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    No Evidence That Gluten-Free Diet Promotes Weight Loss (with Reply by Dr. Ron Hoggan)


    Amy O'Connell
    Image Caption: Photo: CC--Newbirth35

    Celiac.com 12/02/2011 - Some rumors have been circulating in the health foods community that gluten-free eating can encourage weight loss. Unfortunately, this theory is completely unfounded. Wendy Marcason, a registered dietician, published an article in the Journal of the American Dietetic Association in November that reviews some of the theories and controversy surrounding this issue. The article concludes that there is no scientific evidence to support a connection between eating gluten-free and losing weight.


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    Photo: CC--Newbirth35For those of us with celiac disease who start a gluten-free diet, weight gain is more often the case. The healing of the damaged intestines allows better absorption of food, and unless you rapidly change the amount of food you eat when you go gluten-free, most celiacs gain a substantial amount of weight after the switch. If you do not have celiac disease, however, eating gluten-free is unlikely to have any affect on weight independent from decreases in the overall calorie intake due to eating more carefully.

    The consequence of this conclusion by the American Dietetic Association may be that more non-celiacs recognize that gluten-free does not necessarily mean more healthy. Unfortunately, some of the increased availability of gluten-free food over the last decade is owed to these non-celiac gluten-free folks. If these non-celiacs stop eating gluten-free, the demand for gluten-free food will fall and te number of options may decrease.

    All of that said, the paper said that no evidence exists because there are no studies that look at weight loss on a gluten-free diet. While it's impossible to conclude that gluten-free diets cause weight loss, its also impossible to conclude that they don't cause weight-loss. Only a clinical study will be able to put the issue to rest.

    Reference:

    • Marcason W. "Is There Evidence to Support the Claim that a Gluten-Free Diet Should Be Used for Weight Loss?" Journal of the American Dietetic Association. Nov 2011; 111(11): 1786.


    Weight Loss and the Gluten Free Diet by Ron Hoggan, Ed. D.

    First, I’d like to set Dr. O’Connell’s mind at rest. The claims for weight loss following adoption of a gluten-free diet aren’t merely rumors. They are credible claims based on peer reviewed and anecdotal reports, as well as published data from a qualified medical practitioner. For instance, Cheng and colleagues found that “54% of overweight and 47% of obese patients lost weight” (1). They investigated 81 subjects who were overweight and had celiac disease. Congruently, Venkatasubramani et al found that one half of their eight overweight pediatric patients also lost weight on a gluten free diet (2).

    These reports alone cast an ominous shadow over Dr. Marcason’s claims if Dr. O’Connell has represented them correctly. Marcason, we are told, asserts that no research has been done on this question. Yet there are three such reports in the peer reviewed literature (1, 2, 3). One reports a preponderance of weight gain among overweight and obese celiac patients after beginning a gluten free diet, while the other two groups report that about half of the overweight and obese celiac patients, children and adults, lose weight on a gluten free diet. Not only has this research been conducted and most of the findings not only contradict the claim that no such research has been done, but two of the three reports indicate that the gluten free diet helps with weight loss in some individuals. I think it is important to notice that the study showing that a large majority of overweight/obese celiacs was conducted where wheat starch is accepted as appropriate for celiac patients, while the two studies that showed weight loss were conducted in the USA. We still don’t know enough about the interaction between various constituents of gluten and people who lose weight on a gluten free diet.  However, given the contradictions in findings, between research conducted in the USA and some parts of Europe, it is not unreasonable to suggest that these differences may result from wheat starch.  

    Each of the three studies mentioned above have one large, consistent weakness. They are dealing with small numbers of patients. However, Dr. William Davis, a cardiologist has recently authored a book titled WHEAT BELLY, in which he reports that he has seen weight loss and other health improvements in more than 2,000 of his patients following adoption of a gluten free diet. And, of course, there are all the other anecdotal reports of similar benefits.

    Dr. O’Connell’s opposition to the use of a gluten free diet ignores the dynamics of appetite enhancement and satiation that are largely driven by hormones resulting from variations in nutrient density in various parts of the body. From insulin to glucagon to leptin to ghrelin, these and several other fat mobilizing hormones enhance and suppress our hunger based on the nutrients in our bloodstreams, gastrointestinal tract, and adipose tissues.  

    Dr. O’Connell also ascribes Marcason’s views to the American Dietetic Association which is the body that publishes the journal in which Dr. Marcason’s opinion article appears. While it may be true that the American Dietetics Association takes this position, it would be unusual for a journal, and the association that operates that journal, to underwrite the claims of one of its authors so I am skeptical that it has done so. I am especially skeptical of endorsement by the association, if Marcason has, indeed, stated that no studies have been conducted to investigate changes in body mass resulting from the gluten free diet among people who are overweight or obese at diagnosis. Clearly, this is an inaccurate claim whether it emanates from O’Connell or Marcason or even the American Dietetics Association.  

    I am also left wondering if there are any studies that show that “gluten-free does not necessarily mean more healthy” [sic]. I haven’t seen any and I would be very surprised if any exist. Dr. O’Connell didn’t cite any such studies, yet she asserts that a gluten free diet is not a healthy choice for those who do not have celiac disease. This is especially troubling in view of the growing recognition of non-celiac gluten sensitivity as a legitimate disease entity (5, 6, 7, 8, 9, 10). 

    I frequently write opinion articles so I would not want to inhibit such writing. Nonetheless, I believe that taking a rigid stance on either side of this issue is premature. Clearly we all have a lot to learn about weight loss and the gluten-free diet. The scanty evidence that is currently available is entirely too limited to say, with confidence, that the gluten-free diet is an effective weight loss tool, even for overweight patients with celiac disease. It appears to work for some, but other, unseen factors may be at work here.   

    Sources:

    1. Cheng J, Brar PS, Lee AR, Green PH. Body mass index in celiac disease: beneficial effect of a gluten-free diet. J Clin Gastroenterol. 2010 Apr;44(4):267-71.
    2. Venkatasubramani N, Telega G, Werlin SL. Obesity in pediatric celiac disease. J Pediatr Gastroenterol Nutr. 2010 Sep;51(3):295-7.
    3. Dickey W, Kearney N. Overweight in celiac disease: prevalence, clinical characteristics, and effect of a gluten-free diet. Am J Gastroenterol. 2006 Oct;101(10):2356-9.
    4. Davis W. Wheat Belly.Rodale, NY, NY 2011.
    5. Bizzaro N, Tozzoli R, Villalta D, Fabris M, Tonutti E. Cutting-Edge Issues in Celiac Disease and in Gluten Intolerance. Clin Rev Allergy Immunol. 2010 Dec 23.
    6. Ford RP. The gluten syndrome: a neurological disease. Med Hypotheses. 2009 Sep;73(3):438-40. Epub 2009 Apr 29.
    7. Sbarbati A, Valletta E, Bertini M, Cipolli M, Morroni M, Pinelli L, Tatò L. Gluten sensitivity and 'normal' histology: is the intestinal mucosa really normal? Dig Liver Dis. 2003 Nov;35(11):768-73. PubMed PMID: 14674666.
    8. Di Cagno R, De Angelis M, De Pasquale I, Ndagijimana M, Vernocchi P, Ricciuti P, Gagliardi F, Laghi L, Crecchio C, Guerzoni ME, Gobbetti M, Francavilla R. Duodenal and faecal microbiota of celiac children: molecular, phenotype and metabolome characterization. BMC Microbiol. 2011 Oct 4;11:219.
    9. 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 Mar;106(3):508-14
    10. Bizzaro N, Tozzoli R, Villalta D, Fabris M, Tonutti E. Cutting-Edge Issues in Celiac Disease and in Gluten Intolerance. Clin Rev Allergy Immunol. 2010 Dec 23.



    Amy O'Connell, MD, PhD's Reply to Dr. Ron Hoggan:

    This is Dr. O'Connell replying. My piece was merely a summary of an article in the Journal of the ADA. The short summary I wrote was not intended to be an end-all conclusive statement about the matter. That said, the Cheng article that is cited by Ron Hoggard. M.Ed. was not designed to look at the outcome of weight loss in overweight celiacs and is underpowered to make the conclusions that he cites. Another quote from the same article said, "Overall, 54% [of patients who started a gluten-free diet] gained weight and 38% lost weight." The same problem with a lack of statistical power exists for the Venkatasubramani paper. Four obese patients lost weight on a gluten-free diet but 2 gained weight and 1 was lost to follow up. I'd like to apologize if my brief summary seemed too closed-ended, but I will stand by my article conclusion, "While it's impossible to conclude that gluten-free diets cause weight loss, its also impossible to conclude that they don't cause weight-loss. Only a clinical study will be able to put the issue to rest."


     

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    I think that saying any type of diet based on one food source or type causes weight loss or doesn't cause weight loss is a little narrow minded... its like saying a diet with no carbohydrate causes weight loss... it may or it may not dependent on other foods and factors within the diet... why not just look to basic principles that eating unprocessed foods without chemicals, yes without irritants such as gluten, and with plenty of water WILL cause weight loss for the majority of people especially alongside regular activity or exercise... do we need to over-complicate it?

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    Guest Lisa Thompson

    Posted

    I believe Dr. O'Connell was treated fairly. If you are going to make such bold statements in a public arena, you should be prepared for any responses that might contradict you, ready to back them up with the appropriate data.

     

    Perhaps most of those with true celiac disease indeed gain weight after going gluten-free. But those with gluten-sensitivity, like my husband, myself, and a dear friend of mine, all lost a tremendous amount of weight after going gluten-free, not to mention a disappearance of lifetime gastrointestinal illness, arthritis-like pain and skin conditions. The wheat industry and it's lobbyists can try to persuade the Purveyors of Higher Learning to discredit the notion all they want, but it's becoming undeniable by the overwhelming anecdotal evidence that something is terribly wrong with today's wheat. When everyone in the city is sick and gets well after they stop drinking the water, is anyone going to believe the Town Crier who insists the well is pure?

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    Guest Heather Twist

    Posted

    Kudos to Dr. Hoggan!

     

    As anecdotal evidence, I can offer the following. Our whole family went gluten-free. I am celiac, the others are not. THEY lost weight, and are no longer chubby. And I gained weight! It appears that my years of overeating and being skinny have ended, now that I actually digest food.

     

    I don't think there is a simple answer like "gluten makes you gain weight". I do think it is something like "gluten messes with your appetite and weight". For some it makes you overly skinny, for others, overly fat, for some, neither.

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    Guest Suzanne

    Posted

    As one who nearly died before being diagnosed with celiac disease, it's frustrating to see articles that would lead anyone to question the validity of going gluten-free, if necessary, and properly done. Patients who are as ill as I was lose weight prior to diagnosis - I am 5'6" and was down to 89lbs. Weight gain was a desired result of the GFD. Unless the context is taken into account all the stats are useless. The diet itself should be controlled in any study since one can eat as poorly on the GFD as on a wheat based diet. Thank you, Dr. Hogan, for coming to the defense of those of us who need all the support we can get.

    Thank you, Nathan and Lisa for your replies, as well.

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    For me, a gluten-intolerant celiac with wheat allergy, I lost weight, sizes in fact. Why? Because I had to think twice about what I was putting in my mouth for starters. When I was hungry and in a rush, I would not eat the snacks on the shelf. No Oreos. No Hostess cupcakes. Sandwiches became bread-less. No pizza. And the majority of restaurants use flour for sauces and whatnot so it was chicken breasts and veggies. So, YES. When you go gluten-free you WILL lose weight unless you replace every item with a gluten-free equivalent. Most tastes bad, IMO, so you will be eating less of it and therefore less carbs. It did not all drop off immediately, and took a couple months for me. And I agree with Lisa, as many symptoms I had disappeared.

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    Guest frazer edwards

    Posted

    I think it highly likely that those that follow a grain free, legume free, dairy free and industrial oil free diet will lose weight. The "baked" goods espoused on this site do color the conversation as does almost any reliance on the opinions of nutritionists.

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    Here is my educated hypothesis with some anecdotal evidence regarding weight gain/weight loss with celiac or other gluten issues. Normal weight or underweight celiac patients who are diagnosed often gain weight simply from continuing to eat in the huge amounts of food that were never absorbed. They need to adjust their eating now that nutrients are being absorbed, else they will gain weight. Simple enough and well documented.

     

    Many overweight people complain they do not overeat and are exercising but struggle to lose weight – often giving up the fight and easily gaining it back. While doctors have raised the potential link between obesity and celiac disease (or at least that obese people may also have the disease not just thin folks), no one has explained the obesity-celiac process/link well. One month working with my longtime dietician, I lost a few lbs. She trusted me and believed what I was eating and my 20-25 miles a week of mixed-paced walking and other exercise documented on paper. A doctor on another celiac website explained it similarly to Dr. Hoggan – that overweight folks with celiac have bodies that are starving for energy at the cellar level that places them into a low metabolic mode telling their brains, hormones, etc. to eat, eat, eat (feed me!). Dr. Green in his book disappointingly does not handle obesity with celiac disease explanation in this manner and notes obese celiac disease folks have enough of good small intestinal villi with atrophied - flattened that they can absorb nutrients that then make them fat. I prefer to lean towards the former theory or perhaps a combination of both.

     

    I have a personal story that reads like Ms. Celiac – and explains much of my family's issues as well. I refused testing for celiac last year after complaining to my doctor about widespread joint pain when eating anything with added gluten - figuring I would just stay away from it. I was ignorant at the time of all the ramifications of celiac disease. Still, I am a bad patient who went gluten free before being tested after an uptick in symptoms – including GI ones. The result? I have never felt better in my live, and the nutritional and exercise program that lead to just 20 lbs off in 2 years is now more effective, and the weight is coming off (the discovery of a gluten free bakery's goodies put me temporarily off track!). On a program of good healthy protein, gluten free, low fat, and sugar free foods, I am no longer hungry all the time (even forgetting to eat at times until I look at the clock). I eat slower and am full faster. Spirits up, energy up, clearer thinking, no joint pains, bowels normal - thought all my life I was normal in this regard but apparently not, other odd issues improved as well.

     

    I do believe celiac or related gluten issues may indeed as Dr. Green notes be a hidden epidemic and that more obese folks with inflammatory-based diseases need to be tested as they may finally be able to do what they were doing all along to lose weight but the gluten was metabolically prohibiting success.

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    I lost weight after celiac diagnosis. I felt it was primarily due to feeling so much better and having the energy to engage in physical work again.

     

    I also think that having to be careful about snacking and passing up most of the samples at Costco cuts down on calories.

     

    If everybody asks Costco in their suggestion box to have gluten free bread maybe they would start carrying it.

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    Guest Coloradosue

    Posted

    I believe Dr. O'Connell was treated fairly. If you are going to make such bold statements in a public arena, you should be prepared for any responses that might contradict you, ready to back them up with the appropriate data.

     

    Perhaps most of those with true celiac disease indeed gain weight after going gluten-free. But those with gluten-sensitivity, like my husband, myself, and a dear friend of mine, all lost a tremendous amount of weight after going gluten-free, not to mention a disappearance of lifetime gastrointestinal illness, arthritis-like pain and skin conditions. The wheat industry and it's lobbyists can try to persuade the Purveyors of Higher Learning to discredit the notion all they want, but it's becoming undeniable by the overwhelming anecdotal evidence that something is terribly wrong with today's wheat. When everyone in the city is sick and gets well after they stop drinking the water, is anyone going to believe the Town Crier who insists the well is pure?

    With the revolution of genetics in the food industry, it was just a matter of time before someone finally said out loud, "What are we doing to the human body by using this radically changed wheat grain in our food?" Well, more people are getting sick! After the initial trigger of double pneumonia, my celiac disease was "turned on" causing a one week weight loss of 11 pounds. Since going “gluten free†in 2004, (which really is impossible to do when so many products may use one of the 3 confirmed glutens wheat, barley & rye, that are coming from countries that neglect to inform and/or print ALL of the ingredients in their products despite regulations to the contrary. I had gained 38 lbs going gluten free. Then I was diagnosed with Fibromyalgia (to go along with the Spinal Stenosis that I was diagnosed in 2003), the following year so exercising to lose weight became a mote point. Watching my "diet" is an exercise in futility . I can usually expect to be "sick" at least once a month despite due diligence to my diet. And yes I do lose weight during these attacks but my system takes a tremendous hit. And then I gain it back. I greatly fear that may develop "Lymphoma" as my younger sister did and died in 1990 at age 34. My family now believes she had un-diagnosed celiac disease.

    So to those of you trying to lose weight by going on a gluten free diet, good for you. Should you develop celiac disease or sensitivity down the road, at least you had a head start. Good Luck!

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    Guest christine

    Posted

    I too am losing weight after going gluten free. Because of the positive changes that I have seen in my body (I'm 41 and finally have soft, shiny hair, joint pain is gone, muscle weakness gone, no more bleeding gums, no more pasty complexion, no fogginess, especially after eating, more energy than I have ever had in my life, no more congestion, no more curled up hands and feet, no more cravings, and constantly feeling hungry, the list goes on...) I believe that my constant hunger was due to malnutrition from gluten, and not from my thyroid disorder as I had previously thought. I don't feel hungry all the time anymore! It's been nearly a month since going gluten free and I feel like I have my life back. Honestly, the pain and other symptoms were so bad before I wondered what the point was to living a life like this. Now, I'm losing about 1 pound every three days, and I'm eating great! I'm just not constantly eating the junk I was craving before. So, indirectly by causing malnourishment, gluten certainly does contribute to weight issues.

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    I was underweight my whole life, eating gluten free is helping me from fading away. My metabolism is way too fast. I can't gain weight on a gluten or gluten free diet. There may be other issues but thank you Dr. Hoggan for reiterating the facts for us. Everyone is different, it does depend on their genetic history, pathologies that they are facing and the current type of food that they are incorporating in their diet that is "gluten free".

    The rating is for Dr. Hoggan

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  • About Me

    Amy O'Connell is a medical doctor and researcher who was diagnosed with celiac disease in 2003. She began writing professionally in 2010. Dr. O'Connell is working toward becoming a pediatric allergist/immunologist. When not working, Amy enjoys baking and trying out new gluten free recipes. You can check out Dr. O'Connell's blog "Dr. Gluten Free" at http://drglutenfree.blogspot.com.

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    Dr. Ron Hoggan, Ed.D.
    This article originally appeared in the Summer 2011 edition of Celiac.com's JournalofGluten-Sensitivity.
    Celiac.com 08/25/2011 - This is a controversial topic. Elizabeth Hasselbeck’s book, The gluten-free Diet (1), has been attacked because it suggests that a gluten free diet can help some people lose weight. One celiac support group has condemned this book as misleading (2).  However, I thought it was a pretty good book, and I’m grateful for the public attention that Hasselbeck has drawn to celiac disease and non-celiac gluten sensitivity. There are at least two sides to the question of whether a gluten free diet is useful for weight loss. As with much other dietary advice, each of these conflicting views is sometimes presented in very strident voices. On one side there are numerous websites and newspaper articles, with an array of “experts” weighing in on this issue, decrying the use of a gluten free diet for weight loss. I even saw a segment of a television show called “Dr. Oz” where the gluten free diet was asserted to cause only weight gain. On the same show the diet was referred to as a “fraud” with respect to weight loss. Similarly, one group of researchers claim that an important side effect of the gluten free diet is weight gain. Even some very popular advocates of the gluten free diet insist that it is inappropriate for weight loss. Yet there are some individuals who advocate this diet as an effective weight loss tool and there is some evidence to back them up. There are even a couple of research reports of weight loss on a gluten free diet. In fact there is at least one study that provides some support for each paradigm. So who are we to believe? What information supports each side of the argument? And how can we evaluate that information?
    Before we get to the evidence, however, I’d like to say that I have listened to Ms. Hasselbeck express some of her political and economic opinions. I am now of the firm belief that she is one of the five people on this continent who may know even less about these issues than I do. So let’s leave out the politics and confine our discussion to the issue of the gluten free diet and whether it is suitable for weight loss.
    The first and most compelling piece of evidence (for me) is a personal observation. I watched my mom try to lose weight, starting when I was in elementary school. She tried just about every diet out there, from radical fringe to mainstream. She drank protein powders mixed with water instead of eating meals. She tried eating these “rye” crackers that I thought tasted like cardboard.... very crunchy cardboard. She tried a low sodium diet, then a low fat diet, then a sugar free diet, an all fruit diet, a raw food diet, or maybe that was just a single diet of raw fruit. I’m not sure. She probably tried a host of other diets that I don’t remember, but I think you get the idea.  She sometimes lost weight only to gain it back as soon as she stopped the diet.  More often, she gave up because she got tired of being hungry all the time. She eventually gave up on dieting altogether and accepted being overweight. 
    Then, about fifteen years ago, in her early-mid 70s, she started a gluten free diet. It wasn’t aimed at weight loss. She was trying to reduce the pain caused by her arthritis. In the first year and a half or two years, she lost 66 pounds. From that time onward, her weight continued to gradually diminish to the point where she had lost about 100 pounds over about ten years of eating gluten free. She was not trying to lose weight. She had long since given up on that objective. Yet the excess pounds just melted away. If only because of its weight loss benefits, I suspect that the gluten free diet has extended her life substantially.
    At about 85 years of age, she started eating gluten occasionally. Part of her gluten consumption is wilful. She sees something that she thinks she might enjoy eating, and she requests a serving. Perhaps because of mom’s lapses into gluten, the staff at the home where she now lives have also become quite cavalier about her gluten free diet. They frequently serve her dishes that contain gluten. Still, her weight has remained fairly stable. My mom is not the only example of weight loss on a gluten free diet. There are other stories on the Internet. Just Google “gluten free weight loss diet” and you will see what I mean. But I can’t vouch for those stories. I didn’t observe their weight loss. All I saw was my mom’s.
    Currently, there are only a few formal studies that have explored body mass changes on a gluten free diet. One conducted in Ireland reveals that there are eight times as many overweight celiacs as underweight celiacs (Dickey & Kearney). That is quite surprising in light of the common perspective that celiac disease is one of under-nutrition, suggesting that underweight should be a more likely sign of celiac disease. For a long time, that was the dominant belief, but there is clearly a flaw in this paradigm. 
    Suspecting celiac disease only in underweight patients is not the only complication of this issue. Dickey and Kearney also report that after two years of dietary compliance, eighty two percent of their 143 overweight and obese patients with celiac disease had gained yet more weight on a gluten free diet. This would seem to suggest that the gluten free diet is not a good bet as a weight loss tool. However, these results do not seem to have been replicated by other investigators.
    Another follow-up study, conducted in New Rochelle, NY, reports that ’’ 66% of those who were underweight gained weight, whereas 54% of overweight and 47% of obese patients lost weight’’ on a gluten free diet (Cheng et al ). Thus, on this side of the Atlantic, of the eighty one overweight and obese celiac subjects, about half lost weight following a gluten free diet. That is quite different from the findings in Ireland.
    Another, much smaller study of childhood celiac disease revealed that about half of the eight overweight children they studied also experienced weight loss (Venkatasubramani et al ). This research was conducted in Milwaukee and is congruent with the findings from New Rochelle. So, on this side of the Atlantic, about half of the overweight celiac patients studied experienced weight loss on a gluten free diet.   
    Perhaps these differences are the result of variations between the versions of the gluten free diet in North America, as compared with the diet in the United Kingdom.  The primary difference I am aware of is that gluten free in the UK includes wheat starch whereas most American organizations do not accept wheat starch as gluten free. However, the gluten free diet that includes wheat starch has been shown to reduce cancer risk and many other celiac-associated risk factors, and has therefore been deemed safe. Nonetheless, that same wheat starch may be a factor in the different body mass findings between Ireland and the USA. Or maybe the difference lies in variations in research methods. Without further research, it is difficult to guess.... and that is exactly what we would be doing.
    Without solid evidence, our beliefs are no more than just guesses. For instance, my mom’s weight loss could have been the result of some factor other than her gluten free diet. Perhaps the beginning of her weight loss just happened to coincide with when she started the gluten-free diet. I’m convinced by my observations of her experience, but that doesn’t mean that you should be. After all, I could be kidding myself. Or her weight loss could have been caused by some other factor that I’m not even aware of or recognizing. That is why many of us contribute our hard-earned dollars to research. We need something more than stories about my mom’s experiences. We need solid, peer reviewed research such as what is found in medical journals.  However, even there we need to be cautious about reported findings.
    One good indicator that researchers are on the right track is when we see a convergence of results from very different studies. When one study produces a given result, and another study produces a similar result despite very different study designs and objectives, the results of the first study are said to have been replicated by the second study. The advantage, in the case of celiac patients experiencing weight loss following institution of a gluten free diet clearly goes to the two studies conducted in the USA. The studies looked at two different sub-populations of celiac patients yet produced approximately the same results. But both studies still have a problem with selection bias.   
    One of the greatest difficulties in assessing research findings is that we are really just assuming that what we see in one or two small groups will be reflected in the general population.  This is why, where possible, study subjects are picked randomly from the general population. However, this cannot happen in studies of celiac patients. They are a select group. This is partly because these subjects have celiac disease and partly because they have a diagnosis of celiac disease. I’m really not splitting hairs here. Please bear with me for a moment as I try to explain this important distinction.
    Unlike more than 95% of Americans with celiac disease, these study subjects have a diagnosis. And don’t be fooled. Clinicians are missing almost as many cases of celiac disease in Europe as they are in the USA. Thus, all three of these studies are looking at a sub-group (diagnosed with celiac disease) of a select group (celiac disease). And the lengthy delays to diagnosis, somewhere between five and eleven years, also occur in Europe and Canada, so the difference is probably not dependent on whether there is a socialist medical system in place, as some have suggested. The select group is formed by people with celiac disease. The sub-group is people drawn from the three to five percent of those who have been diagnosed with celiac disease. We know some of the ways that those with celiac disease differ from the general population. But we don’t know any of the ways, beyond the diagnostic criteria, that people with undiagnosed celiac disease differ from the general population or from the population of people whose celiac disease has been diagnosed.  
    Studying a small sub-group of celiac patients who have a diagnosis, then assuming that the features observed will be present in all those with celiac disease, whether they have a diagnosis or not, is a flawed approach. Statisticians call this mistake ‘selection bias’. It is a well recognized type of statistical error. For instance, if you wanted to predict the buying habits of people living in Pennsylvania, you would not just observe members of the Amish community. Doing so would not only induce a selection bias, it would lead to very misleading information about the general population of Pennsylvania. While many Amish live in Pennsylvania, their buying habits probably do not reflect the buying habits of most people in Pennsylvania. Similarly, the selection bias driven by extrapolating from observations of sub-groups of people with diagnosed celiac disease and applying those principles to undiagnosed celiacs, leading us to either assume that weight loss will or will not occur on a gluten free diet is mistaken and likely to produce misleading information.
    In addition to selection bias, sample size is another important factor in predicting features of a larger population based on observations of a sub-population. The smaller the group, the less likely it is to reflect the variations present in the larger population of those with celiac disease. For instance, if the US population is currently about 311 million, and the rate of celiac disease is about one in every 133 people, then there should be about 2.3 million Americans with celiac disease. Only three to five percent of Americans with celiac disease are thought to be diagnosed with celiac disease. And the studies of overweight celiacs who gained or lost weight on a gluten free diet include about 89 Americans and 143 Irish people. Is it credible to imagine that we can predict the responses of 2.3 million Americans based on observations of a sub-group of 89 of their compatriots and 143 Europeans? I think that most readers will agree that leaping to such conclusions is unreasonable. Yet that is what we do if we insist on the exclusive correctness of either side of the question of whether the gluten free diet is an effective weight loss tool.
    I am convinced, both by my observations of my mom, and by the results of these two small studies, that some celiacs will lose weight on a gluten free diet. However, I would not presume to insist that it is the best, or even a good tool for all overweight celiacs. Neither would I insist it was a good weight loss tool for all diagnosed overweight celiacs. Given the US studies, that is clearly not the case. Equally, denial of anecdotal reports or the two US studies claiming that the gluten free diet is not an effective weight loss tool for anyone is also unreasonable.
    We can only say, with confidence, that these study results may apply to those who are diagnosed with celiac disease. Yet we have a fairly even split, with American researchers showing that about half of overweight celiacs lose weight on a gluten free diet, and Irish researchers asserting that eighty two diagnosed overweight celiacs gained even more weight on a gluten free diet.
    Yet these statistical problems are not insurmountable. If a group of researchers conducted random screening blood tests for celiac disease in a variety of settings and circumstances, confirmed the celiac diagnosis in a large group of these individuals, and followed up with those who were overweight and undertook the gluten free diet, then their observations might reasonably be applied to the celiac population in general, whether diagnosed or undiagnosed. There would still be a relatively minor statistical error induced by cases of sero-negative celiac disease, but the statistical problems would not be anywhere near as problematic as asserting that any or all of these three studies tell us much about weight loss on a gluten free diet, except that it sometimes happens in small sub-groups of diagnosed celiac patients.
    Since such research has not been conducted, it behooves all of us to take a moderate stance on either side of this debate.    
    That does not mean that we can’t or shouldn’t make use of the available information. Each of us can draw our own conclusions based on our interpretations of the available data. If you believe that, in North America, a gluten free diet can induce weight loss in about half of overweight, newly diagnosed celiac patients, it does seem reasonable to suggest that the gluten free diet may be all that is needed for some diagnosed celiacs to lose weight. However, since we are missing more than 95% of cases of celiac disease, it is difficult to say whether it will help those undiagnosed, overweight celiacs to lose weight. Nonetheless, it is possible. Thus, if it will help some, perhaps about half of them to lose weight, those individuals might well consider this information, limited though it may be, very valuable.
    Anecdotal reports, such as my mother’s story, might also be considered very valuable by those who can lose weight on a gluten free diet. For those who do not lose weight on this diet, I suspect that many of them have walked the path my mother did, and it won’t be the first time that a diet failed to work for them. This, of course, raises the question of why some individuals and organizations have vigorously opposed and decried anecdotal claims that a gluten free diet may help some people lose weight. Clearly, there is hard scientific evidence to support this claim.  The reverse is not the case. Nobody has, or can, prove that the gluten free diet is always ineffective at helping people lose weight.  
    Meanwhile, we can hope for more research that will answer some of the many questions that arise from this relatively new information that there may be many more overweight people with celiac disease than there are underweight people with celiac disease.    
    Several of the questions that remain include:
    What causes overweight and obesity in patients with celiac disease? It is, after all, a disease that is characterized by inadequate absorption of nutrients from the food that passes through the gastrointestinal tract. I have previously suggested that specific nutrient deficiencies may induce food cravings that cause some to continue to eat despite feeling ’’full’’ because their bodies continue to demand these missing nutrients. The new field of metabonomic research may soon shed more light on this area. It has already demonstrated that subjects diagnosed with celiac disease are not as efficient at metabolizing glucose (usually derived from carbohydrates) as those without celiac disease. 
    Does wheat starch have any impact on nutrient absorption or appetite? If even small amounts of opioid peptides survive in wheat starch and are allowed access to the bloodstream and brain, they may well have an impact on appetite. Opioids or some other component of wheat starch might also alter ghrelin (a hormone that incites appetite) and/or leptin (a hormone that suppresses appetite). We just don’t know. 
    Are there other dietary differences between Ireland and the USA? We are aware of the difference in wheat starch, but what other factors might contribute to these divergent research results?
    How does wheat starch compare with the 20 parts per million currently being put forward as the labelling standard for American legislation in the offing? Does wheat starch contain 20 ppm?
    Will the legislation in question change conditions for celiac patients?
    Just how much contamination from gluten grains is present in commercial oats?  Even in the absence of contamination, how many people with diagnosed celiac disease experience cross-reactions with oats?  This is where the selective antibodies are sensitized to protein segments found in oats as well as in gluten grains.
    What other differences between Ireland and the USA might explain these variations in research findings? Could variations in sunlight, or water-borne minerals, or even genetics contribute to the difference in findings?
    How representative are these groups of other groups of celiac patients? Do they reflect what is going on among all the other diagnosed celiacs in their region? And how do these findings apply to the undiagnosed celiacs?
    Is region a genuine factor in all of this? I remember when many researchers were quite willing to believe that there was some difference that had Italy showing a rate of celiac disease of one in 250 while in the USA and Canada it was thought to afflict about one in twelve thousand. We now know that was silly, but at the time, there were a lot of apparently intelligent people who were vigorously asserting the accuracy of those variations and postulating many creative explanations for them. I remember one, now prominent celiac researcher, admonishing me not to take the Italian findings too seriously. He was very confident that they represented a large overestimation of the true incidence of celiac disease in Italy and could not reasonably be suggested as reflecting anything about Canada or the USA.  
    Now here is a really startling thought. Some of the overweight people with non-celiac gluten sensitivity might also be able to lose weight on a gluten free diet. If so, this could produce as much as a ten-fold increase in the number of people who might lose weight on our diet. Has anyone tested obese and overweight people for anti-gliadin antibodies? Could gliadin be a factor in some peoples’ weight problems?
    I wonder how many people might be helped to lose weight if pre-conceived notions about the gluten free diet could be relinquished in favour of a more open minded view.... one that recognizes that there is some evidence that some people can and do lose weight on a gluten free diet?
    The dogmatic certitude that abounds on the question of weight loss through the gluten free diet is profound and disturbing. As is pointed out by nutritionist, Brian Dean, in his article on gluten and heart disease in this issue of The Journal of Gluten Sensitivity, one long-standing dietary sacred cow has been killed. We now know that eating saturated fats is not a causal factor in heart disease.
    Equally, the emerging sacred cow that a gluten-free diet is not appropriate for weight loss is, as yet, supported only by flimsy evidence, all of which is contradicted by other research. So let’s avoid making rigid pronouncements about the gluten free diet until we have a better understanding of the complex and perplexing causes of obesity and overweight in the context of untreated celiac disease.  And please, let’s remember that some people can and do lose weight on a gluten-free diet alone. My mother is an excellent but by no means unique example. Others have similar stories. My own experience on the diet was weight gain, and now I have to work at keeping from gaining any more.
    Only those who know all there is to know should speak in absolutes. The rest of us should constrain ourselves to offering opinions and perspectives. 
    Sources:

    Hasselbeck E, The Gluten-Free Diet: A Gluten-Free Survival Guide. Center Street- Hatchette Book Group, NY, 2009. http://glutenfreegoddess.blogspot.com/2009/05/gluten-free-diet-opinion-from-elaine-monarch.html Dickey W, Kearney N. Overweight in celiac disease: prevalence, clinical characteristics, and effect of a gluten-free diet. Am J Gastroenterol. 2006 Oct;101(10):2356-9. Cheng J, Brar PS, Lee AR, Green PH. Body mass index in celiac disease: beneficial effect of a gluten-free diet. J Clin Gastroenterol. 2010 Apr;44(4):267-71. Venkatasubramani N, Telega G, Werlin SL. Obesity in pediatric celiac disease. J Pediatr Gastroenterol Nutr. 2010 Sep;51(3):295-7.

    Jefferson Adams
    Celiac.com 08/18/2014 - A team of researchers recently set out to better understand the effects of gluten-free diets on obesity.
    The research team included F.L. Soares, R. Matoso de Oliveira, L.G. Teixeira, Z. Menezes, S.S. Pereira, A.C. Alves, N.V. Batista, A.M. de Faria, D.C. Cara, A.V. Ferreira, and J.I. Alvarez-Leite. They are affiliated with the Departamento de Alimentos, Faculdade de Farmácia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais in Belo Horizonte, Brazil.
    Specifically, the team wanted to determine whether a gluten-free diet can prevent the expansion of adipose tissue, and its consequences.
    For their study, the team fed C57BL/6 mice a high-fat diet containing either 4.5% gluten (Control) or no gluten (gluten-free). They noted body weight and adiposity gains, leukocyte rolling and adhesion, macrophage infiltration and cytokine production in adipose tissue.
    The team measured blood lipid profiles, glycaemia, insulin resistance and adipokines. They also assessed the expression of the PPAR-α and γ, lipoprotein lipase (LPL), hormone sensitive lipase (HSL), carnitine palmitoyl acyltransferase-1 (CPT-1), insulin receptor, GLUT-4 and adipokines in epidydimal fat.
    Gluten-free animals showed less body weight and adipose gain, with no changes in food intake or lipid excretion. These results were associated with up-regulation of PPAR-α, LPL, HSL and CPT-1, which are related to lipolysis and fatty acid oxidation.
    The team also saw improved glucose regulation, and pro-inflammatory profile-related over-expression of PPAR-γ. Intravital microscopy revealed a lower number of adhered cells in the adipose tissue microvasculature. The over-expression of PPAR-γ is related to the increase of adiponectin and GLUT-4.
    The results of this study suggest that gluten-free diets can be helpful in reducing fat gain, inflammation and insulin resistance. They suggest that a gluten-free diet should be tested as a way of preventing the development of obesity and metabolic disorders.
    Source:
     J Nutr Biochem. 2013 Jun;24(6):1105-11. doi: 10.1016/j.jnutbio.2012.08.009. Epub 2012 Dec 17.

  • Recent Articles

    Jefferson Adams
    Celiac.com 07/17/2018 - What can fat soluble vitamin levels in newly diagnosed children tell us about celiac disease? A team of researchers recently assessed fat soluble vitamin levels in children diagnosed with newly celiac disease to determine whether vitamin levels needed to be assessed routinely in these patients during diagnosis.
    The researchers evaluated the symptoms of celiac patients in a newly diagnosed pediatric group and evaluated their fat soluble vitamin levels and intestinal biopsies, and then compared their vitamin levels with those of a healthy control group.
    The research team included Yavuz Tokgöz, Semiha Terlemez and Aslıhan Karul. They are variously affiliated with the Department of Pediatric Gastroenterology, Hepatology and Nutrition, the Department of Pediatrics, and the Department of Biochemistry at Adnan Menderes University Medical Faculty in Aydın, Turkey.
    The team evaluated 27 female, 25 male celiac patients, and an evenly divided group of 50 healthy control subjects. Patients averaged 9 years, and weighed 16.2 kg. The most common symptom in celiac patients was growth retardation, which was seen in 61.5%, with  abdominal pain next at 51.9%, and diarrhea, seen in 11.5%. Histological examination showed nearly half of the patients at grade Marsh 3B. 
    Vitamin A and vitamin D levels for celiac patients were significantly lower than the control group. Vitamin A and vitamin D deficiencies were significantly more common compared to healthy subjects. Nearly all of the celiac patients showed vitamin D insufficiency, while nearly 62% showed vitamin D deficiency. Nearly 33% of celiac patients showed vitamin A deficiency. 
    The team saw no deficiencies in vitamin E or vitamin K1 among celiac patients. In the healthy control group, vitamin D deficiency was seen in 2 (4%) patients, vitamin D insufficiency was determined in 9 (18%) patients. The team found normal levels of all other vitamins in the healthy group.
    Children with newly diagnosed celiac disease showed significantly reduced levels of vitamin D and A. The team recommends screening of vitamin A and D levels during diagnosis of these patients.
    Source:
    BMC Pediatrics

    Jefferson Adams
    Celiac.com 07/16/2018 - Did weak public oversight leave Arizonans ripe for Theranos’ faulty blood tests scam? Scandal-plagued blood-testing company Theranos deceived Arizona officials and patients by selling unproven, unreliable products that produced faulty medical results, according to a new book by Wall Street Journal reporter, whose in-depth, comprehensive investigation of the company uncovered deceit, abuse, and potential fraud.
    Moreover, Arizona government officials facilitated the deception by providing weak regulatory oversight that essentially left patients as guinea pigs, said the book’s author, investigative reporter John Carreyrou. 
    In the newly released "Bad Blood: Secrets and Lies in a Silicon Valley Startup," Carreyrou documents how Theranos and its upstart founder, Elizabeth Holmes, used overblown marketing claims and questionable sales tactics to push faulty products that resulted in consistently faulty blood tests results. Flawed results included tests for celiac disease and numerous other serious, and potentially life-threatening, conditions.
    According to Carreyrou, Theranos’ lies and deceit made Arizonans into guinea pigs in what amounted to a "big, unauthorized medical experiment.” Even though founder Elizabeth Holmes and Theranos duped numerous people, including seemingly savvy investors, Carreyrou points out that there were public facts available to elected officials back then, like a complete lack of clinical data on the company's testing and no approvals from the Food and Drug Administration for any of its tests.
    SEC recently charged the now disgraced Holmes with what it called a 'years-long fraud.’ The company’s value has plummeted, and it is now nearly worthless, and facing dozens, and possibly hundreds of lawsuits from angry investors. Meantime, Theranos will pay Arizona consumers $4.65 million under a consumer-fraud settlement Arizona Attorney General Mark Brnovich negotiated with the embattled blood-testing company.
    Both investors and Arizona officials, “could have picked up on those things or asked more questions or kicked the tires more," Carreyrou said. Unlike other states, such as New York, Arizona lacks robust laboratory oversight that would likely have prevented Theranos from operating in those places, he added.
    Stay tuned for more new on how the Theranos fraud story plays out.
    Read more at azcentral.com.

    Jefferson Adams
    Celiac.com 07/14/2018 - If you’re looking for a simple, nutritious and exciting alternative to standard spaghetti and tomato sauce, look no further than this delicious version that blends ripe plum tomatoes, garlic, olive oil, basil, and firm sliced ricotta to deliver a tasty, memorable dish.
    Ingredients:
    12 ounces gluten-free spaghetti 5 or 6 ripe plum tomatoes ¼ cup extra virgin olive oil 2 cloves garlic, crushed ¾ teaspoons crushed red pepper ¼ cup chopped fresh basil 2 tablespoons chopped fresh parsley Kosher salt and black pepper ⅓ cup pecorino Romano cheese, grated ½ cup firm ricotta, shaved with peeler Directions:
    Finely chop all but one of the tomatoes; transfer to large bowl with olive oil and ¼ teaspoon salt.
    Cook spaghetti until al dente or desired firmness, and drain, reserving ¼ cup cooking water. 
    Meanwhile, chop remaining tomato, and place in food processor along with garlic, red pepper, and ½ teaspoon salt; puree until smooth. 
    Gently stir mixture into the bowl of chopped tomatoes.
    Add cooked spaghetti, basil and parsley to a large bowl.
    Toss in tomato mixture, adding some reserved pasta water, if needed. 
    Spoon pasta into bowls and top with Romano cheese, as desired.

    Jean Duane
    Celiac.com 07/13/2018 - I went to a friend’s home for dinner.  A few days before, she called and asked me what I could eat.  I asked her what she was planning to make, and she said she was grilling meats with side dishes.  I said, “Great.  Please just grill a piece of chicken for me with salt and pepper, and I’ll be happy to bring a side.” She said, “No need to bring a side.  I’ve got this.” When I arrived, she greeted me and said, “I spent all day cooking tonight’s dinner so you can eat it. Hey would you just check this salad dressing to see if it is OK for you?” I looked at the ingredients and it contained gluten and dairy, both of which I cannot eat.  Then I glanced around the kitchen and saw evidence of wheat cross-contamination, including buns being toasted on the grill, and gluten-containing barbeque sauce spilling on the grill where my “clean” chicken was cooking. She had other guests to tend to, and I couldn’t offer instruction or read the ingredients of everything she used in the meal. 
    At social gatherings, I’ve been challenged too by those who ask if I am really “allergic,” or just eating gluten free as a “fad.” I’ve been told many times by hosts and hostesses that, “a little won’t hurt you,” or “everything in moderation,” or “if it is made with loving hands, it is good for you to eat.”  Of course, all of this is bunk for those with food allergies or celiac disease.  A little bit may kill us, and whether made with loving hands or not, it will certainly make us sick. 
    Those of us with food allergies and/or celiac disease walk a tightrope with friends and relatives. The old rules of etiquette just don’t work anymore.  We don’t want to insult anybody, we don’t want to be isolated, and we also don’t want to risk our health by eating foods that may contain ingredients we cannot tolerate.  So what do we do? 
    Etiquette books advise us to eat what is put in front of us when we are guests in someone’s home. They caution us at all costs not to insult our hostess. Rather, we are instructed to compliment the hostess on her good cooking, flavor combinations, and food choices.  But when foods are prepared in a cross-contaminated environment with ingredients we are allergic to, we cannot follow the old social constructs that do not serve us.  We need to work together to rewrite the rules, so that we can be included in social gatherings without fear of cross-contamination, and without offending anyone.
    Let’s figure out how to surmount these social situations together.  
    Each edition of this column will present a scenario, and together, we’ll determine appropriate, polite, and most importantly, safe ways to navigate this tricky gluten-free/food allergies lifestyle in a graceful way.  If someone disagrees with our new behavior patterns, we can refer them to this column and say, “Here are the new rules for those of us with food allergies or celiac disease.”  When we are guests in someone’s home, we can give them links to this column so they understand the plight we are faced with, bite after bite. Perhaps this will help those of us living with us to understand, be more compassionate, and accepting of our adaptations to keep ourselves safe. 
    This column will present a scenario such as the one above, and ask that you comment on how you would navigate it. Let’s talk about it. Let’s share ideas.  Using the example above, here’s the scenario for this issue:
    What would you do?
    Your kind-hearted friend invites you to dinner and insists on cooking for you.  You arrive and the first thing she says is, “I’ve spent all day making this for you. Oh, I bought this salad dressing for you, but you might want to read the ingredients first.”  You do, and it contains malt vinegar.  You look around the kitchen and notice evidence of cross-contamination in the rest of the meal.  What do you do? 
    Please comment below and feel free to share the tricky scenarios that you’ve encountered too.  Let’s discuss how to surmount these social situations.  What would you do?

    Jefferson Adams
    Celiac.com 07/12/2018 - Previous research has shown that the oral administration of Bifidobacterium infantis Natren Life Start super strain (NLS-SS) reduces of gastro-intestinal symptoms in untreated celiac disease patients. The reduction of symptoms was not connected with changes in intestinal permeability or serum levels of cytokines, chemokines, or growth factors. Therefore, researchers suspected that the reduction of symptoms might be related to the modulation of innate immunity.
    To test that hypothesis, a team of researchers set out to assess the potential mechanisms of a probiotic B.infantis Natren Life Start super strain on the mucosal expression of innate immune markers in adult patients with active untreated celiac disease compared with those treated with B. infantis 6 weeks and after 1 year of gluten-free diet.
    The research team included Maria I. Pinto-Sanchez, MD, Edgardo C. Smecuol, MD, Maria P. Temprano,RD, Emilia Sugai, BSBC, Andrea Gonzalez, RD, PhD, Maria L. Moreno,MD, Xianxi Huang, MD, PhD, Premysl Bercik, MD, Ana Cabanne, MD, Horacio Vazquez, MD, Sonia Niveloni, MD, Roberto Mazure, MD, Eduardo Mauriño, MD, Elena F. Verdú, MD, PhD, and Julio C. Bai, MD. They are affiliated with the Medicine Department, Farcombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada; the Small Intestinal Section, Department of Medicine and the Department of Alimentation at Dr. C. Bonorino Udaondo, Gastroenterology Hospital and Research Institute at the Universidad del Salvador in Buenos Aires, Argentina.
    The team determined the numbers of macrophages and Paneth cells, along with the expression of a-defensin-5 expression via immunohistochemistry in duodenal biopsies.
    Their results showed that a gluten-free diet lowers duodenal macrophage counts in celiac disease patients more effectively than B. infantis, while B. infantis lowers Paneth cell counts and reduces expression of a-defensin-5.
    This study documents the differential innate immune effects of treatment with B. infantis compared with 1 year of gluten-free diet. The team calls for further study to better understand the synergistic effects of gluten-free diet and B. infantis supplementation in celiac disease.
    Source:
    J Clin Gastroenterol