Wheat, Wheat, Don’t Tell Me!

[Editor’s Note: This article was written by the Trail Sisters’s Pam Smith.]

Reading through blogs and talking with other runners, it is easy to find people who have seemingly sworn off gluten. Three years ago a friend and I sat around drinking wine after the Lake Sonoma 50 Mile, laughing about some of the things people had said or written in regards to their gluten-free preferences because they seemed a bit faddish:

“After reading Wheat Belly, I stopped eating gluten and my recurrent rashes went away completely.”

“Our family doesn’t eat gluten anymore. It really helped our son’s attention-deficit/hyperactivity disorder (ADHD) and everybody feels better… But beer doesn’t have enough gluten to matter.”

“I am gluten intolerant. I never had any testing because I haven’t eaten wheat in so long the tests would all come back negative.”

“I didn’t think I was gluten intolerant, but I hadn’t eaten bread for three weeks but then had bread the night before a race and had terrible gastrointestinal (GI) issues the whole race, so it must be due to the gluten.”

“I rarely eat gluten because I think it is really bad for you. Except I ate it when doing one of the most challenging lines in Colorado. Sometimes you just have to give the body what it wants.”

The above ‘quotes’ are actually my own paraphrasing, but they all refer to actual incidences, most from well-known runners. Well, karma’s a bitch and in those interim years, my friend has been diagnosed with bona fide celiac disease and I have developed my own reasons for modifying my wheat intake. So I am not here to tell people what they should or should not eat, but rather I hope to provide a primer on wheat and gluten so that people can make more informed choices about their own nutrition.

Wheat is a grass grown for its seeds, which are predominantly processed into flour. Wheat is the number-one food crop worldwide and wheat consumption has been increasing steadily as more countries shift to a ‘Western diet.’ Wheat contains approximately 87% starch and 13% protein. Gluten is the generic term for a family of storage proteins found in grains; in wheat it is composed of a mix of glutenin and gliadin proteins. Gluten (which in Latin means glue) provides a stickiness which serves as a great binding agent and also causes dough to have a wonderful chewy texture. Because of the high yield per acre, relative ease of cultivation, and its pleasing nature when eaten, wheat is the dietary staple for the majority of people in the world. Though wheat is only 13% protein, it is  also the biggest source of consumed protein worldwide and is essential in many developing countries for preventing malnutrition.

Yet almost 30% of Americans say they want to eat less gluten and 18% are trying to maintain a gluten-free lifestyle. There are many possible adverse reactions people can have from eating wheat, but only a couple of these issues are related to gluten. However, the majority of people can consume wheat without any adverse effects. Below is a list and explanation of many of the possible health issues wheat can cause.

Allergy

Any substance containing protein can be a possible source of allergy. An allergy is an excessive immune response which triggers mast cells and the histamine pathway. Wheat allergies can be directed toward any of the 27 different allergens in wheat, not just gluten. Histamine causes the classic allergy symptoms like itchy skin, watery eyes, and hives. Food allergies can also cause tingling around the mouth and tongue, swelling, nausea/vomiting, and even asthma-like breathing issues. Most food allergies arise fairly rapidly and so are fairly easy to identify. If necessary, skin testing and immunoglobulin E (IgE) levels can be used for confirmation. Wheat is one of the more common food allergies, but still affects less than 1% of the population. People with wheat allergies need to avoid all sources of wheat but not necessarily gluten.

Celiac Disease

Celiac disease is an autoimmune disease where the body forms antibodies that react to gluten. Those antibodies then cross react with intestinal cells causing damage to the gut lining. Depending on the severity of the gut damage, patients can develop abdominal pain, diarrhea, GI bleeding, and malabsorption. (Iron deficiency is particularly common; malabsorption of calcium can lead to osteoporosis.) Those antibodies can also attack the skin and cause a particular type of skin rash. Additionally, the increased inflammation and gut-cell turnover increases the risk of more serious issues like lymphoma and GI cancers and is associated with an increased risk of other autoimmune disorders. There is evidence that gluten ingestion doesn’t actually cause celiac disease but rather it severely exacerbates the underlying disease and symptoms. For this reason it is imperative that patients avoid all triggering glutens. (Barley and rye contain slightly different but similar glutens to wheat; oats contain a dissimilar gluten but some patients will still react to oat gluten and thus need to avoid oats.) Miniscule amounts can trigger symptoms so even low-gluten foods like beer or periodic ingestion of wheat is not advised.

Approximately 1% of the U.S. population is known to have celiac disease; however, Dr. John Goldblum, MD, a GI pathologist at the Cleveland Clinic, believes celiac disease is very under-diagnosed and the true incidence is probably double this number. Still that represents only 2% of people. Small bowel biopsy is the gold standard for diagnosis. However, blood testing for specific antibodies is positive in 98% of people with celiac disease so that this offers a less invasive first line of screening. Both antibody levels and GI damage can normalize and cause false negative testing if a patient follows a strict gluten-free diet but this can take three to six months. A one week ‘rechallenge’ with gluten is usually enough to cause antibody levels to rise and will often provoke symptoms. Because of the longer-term health effects and the necessity to fully adhere to a gluten-free diet, I think it is important for people to get a definitive medical confirmation rather than making a self-diagnosis. Celiac disease does have a genetic predisposition, so correct diagnosis may also help family members.

Non-Celiac Gluten Sensitivity/Gluten Intolerance

This one is the controversial entity as it is not well defined and there is no good test for it. The term was first coined by Peter Gibson, an Australian researcher who found that even non-celiac patients reported GI symptoms when consuming gluten. However, in a follow-up study done five years later, Gibson refuted his own findings, stating this entity did not exist. The gist of the study is that ‘gluten-intolerant’ subjects were given gluten-containing or gluten-free diets and told to report their symptoms. Patients had nearly identical symptoms no matter which diet they were given. Another study found that the symptoms that ‘gluten-intolerant’ subjects reported most tightly correlated with what people thought they were eating, rather than what they actually ate. Meaning when they ate gluten-free bread but told it had gluten they experienced symptoms and vice versa. Others have noted that gluten intolerance may actually be a form of FODMAP intolerance (see below).

Nutritionist Meredith Terranova notes that one of her most common consults is for ‘gluten intolerance’ but after looking at clients’ eating habits and ensuring they are eating high-quality wheat products, the majority of these people are able to consume gluten (and wheat) without issue. However, several medical-consensus conferences have acknowledged the existence of gluten-triggered symptoms that differ from celiac disease, the most well defined being gluten ataxia, and some patients do appear to have other immune-mediated reactions to gluten, such as an immunoglobulin G4 (IgG4) response. The Center for Celiac Research at the University of Maryland screened nearly 6,000 patients with either GI issues or other symptoms such as behavioral changes, bone or joint pain, muscle cramps, leg numbness, weight loss, and chronic fatigue, using a very specific set of criteria along with nutritional changes. In this group they found 6% met criteria for gluten sensitivity, meaning the incidence in the general population is quite low and likely in line with the incidence of celiac disease.

Non-Gluten-Related Wheat Issues

When it comes to eschewing wheat, gluten gets all the attention, but I think the carbohydrates in wheat are more common cause of GI symptoms and and more likely culprit for some of the extra-intestinal manifestations as well.

Glycemic Index and Blood Sugar

Bread and most other flour-based items (crackers, baked goods, etc.) have a glycemic index around 70. This is even higher than pure sugar (glycemic index of 65). This means flour raises blood sugar faster than pure sugar and because people often eat large portions of wheat products, the glycemic load or amount of carbohydrate entering the blood system is quite high. This is a set-up for blood-sugar spikes with ensuing crashes along with cravings or ‘addictive’-type eating. (You only planned to eat a handful of pretzels but instead you ate half a bag!) This spike and crash can definitely cause behavioral changes, ‘mental fog,’ and fatigue. Additionally, many inflammatory disorders are improved by reducing blood-sugar levels and blood-sugar spikes. I can also imagine improvement in ADHD without wide swings in blood-sugar levels. A high glycemic index doesn’t necessarily make a food ‘evil’ but if you are sensitive to swings in blood-sugar levels it may help to modify consumption of all simple carbohydrates by consuming smaller portions each sitting or by eating in combination with fats and protein to slow digestion.

FODMAPs

FODMAP is an acronym for Fermentable, Oligo-, Di-, Mono-saccharides and Polyols. These are short carbohydrate chains that need to be broken down by enzymes in the small bowel to digest. However, many people lack sufficient enzymes and these FODMAPs cannot be broken down in the small bowel. The undigested carbohydrates then make there way to the colon where they are fermented and turned into gas by gut bacteria. This excessive gas can cause pain, cramping, bloating, flatulence, and diarrhea. FODMAP intolerance seems to be an underlying cause for Irritable Bowel Syndrome as well. Estimates on the incidence on the incidence of FODMAP intolerance range from 15 to 35% of the population with it more common as people age and the body becomes less efficient at making enzymes. Even the low end of this incidence makes FODMAP intolerance 10 times more common than celiac disease or gluten sensitivity. Yet, it hasn’t seemed to get the attention gluten has. But this is my own reason for modifying wheat intake.

The first time I noticed a FODMAP issue was when sugar alcohols (Polyols in the FODMAP acronym) became prevalent in diet sodas. Both my sister and I had serious issues with these to the point we avoided them completely. Even the ‘all natural’ stevia seemed to disagree with me (the sweet compound in stevia, steviol, is a sugar alcohol). Of course at that time, I just thought I had an issue with sugar alcohols. Next it was onions and garlic, but lots of people have issues with those so I didn’t really think much of it. But then it seemed like wheat was a problem if I ate a lot of it, but I just assumed it was linked to eating too much junk food. What finally tipped me off were two incidences involving items from my garden. The first occurred last spring when the asparagus was going gangbusters and I had a seemingly very healthy dinner that was a huge bowl of newly picked shoots and a chicken breast dressed with just some lemon juice and a dollop of pesto. Shortly after I was in agony–like the lay-on-the-floor-in-a-fetal-position kind of agony. Then later that fall, while processing a bumper crop of pears, I ate almost an entire dehydrator’s worth of the candy-like dried fruit (around six pears) and again was miserable. Doing a little search on the link between asparagus, pears, and GI issues is what lead me to info on FODMAPs.

The good news for FODMAP issues is that they are typically dose dependent based on the amount of enzymes a person makes rather than being an all-or-nothing problem. For example, one pear is no problem for me, but six pears is too much! Likewise, a big bowl of pasta can give me trouble but I don’t have issues with a side-dish serving. And while the symptoms might be uncomfortable, there is no damage to the GI lining and no long-term health effects. FODMAP intolerance is also inducible as the body modifies production of enzymes based on need. Enzyme levels can fluctuate in as little as 10 days on a new diet, such that avoiding wheat for an extended period can cause symptoms when it is first reintroduced. (This is well documented in soldiers with milk and lactose intolerance after deployment). If you need a test for this, I suggest eating a large amount of onions and seeing what happens!

Other Sensitivities

There is some emerging evidence that pesticide contaminates like glyphosate (Roundup) and preservatives used in packaged goods can be a source of sensitivities. Eating fresh or organic breads may alleviate the issues.

Conclusion

Wheat products typically have high calorie density, which is good for athletes with high caloric needs. As such, wheat products can be an important part of a good nutrition plan. Top ultrarunner Stephanie Howe, a PhD in Exercise Physiology and Nutrition, describes herself as a ‘gluten advocate’ and considers wheat products to be important to her training and racing success. Indeed, gluten-free diets typically have lower amounts of Vitamins A, D, and all B vitamins, calcium, iron, magnesium, phosphorus, and zinc than wheat-containing diets, often to the point of deficiency in one or more of these vitamins and minerals. Despite this, many people are eschewing wheat in their diets. While there are many reasons to reduce wheat consumption, only a small fraction of people need to avoid wheat entirely. Hopefully, this article provides an objective overview so that you can better decide what level of wheat consumption is right for you.

Call for Comments (from Meghan)

  • Did you learn something new from Pam about wheat, gluten, and digestion/health issues related to either?
  • Have you been diagnosed by a health practitioner with a wheat allergy, celiac disease, or an intolerance to FODMAPs?
  • Do you eat wheat or other foods with gluten?
Pam Smith and her pear tree

Pam Smith and her pear tree. All photos courtesy of Pam Smith.

Pam Smith and pasta

Pam and a moderate portion of pasta.

Trail Sisters

is a group of three women, each with unique opinions, ideas, and attitudes toward all things trail and ultrarunning. Pam Smith is a mom, physician, and lover of running who lives in Oregon. Liza Howard is a mom and 100-mile specialist from Texas. Gina Lucrezi is a Colorado-based short-distance speedster exploring the realms of ultrarunning.

There are 17 comments

  1. Robyn

    Great article! I appreciate the emphasis on the science rather than the woo. It’s a topic I care about deeply because I’ve got a child who develops eczema, stammering, and decreased concentration and emotional regulation when he’s exposed to certain foods, including (we’re pretty sure, after 5 years of experimentation) gluten. Figuring this out has been an incredible positive change in our lives. Not sure what the right name or diagnosis is, but we call it “don’t feed him gluten or Bad Things Happen”!

    If a desire to avoid gluten is steering people toward a diet richer in vegetables and healthy fats (as it did in our case), perhaps it’s a net positive regardless of whether it’s medically necessary for a given individual. But regardless, more knowledge of the actual science is empowering and important. Thank you!

    1. Pam

      Robyn – Sounds like your son would fit into the Non-celiac, Gluten sensitivity category. I didn’t go into all the diagnostic criteria because it was beyond the scope of this article but many of the things you describe are part of the inclusion criteria. Glad you have it figured out for your son.

      I agree it is always good to increase vegetables in the diet, but any diet restricting certain food groups is more likely to be deficient in certain items, but that is not to say they are unworkable. Just because someone is reducing gluten doesn’t mean they are improving the overall quality of their diet. But kudos to you for doing so!

  2. John Bergquist

    Great article! I was misdiagnosed with celiac disease about 10 years ago, and tried switching to a gluten-free existence. Turns out it was stress…and the meds they gave me for the “celiac disease”.

    I’m now a triathlete, and eat wheat/gluten/sugar alcohol products in moderation…I feel better (as you noted) with smaller amounts, and I’ve found other carbohydrates to fuel my training and racing.

    Thanks for laying everything out very clearly!

  3. Olga King

    Good additional info as I managed to, by trial and error, figure out my IBS, which in the height of gluten (un)popularity I thought was due to gluten, is due to FODMAPs sensitivities as well as preservatives in store-bought containers (including pretty much all condiments my husband loves so much). But as you mentioned, when it’s not intolerance (or full-blown celiac), little doses are manageable. As far as preservatives, bread products in Europe never caused me problems. Bread in US – big no-no. Whether it’s additives, preservatives (there is a reason regular shelf bread, not from bakery, can hang in your pantry for a month or so, while back home 3 days – and over), genetic modification, extra gluten (there was a study done that in Europe there is less genetically modification done to wheat to grow bigger, and also their process of drying is under the regular air conditions, which takes time, and some amount of gluten gets “used up” for a continuous growth of the “flower” vs in US drying wheat is done with forced air to speed up the process, and we end up with all – extra to boot – gluten). Don’t quote me on exact words I just typed in parenthesis, it’s been a while since I heard that/watched it, but it’s in a nutshell.

  4. Olga

    I also have a question, Pam. Why is it claimed that people avoiding gluten develop various vitamin and mineral deficiency? Is it proven? Aren’t we supposed to get those with all kinds of vegetables and fruits? Wasn’t it also claimed that people on SAD are the ones with deficiencies? Wondering.

  5. Pam

    Olga- certainly not everyone on a gluten free diet develops nutritional deficiencies and many people are able to maintain healthy well balanced diets without wheat/gluten products. However, any diet with restrictions or decreased variability in types of foods increases the risk for deficiencies. Vegetables are high in many – but not all – vitamins and many do not contain high quantity of minerals. Also, plant derived minerals are often harder to absorb which also makes it difficult to get adequate amounts. Additionally, many people excluding gluten have cut out many other foods as well (think Paleo, Whole 30, GF vegetarians and vegans, etc.). If excluding certain food groups from your diet, it is probably advisable to add a multi-vitamin to cover your bases.

  6. David Christy

    I always learn something from Dr. Smith. I have no real or imaginary problems with wheat consumption and I read this article for more evidence to support my claim that gluten intolerance in a bunch of hooey. Thanks Trail Sisters.

    1. Ogden

      Given that Dr. Smith didn’t give you any evidence to support your claim that gluten intolerance is a bunch of hooey, you will be sorely disappointed when (and if) you actually read the article.

  7. Gayle

    The Wheat Allergy info says it’s “fairly easy to identify”. Not in my case. I used to regularly have problems with bath and hair products, breaking out in rashes, but unable to determine the cause.
    Finally, after a product proclaimed they were making a wheat free version because of the allergic potential for wheat proteins, I discovered the wheat was a trigger for my rashes. It took YEARS to figure this one out.
    Once I knew I was contact sensitive to wheat, I then decided to see what happened if I stopped eating wheat. It was wonderful. The knee problems I had (YEARS of pain) went away after about 3 months. I had previously had: cortisone injections, fluid removed, been tested for Psoriatic Arthritis, Rheumatoid Arthritis, and they finally called it idiopathic arthritis (meaning they didn’t know the cause).
    I don’t know if I was always allergic, or if the allergy developed later in life, but I’ve always had knee problems, I remember issues when I was about 10. I have repeatedly had allergy testing (skin and blood tests) and nothing has identified wheat as an allergen for me.

    Hmmm, just thinking, early tests did identify me as allergic to grass – wheat is a grass… but at that time food allergies were not generally recognized, and I never made the connection (until now) and it was never mentioned as a possibility.
    There’s always something new to learn, Thank You.

  8. Luke

    Great stuff as always! Although I’m not sure how to a react to a piece about gluten/wheat that contains facts and research rather than either blaming wheat for most of what is wrong in the world (health or otherwise) or else trying to classify wheat sensitivity as a mental disorder.

    In general are the symptoms very obvious (no doubt there’s a problem), or is there something sensible that the average person could do to experiment and see if they feel better, recover faster, lose weight, get sick less, etc? In other words, are there realistic ‘I didn’t know something was wrong until I cut things out and now I’m better’ scenarios? And if so, is there a good protocol?

  9. Luke

    One more thing:

    “However, blood testing for specific antibodies is positive in 98% of people with celiac disease so that this offers a less invasive first line of screening.”

    What’s the positive rate for people without celiac disease? Beyesian statistics can be rough on tests when the base rate is low, resulting in things like most positive results being false even if the false alarm rate is low, but I’m sure you know all that (although my personal experience is that too many doctors do not)…

  10. Miha

    After hand-foot and mouth disease one year ago I suddenly couldn’t run anymore, I had tingling in arms and legs and was fatigued all the time. I was totally exercise intolerant. Some days it was difficult to climb the stairs. After visiting all kind of doctors nothing showed up, except creatine kinase was slightly over the normal values and iron was slightly low, but still normal. Muscle biopsy showed nothing, EMG was OK, lungs were OK. Despaired I even went to the bio resonance therapist who said it is candida and amalgam (a therapy actually helped a little bit, but only until I tried exercise again). After six or seven months I decided to stop eating gluten. I didn’t have any particular digestive problems, but it is true that I always needed to go to the toilet very frequently – some days might be even 7 times (not peeing), however this was pretty much the same from the time I was a teenager.

    After stopping eating gluten my arms were pretty much normal in a week or two – I had my power again, I could climb again and I actually had better regeneration than before. However, my legs were still somehow weak, although I didn’t feel tingling any more. Digestion improved, but was still not normal (going to the toilet 3 times per day). After another couple of months I stopped eating nuts and seeds too (I ate plenty of them for breakfast after I stopped eating gluten, most of the time not soaked). At this point my legs started improving and digestion became normal. I started running and after a month I can finally run pretty much as I used to. I am still not sure what exactly is disturbing my body, but eliminating gluten (or foods that have gluten) helped a lot and full recovery started after eliminating also nuts and seeds. That might mean that some gluten traces were present in nuts and seeds or perhaps it has something to do with phytic acid. Not sure, but at the moment I would just like to fully recover, then I might do some experiments to find out.

  11. lancejohnson

    Interesting article.

    I used to be a consultant in the cycling world and remember when my friend (and also consultant with the Garmin team) Allen Lim was advocating an ‘anti-inflammatory’ diet. Gluten is a massive source of inflammation for most people and by reducing or eliminating gluten, riders showed better recovery.

    One other aspect that seems to have been missed, that can cause a cascading number of issues for athletes, is SIBO – which can be spurred by Celiac or FODMAPS. I went through a completely debilitating period of blood-sugar problems which were caused by SIBO brought about by Celiac and the damage I did before finding out I had the issue.

    Changing perspective from food simply being a source of energy, to food serving as a primary medicine and source of health seems to be anathema to western medicine, but it can be one of the most-impactful things you do as a person and as an athlete.

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