July 20, 2020

What is gluten?

Gluten is the generalized name for proteins found in wheat, rye and barley. It acts as a glue to help foods maintain their shape and gives dough its elasticity – that chewy, soft texture of bread.

What foods contain gluten?

Common foods that contain gluten include breads, pastas, cereals, pastries, crackers, flour, beer. It can also be hidden in certain sauces (soy), salad dressings and soups.

Spectrum of response

The response to gluten is varied. There are those who have a true allergy (celiac disease), some with non-celiac gluten sensitivity and still others with no reaction to gluten proteins. 

Celiac disease is an autoimmune disease and often genetic disease that runs in families. It results in intestinal damage when gluten is ingested. It is estimated that 1 in 100 people worldwide have celiac disease. 2.5 million Americans are undiagnosed and at risk of long-term health complications.

When a person with celiac disease ingests gluten, their body mounts an immune response that attacks the small intestine. Your small intestine is lined with villi (little finger-like projections) that aid in nutrient absorption. These villi become blunted (nubbed fingers) with continued exposure to gluten and nutrients are not absorbed properly as a result.

For those with celiac disease, ingestion of even a crumb of gluten is enough to cause symptoms. If left untreated, complications such as coronary artery disease (2 x greater risk), small bowel cancer (4 x greater risk), anemia, development of other autoimmune diseases, osteoporosis, infertility and miscarriage. Classic symptoms can include chronic diarrhea, steatorrhea (pale, foul smelling stools), bloating, abdominal pain, constipation and weight loss.

GI symptoms are more commonly seen with younger patients. However, adults may experience other symptoms and only about ⅓ experience diarrhea. Adults may have symptoms of iron deficiency anemia, bone or joint pain, skin rash (dermatitis herpetiformis), depression/anxiety, missed menstrual periods, peripheral neuropathy.

Still others may have no symptoms at all and may present with other autoimmune disorders, but are still at risk of long-term complications.

Non-Celiac Gluten Sensitivity

Some people’s bodies and immune systems react to gluten negatively with similar symptoms to celiac disease. However, unlike those with celiac disease, Non-Celiac Gluten Sensitivity (NCGS) patients do not have the same autoantibodies, gene markers or intestinal damage. Symptoms can include, joint pain, fatigue, hormone imbalances, bloating, brain fog, gas, acne and headaches.

Diagnosing Celiac and Non-Celiac Gluten Sensitivity

Celiac disease is diagnosed initially with blood testing and confirmed with endoscopy and biopsy of the small intestine. Non-Celiac Gluten Sensitivity (NCGS) is harder to diagnose as many symptoms can overlap with other gastrointestinal disorders. Celiac disease, wheat allergies and other possible conditions must be ruled out first. A trial of an elimination diet can then be performed to see if symptoms improve.

Celiac and NCGS are on the rise

There is no consensus about why that is. There is some evidence to suggest wheat breeding (hybridization) has contributed to increased immune system response. When scientists hybridize wheat, different strains of crops are cross-bred to generate more desirable characteristics. These hybridized products contain different proteins and when repeated over many plant generations, the crop looks mighty different from its ancestors. 1, 2

Others believe there is a link between gut microbes (gut microbiome is critical in strengthening the immune system, and if damaged, the immune response is weakened) and the onset of celiac disease, with specific bacteria associated with celiac disease.  


Notably, those with gluten sensitivity often find they have no issues with foods containing gluten when traveling abroad (Europe for example). There are many theories as to why this is the case. One theory is that compared to European countries, most of the wheat grown in the United States is hard red wheat which contains more gluten proteins compared to the soft wheat grown in Europe. Another theory is that non-organic wheat grown in the US is often treated with glyphosate (Round-Up). While not banned in Europe, many countries have restrictions on its usage and less exposure to glyphosate in foods. Finally, there are less additives and preservatives in European baked goods creating yet a third possible explanation for better toleration of gluten abroad.

Should you go gluten-free?

If you are experiencing some of the above symptoms you may have an intolerance or allergy to gluten with the caveat that other GI disorders can present with similar symptoms. Anyone wishing to start a gluten-free diet  should consider seeing a doctor to test whether celiac disease is present as well as evaluate the reasons for going gluten free. Gluten antibodies only have the potential to return positive if gluten is being consumed. If already omitted, the tests are useless. If an elimination diet is begun, I generally recommend an elimination of all gluten containing and other inflammatory foods for 30 days with slow reintroduction of individual foods to determine specific reactions. Food labels should be read carefully and servers at restaurants inquired about ingredients as it is not always obvious. 

While gluten itself has no specific health benefits, omitting foods that contain gluten could change your overall intake of nutrients such as B vitamins, iron and fiber as many flours are enriched with vitamins and minerals. Regardless of your reasons for following a gluten-free diet, it’s important to know how it can affect your nutritional needs. 

Bread is delicious, do I really have to give it up?

There is some research suggesting gluten itself can cause gut inflammation even in those without intolerances but studies are conflicting. At this time, I would say healthy people do not need to deprive themselves of gluten as there may be no health benefit. You are also sure to be poorer as gluten free items are often much more expensive – on average 242% more expensive than similar gluten containing foods!4 If you do not have specific symptoms then don’t give up the bread! You don’t have to deprive yourself of this chewy goodness to “be healthy.” Remember, just because an item is “gluten-free” doesn’t mean it is good for you. Gluten free crackers and breads often are highly processed with elevated sugar and carbohydrate content to help them taste more like gluten laden foods. A gluten free diet is not a weight loss plan! Increased consumption of these foods could lead to increased weight gain. 

Certainly make sure that the gluten you are consuming is in the form of wholesome freshly baked, whole grain foods and only the occasional pastry. Avoid gluten containing items with white flour and highly processed packaged foods as these will spike your blood sugar and cause inflammation. 

We ALL (celiacs, NCGS, gluten tolerant) should eat more fresh vegetables, fruits, beans, legumes, whole grains (oats, quinoa, brown rice), nuts and seafood. Plentiful in essential nutrients, these foods are healthy, delicious and conveniently all gluten free and free of potential inflammatory reactions. 

Still have Questions?

If you think you may have an issue with gluten come see us at Spruce MD or shoot me an email at [email protected]. We provide extensive evaluation and in-depth testing to identify the etiology of your symptoms, whether gluten or other causes. For the rest of you, don’t worry, I’m not going to take away your baguette!

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Mary Brittain Blankenship, MD, FAIHM

Dr. Blankenship

Mary Brittain Blankenship, is the founder and physician at Spruce MD Integrative Medicine. Board certified in both Internal Medicine and Integrative Medicine, she sees patients locally at her practice in Greenville, SC and virtually nationwide.

Registered Dietician

Integrative and Functional Medicine Providers