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  • Dr. Rodney Ford M.D.

    Gluten-Free Logic: The Three Steps

    Dr. Rodney Ford M.D.
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    Reviewed and edited by a celiac disease expert.

      Journal of Gluten Sensitivity Summer 2015 Issue - Originally published July 16, 2015


    Image: CC--Anders Sandberg
    Caption: Image: CC--Anders Sandberg

    Celiac.com 10/27/2015 - In 2006, I presented a research paper called "Who warrants a gluten-free diet?". At that time I was thinking about the sick children who were coming through my clinic with skin, gut and brain symptoms: that is they had eczema and itchy skin; sore tummies and constipation; and behaviour disturbances. It turned out that most of this group of children had high levels of Anti-Gliadin-Antibodies (AGA), of whom 80% got completely better when they went on a gluten-free diet. This was a landmark paper for me, and it led me to describe "The Gluten Syndrome".

    However, that was nearly 10 years ago! and a lot has happened since then. Perhaps most notable the publication of the consensus paper on the Spectrum of Gluten-Related-Disorders. The algorithm developed to diagnose gluten sensitivity/ intolerance relies on the elimination and challenge of gluten, rather than immunologic blood tests. I have been using the AGA test in my clinic since 1989 (that is for 25 years!) and I have found it extremely useful as a diagnostic test, when it is positive. But, many people react to gluten and have negative AGA results. So I agree with the authors of the "Spectrum" paper. The basis of a gluten-sensitivity/intolerance diagnosis should be based on elimination and challenge. Importantly, prior to removing gluten from your diet, please ensure that you get the appropriate tests for celiac disease (see this link for a gluten-blood-test discussion).



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    So who in the year 2015 should be suspected of having a gluten-related-illness? Well anyone who has chronic symptoms. Even if they have a diagnostic label - because they might have the wrong diagnosis. so here are the 3 steps in my gluten-free logic:

    Step ONE - the premise IF:

    • a) Gluten sensitivity is common: estimates show it affects over 10% of the population;
    • B) Gluten-related illnesses are varied and have multiple symptoms: a quote from the consensus paper on the Spectrum of Gluten-Related-Disorders emphasizes this. The symptoms in gluten sensitivity may resemble those associated with celiac disease but with a prevalence of extra-intestinal symptoms, such as behavioral changes, bone or joint pain, muscle cramps, leg numbness, weight loss and chronic fatigue. Their symptoms include abdominal pain (68%); eczema and/or rash (40%); headache (35%); "foggy mind" (34%); fatigue (33%); diarrhea (33%); depression (22%); anemia (20%); numbness in the legs, arms or fingers 20%; and joint pain (11%);
    • c) There is no definitive diagnostic test for gluten sensitivity: the Consensus paper goes on to say "However, currently there are no laboratory biomarkers specific for gluten sensitivity. Usually the diagnosis is based on exclusion criteria; an elimination diet of gluten-containing foods followed by an open challenge is most often used to evaluate whether health improves with the elimination or reduction of gluten from the patient’s diet";
    • d) There is no harm from going on a gluten-free diet; in other words a gluten-free is healthy.

    Step TWO - The logical THEN:
    Then the logical conclusion is that "anyone", with "any symptoms" that are "chronic and unexplained" (that is they do not have a definite diagnosis) and "at any time" (people can develop gluten-illness at any time in their life) should be put onto a gluten-free diet for a clinical trial for three months or more.

    Step THREE - The CONCLUSION:
    The logical conclusion is that whatever the blood-test results, and whatever the endoscopy results, and whatever the symptoms, a beneficial response to a gluten-free diet suggests that their illness is gluten-related (some people might demand a double blind food challenge).

    Comment
    Up until now, most gluten/celiac doctors have dismissed the idea that their patients might be suffering from "non-celiac gluten-sensitivity" (NCGS). They have attributed their patients beneficial response to a gluten-free diet as a placebo response (all in their head!). This is clearly not the case. There is mounting evidence for this: see this research paper - Small Amounts of Gluten in Subjects with Suspected Nonceliac Gluten Sensitivity: a Randomized, Double-Blind, Placebo-Controlled, Cross-Over Trial. In this paper the authors conclude: "In a cross-over trial of subjects with suspected NCGS, the severity of overall symptoms increased significantly during 1 week of intake of small amounts of gluten, compared with placebo".

    The above logic means that ALL people, with ANY undiagnosed illnesses, at any TIME in their life, should be given a gluten-free trial. This is likely to have huge health benefits and wide ramifications on the management and burden of ill health on the community. Already 10% of Australians and Canadian are adopting a gluten-free diet, and 30% percent of adults in the USA are interested in avoiding or cutting down on gluten in their diets, says a survey from the NPD Group, a consumer research firm. NDP has been following gluten-free issues since 2009 and its January 2013 survey revealed the highest interest in gluten-free diets yet (reported in HuffPost - 26 Feb 2015).

    It is my prediction that in another generation most people who wish to stay healthy, will choose to adopt a gluten-free diet, before they get harmed by gluten.

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    Thank you for your voice of logic, Dr. Ford. I have thought for a long time that anyone who has chronic, unexplained symptoms should try the gluten free diet, after, as you mentioned, first getting tested for celiac disease. I had two big symptoms but also many minor symptoms I never would have suspected to be from gluten that all disappeared after adopting a gluten-free diet that has led to a far superior quality of life. Even today, after 17 years, something will pop into my mind that makes me realize "that doesn't happen to me anymore." For instance, I no longer routinely get bronchitis after a cold (and, in fact, rarely even get colds). No more recurrent strep throat, canker sores, muscle spasms and subluxions, esophageal spasms, white spots on my finger nails or heart palpitations, besides the biggies of chronic migraine and diarrhea. I am not diagnosed celiac because I tried the gluten-free diet on my own and didn't have the testing first. But I know I never looked back.

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    P.S. I am glad to hear that you find the AGA to be very useful. When I worked for the Center for Celiac Research (15 years ago), the tTg test was on the verge of making the AGA obsolete and I argued strongly for keeping it in the arsenal which caused a bit of conflict there! I tried to improve the sensitivity of the assay by expanding the ELISA target to other gliadin molecules besides alpha but don't think I knew to include deamidated gliadin. But I felt strongly in my gut that there was more to gluten sensitivity than celiac disease and it's nice to feel vindicated.

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    Love to hear that gluten sensitivity is being treated as real. I went gluten free 4 years ago because of sinus allergies. 3 doctors were not helping me. I went gluten free on my own. At first I could fudge a little. Then I realized that I had stomach pain and diarrhea every time that I ate gluten. I have had stomach problems for over 20 years that the doctor could not figure out what was the cause. I might add that I have suffered with eczema most of my life. I became more diligent at staying off the gluten. Over time I realized that my restless leg problem is severe when I get a hold of something with gluten. This usually is from cross contamination at a restaurant. It is like my body was fighting a war inside while the outside of me just wants to go to sleep. Gluten free is my normal life now. I will never go back.

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  • About Me

    Dr. Rodney Ford is a Pediatric Gastroenterologist. He was Professor of Pediatrics at the Christchurch School of Medicine. He runs the Children's Gastroenterology and Allergy Clinic in New Zealand. He has written a series of 7 books on gluten (www.DrRodneyFord.com). His main theory is that symptoms from gluten reactions arise from brain and nerve damage. His latest book is "The Gluten Syndrome" which encapsulates current ideas and concepts of gluten and the harm that it does.


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