Gluten Freedom: my thoughts on the book

I just finished reading Dr. Alessio Fasano's book, Gluten Freedom, and it is amazing!  Definitely a must-read for any clinician who works with patients suffering from digestive, dermatological, neurological conditions or for anyone who is a patient and thinks they might have a gluten-related condition.  It is especially helpful for anyone whose doctor has ever said "it's all in your head"!

The leading expert in gluten-related disorders, Dr. Fasano tells the history of celiac disease, explains the improvements in diagnostic methods throughout the years, and also covers the spectrum of non-celiac, gluten-related disorders, including wheat allergy (think hives and difficulty breathing) and the more recently accepted non-celiac gluten sensitivity (NCGS) - which is a real condition!  He uses friendly analogies to explain scientific concepts and includes multiple real-patient stories to help illustrate key points, both of which make the book fun and easy to read.

I read the book Wheat Belly last fall and, although I enjoyed the facts Dr. William Davis provided, I didn't agree with his point of view that everyone should avoid high-yield, semidwarf wheat.  Indeed, there are scientist who believe that gluten is toxic for humankind and everyone should follow a gluten-free diet. While there is some evidence to support this -- for example, it is true that no one is able to completely digest the protein gluten and that that fragments of undigested gluten peptides can make the intestines leak, attract immune cells into the intestines causing inflammation, or kill cells -- it doesn't make sense that a food that humans have been eating for thousands of years is the root of all disease.

Zonulin and Its Regulation of Intestinal Barrier Function:
The Biological Door to Inflammation, Autoimmunity, and Cancer
Read the study here

Although Dr. Fasano has contributed to the above discoveries about gluten, he does not share the same position.  Instead, he writes that "we engage daily in a ware with many dangerous bacteria but rarely do we lose this battle, which is an event that leads to infection.  We are also engaged in daily confrontation with gluten, but only a minority of us will lose this battle.  These are the genetically susceptible individuals who will develop gluten-related disorders."

My own beliefs align more closely with those of Dr. Fasano, that only genetically susceptible individuals need to follow a gluten-free diet.  Instead of silver bullets and one-size-fits-all approaches, it is my opinion that practicing personalized medicine is the best way to help clients achieve health.  How do you know if you need to follow a gluten-free diet?  Learn more here!

Perhaps my favorite part of the book is near the end when Dr. Fasano gives an overview of the human genome project ("genomics") - how many scientists thought that cracking the code would help us better understand and eradicate human disease...until we realized that humans actually have way fewer genes than originally expected...so we focused on "proteomics," which also failed to answer our complex questions about health.... so we eventually turned to "microbiomics."

Ultimately, he hypothesizes that humankind is made up of two genomes - the human genome and our individual microbiome, which is expressed by the trillion of bacteria that live on and in us.  He advocates for vaginal birth (the best way to inoculate baby with a healthy dose of probiotics) and concludes by saying "In my opinion, the result of this interplay between the human genome and the human microbiome ultimately holds the key to the answer of how to maintain the yin and yang between health and disease."

Check out this NPR story - Finally, a map of all the microbes on your body

It is obvious that Dr. Fasano has spent his life dedicated to "increasing the awareness of celiac disease in order to provide better care, better quality of life, and more adequate support for the celiac disease community," -- the paramount goal of the Center for Celiac Research, which he founded in 1996.  When treating his first patients, Dr. Fasano asked them to write down their top three wishes in regard to celiac disease.  Here are the "Aladdin's lamp" wishes:

1. A treatment alternative to the gluten-free diet
2. Improving their quality of life by educating physicians about celiac disease and by providing more palatable gluten-free food
3. A way to avoid the cumbersome intestinal biopsy as a necessary step to diagnose celiac disease, especial for children.

Nearly 20 years later, almost all three wishes have been granted.

This book inspires me to finally choose ONE thing to focus on and become an expert at something, just as Dr. Fasano has become an expert on celiac disease and gluten-related disorders.  It also reminds me how much I love the mystery of the gut - this black box where food goes in one end, waste comes out the other, and exactly what happens in between is largely unknown.  If I had to bet, I would bet that the next big discovery in health and medicine has to do with the microbiome.  I just hope that I can be a part of it!

Should I follow a Gluten Free diet?

There is currently a lot of confusion around gluten.  Due to increasing availability of gluten-free products as well as coverage in the media, more and more people are choosing to follow a "gluten-free" diet.  What amazes (and worries) me is that some folks adopt this diet without even knowing what gluten is!

What is gluten?
Gluten is the general name for proteins, gliadin and glutenin, found in the cereal grains wheat, rye, barley and triticale that makes bread dough elastic enough to rise, giving it that light and fluffy texture (read more here).

This picture came from grist.org (follow link above)

Who should avoid gluten? 
People who have celiac disease, an autoimmune disorder that affects approximately 1 in 100 people, must avoid gluten because ingestion of gluten leads to damage in the small intestine.  Left untreated, celiac disease can cause serious health problems such as vitamin and mineral deficiencies (including anemia), early onset osteoporosis, infertility, and gastrointestinal cancers (read more about celiac disease at The Celiac Disease Foundation).  Until new treatments are approved (e.g. Lazarotide acetate), people diagnosed with celiac disease must follow a gluten-free diet to remain healthy.

What about the other 99%?
Although many people claim to feel better when they follow a gluten-free diet, the scientific community is still conflicted as to whether individuals without celiac disease might benefit from a gluten free diet.

Some scientists, like Dr. William Davis, believe that gluten is toxic for humankind and everyone should follow a gluten-free diet.  There is some evidence to support this.  For example, it is true that no one is able to completely digest gluten.  It is also true that fragments of undigested gluten peptides can make the intestines leak, attract immune cells into the intestine causing inflammation, or kill cells.

Zonulin and Its Regulation of Intestinal Barrier Function:
The Biological Door to Inflammation, Autoimmunity, and Cancer
Read the study here

However, according to Dr. Alessio Fasano, the leading expert in gluten-related disorders, "we engage daily in a war with many dangerous bacteria but rarely do we lose this battle, which is an event that leads to infection.  We are also engaged in daily confrontation with gluten, but only a minority of us will lose this battle.  These are the genetically susceptible individuals who will develop gluten-related disorders."

Who are these genetically susceptible individuals?
In addition to celiac disease, there exist spectrum of non-celiac, gluten-related disorders, including well-known wheat allergy (think hives and difficulty breathing) and the more recently accepted non-celiac gluten sensitivity (NCGS) - which is a real condition!

How do I know if I have gluten sensitivity?
While there are several diagnostic tests for celiac disease -- including elevated levels of tissue transglutaminase (tTG), the presence of genetic markers HLA-DQ2 or -DQ8 and, of course, the "gold standard" intestinal biopsy -- a biomarker for gluten sensitivity has not yet been found.  However, researchers at the Center for Celiac Research are working hard to identify one!  I am excited for this!  Once a biological marker is discovered, we will be able to measure levels in the body, making it much easier to figure out whether or not insidious symptoms like gas, bloating, muscle aches and brain fog are being caused by gluten!

What the heck are FODMAPS?
The tricky thing is that sometimes gastrointestinal (GI) distress is caused by the ingestion of FODMAPs. FODMAP stands for Fermentable Oligo-saccharides, Di-saccharides, Mono-saccharides, and Polyols. These sugars, when poorly absorbed, draw water into the intestines (diarrhea) and feed colonic bacteria (resulting in gas and bloating). While glutenous foods are a type of FODMAP (i.e. they contain oligo-saccharides), there exist many other foods that may be contributing to GI discomfort if you are sensitive to FODMAPs. This is a new area of research, but I do my best to explain it here (link coming soon!).

Which condition do I have?

The best way to determine if a gluten-free diet is appropriate for you is to see your doctor or dietitian nutritionist.  Before you change your diet, it is imperative to get tested to rule out celiac disease.  Once you stop eating gluten, your body no longer produces the biomarkers (i.e. tTG, villous atrophy) needed to diagnose the disease.  If your doctor is not up-to-date on the latest gluten-related research, recommend that he or she read the book Gluten Freedom by Dr. Alessio Fasano and/or the book released by The Mayo Clinic this past November called Mayo Clinic Going Gluten Free, which provides the checklist* for diagnosing non-celiac gluten sensitivity.
*checklist available in New York Times article, here

My own beliefs align more closely with those of Dr. Fasano, that only genetically susceptible individuals need to follow a gluten-free diet.  Instead of silver bullets and one-size-fits-all approaches, it is my opinion that practicing personalized medicine - which considered genetics (fixed), microbiomics (modifiable) and environmental factors (culture) - is the best way to help clients achieve health.

I just finished reading Dr. Fasano's book, Gluten Freedom, and it is amazing!  Read my review here.