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Another detrimental aspect of this diet is the cost; it is estimated that gluten-free foods cost 162% more than regular foods. However, a recent cost-comparison study shows that gluten-free foods are equalizing in price with regular foods, because the more competition in the market has driven down cost.<ref name=Macleans />
Another detrimental aspect of this diet is the cost; it is estimated that gluten-free foods cost 162% more than regular foods. However, a recent cost-comparison study shows that gluten-free foods are equalizing in price with regular foods, because the more competition in the market has driven down cost.<ref name=Macleans />


Evidence of the diet's efficacy as an autism treatment is poor,<ref name="Millward2008">{{cite journal| author=Millward C, Ferriter M, Calver S, Connell-Jones G| title=Gluten- and casein-free diets for autistic spectrum disorder. | journal=Cochrane Database Syst Rev | year= 2008 | volume= | issue= 2 | pages= CD003498 | pmid=18425890 | doi=10.1002/14651858.CD003498.pub3 | pmc= | url=| editor1-last=Ferriter| editor1-first=Michael }}</ref> but there probably is a subset of patients who might improve with a gluten-free diet.<ref name=SzaflarskaPopławska>{{cite journal | vauthors = Szaflarska-Popławska A| title = The Relationship of Autism Spectrum Disorders and Celiac Disease and Gluten-free Diet | journal = International Journal of Celiac Disease | volume = 3 | issue = 4 | pages = | date = 2015 | url= http://pubs.sciepub.com/articleinpress/ijcd/ijcd-3-4-1.pdf | doi = 10.12691/ijcd-3-4-1}}</ref><ref name=Buie>{{cite journal | author = Buie T | title = The relationship of autism and gluten | journal = Clin Ther| volume = 35 | issue = 5 | pages = 578-83 | date = May 2013 | pmid = 23688532 | doi = 10.1016/j.clinthera.2013.04.011}}</ref>
There is no good evidence that a gluten-free diet is of any benefit to people with autism.<ref name="Millward2008">{{cite journal| author=Millward C, Ferriter M, Calver S, Connell-Jones G| title=Gluten- and casein-free diets for autistic spectrum disorder. | journal=Cochrane Database Syst Rev | year= 2008 | volume= | issue= 2 | pages= CD003498 | pmid=18425890 | doi=10.1002/14651858.CD003498.pub3 | pmc= | url=| editor1-last=Ferriter| editor1-first=Michael }}</ref><ref>{{cite journal |vauthors=Buie T |title=The relationship of autism and gluten |journal=Clin Ther |volume=35 |issue=5 |pages=578–83 |year=2013 |pmid=23688532 |doi=10.1016/j.clinthera.2013.04.011 |type=Review}}</ref>


===Wheat allergy===
===Wheat allergy===

Revision as of 02:12, 6 November 2015

Wheat

A gluten-free diet is a diet that excludes gluten, a protein composite found in wheat and related grains, including barley and rye. Gluten causes health problems in sufferers of celiac disease (CD) and some cases of wheat allergy. For those diagnosed with celiac disease, a strict gluten-free diet constitutes the only effective treatment to date.[1] There is ongoing research and debate on non-celiac gluten sensitivity. While gluten-free diets are a popular fad diet, there is no published experimental evidence that they provide any benefit to the general population, and they carry serious risks of malnutrition.

Rationale behind adoption of the diet

Coeliac disease

Main article: Coeliac disease

Coeliac disease is an autoimmune disease that attacks the small intestine due to the presence of gluten, for which a gluten-free diet is the only medically-accepted treatment.[1][2] The disease affects an estimated 1% of adults worldwide[3] and appears to be on the increase,[4] but because of the rare occurrence of symptoms, it is believed only 5-10 percent of cases are diagnosed.[5] The amount of tolerable gluten varies among people with celiac disease. Although there is no evidence to suggest a single definitive threshold, a daily gluten intake of less than 10 mg is unlikely to cause significant histological abnormalities.[6]

Non-celiac gluten sensitivity

Main article: Non-celiac gluten sensitivity

Non-celiac gluten sensitivity (NCGS) is described as a condition of multiple symptoms that improves when switching to a gluten-free diet, after celiac disease and wheat allergy are excluded.[7][8] Patients develop gastrointestinal symptoms, which resemble those of irritable bowel syndrome (IBS)[9] and/or a variety of systemic symptoms, such as headache, mood disorders, fatigue, bone or joint pain, and skin manifestations.[10] Neurological signs are the most common among extra-intestinal manifestations of NCGS.[9]

The ingestion of gliadin (a component of gluten) is responsible for symptoms in celiac disease and, at least in some cases, in NCGS.[11] Much recent research on NCGS has aimed at determining which agents trigger a response in NCGS patients: to which extent gluten, FODMAPs, ATIs or other substances are involved.[12] Some double-blind, placebo-controlled challenge (DBPC) have been performed to evaluate if the improvement of the NCGS symptoms after a gluten-free diet can be induced by a placebo effect, manifesting discordant results. Nevertheless, these trials have been performed only in NCGS patients with irritable bowel-like symptoms (IBS). One DBPC trial performed by Biesiekierski et al. firstly confirmed the existence of NCGS and found that gluten caused significantly worse pain, tiredness, bloating and stool consistency than a placebo diet in IBS patients, with no difference in celiac or gliadin antibodies between the gluten and control groups. Similar results were obtained by Carroccio et al. in another DBPC study.[9] However, in a second DBPC trial of Biesiekierski et al. in a few patients with IBS, the authors found no difference between gluten or placebo groups[9][10] and the concept of NCGS as a syndrome was questioned.[10] They concluded that gluten was responsible of neurological, but not gastrointestinal symptoms, and that the intestinal symptoms were attributable to FODMAPs in the majority of participants.[9] Nevertheless, probably the reintroduction of both gluten and whey protein had a nocebo effect similar in all patients, and this could have masked the true effect of gluten/wheat reintroduction.[10]

In NCGS, both wheat and gluten may contribute to different symptoms that can occur in the same individuals.[12] Consequently, there is a discussion on whether the term should be non-celiac's gluten sensitivity or non-celiac wheat sensitivity.[13]

Also, a subgroup of NCGS patients can't improve by eating commercially available gluten-free products, wich are usually rich of preservatives and additives, because chemical additives (such as sulphites, glutamates, nitrates and benzoates) might have a role in evoking functional gastrointestinal symptoms of NCGS. Thus, this patients need a diet based on natural gluten-free foods.[9]

NCGS, which is possibly immune-mediated, now appears to be more common than celiac disease,[14] with a prevalence estimated to be 6-10 times higher.[15]

As a fad diet

Gluten-free fad diets are popular and endorsed by celebrities such as Miley Cyrus.[16] The book Wheat Belly which refers to wheat as a "chronic poison" became a New York Times bestseller within a month of publication in 2011.[17] IHowever, there is a lot of confusion out there and some people buy gluten-free food "because they think it will help them lose weight, because they seem to feel better or because they mistakenly believe they are sensitive to gluten".[18] Nevertheless, the gluten-free diet is not recommended as a means to eat healthier or to lose weight.[19] Many people seek information about this diet on blogs or books and they go on this diet in order to lose weight, but they can actually end up gaining weight. This is because processed gluten-free foods may be higher in fat and lower in protein.[20]

One risk for gluten avoiders is to miss out on important diagnoses, if they do have celiac disease and aren’t tested, because tests for celiac disease are reliable only if the patient has been consuming gluten.[20] This diet should not be undertaken to diagnose one's own symptoms.[21] But in practice, what happens is that since the patients first start feeling sick, it takes on average 12 years to be diagnosed with celiac disease. The reason is that celiac disease is not just an intestinal disease, but is a systemic disease: the symptoms can affect almost any part of the body and could hint at any number of disorders. Because they can’t get answers, these persons take matters into their own hands and start a gluten-free diet. Often, they perceive an improvement in their symptoms and then, they want to confirm that gluten is the problem. Nevertheless, now diagnosing celiac disease is all but impossible, because before getting tested, patient must consume gluten for at least a couple of months or even up to a year. Some people refuse to start eating gluten again and continue the gluten-free diet. Others are wrongly informed that they don’t have the disease.[20]

Another complicating matters is the fact that “most people who think they’re on a gluten-free diet aren’t, unless they’ve really done their research". They think that is enough if they’re just avoiding pasta and bread. Nevertheless, that’s not enough, because gluten is in almost everything. Industry want to get their money’s worth and gluten is a readily available, inexpensive component, that is used as a flavouring, thickener, stabilizer or as filler in most products. Furthermore, reading labels may be not enough to know whether or not the products contain gluten, because it may appear in Latin (Triticum vulgare, Secale cereale or Hordeum vulgare) or in ingredients that people don’t realize contain gluten (like farina, malt, bulgur, couscous, seitan, etc.).[20]

Another detrimental aspect of this diet is the cost; it is estimated that gluten-free foods cost 162% more than regular foods. However, a recent cost-comparison study shows that gluten-free foods are equalizing in price with regular foods, because the more competition in the market has driven down cost.[20]

There is no good evidence that a gluten-free diet is of any benefit to people with autism.[22][23]

Wheat allergy

In some cases, a wheat allergy is a valid medical reason for eating a gluten-free diet.[citation needed]

Eating gluten-free

Quinoa is a pseudocereal that is gluten-free.
Rice bread

The gluten-free diet includes naturally gluten-free food, such as meat, fish, nuts, legumes, fruit, vegetables, potatoes, pseudocereals (in particular amaranth, buckwheat, chia seed, quinoa), only certain cereal grains (corn, rice, sorghum), minor cereals (including fonio, Job's tears, millet, teff, called "minor" cereals as they are "less common and are only grown in a few small regions of the world"),[24] some other plant products (arrowroot, mesquite flour[25]) and products made from these gluten-free foods, such as breads and gluten-free beer. Gluten-free bread may be less fluffy, so additives are used to compensate, such as corn starch, eggs, xanthum gum, guar gum, and hydroxypropyl methylcellulose.

Processing of some glutenous ingredients removes the gluten, such as maltodextrin, and some distilled beverages.[26]

Some vineyards use flour paste to caulk the oak barrels, but tests have not detected the presence of gluten in the wine.[27] Gluten may be used as a clarifying agent in wine, some of which might remain in the product.[28]

The diet excludes foods containing gluten, such as wheat, rye, barley, triticale, kamut, malt,[24] and foods that may include them, or shared transportation or processing facilities with them.[29]

Some cereal grains, although gluten-free in themselves, may contain gluten by cross-contamination during processing steps or transport; this includes oats.[30] Some processed foods may contain gluten, so they would need specific labeling, such as gluten-free ice-cream, ketchup, chicken bouillon, corn cereal, ice cream toppings, malt flavoring, and chocolate. And some non-foodstuffs may contain gluten as an excipient or binding agent, such as medications and vitamin supplements, especially those in tablet form.[31][32] People with gluten intolerance may require special compounding of their medication.[29]

Risks

Unless great care is taken, a gluten-free diet can lack the vitamins, minerals, and fiber which are found in wheat, barley, rye, kamut, and other gluten-containing whole grains[5] and may be too high in fat and calories.[25][33] Processed gluten-free foods are often higher in salt, sugar, glycemic index, transfats and other processed fats.[25] Although the lack of vitamins, minerals and fiber can be mitigated through the consumption of brown rice and quinoa,[34] many practitioners of the diet do not consume the recommended number of grain servings per day.[35][36] Many gluten-free products are not fortified or enriched by such nutrients as folate, iron, and fiber as traditional breads and cereals have been during the last century.[37]

Advances towards higher nutrition-content gluten-free bakery products, improved for example in terms of fiber content and glycemic index, have been made by using not exclusively corn starch or other starches to substitute for flour. In this aim, for example the dietary fiber inulin (which acts as a prebiotic[38]) or quinoa or amaranth wholemeal have been as substitute for part of the flour. Such substitution has been found to also yield improved crust and texture of bread.[39]

Regulation and labels

Regulation of the label gluten-free varies by country. Most countries derive key provisions of their gluten-free labeling regulations from the Codex Alimentarius international standards for food labeling has a standard relating to the labeling of products as gluten-free. It only applies to foods that would normally contain gluten.[40] Gluten-free is defined as 20 ppm (= 20 mg/kg) or less. It categorizes gluten-free food as:

  • Food that is gluten-free by composition
  • Food that has become gluten-free through special processing.
  • Reduced gluten content, food which includes food products with between 20 and 100 ppm of gluten. Reduced gluten content is left up to individual nations to more specifically define.

The Codex Standard suggests the enzyme-linked Immunoassay (ELISA) R5 Mendez method for indicating the presence of gluten, but allows for other relevant methods, such as DNA. The Codex Standard specifies that the gluten-free claim must appear in the immediate proximity of the name of the product, to ensure visibility.

There is no general agreement on the analytical method used to measure gluten in ingredients and food products.[41] The ELISA method was designed to detect w-gliadins, but it suffered from the setback that it lacked sensitivity for barley prolamins.[42] The use of highly sensitive assays is mandatory to certify gluten-free food products. The European Union, World Health Organization, and Codex Alimentarius require reliable measurement of the wheat prolamins, gliadins rather than all-wheat proteins.[43]

Australia

The Australian government recommends[44] that:

  • food labeled gluten-free include no detectable gluten (<5ppm [citation needed]), oats or their products, cereals containing gluten that have been malted or their products
  • food labeled low gluten claims such that the level of 20 mg gluten per 100 g of the food

Brazil

All food products must be clearly labelled whether they contain gluten or they are gluten-free.[45]

Canada

Health Canada considers that foods containing levels of gluten not exceeding 20 ppm as a result of contamination, meet the health and safety intent of section B.24.018 of the Food and Drug Regulations when a gluten-free claim is made.[46] Any intentionally added gluten, even at low levels must be declared on the packaging and a gluten-free claim would be considered false and misleading. Labels for all food products sold in Canada must clearly identify the presence of gluten if it is present at a level greater than 10 ppm.[47]

European Union

The EU European Commission delineates[48] the categories as:

  • gluten-free: 20 ppm or less of gluten
  • very low gluten foodstuffs: 20-100ppm gluten.

In the United Kingdom, only cereals must be labelled; labelling of other products is voluntary.[49]

United States

Until 2013 anyone could use the gluten-free claim with no repercussion. In 2008, Wellshire Farms chicken nuggets labeled gluten-free were purchased and samples were sent to a food allergy laboratory[50] where they were found to contain gluten. After this was reported in the Chicago Tribune, the products continued to be sold. The manufacturer has since replaced the batter used in its chicken nuggets.[51] The U.S. first addressed gluten-free labeling in the 2004 Food Allergen Labeling and Consumer Protection Act (FALCPA). The FDA issued their Final Rule on August 5, 2013.[52] When a food producer voluntarily chooses to use a gluten-free claim for a product, the food bearing the claim in its labeling may not contain:

  • an ingredient that is a gluten-containing grain
  • an ingredient that is derived from a gluten-containing grain that has not been processed to remove gluten
  • an ingredient that is derived from a gluten-containing grain, that has been processed to remove gluten but results in the presence of 20 ppm or more gluten in the food. Any food product claiming to be gluten-free and also bearing the term "wheat" in its ingredient list or in a separate "Contains wheat" statement, must also include the language "*the wheat has been processed to allow this food to meet the FDA requirements for gluten-free foods," in close proximity to the ingredient statement.
  • Any food product that inherently does not contain gluten may use a gluten-free label where any unavoidable presence of gluten in the food bearing the claim in its labeling is below 20 ppm gluten.

See also

References

  1. ^ a b Lamacchia C, Camarca A, Picascia S, Di Luccia A, Gianfrani C (2014). "Cereal-based gluten-free food: how to reconcile nutritional and technological properties of wheat proteins with safety for celiac disease patients". Nutrients (Review). 6 (2): 575–90. doi:10.3390/nu6020575. PMC 3942718. PMID 24481131.{{cite journal}}: CS1 maint: multiple names: authors list (link) CS1 maint: unflagged free DOI (link)
  2. ^ De Palma, Giada; Nadal, Inmaculada; Collado, Maria Carmen; Sanz, Yolanda (2009). "Effects of a gluten-free diet on gut microbiota and immune function in healthy adult human subjects". British Journal of Nutrition. 102 (8): 1154–1160. doi:10.1017/S0007114509371767. Retrieved July 25, 2013.
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  4. ^ Anderson B (2011). "Coeliac disease: new tests, new genes and rising prevalence". Medicine Today. 12 (6): 69–71.
  5. ^ a b Jaret, Peter. "The Truth About Gluten". WebMD. WebMD. Retrieved March 30, 2014.
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  14. ^ Hogg-Kollars S, Al Dulaimi D, Tait K, Rostami K (2014). "Type 1 diabetes mellitus and gluten induced disorders". Gastroenterology and Hepatology from Bed to Bench (Review). 7 (4): 189–97. PMC 4185872. PMID 25289132.{{cite journal}}: CS1 maint: multiple names: authors list (link)
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  16. ^ Gluten-Free, Whether You Need It or Not. New York Times.
  17. ^ David Quick (September 11, 2012). "'Wheat Belly' continues its run on NYT Best Seller list, but is demonizing wheat and gluten justified?". The Post and Courier. Retrieved December 16, 2012.
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  20. ^ a b c d e "The dangers of going gluten-free - Macleans.ca". Macleans.ca. Retrieved November 5, 2015.
  21. ^ Lewis, Shannon. "Three Reasons to Go Gluten Free and Three Reasons Not to". Related Forms & Information. Province Health & Services. Retrieved March 30, 2014.
  22. ^ Millward C, Ferriter M, Calver S, Connell-Jones G (2008). Ferriter, Michael (ed.). "Gluten- and casein-free diets for autistic spectrum disorder". Cochrane Database Syst Rev (2): CD003498. doi:10.1002/14651858.CD003498.pub3. PMID 18425890.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  23. ^ Buie T (2013). "The relationship of autism and gluten". Clin Ther (Review). 35 (5): 578–83. doi:10.1016/j.clinthera.2013.04.011. PMID 23688532.
  24. ^ a b Saturni L, Ferretti G, Bacchetti T (January 2010). "The gluten-free diet: safety and nutritional quality". Nutrients (Review). 2 (1): 16–34. doi:10.3390/nu20100016. PMC 3257612. PMID 22253989.{{cite journal}}: CS1 maint: multiple names: authors list (link) CS1 maint: unflagged free DOI (link). See Table 2 and page 21.
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  26. ^ Adams, Scott. "Which alcoholic beverages are safe?". Retrieved August 21, 2014.
  27. ^ Celiac.com, referencing a study from The Gluten-Free Dietician, retrieved September 29, 2013
  28. ^ Simonato, Tolin, and Pasini, March 4, 2011 "Immunochemical and Mass Spectrometry Detection of Residual Proteins in Gluten Fined Red Wine," Journal of Agricultural and Food Chemistry
  29. ^ a b Spersud, Erik and Jennifer (January 3, 2008). Everything You Want To Know About Recipes And Restaurants And Much More. USA: Authorhouse. p. 172. doi:10.1007/b62130. ISBN 978-1-4343-6034-2.
  30. ^ "What Foods Have Gluten?". American Diabetes Association. Retrieved August 13, 2014.
  31. ^ "Frequently Asked Questions". IPC Americas Inc. February 27, 2008. Archived from the original on April 11, 2008. Retrieved April 15, 2008. {{cite web}}: External link in |publisher= (help)
  32. ^ "Excipient Ingredients in Medications". Gluten-Free Drugs. November 3, 2007. Retrieved April 15, 2008. {{cite web}}: External link in |publisher= (help)
  33. ^ Bernadette Capili; Michelle Chang; Joyce K. Anastasi (October 2014). "A Clinical Update: Nonceliac Gluten Sensitivity—Is It Really the Gluten?". The Journal for Nurse Practitioners. Special Focus: Legal Matters. Vol. 10, no. 9. pp. 666–673.
  34. ^ Lee AR, Ng DL, Dave E, Ciaccio J, Green PHR (2009). "The effect of substituting alternative grains in the diet on the nutritional profile of the gluten-free diet". Journal of Human Nutrition and Dietetics. 22 (4): 359–363. doi:10.1111/j.1365-277X.2009.00970.x. PMID 19519750.{{cite journal}}: CS1 maint: multiple names: authors list (link)
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  36. ^ Stazi, A. V.; Trinti, B. (2008). "Selenium deficiency in celiac disease: Risk of autoimmune thyroid diseases". Minerva medica. 99 (6): 643–653. PMID 19034261.
  37. ^ "Side Effects of the Gluten-Free Diet". about.com. 2009.
  38. ^ Gibson GR, Roberfroid MB (1995). "Dietary modulation of the human colonic microbiota: introducing the concept of prebiotics". The Journal of Nutrition (Review). 125 (6): 1401–12. PMID 7782892.
  39. ^ Gallagher E, Gormley TR, Arendt EK (2004). "Recent advances in the formulation of gluten-free cereal-based products". Trends in Food Science & Technology. 15 (3–4): 143–152. doi:10.1016/j.tifs.2003.09.012. ISSN 0924-2244.
  40. ^ "Codex Standard For "Gluten-Free Foods" CODEX STAN 118-1981" (PDF). Codex Alimentarius. February 22, 2006.
  41. ^ Hischenhuber C, Crevel R, Jarry B, Makai M, Moneret-Vautrin DA, Romano A, Troncone R, Ward R (2006) Review article: safe amounts of gluten for patients with wheat allergy or coeliac disease. Aliment Pharmacol Ther 23(5):5590575
  42. ^ Poms, R. E.; Klein, C. L.; Anklam, E. (2004). "Methods for allergen analysis in food: A review". Food Additives and Contaminants. 21 (1): 1–31. doi:10.1080/02652030310001620423. PMID 14744677.
  43. ^ Codex Alimentarius (2003) Draft revised standards for gluten-free foods, report of the 25th session of the Codex Committee on Nutrition and Foods for Special Dietary Uses, November 2003
  44. ^ "FINAL ASSESSMENT REPORT PROPOSAL P264 REVIEW OF GLUTEN CLAIMS WITH SPECIFIC REFERENCE TO OATS AND MALT". Australian Government. Retrieved August 9, 2014.
  45. ^ "General labeling for Packaged Foods (free translation)". ANVISA. July 2014.
  46. ^ "Health Canada's Position on Gluten-Free Claims". Health Canada. Retrieved August 9, 2014.
  47. ^ Canadian Celiac Association
  48. ^ "Gluten-free food". Directorate-General for Health and Consumers. Retrieved July 25, 2015.
  49. ^ "Guidance Notes on the Food Labelling (Amendment) (No. 2) Regulations 2004" (PDF). Food Standards Agency. November 2005.
  50. ^ Roe, Sam. "Children at risk in food roulette". Chicagotribune.com. Retrieved September 20, 2009.
  51. ^ Roe, Sam. "Whole Foods pulls 'gluten-free' products from shelves after Tribune story". Chicagotribune.com. Retrieved September 20, 2009.
  52. ^ 78 FR 47154 (5 August 2013). Codified at 21 CFR 101.91.
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