Going Gluten-Free
Understanding the hype vs. reality
By Ruth Diamond

Gluten, a protein found in wheat, barley and rye was barely a blip on most people’s radar a few decades ago. Today, it’s a term everyone seems to know, with many actively avoiding foods containing it. What was once a strict dietary requirement for people with specific medical conditions has evolved into a widespread lifestyle trend – championed by health enthusiasts and TikTok influencers who claim that cutting out gluten is one of the secrets to boosting energy and improving health. While the trend has sparked an increase in gluten-free food options in restaurants and grocery stores, the reality of going gluten-free isn’t as straightforward as it might seem.

Karen Dong, MD

“Gluten-free is now a pop culture term and a wellness trend that’s made people more conscious of the impact of their diet on their wellbeing, and in that sense, it’s a relatively harmless trend, especially compared to some of the cleanse diets that could actually be dangerous,” says Karen Dong, MD, a family medicine doctor and obesity medicine specialist at Jefferson Health. 

Dong says she has seen an uptick in patients, predominantly women, curious about whether a gluten-free diet is a medical necessity for them or is simply worth trying to enhance their well-being. The answer is rarely clear-cut and depends largely on their symptoms, family medical history and sometimes how willing they are to change their lifestyle. 

The challenges of going gluten-free

Going gluten-free can be tricky because gluten pops up in so many different foods – not just in bread and pasta, but also in places you wouldn’t expect, like sauces, soups and even some makeup, says Evelyn Arteche, a registered dietician with Cooper University Health Care. This makes it hard to avoid gluten completely if you’re not making foods from scratch and studying labels on food and skin products.

“Even most restaurants that have gluten-free options have no way of guaranteeing that there hasn’t been a cross-contamination with other foods,” says Arteche, noting that people with certain conditions cannot be exposed to a morsel of gluten without suffering serious consequences. “You also have to be mindful of your nutrition, ensuring you’re getting essential vitamins and minerals like iron to avoid deficiencies.”

Evelyn Arteche, RD

When symptoms blur the lines

On top of that, deciding if a gluten-free diet fits your needs can be confusing. It’s clear-cut for those with wheat allergies or celiac disease, an autoimmune condition in which avoiding gluten is a must. But then there’s the fuzzier area of gluten sensitivity, where people feel similar discomfort to celiac disease but don’t have a straightforward diagnosis. Plus, sometimes the symptoms, like bloating and gas, might be from irritable bowel syndrome (IBS), a different gut issue. In some cases, an alternative diet might be the answer, says Dong.

“It usually comes down to how severe the symptoms are,” explains Dong. “If someone is experiencing intense symptoms, like bleeding or disruptions, it makes me concerned that it’s celiac disease, the most well-known condition related to gluten. Severe symptoms, especially if there are multiple – including neurological ones like brain fog or memory issues – aren’t uncommon in celiac disease. However, more common are people complaining of feeling off, with non-specific symptoms like constant tiredness or bloating. They’re trying to figure out if it’s gluten sensitivity, celiac disease, or if a gluten-free diet might help.”

The strongest case for gluten-free

Wheat allergies are straightforward – think of immediate reactions like hives or even severe anaphylaxis after a bite of bread. Celiac disease, though affecting just 1% of Americans, is a more complex condition where eating gluten triggers an immune response that attacks the small intestine. Symptoms include bloating, chronic diarrhea, constipation, stomach pain and nausea. Over time, this can cause more serious problems. The only treatment is complete elimination of gluten from the diet, which leads to healing of the small intestine and normal absorption of nutrients, says Arteche.  

“While a lot of people are going gluten-free, if they actually have celiac disease, they should definitely remain gluten-free for the rest of their lives,” she says. “If they start eating gluten again, they put themselves at risk for several other autoimmune diseases.”

Diagnosing celiac disease can be a complex process, Dong adds. It starts with a blood test. Following that, a more invasive procedure, such as an endoscopy of the stomach or colon, is done to obtain a biopsy. Even still, such measures aren’t always conclusive. Exposure and the symptoms can be so far separated from each other, making it difficult to directly link the symptoms to gluten exposure. “It can take years before someone receives a celiac diagnosis,” she says. 

The difficulty of a diagnosis 

Even less clear cut is a diagnosis of gluten sensitivity. Although many of the symptoms are the same as with celiac, gluten sensitivity doesn’t show up on blood tests and is not thought to cause the same severity of harm, Dong says. 

“Many people with gluten sensitivity might manage small amounts of gluten without noticeable symptoms,” Arteche says. “However, if symptoms like abdominal pain or bloating appear, it’s a sign to cut back.” 

For example, she says, while 2 slices of bread might cause an adverse reaction, one slice might not. “It’s highly individual,” she says. “Not everyone with gluten sensitivity reacts the same way to gluten, and some might tolerate a little without symptoms. But until further research is done, it’s important to be cautious because you could still be damaging your intestines.”

“Not everyone with gluten sensitivity reacts the same way to gluten, and some might tolerate a little without symptoms. But…it’s important to be cautious because you could still be damaging your intestines.”

While digestive problems affect people of all ages and both genders, many women find these issues become more pronounced in middle age, prompting them to seek answers. The good news is that an increase in symptoms for women later in life often rules out celiac disease, Dong says. While autoimmune diseases are more common in women than in men, the difference lessens with menopause. “Gastrointestinal complaints post-menopause are often linked to the reduction in estrogen levels, as the body adjusts to these hormonal changes,” she says.

When it comes to complaints of vague digestive issues, Dong often suggests a low FODMAP diet. FODMAP, an acronym for fermentable oligosaccharides, disaccharides, monosaccharides and polyols, includes certain types of carbohydrates found in food that aren’t easily absorbed by the small intestine, leading to symptoms like gas, bloating and either constipation or diarrhea – common issues for those with IBS and similar to what people with celiac disease experience. 

Because foods that contain gluten, such as wheat, barley and rye, are also rich in FODMAP carbs, choosing a gluten-free diet naturally reduces the amount of FODMAPs you eat. This reduction in FODMAPs might be why many people start feeling better when they go gluten-free, Dong says.

Still, she says, if people want to explore gluten-free first, she is supportive. Many of her patients report feeling better after reducing gluten, though some don’t see any difference. “I will say this, I’ve had no one tell me they went gluten-free and felt worse.”   

March 2024
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