Is Gluten Really That Bad?

Determining who a gluten-free diet is beneficial for, how to begin an elimination diet, and when to look into FODMAPs and other culprits causing gut inflammation 

Knowing whether or not gluten is an issue for you is important. If it is, it can cause inflammation and uncomfortable digestive issues. If not, your diet may be more limited than it needs to be. In this video, I cover how to eliminate and then reintroduce gluten in your diet as well as when to consider other potential culprits of your symptoms, like FODMAPs and prebiotics.

Hi, everyone. This is Dr. Michael Ruscio. I just want to make a quick preface that the audio that you’re about to listen to is actually the audio compendium to a video, which has appeared both on our YouTube channel and on our Instagram page for your convenience. We want to always release the audio version of a video here on the podcast. However, it’ll be evident in some videos, more so than others, that the visual aids may be heavily referenced and leaned on. In some cases, having a depiction of a concept can be very helpful in portraying and making comprehendible that concept. So in any case, if you are listening to this and you want the visual aids, please see our YouTube and/or Instagram page so you can have access to those. Okay. And here we go to the audio for today’s video.

Intro:

Welcome to Dr. Ruscio radio, providing practical and science-based solutions to feeling your best. To stay up to date on the latest topics, as well as all of our prior episodes, make sure to subscribe in your podcast player. For weekly updates, visit DrRuscio.com. That’s DRRUSCIO.com. The following discussion is for educational purposes only and is not intended to diagnose or treat any disease. Please do not apply any of this information without first speaking with your doctor. Now let’s head to the show.

Dr Ruscio:

Hi, everyone. This is Dr. Michael Ruscio. I just want to make a quick preface that the audio that you’re about to listen to is actually the audio compendium to a video, which has appeared both on our YouTube channel and on our Instagram page for your convenience. We want to always release the audio version of a video here on the podcast. However, it’ll be evident in some videos, more so than others, that the visual aids may be heavily referenced and leaned on. In some cases, having a depiction of a concept can be very helpful in portraying and making comprehendible that concept. So in any case, if you are listening to this and you want the visual aids, please see our YouTube and/or Instagram page so you can have access to those. Okay. And here we go to the audio for today’s video.

Dr Ruscio:

Did you know that up to 90% of celiac patients who don’t respond to a gluten-free diet may actually have another food intolerance present? Celiac disease and non-celiac gluten sensitivity are real conditions, but gluten is not a problem for everyone. It’s possible that you or your doctor might be missing the true cause of your symptoms. And you might be overly avoiding gluten. So let’s unpack this, allowing you to have that correct balance between how much you should and should not include gluten in your diet.

The prevalence of gluten sensitivity

Dr Ruscio:

Gluten is a problem, even for those without celiac, this is true. And this entity has been well documented in the published literature. But the stats and the data here matter quite a bit. Looking at the prevalence of celiac disease, this is about 0.5% of the population in North America. So 0.5% is the prevalence of celiac. Let’s compare that against non-celiac gluten sensitivity. This means that a reaction has been documented to gluten in randomized control trials, but you don’t fit the criteria for celiac. The estimates here range from 0.6-6% of the population via most of the data. The best data have really found this range. However, some other estimates have found perhaps up to 13% of the population. A systematic review of 17 studies found that the rates varied, again from 0.6-13%.

Dr Ruscio:

The best study here was a paper by Volta at the University of Bologna and they found a 6% prevalence. So this is something. And if you have digestive symptoms, unsurprisingly, you are more likely to report non-celiac gluten sensitivity. And in this case, the prevalence of someone having a problem with gluten, even though they are not celiac is 19-46%. So even at the best case, most prevalent scenario, under 50% of people have a problem with gluten. How do we interpret this? Well, we can look at this a few ways. We should not look at this as everyone with any type of digestive symptom should be avoiding gluten. That would be incorrect, right? Perhaps at the most generous, we could say one in two. And why this matters as a clinician who sees patients on a weekly basis is because you don’t want to be avoiding foods that you don’t need to, especially when people are not feeling well.

Dr Ruscio:

There is this propensity toward gradual and progressive restrictions—low carb, grain-free, paleo, gluten-free—and eventually this can lead to ARFID or this overly restrictive eating. We want to get the balance point where you can modify your diet in such a way for maximum symptomatic gain, but also not hinder your social life and be back into this reclusive corner where you don’t enjoy food.

It might not be a gluten issue

Dr Ruscio:

Now, another piece of information that can be really empowering for patients is understanding that other food stuffs may drive the reaction that one is attributing to gluten. In this case, FODMAP (or foods that are high or rich in prebiotics which feed intestinal bacteria), FODMAP intolerance has been documented in 41% of those who report gluten sensitivity. Now continuing, FODMAP intolerance in those who have IBS who have digestive symptoms, may be as high as 50-80%.

Dr Ruscio:

So zooming way out, if you have IBS gut symptoms, the likelihood of FODMAP intolerance is 50-80%. Whereas, as we just covered, gluten intolerance ranges from 19-46%. What this means is gluten can be a problem and will be a problem for some. However, it’s important to understand that there might be a different type of modification to your diet that could improve your symptoms, and it might be more likely to improve your symptoms than gluten. And this is FODMAPs. All of this is to help empower you in being able to make the dietary decisions that will allow you to have the maximum improvement with the minimum amount of dietary restriction.

Dr Ruscio:

As an aside, are you avoiding gluten? Have you tried low FODMAP? And perhaps most importantly, have you tried to reintroduce? I’d be very curious to hear your thoughts on this. So please let me know in the comments.

The symptoms of gluten sensitivity aren’t just digestive

Dr Ruscio:

Coming back to the paper from Volta, he looked at 38 Italian centers and over 12,000 patients to assess how common is non-celiac gluten sensitivity. He wanted to look at the common symptoms, both digestive and extra intestinal (or outside of the gut). This breakdown is very helpful in allowing us to better understand what symptoms we might be able to attribute to gluten sensitivity. Bloating in 87%, abdominal pain in 83%, diarrhea at 54%, nausea and heartburn at 44 and 32%. So certainly a wide consolation of GI symptoms can be attributed to non-celiac gluten sensitivity.

Dr Ruscio:

Again, according to this best data point to date by Volta, additionally, and this is where gluten can be most pernicious perhaps, these extra-intestinal or non-digestive symptomatic manifestation—fatigue in 64% of individuals, headaches in 50% of individuals, anxiety in about 39% of people, brain fog in 38% of people, joint and muscle pain or aches in 31%, rashes in 29%, and this general feeling of lack of wellbeing in 68%. This is important because it validates that those who feel they have a problem with gluten but don’t have celiac are justified in describing non-digestive symptoms.

Dr Ruscio:

In fact, looking at celiac as a model for this, we know that celiac can manifest gastrointestinally, neurologically, or dermatologically. So it has been documented that you can have inflammation in the gut and only be experiencing symptoms outside of the gut. So if you’re puzzled as to why you have fatigue, headaches, brain fog, anxiety, and your bowels are fine, the source of the problem could still be your gut. It’s important to keep that in mind.

How to improve a gluten sensitivity

Dr Ruscio:

Now it’s also important to consider that probiotics can improve symptoms of gluten sensitivity. This is something I discuss in “Healthy Gut, Healthy You.” We want to be careful not to force a dietary solution to what might not be solely a dietary problem. Now, looking at a 2020 systematic review with meta-analysis of six clinical trials and over 5,000 patients in the model of celiac, probiotics improved gastrointestinal symptoms 29%. There’s also been a smaller trial in non-celiac gluten sensitivity and they documented that probiotics improve symptoms more than a gluten-free diet alone.

Dr Ruscio:

And if you’re non-responsive to a gluten-free diet, there are other factors to keep in mind. Now probiotics ostensibly are treating some type of disruption in the gut micro flora. However, there’s also the likelihood of FODMAP intolerance, as we discussed a moment ago. And in those with gastrointestinal symptoms, FODMAP intolerance, 50-80% of patients have reported. Histamine intolerance has also been reported in 43% of those with digestive symptoms. Histamine can be so insidious because it’s contained in some stereotypically healthy foods—kombucha, sauerkraut, kimchi, really anything fermented. Also in cured meats, avocados, spinach. This was a problem I suffered from, personally, where I would be having a very high histamine breakfast. Let’s say because I was always in a rush, a can of tuna and a kombucha and some wilted spinach, and then 20 minutes later I was wondering why I was irritable and foggy. And eventually I pieced this together. So just important to keep that in mind.

What else may be driving symptoms

Dr Ruscio:

And third, and finally, in terms of what else can be present that’s driving this constellation of symptoms beyond gluten, well, it’s also been demonstrated that SIBO or an infection could be present. This might be why probiotics are helpful. In the American Journal of Gastroenterology, looking at, again, a small group in this study, 15 celiac patients with persistent symptoms, despite the fact that they had gone gluten-free, 80% of these individuals had either SIBO and infection or some other type of microbial imbalance. And most importantly, treatment of the SIBO or the infection, what have you, improved symptoms in all of the patients.

Dr Ruscio:

And there’s one other similar data point we should put on the table here. Looking at 20 non-responsive celiac patients, meaning they went gluten free and they still had persisting recalcitrant symptoms. 90% of these individuals had a different food intolerance present, perhaps dairy, perhaps FODMAP, et cetera. 55% had histamine intolerance and 30% had H. Pylori.

Dr Ruscio:

Again, zooming way out, why this matters is you don’t want to force a dietary solution to what might not be a dietary problem. Yes, we want to eat the healthiest diet that we can. But no, we want to be careful not to think that dieting harder and harder and harder is going to solve all of the problems. There is this point of diminishing returns where in changing your diet or restricting your diet further does not lead to any gain. And in many cases seems to lead to this fear of food, this social withdrawal, and we really want to be diligent and attentive to avoid this.

Dr Ruscio:

Now, coming back to the Volta paper, 14% of those who had non-celiac gluten sensitivity also had autoimmunity. In fact, a subset of that was 9% thyroid autoimmunity. So there is this overlap between gluten sensitivity and auto immunity. However, again, very important to keep in mind that this does not mean that if you have, let’s say Hashimotos or RA, what have you, that you have a 100% guarantee that gluten is driving that and then you have to be gluten-free. Yes, this can help. Yes, this is something that we routinely advise patients on in the clinic. But no, you don’t want to avoid gluten in perpetuity based upon faith alone. This is where the reintroduction is really important.

Dr Ruscio:

Now we should also acknowledge that data do exist documenting health benefits from grain consumption. Now, I also wouldn’t say that especially processed grains are necessarily a health food but we should acknowledge the fact that a 2016 meta-analysis of 45 trials did find that higher consumption of whole grains was associated with a 22% decrease in cardiovascular disease risk and a 17% decrease risk in all cause mortality death from any cause. And a 2013 meta-analysis of 16 studies found that three servings of whole grains per day decreased the risk of type 2 diabetes by 32%.

Dr Ruscio:

I should also clarify that part of this could be due to the healthy user effect, meaning people who are inclined to do things benefiting their health are more likely to follow dietary guidelines. In this case ostensibly, the most prevalent dietary guidelines have been whole grains. Plus they would not smoke, exercise, tend to their sleep, so these other behaviors are likely skewing this data set. But nonetheless, I think it’s reasonable to conclude that if gluten was so problematic for so many, we wouldn’t see these health benefits attributed to an association of increasing the consumption of healthy whole grains. You can poke holes in that argument, but I think that’s important to maybe counter veil this gravitational pull into 100% gluten avoidance.

What to do now?

Dr Ruscio:

So trying to round this all out, what do you do? How do you integrate this data into trying to find your path to the diet that’s best for you? Well, firstly, eliminate gluten. Over 90% of people with gluten intolerance will experience a reaction within 24 hours. So this is something that you should be able to delineate fairly quickly. Cut out gluten, do I feel better, yes or no? Now, if you don’t feel better or only minimally so, consider a broader elimination. Because remember the other data point we discussed where people would have other food intolerances and deploy a broader elimination diet. This is where I think a paleo diet template can be helpful.

Dr Ruscio:

Of course, keep in mind a low FODMAP diet and consider probiotics if you’ve made dietary changes and are still not seeing improvements in your gut health. And crucially important, remember to reintroduce to tolerance and not to avoid based upon faith or fear. At some point you should reintroduce. And even to entertain the most concerned healthcare consumer’s perspective, that gluten should never be a dietary staple. Fine. I hear your argument. The one thing I’d want you to take away from this video is if you’re going out to dinner, traveling, there’s a social event, that you don’t feel encumbered by this unnecessary gluten restriction and you can at least have it in an exceptional time and place.

Dr Ruscio:

In close, remember that gluten can be a problem for some, but not for all. Symptoms can be broad ranging. And if you don’t respond to a gluten-free diet, try other permutations on dietary restrictions or treating your microbiota. Presumably the best place to start is probiotics. And if you’re looking for more of these guidelines codified into a handout, we do have a free guide entitled “Should You be Gluten Free?” And I’ll link for that in description. And if you found this helpful, please like and subscribe for more of these science-based practical guidelines to help you find the ideal path for optimum health and wellbeing.