FODMAPS SENSITIVITY OR GLUTEN SENSITIVITY?
What was the biggest news in GLUTEN SENSITIVITY in 2014? We'll get there, but let me first tell you a story. Last Friday we were invited to some friends to eat. The main course was a pasta dish. I knew I should not have done it, but I pulled a "Doug Wilson" and ate it anyway (HERE) --- two servings. If I ever do that again, someone please slap me. My eyes swelled up rather severely and my whole body itched like crazy (I looked like I had not slept in a week seeing patients yesterday). Things are just now really starting to come back to normal. How does all of this correlate to the numerous articles that deal with last year's study published in the journal Gastroenterology (No Effects of Gluten in Patients With Self-Reported Non-Celiac Gluten Sensitivity After Dietary Reduction of Fermentable, Poorly Absorbed, Short-Chain Carbohydrates)?
In this interesting study, people who "self-reported" an intolerance for Gluten, but did not have Celiac Disease (a Gluten-induced AUTOIMMUNE DISEASE of the small intestine) were not only put on a Gluten Free diet, but a Low FODMAP diet as well. After two weeks, Gluten was reintroduced. Steven Ross Pomeroy, writing for Forbes ([Non-Celiac] Gluten Intolerance May Not Exist), explained how meticulous this particular study was when he wrote that, "Subjects would be provided with every single meal for the duration of the trial. Any and all potential dietary triggers for gastrointestinal symptoms would be removed, including lactose (from milk products), certain preservatives like benzoates, propionate, sulfites, and nitrites, and fermentable, poorly absorbed short-chain carbohydrates, also known as FODMAPs. And last, but not least, nine days worth of urine and fecal matter would be collected. With this new study, Gibson wasn’t messing around."
After several experiments where subjects were put on different diets, the authors concluded that Gluten was not the culprit in their subject's GI symptoms (gas, bloating, cramping, CONSTIPATION, diarrhea, etc). In fact, because the placebo diet was the same as the baseline diet in the second experiment, the authors said that subject's reactions to Gluten were psychological ---- all in their head.
In other words, whether or not the treatment diets contained Gluten or not, had no bearing on the outcome. But obviously, there was something going on with these folks. What was the culprit? Listen to the study's conclusions. "In all participants, gastrointestinal symptoms consistently and significantly improved during reduced FODMAP intake..... In a placebo-controlled, cross-over rechallenge study, we found no evidence of specific or dose-dependent effects of gluten in patients with NCGS (Non-Celiac Gluten Sensitivity) placed diets low in FODMAPs." To put it plainly, understanding (and removing) FODMAPS may be the key to solving many mysterious cases of GI symptoms --- particularly once we realize that Gluten-containing grains (wheat, rye, and barley) contain high levels of them.
Although I have written a bit about FODMAPS previously (see the link above), everything I could find indicated that they are involved in the GI issues that people with Gluten Sensitivity so commonly complain of. Don't get me wrong, solving ugly GI symptoms is fantastic. But where do the wide range of ugly Neurological Symptoms of Gluten Intolerance fit in to this picture --- particularly those found in folks that are not Celiac? In my mind, it is not a stretch to believe that undigested / partially digested / "fermented" carbohydrates have the ability to fuel DYSBIOSIS --- particularly the Dysbiosis of the Small Intestine, commonly known as SIBO (Small Intestine Bacterial Overgrowth). In fact, this process is probably similar in nature to what happens when proteins are improperly digested (PUTREFACTION), and due to rampant INFLAMMATION, absorbed into the blood stream, which we know as LEAKY GUT SYNDROME. Furthermore, we know that GUT HEALTH is critical to overall health, and that the Gut is not only often referred to as "the second brain" (HERE), but it contains 80% of your Immune System as well (HERE).
This all begs the question: Is it all FODMAPS now? Can we simply dismiss studies like the one published in the one of this year's issues of Gastroenterology Research and Practice (Gluten Sensitivity Presenting as a Neuropsychiatric Disorder)? Listen to what the authors (renowned physicians from the University of Alberta in Canada) have to say on this topic of NCGS and neurological symptoms (I am cherry-picking here). "Over the last decade, there have been increasing reports of myriad adverse reactions associated with gluten exposure. It has been hypothesized for quite some time that gluten sensitivity may also impair central nervous system functioning. Celiac disease (CD) was initially believed to be the sole source of this phenomenon. Signs and symptoms indicative of nonceliac gluten sensitivity (NCGS), in which classical serum and intestinal findings of CD may be absent, have been frequently reported of late. Clinical manifestations in patients with NCGS are characteristically triggered by gluten and are ameliorated or resolved within days to weeks of commencing a gluten-free diet. Emerging scientific literature contains several reports linking gluten sensitivity states with neuropsychiatric manifestations including autism, schizophrenia, and ataxia. A clinical review of gluten sensitivity is presented alongside a case illustrating the life-changing difference achieved by gluten elimination in a patient with a longstanding history of auditory and visual hallucinations." And while this is great information, it does not even begin to scratch the surface of the link between neurological symptoms and NCGS.
The truth is, when the authors mention 3 or 4 neurological (mostly psychological) issues related to Gluten, they are barely scratching the surface. If you begin going through my posts on Gluten Sensitivity, you will find all sorts of information linking Gluten to neurological findings (HERE, HERE, HERE, HERE, HERE, HERE, HERE, HERE, HERE, HERE, and HERE are a few of them). Will the day come that we tie the neurological findings we are currently associating with NCGS to FODMAPS? I really have no idea, but it is certainly possible via the pathway I suggested two paragraphs ago. The only thing we know for sure is that for many people, Gluten is a massive problem. And likewise, pulling chronically ill people off Gluten can make a massive (the authors above used the word "life-changing" difference in one's neurological health.
The bottom line is that many people simply feel better when they don't consume Gluten --- even in the absence of a positive test. One example of this phenomenon that comes immediately to mind is THIS PERSON, who despite testing negative (Cyrex Labs) for Gluten Sensitivity (she did test positive for corn), sees a return of the symptoms of Interstitial Cystitis is she eats Gluten. Dr. Datis Kharrazian says that, "Sometimes the immune system can be so worn out that, even though it is attacking gluten, the total number of antibodies being produced is extremely low. As a result, test results may look negative, when in fact gluten intolerance is raging." Although I totally get this, I have dealt with lots of sick people over the years, and am not sure she would fall into that category of illness.
Either way you slice it, I don't think you can go wrong with an ELIMINATION DIET. There's nothing to buy and you do not go out and purchase any specialty "Gluten Free" foods for this diet. Plus, it does away with your need for (expensive) testing. And because of what I mentioned in the paragraph above, I find it to be more accurate. Furthermore, it can be modified in several different ways. If your main problem is joint pain, add NIGHTSHADES to your Elimination Diet, and if you are struggling chiefly with GI symptoms, make sure to add FODMAPS to the protocol as well.
Dr. Schierling completed four years of Kansas State University's five-year Nutrition / Exercise Physiology Program before deciding on a career in Chiropractic. He graduated from Logan Chiropractic College in 1991, and has run a busy clinic in Mountain View, Missouri ever since. He and his wife Amy have four children (three daughters and a son).