Allergy, disease or sensitivity: understand the different reactions to gluten

Gluten?

Yes, it's bad!

Could it be you do you have any allergies, sensitivities or intolerances?

More at:
https://icaro.med.br/Gluten/

The great Dr. Guilherme Renke explains:

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Allergy, disease or sensitivity: understand the different reactions to gluten
By Guilherme Renke, in Eu Atleta

When it comes to gluten, we can expect heated discussions and various opinions, many of them divergent, about its possible harm to health. This generates many doubts among the population and even among health professionals who are unable to reach a concrete opinion based on scientific evidence.

But what is gluten anyway? Gluten is an amorphous protein found in wheat, rye and barley. The most widely consumed of these is wheat, and gluten is formed, contrary to popular belief, by the process of mixing and heating the prolamins (gliadin and glutenin) with water.

Gluten is considered to be one of the major food components that can trigger a gastrointestinal symptom. In fact, the study published in 2011 in the American Journal of Gastroenterology states that “even in patients without celiac disease, ingestion of gluten can cause gastrointestinal symptoms such as pain, abdominal distension, change in fecal consistency and fatigue”. 

In addition to gastrointestinal symptoms, there seems to be a relationship between gluten and the immune system at a global level, which may explain the occurrence of extraintestinal symptoms related to gluten such as: headache, eczema or skin rash, chronic fatigue, depression, anemia and joint pain, as shown in the study by Sapone et al. published in 2012.

Gluten can be found in foods such as: wheat flour; beer; breads, toasts and pizzas; cakes and pies; cookies, cookies and crackers; sweets and cereal bars; breakfast cereals; pasta and instant noodles; industrialized sauces and dressings (tomato, soy sauce); snacks and chips; most soy products; some cheeses, mayonnaise and ketchup; processed meats and sausages.

Wheat allergy, celiac disease and gluten sensitivity?

Gluten-related disorders are classified according to their immunological mechanism: autoimmune, allergic and those that are neither autoimmune nor allergic. Celiac disease (prevalence of 0.5% in the population) and wheat allergy (prevalence of 1% in the population) are the best examples of gluten-related autoimmune and allergic disorders, respectively. Thus, when gluten causes gastrointestinal symptoms in the absence of celiac disease or wheat allergy, this is considered gluten sensitivity (GS).

GS is a condition that is not allergic or autoimmune in nature and can be diagnosed when an individual has a gastrointestinal or extraintestinal symptom related to gluten intake that improves with its exclusion and also when celiac disease and wheat allergy have been excluded, as shown in the study by Catassi et al. in 2013. More specifically, in the case of celiac disease: negative serological tests (anti-transglutaminase and anti-endomysial antibodies) and a negative intestinal biopsy. 

In fact, it is not possible to diagnose gluten sensitivity using laboratory markers, so the diagnosis is made by clinical criteria alone. GS is a food hypersensitivity mediated by the relationship between gluten-derived antigens and a global immune reaction, unlike celiac disease where the mechanism is autoimmune.  

GS should also not be confused with food intolerance because the mechanisms are different. Food intolerance, with or without gastrointestinal symptoms, is a non-immunological adverse reaction that occurs when a nutrient is not completely digested due to a lack of digestive enzymes or an excess of that nutrient in the gastrointestinal tract, as shown in the studies by Boyce and Fasano. The most common food intolerances are lactose from milk and fermented mono-, di- and oligosaccharides, which present different symptoms to GS. 

Biesiekierski's double-blind, randomized study suggests that even in individuals without celiac disease, the ingestion of gluten is capable of triggering an innate immune system response or “immediate response“. This is seen through the elevation of immunological markers and pathogen recognizers such as Toll-like receptors. This immune response is completely different from that seen in celiac disease, which is triggered by the adaptive immune response or “specific response“. It is important to note that the innate immune response is our body's first line of defense, which depends on chemical signals or cytokines and does not confer long-term immunity. In contrast, the adaptive immune response observed in celiac disease stimulates the production of antibodies that confer an immune response for future reactions, which explains the characteristic of this disease.

Catassi's study shows that we are living through an epidemic of celiac disease and gluten sensitivity. Between 2004 and 2010, more than five thousand patients were evaluated by the Celiac Research Center at the University of Maryland in the USA. Of these individuals, 6% were classified as having GS. In some of these individuals the symptoms were similar to those of celiac disease, however, with a higher prevalence of extraintestinal symptoms such as: mood and behavioral changes, bone and joint pain, chronic fatigue and muscle cramps.

Why might the explanation lie in the “involution” of wheat?

It is apparent that reactions to gluten are not limited to celiac disease and we recognize the existence of a broad spectrum of gluten-related disorders. The high frequency of various symptoms and adverse reactions related to its ingestion raises the question about gluten: why is this protein toxic to so many people in the world? One answer may lie in the genetic selection that wheat has undergone over the last 10,000 years, which has significantly increased the amount of gluten in wheat for financial rather than nutritional reasons.

Wheat has been used by mankind for thousands of years since the Middle Ages, when Triticum mococcum and T. Dicoccum were consumed, which contained smaller quantities of the 33-mer peptide that is “extremely toxic to humans“, as Molberg's study mentions. This same study analyzes the modification of wheat over the years and shows a big difference from the Einkorn wheat, which was diploid and had 14 chromosomes, to what we consume today, which is the hexaploid Triticum Aestivum with 42 chromosomes. Interestingly, the study also shows different responses of intestinal T lymphocytes (defense cells) to different wheat specimens. Thus, we can analyze that the human organism still has different immune responses and seems to be highly vulnerable to the effects of gluten.

It's worth pointing out that a diet that excludes gluten without medical advice and without the guidance of a nutritionist can be harmful to health and lead to serious nutritional deficiencies. In addition, it is up to health professionals to guide and educate their patients to avoid restrictive and “trendy” diets, emphasizing dietary re-education programs that can bring long-term health benefits. This review aims to provide an explanation of gluten-related phenomena and expand our knowledge of gluten sensitivity. Further studies and randomized clinical trials are still needed to define the long-term harm of gluten in individuals without celiac disease or wheat allergy.

Bibliographical references:

1 - Biesiekierski J et al. Gluten Causes Gastrointestinal Symptoms in Subjects Without Celiac Disease: A Double-Blind Randomized Placebo-Controlled Trial. The American Journal of Gastroenterology 106, 508-514 (2011) doi:10.1038/ajg.2010.487

2 - Sapone A, Bai JC, Ciacci C, et al. Spectrum of gluten-related disorders: consensus on new nomenclature and classification. BMC Med. 2012;10:13

3 - Catassi C, Bai JC, Bonaz B, et al. Non-Celiac Gluten sensitivity: the new frontier of gluten related disorders. Nutrients. 2013; 5(10):3839-3853.

4 - Boyce JA, Assa'ad A, Burks AW, et al. Guidelines for the Diagnosis and Management of Food Allergy in the United States: Summary of the NIAID-Sponsored Expert Panel Report. J Allergy Clin Immunol. 2010;126(6):1105-1118.

5 - Fasano A, Sapone A, Zevallos V, Schuppan D. Nonceliac gluten sensitivity. Gastroenterology. 2015;148(6):1195-1204.

6 - Sapone A, Lammers KM, Casolaro V, et al. Divergence of gut permeability and mucosal immune gene expression in two gluten-associated conditions: celiac disease and gluten sensitivity. BMC Med. 2011;9:23.

7 - Biesiekierski JR, Newnham ED, Irving PM, Barrett JS, Haines M, Doecke JD, Shepherd SJ, Muir JG, Gibson PR: Gluten causes gastrointestinal symptoms in subjects without celiac disease: a double-blind randomized placebo-controlled trial. Am J Gastroenterol. 2011, 106: 508-514. 10.1038.

8 - Molberg O, Uhlen AK, Jemsen T, Flaete NS, Fleckenstein B, Arentz-Hansen H, Raki M, Lundin KE, Sollid LM: Mapping of gluten T-cell epitopes in the bread wheat ancestors: implications for celiac disease. Gastroenterology. 2005, 128: 393-401. 10.1053/j.gastro.2004.11.003.

9 - Catassi C, Kryszak D, Bhatti B, Sturgeon C, Helzlsouer K, Clipp SL, Gelfond D, Puppa E, Sferruzza A, Fasano A: Natural history of celiac disease autoimmunity in a USA cohort followed since 1974. Ann Med. 2010, 42: 530-538. 10.3109/07853890.2010.514285.

10 - Di Sabatino A, Volta U, Salvatore C, et al. Small amounts of gluten in subjects with suspected nonceliac gluten sensitivity: a randomized, double-blind, placebo-controlled, cross-over Trial. Clin Gastroenterol Hepatol. doi:10.1016 /j.cgh.2015.01.029.

*The information and opinions expressed in this text are the sole responsibility of the author and do not necessarily correspond to the views of Globoesporte.com / EuAtleta.com.

GUILHERME RENKE
Doctor from Estácio de Sá University, with post-graduate degrees in Cardiology from the National Institute of Cardiology INCL RJ and Endocrinology from IPEMED. Member of the Brazilian Society of Exercise and Sports Medicine, Member of the American College of Sports Medicine, Member of the Brazilian Society of Cardiology (SBC), Member of the Department of Ergometry and Rehabilitation of the SBC.