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Let's Talk About Gluten

You may have noticed that gluten has garnered a lot of attention over the past few years as a potential trigger for physical symptoms, especially in the digestive system.  Anecdotal evidence, whether it's written in a blog or on a message board, or shared between friends over lunch, shows that many people report feeling kind of icky after eating gluten.  But the negative effects of gluten don't stop with our digestive tract.  A simple Google search on what conditions gluten may cause yields hundreds (thousands?) of articles on the topic - some rather alarmist and hyperbolic, stating gluten  

Gluten has been linked to over 55 conditions including ADHD, autism, multiple autoimmune diseases, depression, migraine headaches, epilepsy, and schizophrenia.  Schizophrenia?!  I'm not going to get into all of that here, because a) not my area of expertise and b) too much controversy, even for Prince. But what does the research show about gluten intolerance and digestive problems?  Like a lot of things, the story is evolving.

Dr. Peter Gibson, a gastroenterologist and researcher in Australia, produced compelling evidence for the idea of "Non Celiac Gluten Sensitivity" (NCGS) in a study published in 2011.  This study reported that a percentage of people without Celiac disease experienced gastrointestinal distress when eating gluten.  I've seen many clients with Irritable Bowel Syndrome (IBS) or other chronic GI conditions that report being more symptomatic if they eat gluten.  Many have cut gluten from their diets.  In fact, up to 30% of Americans report eating less gluten.  People living with Celiac disease probably remember when gluten-free products were relegated to specialty food stores like Whole Foods or a corner of an aisle in a mainstream grocery store.  Now?  Gluten-free products have exploded into a multi-billion dollar industry in only 2 years and gluten has turned into a bit of a black sheep of our foods.

Dr. Gibson decided to replicate his study with more scientific rigor to try to explain why this was happening and control for other factors that might be explaining the symptoms.  He tested his hypothesis in 37 people with confirmed NCGS in a very controlled fashion.  First, participants were placed on a low FODMAP diet for 2 weeks.  FODMAPs are short-chain carbohydrates that are poorly absorbed by the small intestines, and are found in several foods but are most prominent in gluten-rich food.  After the baseline 2 weeks, each participant was given 3 diets, each of which they ate for 1 week:  high gluten, low gluten, and protein only (placebo).  Participants and researchers were blinded (aka, they didn't know) to what diet participants were eating.  Then Dr. Gibson had 22 of the 35 participants redo the experiment again with the protein and high gluten diet, and also the baseline FODMAP (the placebo this time) diet again.

So what did they find?  It didn't matter what diet the participants were on.  Pain, bloating, nausea, and gas symptoms were all reported to be increased to a similar degree over the baseline FODMAP diet.  In the 2nd experiment, participants who reported improved symptoms on the baseline FODMAP diet reported worse symptoms on the placebo FODMAP diet.

Dr. Gibson concluded that something called the "nocebo effect" was going on.  The symptoms appeared because participants expected to feel sick on the gluten diet, but because they didn't know what they were eating, the symptoms were brought on by psychological processes and not the actual food they were eating.

In my experience, telling people with real physical symptoms that their distress is brought on by psychological processes tends to not go over very well.  Our research on stigma perceptions in people with IBS has shown that many fight the notion that their condition is "all in their head" whether it's from friends, family, or physicians.  Part of my introduction to clients referred to me by their gastroenterologist is "you're not here because your doctor thinks you're crazy."

But does that mean we should dismiss the findings by Dr. Gibson because they identified a psychological process driving symptoms in NCGS patients?  Absolutely not.  We can't ignore the relationship our brains have with our body and subsequent physical symptoms.  Dualism, or the idea that the mind and body are separate entities, is an antiquated idea that is being rejected by modern western medicine more and more.  If you think about it, being told that you're not allergic or sensitive to gluten should be good news.  But in the world of poorly understood illnesses like IBS, it's incredibly helpful for many patients to be able to identify something that explains why they're ill.  Food is a completely logical idea and it's something I can control.

The good news is we can also control our psychological processes.  It may seem harder than simply removing gluten from our diet, but it's really not.  We just need the right tools and, most importantly, an acceptance that it's not a bad thing, a weakness, a flaw, or any other negative quality in ourselves when we address psychological contributions to chronic symptoms.  This isn't me sitting on my psychologist high-horse.  I'm thinking of the clients whom I've worked with to understand the role of psychology in their medical conditions and say, usually with a lot of excitement, "I thought it was all these foods but it wasn't.  I can eat normally again.  I don't have to stress out about what I put in my mouth on a daily basis."

Their quality of life improved dramatically because food no longer produced anxiety, or stress in their marriage, or social isolation from fear of eating out in a restaurant.

Research on the role of diet in chronic medical conditions continues to evolve.  We shouldn't assume Dr. Gibson's study is the final word on gluten's role, but it does remind us of the importance of the mind-body connection.

Dr. T.

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