[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.
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 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.
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!
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.
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?