GLUTEN SENSITIVITY AND THE RISE: OUR SEARCH FOR ANSWERS

First, some background for this information on gluten which I am going to present you with. This article was born out of the experience of our CEO, David Vollmer’s, trip to Italy with his family. Now, David and his wife, Paige, religiously adhere to very specific diets, which would give most carb- lovers nightmares) to avoid GI discomfort. He follows a strict ketogenic diet (almost no carbohydrates, low gluten, very high fat), while she follows a gluten, grain, dairy, and egg- free diet, and both of them do their very best to avoid any boxed or jarred foods in general. As you can imagine, venturing into the Land of Carbs foreshadowed a poor prognosis for the sustainability of either of their diets, but the two reluctantly embraced the inevitable. AKA: they nose- dived into vats of gluten- containing vats of pasta and Italian bread with reckless abandon. What about their GI discomfort? “Never had a problem,” they equivocally reported. Oh, and each of them maintained their weight in the process.

How could this be? This led us to ask the question: If gluten- containing products here in the US seem to negatively impact their GI health to the point of necessitating a gluten- free lifestyle change, why then, did they experience 0 difficulty with consuming gluten- containing foods, such as pastas and breads? We wondered if there could be some type of epidemiological difference in grain consumption or processing mechanisms. From there, we set out on a literature search. We began by asking: could the way the grains are being processed make a difference in this case? Was there some kind of secret ingredient in Italian grains that resulted in less reactive gluten, abolishment of existence of Celiac Disease (CD) throughout the country, and superhero gut status (unicorn hair, maybe)?

It turns out, the prevalence of intolerance (CD) is not only rising in the States, but in other countries. In fact, in the 1990’s, multiple studies have showed the incidence rate of celiac disease in Italy has been among the highest in Europe at times.1 Discovering that Italians were not fostering some kind of superpower to transform gluten- containing products into a non- inflammatory form was anticlimactic at best.

I should note that the US and several European countries have shown upwards trends in diagnosed cases of gluten intolerance over the years. Until recently, celiac disease was considered to be a rare disorder in the U.S., with an estimated prevalence rate of 1 in 5,000 people in 1994.2 However, a large epidemiological study in 2003 estimated a prevalence rate of 1 in every 133 within the general U.S. population.3 Other reasons  for increased prevalence could, however, be attributable to advances in medical technology; i.e. the introduction of serological tests, increased awareness about the condition and changes in diagnostic criteria. If our advances in technology are simply allowing for earlier, more accurate detection of the disease, it makes sense that the number of diagnosed cases per year would rise.

Interestingly though, people everywhere are eating more wheat as the prevalence of Celiac Disease rises. In the Middle East, North Africa, Europe and North America, wheat has always been a diet staple, and annual per capita consumption is around 100–300 kg. In Asian countries, rice was always preferred over wheat products, and the consumption is about ½ of the reported western intake. However, as the wheat intake has increased in those countries, so has the incidence of CD.4

It has been speculated that the increase in Celiac Disease may have occurred because of changes in wheat proteins that resulted from wheat breeding, mainly an increase in the gluten content.5 However, a 2013 review in the Journal of Agricultural and Food Chemistry, used data to show that there is no rise in the gluten content of our grains in the US, aside from small and typical annual fluctuations. Here we are again, at a loss for answers on our search… increasing gluten content of US products is likely not the issue either.6

Food processing mechanisms alter the chemical structure of our food in different ways, and there is evidence that these mechanisms have the potential to affect food sensitization, or the way our immune system reacts to them. The chemical changes occurring through food processing will alter the way the components are broken down by the body during digestion, and similarly alter the way the immune system will identify them, meaning that an inflammatory reaction may or may not occur. Research is still limited, but current evidence shows the potential for food processing to amplify or decrease allergenicity in gluten- sensitized individuals. The extent of the changes to protein structure depends on the process, and includes factors such as time, temperature, and the presence of fats or sugars.7

Baking bread dough (heating at high temperature in the presence of carbohydrates), may cause the formation of proteins with allergenic potential that are not abolished during digestion, as opposed to unbaked dough. However, in contrast to what was observed for bread, digestion of cooked pasta resulted in almost complete disappearance of its potential allergens, meaning that they may be entirely degraded before actually reaching the intestine. Therefore, although durum wheat used in this study seems to contain potential allergens similar to those of bread wheat, patients with food intolerance to wheat may tolerate pasta better than bread, simply due to the cooking process.8

In several countries, leavening agents are used to make bread rise and expedite the bread- making process, whereas sourdough bread is made through a natural leavening process. Recent studies have revealed that when cereal products, pastas, and other grain products, are made using a lacto- fermentation process similar to that of sourdough bread, instead of with the leavening agents, individuals with Celiac Disease are able to tolerate the gluten products without symptoms. Sourdough bread produced with a strain of lacto-bacilli resulted in very low levels of gluten levels of 12 ppm, while bread made with the same wheat but with conventional leavening agents, resulted in gluten levels of 75,000 ppm.8 This research shows that the sourdough fermentation process decreases toxicity to allow for a grain- based product that is below the threshold tolerated by those with Celiac Disease, which has been suggested as low as 20 ppm. Considering the beneficial effects of removing these leavening enhancements, we consider that these enhancements may be another contributing factor to the rise of Celiac Disease. Especially considering that in 1983, the FDA increased the mandated amount of leavener in bread products, indicating increased toxicity of our gluten- containing foods for those with Celiac Disease.9

Though it is a popular explanation for the rising trend in gluten intolerance, there really isn’t great supporting evidence to suggest that the composition of modern grains, in reference to their variable number of chromosomes in comparison to ancient grains, is having any significant impact on allergenicity. However, there is some evidence to suggest that amount and type of agrochemicals used in the fertilizer will affect the wheat protein (and therefore gluten) structures, potentially influencing the way your immune system responds. In light of this evidence, we can speculate that perhaps organic products containing gluten may potentially not cause the same digestive discomfort as non- organic.10

Again, little is known about the effects of processing on food allergenicity, but it does make us wonder… Is it possible that our tourist friends were simply reaping the GI benefits of a more optimal cooking process? What was the leavening process used in the breads, and how were the grains grown? While in Italy, ALL of the food within their control was served fresh, meaning made in- home, no ingredients obtained from a jar or box. Even the bread, noodles and sauces were home- made, giving them more control over the ingredient quality and cooking process. Do you really know exactly what your grains have been through before making it onto your plate? If we at least had more control over the processing, would it make a difference in our tolerance?

Something labeled “gluten- free” may not actually be gluten- free, but actually just contain a very low gluten content. The amount of gluten that “gluten- free” labeled products can contain is based on research with threshold values. An individual threshold is the amount of gluten that a gluten- intolerant individual can ingest without symptoms of intolerance. There is high variability among people; therefore, population thresholds are impossible to truly obtain. Although a definitive threshold cannot be established due to variability, there is evidence that a daily gluten intake of less than 10 mg (200 ppm) is unlikely to cause inflammatory symptoms.

The World Health Organization and the Food and Agriculture Organisation have established an index of “safety standards” to protect consumers around the world, but not every country accepts the standards. Based on scientific evidence of average thresholds, the safety standard for which most people with gluten intolerance can ingest gluten without an issue, is 200 ppm (parts per million). Because of the wide variability in thresholds, a “gluten free product” that contains 200 ppm (or 10 mg) may still not be well- tolerated by some individuals with Celiac Disease, although values have been suggested as low as 20 ppm.11

Keeping in mind that each person with any level of gluten reactivity will vary with how much they can tolerate, it is possible that someone with an intolerance may be able to consume certain gluten- containing products and not others, depending on the content of the product and your individual threshold. This also indicates that living a “gluten- free” lifestyle really means “relatively gluten- free.”

These levels are unavailable on packaging; however, the US allows a product to be labeled “gluten- free” when a product contains 200 ppm or less. In this case, if following gluten- free diet with a confirmed diagnosis of Celiac Disease, it would be best to monitor your symptoms rather than simply trusting labels, and you can also request a safe products list from supermarkets which contain 200 ppm gluten or less.

Though it is unlikely that the gluten- laden Italian foods our friends consumed were below threshold values, this still offers one potential piece of the puzzle in regards to why some foods with gluten may elicit symptoms, while others do not.

The gluten- free thing is also a fad now. Some studies allude to the idea that gluten sensitivity could be a psychological phenomenon, by which individuals report gluten- induced physical  symptoms when the presence of gluten was perceived, even in the absence of gluten ingestion.12 See our previous article to learn more about gluten sensitivity and the aforementioned articles. That doesn’t mean that our ISO- bosses are just a couple of head cases, but it serves as a reminder that it is one element that can majorly influence an individual’s food attitudes and potential physical symptoms.

This review does not provide a definitive answer to “the Italy phenomenon,” but it certainly poses some interesting questions as to the rise in gluten sensitivity and intolerance, in addition to why some grain- based products elicit symptoms, while others do not. A lot of research needs to be done, and the effects of processing on food allergenicity is still in its infancy. However, one who experiences a potential gluten sensitivity (not an intolerance, in the case of CD) might deduce from the results of recent evidence that the quality of their food may sometimes be more important than the content. Instead of immediately abstaining, they might start by avoiding products on the grocery shelves and have more control over the content of their food sources, including buying organic and making bread the old- fashioned way, without leavening agents, to manage their symptoms. Noodle maker, anyone?

References

1. Corrao G. Estimating the incidence of coeliac disease with capture-recapture methods within four geographic areas in Italy. J. Epidemol Community Health. 1996.
2. Talley N. et al. 1994. Epidemiology of celiac sprue: a community-based study. Am J Gastroenterol. 89(6); 2003.
3. Fasano A. Celiac disease–how to handle a clinical chameleon. N Engl J Med. 2003
4. Pingali P. et al. Supplying Wheat for Asia’s Increasingly Westernized Diets. Am J Agric Econ. 1998.
5. Sapone A et al. Spectrum of Gluten-Related Disorders: Consensus on Nomenclature and Classification. BMC Med. 2012.
6. Kasarda D. Can an Increase in Celiac Disease Be Attributed to an Increase in the Gluten Content of Wheat as a Consequence of Wheat Breeding? J of Argicultural and Food Chemistry. 2013.
7. Kitty C et al. Review: Food Processing and Allergenicity. Food and Chemical Toxicology. 2015.
8. Rizzello C et al. Highly Efficient Gluten Degradation by Lactobacilli and Fungal Proteases during Food Processing: New Perspectives for Celiac Disease . Applied and Environmental Microbiology. 2007.
9. Zhou SS and Zhou Y. Excess vitamin intake: An unrecognized risk factor for Obesity. World J Diabetes. 2014.
10. Grove H et al. Proteome changes in wheat subjected to different nitrogen and sulfur fertilizations. J Agric Food Chem. 2009.
11. Approaches to Establish Thresholds for Major Food Allergens and for Gluten in Food. http://www.fda.gov/Food/GuidanceRegulation/GuidanceDocumentsRegulatoryInformation/Allergens/ucm106108.htm. Accessed 02/08/2016
12. Biesiekierski J et al. No effects of gluten in patients with self-reported non-celiac gluten sensitivity after dietary reduction of fermentable, poorly absorbed, short-chain carbohydrates.” Am J Gastroenterology. 2013.

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