Gluten- a Short Course: When and How to Choose It

Many people today are talking about diets that are “gluten-free.” Restaurants are offering “gluten-free” menus. There are websites, chiropractors, and others proclaiming that going on a gluten-free diet will provide improved health. But lets be clear- unless you have an allergy to gluten, removing gluten from your diet will not provide better health, weight loss, but eliminating gluten will dramatically limit what you can eat.

But there are some people who are “allergic” to gluten- and for them having a gluten free diet is the difference between health and illness – between a risk of some rare cancers for which we don’t have great treatment for. We call that condition celiac disease – for those who have celiac disease, being gluten free is critical. Other names for this disease include celiac sprue, gluten sensitive enteropathy, non-tropical sprue, and a few other names.

Gluten is a protein that is found in wheat, barley, rye, and oats. Gluten is a protein that allows wheat to have “elasticity” – meaning you can roll out the dough- or toss it in the air and make a great pizza crust. You can’t do that with non-gluten grains—no one can make a pizza or great bread from corn alone. Gluten is also used to thicken soups, ketchup, soy sauce, and is found in almost every processed food out there. Take gluten out of the American diet and you will be challenged to find good alternatives.

When a person is allergic to gluten their symptoms include malnutrition, anemia, osteoporosis, infertility, short stature, and inability to thrive. However, the “classic” symptoms are not necessarily common. There are a number of patients who have silent celiac disease, where they will be discovered to have atrophy of their absorptive surface of the small bowel without any symptoms, or just mild symptoms such as an iron deficiency anemia. There are a number of forms of celiac disease that respond well to a gluten free diet – and remain normal after introduction of gluten into the diet.

Celiac disease is best diagnosed with a biopsy of the small intestine. Most often the biopsy is performed endoscopically from the first part of the small bowel, the duodenum. However, those biopsies can be negative, and more distal small bowel may show the classic pathologic appearance. Those biopsies most often have to be done surgically, or with advanced endoscopic equipment.

The small bowel, under a microscope, has many small finger-like projections called villi. These serve to increase the surface area of the small bowel to allow for maximum absorption of nutrients. In celiac disease, there is atrophy of these villi – seen microscopically- and this improves when gluten is removed from the diet.

Above normal villi, below- atrophied

While celiac disease is classically called an “allergy” to gluten – it does promote some antibodies against the connective tissue elements – leading physicians to call this an auto-immune disease. However, when the foreign protein is withdrawn, there is no residual auto-immune function. Hence, no gluten and people improve however true celiac disease still has a higher than normal incidence of small bowel cancer, and that incidence does not decrease with elimination of gluten..

There have been various reports about the prevalence of celiac disease – ranging from 1:300 among Northern Europeans (Celtic) to 1:122. There is a large genetic distribution of the disease – with a high concordance among identical twins of up to 70 per cent. There are some genetic markers that have a high association with celiac disease, but the expression of the disease is variable – meaning that the genetic marker is a tendency but not a certainty of celiac disease. If everyone who had the genetic markers were to develop the disease, it would be estimated that 1 in 22 people would have this. However, this is not the case.

Diagnosis of celiac disease is made based on clinical suspicion of the classical presentation (iron deficiency, osteoporosis, with abdominal complaints) followed by some tests. A biopsy is the most reliable test, however there are blood tests ( IgA anti-gliadin and IgA anti-endomysial and anti-tissue transglutaminase) that are over 90 per cent accurate. Even with a negative blood test but a high enough suspicion, duodenal biopsy or even surgical biopsy is warranted.

There are plenty of questions about celiac disease- we don’t know the actual prevalence in the population, we don’t know if being gluten free as demonstrated by follow up biopsy has a lower incidence of lymphoma.

What we do know is that gluten is not a health issue in people who do not have celiac disease. Gluten-free will not cure autism. Gluten free will not facilitate weight  loss. There are, however,  groups who will claim that gluten is a health issue- there is no basis for this claim. If someone has told you to remove gluten from your diet, and you do not have a test showing celiac disease (one of the tests listed above)- please see a physician to resolve this.

For people who have celiac disease- there is a bit of culinary hope. Thomas Keller, one of the world’s greatest chefs and owner of Ad Hoc, French Laundry, Per Se, and Bouchon- has developed a flour that works well. You can purchase it from Williams-Sonoma.

But gluten-free products have more sugar- and are not any “healthier” for you if you don’t have a gluten issue.

Most people have no idea what gluten is- they don’t know it is a protein that is rich in proline amino acids. They just hear that “its bad.”

Science and tests are clear – if you don’t have celiac disease, you don’t need to avoid gluten. If you have gluten sensitivity the reality is that it is in your mind, and not your gut.

Thomas Keller has come up with a great flour, gluten Free.

Dr. Terry Simpson About Dr. Terry Simpson
Dr. Terry Simpson received his undergraduate and graduate degrees from the University of Chicago where he spent several years in the Kovler Viral Oncology laboratories doing genetic engineering. He found he liked people more than petri dishes, and went to medical school. Dr. Simpson, a weight loss surgeon is an advocate of culinary medicine. The first surgeon to become certified in Culinary Medicine, he believes teaching people to improve their health through their food and in their kitchen. On the other side of the world, he has been a leading advocate of changing health care to make it more "relationship based," and his efforts awarded his team the Malcolm Baldrige award for healthcare in 2011 for the NUKA system of care in Alaska and in 2013 Dr Simpson won the National Indian Health Board Area Impact Award. A frequent contributor to media outlets discussing health related topics and advances in medicine, he is also a proud dad, husband, author, cook, and surgeon “in that order.” For media inquiries, please visit www.terrysimpson.com.

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Latest Comments

  1. Kathy Plouffe says:

    Great information on “Gluten” and how it is diagnosed, what it does and how to treat it. Thank you for this. Many people do not understand this problem and you have once again cleared any doubts or incorrect information.

  2. Denise Miller says:

    Your comment “What we do know is that gluten is not a health issue for those that do not have Celiac Disease” is incorrect, misleading and shocking. Aldous Huxley’s quote, “Facts do not cease to exist because they are ignored” comes to mind. Please research the brilliant work of Dr. Rodney Ford on Gluten Syndrome and you will change your narrow minded perspective!

  3. The Doc says:

    People always want to lump diseases together and find the magic disease that is a problem for everyone- then use anecdotal data. It use to be everyone suffered from hypoglycemia – then everyone had some auto-immune disorder- now someone else is calling it Gluten syndrome, based on loose criteria.

  4. ICDogg says:

    The gluten-free diet works possibly for weight loss because people consume less of the processed foods that contain it, and because if they are not replaced by other carbs it probably helps decrease insulin resistance.

  5. gracie says:

    DRASTICALLY REDUCE WHAT YOU CAN EAT!!! YES, bread, pasta, lots of deserts and prepackaged foods.
    there are other types of bread, and pastas if you really miss them. other grains that don’t contain gluten and flours made from other foods like chestnuts, chic peas etc… and i personally find that with my decrease in quick fixes like pasta, sandwhiches for lunch and ordering pizza when i don’t want to cook, i’ve been eating a lot more varieties of vegetables, fruit, and a lot of other interesting recipes that is making life fun!
    yes it is a challenge. a challenge of not being too lazy to cook, and giving up things that honestly were really tasty and addictive at times! especially if you are always on the run. i find that taking the time to eat well is well worth it.

    GLUTEN IS NOT A HEALTH ISSUE IN PEOPLE WHO DO NOT HAVE CELIAC DISEASE: what??? so all these stories of people getting better is just make believe? and i can tell quite a few. but i won’t go into that now. this comment doesn’t even deserve a response. utter nonsense. and anyone who has been tested negative for celiacs but has gotten rid of thier issues by going gluten free can be a testament to that.

    THERE ARE GROUPS WHO WILL CLAIM THAT GLUTEN IS A HEALTH ISSUE, THERE IS NO BASIS FOR THIS CLAIM. : okay. i was sick. very sick. and now i’m not. isn’t that basis enough? and many people who decide to go gluten free are not merely giving up thier bread and pizza for a fad. they do it because they feel GOOD. and they decide that thier favorite foods are just not worth it for them. not worth the suffering. not worth the risk it was posing to thier health. you don’t have to be a docter to know when you feel better and when you don’t.

    IF SOMONE HAS TOLD YOU TO REMOVE GLUTEN FROM YOUR DIET, PLEASE SEE A PHYSICIAN TO RESOLVE THIS: why????? is not eating bread,pasta,deserts and many packaged foods a real threat to our health..really? i DO agree that if a person does go gluten free they should definatly do thier research. you don’t want to go gluten free and then eat lots of chocolate instead. going gluten free on it’s own is not neccesarily healthy, you still need to eat well.. but why make it sound like such a risk? where is the risk? i want to know. has anyone gotten sick by not eating bread before?

  6. The Doc says:

    Personal anecdotes are not science. Science is what we test, what we can show, and what we can ideally take from the laboratory bench to the patient. There are a lot more factors in flour than gluten.
    If someone has an allergy to gluten, then yes, they need to see a physician because they are at an increased risk of certain small bowel cancers, and need to set up a screening program for that. Even if a person is perfectly gluten free- their increased risk of those cancers is real, and continues. So, yes, they should see a physician, and be screened for those small bowel cancers. That is a real and defined risk.
    Life is more complicated than not eating bread and pizza and feeling better.

  7. Libby says:

    Science? I could not care less about science regarding this issue. 6 weeks grain free and 5 years of depression lifted for me (not to mention 20 lbs gone). I don’t care whether a study exists to “prove” that this is or is not related to wheat. One pasta meal 6 weeks in and depression and bloating returned. 3 weeks in, my diabetic husband’s blood sugars were normal. He is off all diabetic meds and somehow he no longer has rheumatoid arthritis symptoms and no longer needs to take Big Pharma’s really expensive medications for the pain. So, what’s the problem? Science or no, we’re not going back to wheat, ever. Poor Big Agribusiness will just have to sell it to somebody else. By the way, we’re eating healthier than ever. We’ve filled the calorie void with vegetables! What a disaster!

  8. The Doc says:

    Nothing beats science like confirmation bias. I have no issue with people getting off highly processed food. Of course you will feel better and if you eat better it is great. So don’t go back to wheat – not my point. Happy you are healthier. Losing weight certainly helped- showed that you ate too much crap and now you are eating better. Food can’t cure you but it can kill you

  9. Norbert Wronkletoad says:

    “It use to be everyone suffered from hypoglycemia – then everyone had some auto-immune disorder- now someone else is calling it Gluten syndrome, based on loose criteria.”

    YES! this!!!

    and all of the indignant “anecdata” above. lolz

    and Dr Internet helps with the confirmation bias.

    and don’t forget “inflammation” (catch-all/monolith), too

    Weight loss is very difficult, and many people feel like crap and have a lousy self-image that they protect, sometimes using an affliction to buy them some extra social slack or extra social capital or just to deflect the cognitive dissonance. I do hope they find a way to feel better, lose the weight, maybe get stronger. And I hope they do it in an honest/real, healthful way!

    Belief in psdueoscience, brodiagnoses, ghosts, and designer disease does not seem to accomplish any of that.

  10. mhikl says:

    Good Doctor, on this one I have to disagree and I am certainly happy this wasn’t the first article of yours I had the good chance to come upon.

    I don’t’ see the need for the empty calories in grains. Most of the nutrients are in their germ, I believe, so buy raw germ and Bob’s your uncle. And all the nutrients in wheat can be easily gotten from other food sources. (One brazil nut gives you more than a days supply of selenium, for example.) And there are the anti-nutrient aspects of grains. They may take a lot of calcium and other nutrients to digest cab-sugars. They are little robbers and should be banished.

    This is a long meander but it continues to be tested every time I introduce wheat into my system.

    I don’t think I have celiac disease. However, I began following Dr Peter D’Adamo’s O Blood type diet in 2000. I eliminated all grain products except for occasional rices, red rice in particular. I was fastidious in this. To make a long story short there were noticeable results. The excruciating pain in my left hip due to a sudden movement getting out of a chair too short for the table caused a sudden wrenching or tearing. I was young, 29, and living in Borneo at the time so medical facilities were flying distance away. Besides, as a man I just didn’t go to doctors for every little problem. It took months before I could get up from a chair or from bed without slowly stretching out the leg so I could walk without excruciating pain. Sitting in a chair for more than a few minutes meant that would have to standstill, slowly stretch and wait for the pain to dissipate before walking. Over the years the leg seemed to heal but left me with a pain in the hip that was always present and at times excruciating. Driving and then getting out of my low slung car would almost bring tears just at the thought of the pain it would take to get out of the car. Twenty-three years later, after following the O blood diet and giving up all wheat products here are the surprising results: (In 2000 a doctor sent me for a full body bone scan for cancer due to my hip deformation. Nothing came of that.)
    – after about 3 weeks the pain began to noticeably subside and after about nine months, though there was some residual ache, the vast major of discomfort had subsided.

    – Even before the tear I had never been able to walk, jog or run long distances. My legs would just tire out. This made playing ice hockey impossible. Short runs in softball were possible. Hiking was difficult. Now I could walk and jog for hours.

    – after about five week I suddenly had, for the first time in my life, sensation (sensuousness) to the skin of my legs. I noticed this suddenly one day when I felt my pants rustled against the hairs of my legs. It was so thrilling that I would leave my class just to walk unencumbered in the hallways to meditate on the sensation. I then realised that for as long as I could remember, my legs had never had such sensations. As well, the souls of my feed became sensuous to the touch. I became ticklish (that I would have skipped.)

    – I remember in my early twenties, my doctor asking me if there was anything else (beyond what I had come for) and I replied that my left food seemed to have a slight aching. When I removed my shoe it was found to be full of blood. I had somehow injured it yet for the most part did not feel any pain, only a slight discomfort.

    Whenever I eat much wheat (one slice of toast does not seems to set off any noticeable reaction if I don’t touch wheat for more that a few weeks) the fist problem that occurs is the problem with walking any distance. Next the hip pain increase. Therefore, I have learned to avoid all wheat and grain glutens of any source.

    Could it be the way grains are processed may be the problem. From what I have read it may be that our ancestors first processed grains in water soaking with or without salt and this started the gemination process and deactivated some sort of protective lectins?? or defensive measures against predators and the grains became easier to digest.

    I never was one for starchy carbohydrates. I should have listen to my body more. The lose of pain, the gain of movement and skin sensation are enough for me to avoid wheat. No doctor has ever been able to or interested in finding out the cause of my discomfort; but it sure messed up the first fifty years of my life. The past twelve have not been pain free, I still hobble a bit and can’t run or jog much, but it is nothing as terrible as the pain I suffered in my thirties and forties.

    I do agree that not all traditional medical beliefs are accurate, but there are some traditional means that befuddle medical science. The problem comes when they become recorded and standardised and not further studied. But the same stands true with medical science. But with science, at least there is the possibility that someone may question the assumed norm and attempt to verify the science. The problem is that they stand as fact until someone thinks or finds means to retest them and find their defaults.

    Aside, my blood test usually indicate my iron at sub levels, even though I eat a lot of red bovine. I am usually borderline anaemic. My red bloods cells are malformed and called immature. There is no history of celiac disease in my family.

  11. The Doc says:

    Most people- when they go from a crappy diet, to something better- feel improved. Does not mean that it is gluten, but gluten is merely a protein, and is not the bad guy for a lot of people. In fact, it was gluten that allowed civilization to be

  12. Judith Lawrence says:

    Hey Doc. You obviously have everyone up in arms here! I’m going to approach it differently but still would like to make a valid point. The doctor who wrote The Blood Sugar Solution..the first thing he does is put his patients on a gluten free diet to get his patients’ blood sugars under control. The cardiologist who wrote Lose the Wheat, Lose the Weight, the first thing he does it put his patients on a gluten free diet to lose weight and get their heart in healthy condition. And lastly, all the neurologists who run MS clinics and the first thing they do is put their patients on a gluten free diet in order to get them to go into remission and stay there. Are these medical conditions not as important or just celiac? Aren’t their methods based on scientific fact as well? Especially since studies in the last few years have shown that the virus’ that causes MS and diabetes when placed in a test tubes side by side looks identical? Also, tests in the last year have shown that people that have MS are 10 times more likely to have Celiac and children of MS mother’s are 32 times more likely to have Celiac disease. So wouldn’t you draw the conclusion that there is a scientific connection between immune disorders of Diabetes, MS and Celiac and perhaps a gluten free diet may be in order for all 3 diseases? I’m just asking a question not arguing. I happen to be a child of a(n) MS woman and I have both MS and Celiac and my diabetes is definitely under control by my gluten free diet. I probably have had MS since I was 10 yrs old but all my symptoms became exascerbated when I had a gastric bypass 10 years ago. Obviously, the trauma of that surgery and the malabsorption that followed…well let’s just say you shouldn’t change around the way the good lord made you. Oh yeah…Sjordren’s is another autoimmune disease and also runs hand and hand sometimes with celiac and Sjordren’s patients are put on a special diet…and guess what? It’s a gluten free diet. Perhaps Doc you should modify your modify your stance on what medical conditions warrant being on a gluten free diet. Just a thought.

  13. thedoc says:

    Ok- so lets go through a few things first: when someone has a point of view and writes a book, that isn’t an authority. That is an opinion in a book. When there is a peer-review study done, or science done – that is science. Some physicians “believe” that gluten free is the answer to all the problems of the world- and for them I refer to China- where 1.4 billion people eat noodles and the Northern part of China has wheat noodles, and they are thin, and healthy.
    There is no virus responsible for Diabetes, and you cannot see a virus in a test tube. In terms of celiac disease and MS- remember, correlation is not causation. Yes- there is a genetic allel that contrary to what has been described previously, the less frequent allele of the functional polymorphism Arg381Gln (rs11209026) seems to be increasing susceptibility to CD and MS, although in this last group of patients a stronger effect is observed in patients affected of a primary-progressive form.
    That does not mean that fixing celiac disease will fix MS – it means those two diseases are coded for in the same general area on the genome. Another example of this occurs with association of the IL23R gene with inflammatory bowel disease, psoriasis and ankylosing spondylitis. Curing psoriasis does not fix ankyosing spondylitis or inflammatory bowel disease.
    Gastric bypass, by the way- does bypass the place where most gluten is broken down, thus the distal gut is exposed to a protein it normally does not see.
    IF you have celiac disease- you must have a gluten free diet or a lot of bad things will happen. But that does not mean that if you have diabetes, or MS, and do not have celiac disease that you will be better off without gluten.

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