a lot of people with vague gastrointestinal symptoms who think they are gluten intolerant, again, what’s the harm?

It turns out that there is harm, as this article discussing a recent article by Dr. Norelle Reilly in The Journal of Pediatrics entitled The Gluten-Free Diet: Recognizing Fact, Fiction, and Fad. The article begins to make its point with a simple Google Trends plot of search histories related to the terms “gluten free” and “celiac disease.”

You’ll notice right away that searches for “celiac disease” have increased slightly since 2004 but that searches for “gluten free” have increased by at least seven-fold, appearing to have leveled off in 2013. Reilly notes, as I have in the past, that the prevalence of celiac disease (CD) appears to be increasing but nowhere near enough to account for the massive growth of the gluten-free diet (GFD) industry. Here’s another interesting thing that she notes. The reasons that people choose gluten-free products have little to do with celiac disease (which isn’t surprising given that such people only make up around 1% of the population) or and not nearly as much to do with “gluten intolerance” as you might think:

In reality, remarkably little is known about the motives of most individuals who adopt a gluten-free lifestyle. According to a 2015 survey of more than 1500 American adults, “no reason” (35%) was the most common explanation for selecting gluten-free foods, followed by “healthier option” (26%), and “digestive health” (19%).3 “Someone in my family has a gluten sensitivity” (10%) was more common than those reporting, “I have a gluten sensitivity,” which was the least common rationale cited (8%).

In other words, the vast majority of the customers who buy gluten-free products don’t think they have gluten intolerance. In fact, less than 20% of the customer base for gluten-free food actually thinks that they or someone they live with has a “gluten sensitivity.” The rest have bought into the message that gluten-free is somehow more healthy, that gluten is somehow bad for you. I wonder where they might have gotten that idea…? It couldn’t be from articles and videos with titles like Why is Gluten Bad?, 6 Shocking Reasons Why Gluten Is Bad for You, 10 Signs You Have Gluten Intolerance And How To Treat It, and many more that pop up on my Facebook and Twitter feeds on a daily basis, shared by the credulous, along with images like this:

And memes like this:

Of course, gluten-free diets have not been shown in randomized controlled clinical trials to benefit any condition other than CD, a fact Reilly reiterates, while pointing out that patients perceive benefit from such diets. That’s not that they’re never indicated outside of treating CD, but the list of accepted medical indications for instituting a gluten-free diet is small and does not include “gluten sensitivity,” which is basically a nonexistent condition. It does include dermatitis herpetiformis, wheat allergies, and non-celiac gluten sensitivity, a condition whose existence in children has precious little evidence to support it.

Here’s the problem with gluten-free diets. It has mainly to do with children, as parents not infrequently put their children on gluten-free diets, either because they themselves have started a gluten-free diet or to treat a wide variety of conditions, leading Reilly to note that of these children “many are asymptomatic from the start” and that the “health and social consequences worthy of consideration in advance of starting a child on a GFD are not described adequately online or in books promoting an empiric GFD trial.”

Reilly notes later:

Gluten-free packaged foods frequently contain a greater density of fat and sugar than their gluten-containing counterparts. Increased fat and calorie intake have been identified in individuals after a GFD. Obesity, overweight, and new-onset insulin resistance and metabolic syndrome have been identified after initiation of a GFD. A GFD also may lead to deficiencies in B vitamins, folate, and iron, given a lack of nutrient fortification of many gluten-free products.

There is emerging evidence that those consuming gluten-free products without sufficient diversity may be at greater risk of exposure to certain toxins than those on an unrestricted diet. Arsenic is frequently present in inorganic form in rice, a concern for those on a GFD given that rice is a common ingredient in gluten-free processed foods. Serum mercury levels were 4-fold greater among adults with CD consuming a GFD than controls not restricting gluten. The source of mercury and other toxins is not known nor have the health implications of these findings been fully delineated.

And:

There also are noteworthy non-nutritional implications of a GFD. Worldwide, those purchasing gluten-free products will encounter far greater food costs than gluten containing competitors. Social isolation and inconvenience have been reported by children with CD requiring a GFD, and some with CD report a deterioration in their quality of life while on a GFD, linked in many cases to the diet itself.

Routine initiation of a GFD may obscure a diagnosis of CD for adults and children. Those with relief of symptoms after gluten exclusion may be unwilling or unable to resume a gluten-containing diet to allow for diagnostic testing. In this regard, wider adoption of a GFD may have implications for CD detection rates at a population level.

So basically (and ironically), gluten-free diets are associated with increased mercury in the blood, arsenic, obesity, vitamin deficiencies, and metabolic syndrome. If you have CD, those risks are a reasonable tradeoff for symptom relief and being able to eat more of what you want, but if you don’t have CD, contrary to what the gluten-free industry tells you, gluten-free diets are probably more unhealthy than a regular diet. Adopting a gluten-free diet is thus more likely to cause health issues than to solve them.

It is also, as Reilly points out, a myth that gluten is toxic. It is also a myth that first-degree relatives of those with celiac diseases need to be on a gluten-free diet as well. The reason is that pooled rates of CD among first-degree relatives are only around 7.5%. Screening for CD is recommended for many first degree relatives of patients with CD, but there is no need to institute a gluten-free diet without a definite diagnosis.

The bottom line:

There is no evidence that processed gluten-free foods are healthier than their gluten-containing counterparts, nor have there been proven health or nutritional benefits of a GFD, except as indicated previously in this commentary.

And:

Adults considering, or who have already implemented, a GFD because of physical symptoms should immediately involve a health care provider and request testing for CD. If a GFD is planned regardless of the results of CD testing, the guidance of a registered dietitian should be sought to safeguard against GFD-associated nutritional hazards. Despite ostensible similarities, there are important distinctions in management for those gluten-free by choice vs for treatment of CD, such as surveillance for autoimmune conditions, family members’ health, and malignancy. An empiric GFD may come at considerable expense, and cost-benefit analyses are warranted to investigate routine CD screening for asymptomatic adults who opt to lead a completely gluten-free lifestyle.

In other words, there are no benefits to gluten free diets except in a few, defined health conditions, and there are actual downsides. So when I ask the question “What’s the harm?” the answer is not “None.” There are definite downsides to such a diet, aside from the different taste, which might not be as good as the regular gluten-containing versions of the same food items.

The other downside is economic, as described in this article about the study:

In the real world, gluten-free versions of foods are most often more expensive than the standard formulations, as well. (An especially pointed factor for the 20 percent of households earning less than $30,000 annually and yet worrying about procuring gluten-free products.)

Yes, the gluten-free industry has become very profitable, and part of the reason it’s so profitable is that it can charge a premium on its products, and it has succeeded in framing gluten-free foods as not just good for patients with CD but generally healthier than gluten-containing versions of the same foods. As Reilly put it:

In the medical journal, Reilly’s message is that physicians should be educating people that this is not okay. “You have the gluten-free industry speaking with a megaphone,” she said, “and we’re trying to do our part to put accurate information into circulation.”

Basically, the gluten-free industry has been fantastically successful. Its success has been built not on providing a product that allows patients with CD to have a more enjoyable, less restrictive diet, but rather on convincing everyone else that gluten is evil and that purging it from your diet will lead to greater health. While I’m happy that people with CD have many more options for food (and there is one person with true CD in my family), I have a real problem with how the gluten-free industry has gone far beyond what science supports in promoting its product.