Frank is an overweight 59-year-old man with a history of fatty liver disease, high blood pressure, high cholesterol, pre-diabetes, joint pain and a strong love for pasta, bread and wine. One day, he asked me in passing what he could do about, of all things, his unsightly toenail fungus; nothing topical had worked. I explained to him that it is possibly a sign of an overgrowth of naturally occurring yeast in his gut, Candida Albicans. Through a diet filled with sugar and excessive wheat combined with a possible history of excessive antibiotic use, Candida can overgrow causing vaginal yeast infections in women, joint pain, brain fog, skin rashes, and toenail fungus. So I suggested to Frank that he cut down considerably on sugar and wheat products. He was game.
Within 4 months:
- He lost 30 pounds;
- His doctor took him off his cholesterol medication, with just an omega-3 fish oil supplement remaining;
- His blood pressure is well-controlled on his medication;
- He is no longer pre-diabetic;
- His joints ache less;
- His overall energy has improved tremendously;
- His snoring has reduced;
- And yes, his toenail fungus improved considerably.
In 2010, the gluten-free food industry had $2.5 billion in sales with projected 2015 earnings of $5 billion (1). If you yourself have not gone gluten-free, you probably know someone who has. Correctly adopting this lifestyle can be life-changing. Incorrectly doing so can be arduous, misplaced, confusing, expensive, and may have made no difference at all in your health.
So what is the truth about gluten? And does Frank’s case have anything to do with gluten?
The Gluten-Related Spectrum of Conditions
Gluten is a naturally occurring protein in wheat, rye and barley.
Patients diagnosed with Celiac Disease (CD) have an auto-immune genetic predisposition for gluten intolerance, positive antibody tests to gluten, and often biopsy confirmed proof of small intestine damage due to gluten consumption (2) leading to malabsorption, significant weight loss or gain, diarrhea, indigestion, joint pain, brain fog, possible neurological impairment (gluten ataxia), and skin rashes (dermatitis herpetiformis) (3). The way gluten is talked about these days would lead you to believe CD is very common. Yet, only .71% of the United States’ population has CD (4). If you have been correctly diagnosed with CD, then a gluten-free diet is the best and only choice for you for the rest of your life. And given that gluten contamination in “gluten-free” products is a possibility—9.5% of 640 Canadian samples tested above the accepted limit of 20mg/kg of bodyweight (5) — I advise living gluten-free but avoiding “gluten-free” products. Stick with organic brown rice and quinoa for your grains.
Research has shown that at least three other conditions can be made worse by the introduction of gluten into a diet:
- Autism Spectrum Disorders (ASD): gluten along with casein, the principle protein in dairy, have been shown to stimulate a worsening of symptoms of ASD (6);
- Fibromyalgia: a condition whereby scar tissue forms in muscle tissue causing all over body pain. One study found that eliminating gluten from the subjects’ diet had a positive effect on overall pain and a resumption of activities of daily living (7).
- Irritable Bowel Syndrome (IBS): abdominal cramping and pain accompanying alternating periods of constipation and diarrhea. IBS affects 7-20% of the US population and to date has no reliable labs or biomarkers to correctly diagnose this syndrome. One study found that IBS subjects ruled out for CD but considered positive for Non-Celiac Gluten Sensitivity (NCGS), had all gastrointestinal symptoms made worse by addition of gluten containing foods as compared to placebo. (8)
But if you, like the other 99.3% of Americans, do not have CD, then how does that extremely low incidence rate translate to a $2.5 billion dollar a year industry? Perhaps you have felt better staying off “gluten,” but are unsure why? There must be something else in wheat, rye and barley that is leading so many people away from such grains that have been eaten for thousands of years.
Enter Non-Celiac Gluten Sensitivity (NCGS). This very new diagnosis has no widely accepted definition. Patients with NCGS may test positive for the same CD genetic markers (9) and while there is no intestinal damage with gluten ingestion, they may develop antibodies to gluten. Symptoms can include digestive upset (diarrhea, bloating, gas, etc) as well as headaches, lethargy, Attention Deficit/Hyperactive Disorder, depression, and ataxia all of which are improved by removal of gluten products from their diet (10).
Wheat today is not what wheat used to be. In the mass production of wheat, this ancient grain has been hybridized to be more glutinous (11) and therefore more durable, able to be grown in more climates, and to be more pest resistant. All of these changes have been made without a deeper understanding or testing of their effect on our health. So it stands to reason that gluten-related conditions like CD and NCGS might be increasing with modern day wheat consumption.
Of all the patients I have seen who have come in saying they have a gluten issue, I have only had one for whom that has been true. All the rest might fall under the vague diagnoses Non-Celiac Wheat Sensitivity (NCWS) (12) or Wheat Allergy (WA). With patients like Frank, I continue to find evidence of at least one of three different aspects of wheat that adversely affect my patients’ health:
- Mold. Wheat in this U.S. is mass produced and stored in silos allowing moisture in the wheat or ambient moisture to create a breeding ground for mold spores to grow (13). Fungus in the wheat distracts the immune system from keeping in check the pre-existing Candida overgrowth in the gut. Going gluten-free for patients with mold issues from wheat might get them 75% of the way toward feeling better. But if the issue is indeed mold, then you have to cast a wider net. Foods that are likely to have mold include: nuts (especially peanuts, almonds, and walnuts), dried fruit, tomatoes (canned or sauce), juicy fruit like bruised apples, grapes and berries; bread, cereals, malty foods like beer or vinegar. According to the EPA, 25% of the world’s food crops are affected by mycotoxins, in particular grains, nuts, celery, grape juice and apples (14). Since this issue is about the quality of the grain and how it is stored and processes, it might mean that one plate of pasta might be ok for you, while the next one won’t.
- Wheat flour as a growth medium for other infections. The more processed a food is, the fewer nutrients, like fiber, it has left. When whole wheat is processed into wheat flour, you speed up its breakdown into sugar in the digestive tract. According to the American Diabetes Association, the glycemic index (GI; the measurement of how quickly a food converts to and raises your blood glucose, with glucose scored at 100 for reference) of 100% stone ground wheat is 55 or less, whole wheat 56-69, and white bread over 70 (15). The quicker food converts to sugar, the greater the likelihood of feeding pre-existing fungal and bacterial infections in the gut and cause fermentation of food stuffs in the digestive tract leading to gas, bloating, indigestion, weight gain, joint pain, and even toenail fungus. A higher GI can also lead to low or high blood sugar/insulin resistance (Diabetes Type II) depending on other dietary factors. Low blood sugar can then lead to eating more frequently and therefore added weight gain. Yet, studies show that foods with a higher GI like wheat fiber actually lowers triglyceride levels reducing the risk of cardiovascular disease (16) and has a blood sugar lowering and stabilizing effect reducing our risk of diabetes (17). But you take away all the fiber, and the end product will send your health in the exact opposite direction. A combination of these first two factors in wheat is likely what was most relevant to Frank’s case.
- Beta Glucans are a naturally occurring part of plant and grain fiber (oats, barley, rye and wheat), mushrooms and certain bacterial and fungal strains. They can act as a potent immune stimulator (18). If you have a pre-existing auto-immune condition (CD, Lupus, Rheumatoid Arthritis, etc.), consuming beta glucan containing foods can shift that confused immune system into overdrive, making you worse.
Food Does Not Exist in a Vacuum
The science of nutrition focuses entirely on nutrients, as if nutrients exist free of environmental influence. Such reductionist thinking leads you, the consumer, to focus on gluten and not wheat, on the part rather than the whole. There are times when this helps elevate the conversation and deepen our scientific understanding; but let’s not lose the forest for the trees. Food is grown, farmed, shipped, brought to market and ultimately to your table with ample opportunity to be tainted by endogenous (within the animal or plant/grain) or exogenous bacteria, mold, viruses, and toxins. I see this every day in my clinical practice; fecal bacteria from chicken or eggs, antibiotic and hormone residues in dairy, blood vessel inflammation, atherosclerosis and hyperlipidemia from coffee, and mold from wheat, to name just a few. We are deeply connected to our environment; we part of it, changing cyclically as nature changes, reflecting within the balance or imbalance outside us. As above, so below. Learning to see where and how we are out of balance empowers you to make a choice. But it must start with clarity.
I encourage you to experiment with food. Start by doing a 7-day Food-Mood Journal, writing down what you eat, when you eat, and any symptoms you experience when you feel them. Be critical but not judgmental. Be willing to look objectively at each thing you eat, free of any preconceived ideas—“Eating salad is healthy,” “Dairy is good for me and builds strong bones,” etc. If your belly hurts every time you eat pasta or have bread cut it out for at least 3 weeks. If you are still curious, then re-introduce it and only it and see how you feel. When it is the right food choice, you will know. Like with Frank, we identified some likely food culprits, and I explained how they may have been adversely affecting his health. He made those changes and within a very short period of time began feeling considerably better as his overall health improved.
Grounding my patients in their own physical reality, helping them to clarify their relationship with food, inspiring them to make well-informed choices and cultivate self-awareness around how those choices lead to greater health and wellness; these are my goals with every patient entering my practice. Including you.
Knowledge is power.
- Spectrum of gluten-related disorders: consensus on new nomenclature and classification. BMC Med. 2012 Feb 7;10:13. doi: 10.1186/1741-7015-1013. Sapone A, Bai JC, Ciacci C, Dolinsek J, Green PH, Hadjivassiliou M, Kaukinen K, Rostami K, Sanders DS, Schumann M, Ullrich R, Villalta D, Volta U, Catassi C,Fasano A. Mucosal Biology Research Center and Center for Celiac Research, University of Maryland School of Medicine.
- What Role Does Wheat Play in the Symptoms of Irritable Bowel Syndrome? Gastroenterol Hepatol (N Y). Feb 2013; 9(2): 85–91. Shanti Eswaran, MD, Akash Goel, MD, and William D. Chey, MD, University of Michigan Health System.
- Sapone, et al.
- The prevalence of celiac disease in the United States. Am J Gastroenterol. 2012 Oct;107 (10):1538-44; quiz 1537, 1545. doi: 10.1038/ajg.2012.219. Epub 2012 Jul 31. Rubio-Tapia A, Ludvigsson JF, Brantner TL, Murray JA, Everhart JE. Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
- Gluten contamination of naturally gluten-free flours and starches used by Canadians with celiac disease. Food Addit Contam Part A Chem Anal Control Expo Risk Assess. 2013;30 (12):2017-21. doi: 10.1080/19440049.2013.840744. Epub 2013 Oct 14. Koerner TB, Cleroux C, Poirier C, Cantin I, La Vieille S, Hayward S, Dubois S. Bureau of Chemical Safety, Food Directorate, Health Canada, Ottawa , ON , Canada.
- Antibodies against food antigens in patients with autistic spectrum disorders. Biomed Res Int. 2013;2013:729349. doi: 10.1155/2013/729349. Epub 2013 Aug 1. de Magistris L, Picardi A, Siniscalco D, Riccio MP, Sapone A, Cariello R, Abbadessa S, Medici N, Lammers KM, Schiraldi C, Iardino P, Marotta R, Tolone C,Fasano A, Pascotto A, Bravaccio C. CIRANAD, Second University of Naples, Italy.
- Fibromyalgia and non-celiac gluten sensitivity: a description with remission of fibromyalgia. Rheumatol Int. 2014 Apr 12. Isasi C, Colmenero I, Casco F, Tejerina E, Fernandez N, Serrano-Vela JI, Castro MJ, Villa LF. Department of Rheumatology, Hospital Puerta de Hierro, Majadahonda, Madrid, Spain.
- Gluten causes gastrointestinal symptoms in subjects without celiac disease: a double-blind randomized placebo-controlled trial. Am J Gastroenterol. 2011 Mar;106 (3):508-14; quiz 515. doi: 10.1038/ajg.2010.487. Epub 2011 Jan 11. Biesiekierski JR, Newnham ED, Irving PM, Barrett JS, Haines M, Doecke JD, Shepherd SJ, Muir JG, Gibson PR. Monash University Department of Medicine and Gastroenterology, Box Hill Hospital, Victoria, Australia.
- Ibid. Biersiekierski.
- Eswaran, et al.
- Gluten and wheat intolerance today: are modern wheat strains involved? Int J Food Sci Nutr. 2014 Feb 13. de Lorgeril M, Salen P. Laboratoire Cœur et Nutrition, Faculté de Médecine , TIMC-IMAG CNRS 5525, Université Joseph Fourier, Grenoble, France.
- Non-celiac wheat sensitivity diagnosed by double-blind placebo-controlled challenge: exploring a new clinical entity. Am J Gastroenterol. 2012 Dec;107 (12):1898-906; quiz 1907. doi: 10.1038/ajg.2012.236. Epub 2012 Jul 24. Carroccio A, Mansueto P, Iacono G, Soresi M, D'Alcamo A, Cavataio F, Brusca I, Florena AM, Ambrosiano G, Seidita A, Pirrone G, Rini GB. Division of Internal Medicine, Hospital of Sciacca, ASP, Agrigento, Italy.
- Analysis of fumonisin contamination and the presence of Fusarium in wheat with kernel black point disease in the United States. Food Addit Contam Part A Chem Anal Control Expo Risk Assess. 2012; 29 (7):1092-100. doi: 10.1080/19440049.2012.671787. Epub 2012 Apr 11. Busman M, Desjardins AE, Proctor RH. Bacterial Foodborne Pathogens and Mycology Research Unit, National Center for Agricultural Utilization Research, Peoria, IL, USA.
- United States Department of Agriculture: www.USDA.gov Food Safety and Inspection Service.
- The American Diabetes Association: http://www.diabetes.org/food-and-fitness/food/what-can-i-eat/understanding-carbohydrates/glycemic-index-and-diabetes.html
- Effect of wheat bran on serum lipids: influence of particle size and wheat protein. J Am Coll Nutr. 1999 Apr;18 (2):159-65. Jenkins DJ, Kendall CW, Vuksan V, Augustin LS, Mehling C, Parker T, Vidgen E, Lee B, Faulkner D, Seyler H, Josse R, Leiter LA, Connelly PW, Fulgoni V 3rd. Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Ontario, Canada.
- Oat β-glucan: physico-chemical characteristics in relation to its blood-glucose and cholesterol-lowering properties. Br J Nutr. 2014 Oct; 112 Suppl 2:S4-S13. doi: 10.1017/S0007114514002256. Wang Q, Ellis PR. Guelph Food Research Center, Agriculture and Agri-Food Canada, ON, Canada. Biopolymers Group, Diabetes and Nutritional Sciences Division, School of Medicine, King's College London, UK.
- Enhancement of LPS triggered TNF-alpha (tumor necrosis factor-alpha) production by (1-->3)-beta-D-glucans in mice. Biol Pharm Bull. 1995 Jan;18 (1):126-33. Ohno N, Asada N, Adachi Y, Yadomae T. Tokyo College of Pharmacy, Japan.