Is gluten intolerance bullsh*t?

by Ronald Hoffman, MD

“All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident.”

Arthur Schopenhauer, German philosopher (1788 – 1860)

To this we might add, in this era of click-bait journalism, a fourth stage: “Then it is ridiculed again.”

Such is the case with gluten intolerance, a real phenomenon that is suddenly taking a shellacking in certain less-enlightened segments of the media.

Articles with lurid titles like these are appearing with greater frequency:

“Does it Even Matter if Gluten Sensitivity is Bogus?” –PLOSblogs

“Gluten Intolerance is Apparently Bullsh*t” –Jezebel

“Your Gluten Allergy is Fake and I Hate You” –Redditt

“Being Gluten-free is Dumb—And Gluten Intolerance May Not Even Exist” –Muscle-for-life

“Calling Bullsh*t on a Fake Gluten Allergy” –LocalBizComedy

“Why a Gluten-Free Diet is Unnecessary and Even Unhealthy” –XoJane

If you haven’t heard of many of these pop culture outlets, don’t worry. The stories aren’t written by health professionals who’ve ever seen a patient. Their snarky, sensationalistic style typifies a new genre of health reporting that’s been unleashed by the democratization of the Internet and social media. The name of the game is to garner the most “clicks” – he who trends most wins.

It’s not surprising that a recent survey showed that only 6% of the population has a “high degree of trust” in the media.

Even Presidential contender Ted Cruz took a swipe at gluten correctness: He pledged not to provide gluten-free MREs to military personnel, signaling his disdain for effete, “PC” liberalism. (Cruz needn’t worry—the military already takes a dim view of gluten intolerance, and provides no special accommodation for soldiers who claim the affliction)

I get that “gluten-free” has become a fashion statement in certain pretentious precincts, and it’s spawned a growth industry for opportunistic food manufacturers who offer a plethora of (often not very nutritious) products. Many people who claim a gluten “allergy” do so with no objective evidence. They’ve never undergone testing, but claim to feel subjectively “better” when they skip wheat and related grains. Undoubtedly, some of the benefits they experience are due to the placebo effect.

So let’s drill down on the scientific study that has all the gluten skeptics exulting. The trial was published in the August 2013 edition of Gastroenterology. It involved 37 subjects with irritable bowel syndrome, all of whom were given a preliminary “FODMAPs” diet for 2 weeks. None of them had tested positive for celiac disease, the uncontroversial “classic” form of gluten intolerance.

The FODMAPs diet is designed to reduce intestinal bloating and gas by eliminating fermentable carbohydrates (fructans, oligosaccharides, disaccharides, monosaccharides, and polyols). That means no grains, no milk products, no sugars, and elimination of certain fruits, nuts and vegetables. While highly restrictive, this diet often yields superb results in sufferers of IBS.

No surprise: The subjects felt much improved. Then they were challenged with either a high-gluten, low-gluten, or no-gluten meal plan and the effects were assessed.

All 3 diets—whether or not they included gluten—produced identical symptoms in the testers: they reported feeling worse.

This was interpreted by the researchers as evidence that gluten intolerance—outside of celiac disease—does not exist. That the subjects felt worse during the challenge period was attributed to the “nocebo” effect—the opposite of a placebo. In other words, gluten intolerance was a figment of their imaginations, since the presence—or non-presence—of gluten made little difference to their subjective responses.

But I see several problems with this study, and its appropriation by gluten-intolerance skeptics:

• The selfsame researcher—Dr. Peter Gibson at Monash University in Australia—had previously demonstrated the very opposite in a 2011 double-blind placebo-controlled study in which sufferers of non-celiac gluten intolerance showed strong reactions to gluten feeding. Why the discrepancy? Was the first study wrong?
• Even if gluten-intolerance isn’t really a specific reaction to gluten, but instead is a form of FODMAPs intolerance, isn’t that moot? Patients with fatigue, brain-fog, gas, bloating, diarrhea, constipation and many other baffling symptoms get better with gluten-free diets. I can certainly attest to that based on over 30 years of clinical experience. What difference does it make whether they have candida, wheat allergy, gluten-intolerance, or SIBO (small intestine bacterial overgrowth) when the net result is that they improve when they eliminate gluten? Does that make self-reported gluten intolerance any less “real”?
• The re-challenge control meals consisted of whey protein—a known precipitant of GI symptoms for a high percentage of IBS sufferers! Isn’t it unfair to conclude that reactions to the gluten were “imagined” because they were indistinguishable from those experienced with whey?
• In any case, the authors note that “only 8%” of symptoms reported by study participants could be attributable to gluten, which they dismiss as trivial. But, while not statistically significant in this small study, isn’t it worth considering as a trend supporting gluten intolerance?
• The reintroduction of gluten lasted only 3 days. In my experience, people who benefit from gluten elimination may get away with a little gluten for a short time before symptoms recur. I would’ve liked to see longer term follow up during which time I’m pretty certain that gluten intolerance would have re-emerged in a way that would clearly distinguish itself from the symptoms reported by control subjects who consumed only whey.
• Finally, if gluten really didn’t make a difference for the folks in this study, you might expect that its reintroduction wouldn’t provoke the adverse reactions the subjects reported. But it did. And maybe it wasn’t just their overactive imaginations at work (Just sayin’!).

BOTTOM LINE: I’m sure even Dr. Peter Gibson would downplay gluten intolerance deniers’ attempts to use his study to call BS on gluten avoiders who aren’t diagnosed with full-blown celiac disease. He’s a FODMAPs guy, having written many papers on the subject, and maybe his message is that some are claiming gluten intolerance when what they’re actually reacting to are fermentable carbohydrates.

I’m not certain it really matters, because many people are obtaining relief from a wide variety of symptoms when they stop eating bread, cookies, and pasta. Of course, it’s dumb to skip gluten just because it’s trendy; on the other hand, don’t let the detractors daunt you if your gluten avoidance has delivered you from bothersome complaints.

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