Nutrition Publication

Gluten - Friend or Enemy?

Editor(s): R. Shamir, H. Szajewska. 73 / 3

The global food supply depends heavily on the availability of cereal-based food products, with wheat being one of the largest crops in the world. The high demand is due to the unique properties of wheat gluten, which has a high nutritional value and is crucial for the preparation of high-quality dough.In the last 10 years, however, wheat and gluten have received much negative attention. Many people believe that wheat is inherently bad for our health, and try to avoid consumption of gluten-containing cereals - a low-gluten lifestyle so to speak. In reality, there is only one medical condition where gluten is definitively the culprit: celiac disease.

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Primary Prevention of Celiac Disease: Environmental Factors with a Focus on Early Nutrition

Author(s): A. Chmielewska, M. Pieścik-Lech, H. Szajewska, R. Shamir

Celiac disease (CD) is a common autoimmune disordercaused by ingestion of gluten. When diagnosed, it should betreated with a lifelong, strict gluten-free diet. Early infantfeeding practices have been suggested as a means of preventingCD. In the last few decades, observational data havesuggested that breastfeeding, especially at the time of introducinggluten into the infant’s diet, as well as the time and mode of gluten first being given to a child could prevent ordelay the occurrence of CD. As a result, recommendationsadvised that it is prudent to avoid both early (<4 months) andlate (>7 months) introduction of gluten, and to introducegluten gradually while the infant is still being breastfed, asthis may reduce the risk of celiac disease, type 1 diabetesmellitus, and wheat allergy. Recently, the results of two largerandomized trials have shown that breastfeeding in general,breastfeeding during gluten introduction, and early or delayedgluten introduction do not influence the total risk ofCD in genetically predisposed individuals. Introducing glutenat 4 versus 6 months in very small amounts, or at 6 versus12 months, resulted in similar rates of CD in these children.Thus, early feeding practices seem to have no impact on therisk of developing CD during childhood. In children withoutthe genetic predisposition, the age and mode of gluten introductiondo not influence the risk anyway.

Microbiome and Gluten

Author(s): Y. Sanz

Celiac disease (CD) is a frequent chronic inflammatoryenteropathy caused by gluten in genetically predisposedindividuals that carry disease susceptibility genes (HLADQ2/8).These genes are present in about 30–40% of the general population, but only a small percentage of carriersdevelops CD. Gluten is the key environmental trigger of CD,but its intake does not fully explain disease onset; indeed,an increased number of cases experience gluten intolerancein late adulthood after many years of gluten exposure.Consequently, additional environmental factors seem to beinvolved in CD. Epidemiological studies indicate that commonperinatal and early postnatal factors influence bothCD risk and intestinal microbiota structure. Prospectivestudies in healthy infants at risk of developing CD also revealthat the HLA-DQ genotype, in conjunction with otherenvironmental factors, influences the microbiota composition.Furthermore, CD patients have imbalances in theintestinal microbiota (dysbiosis), which are not fully normalizeddespite their adherence to a gluten-free diet.Therefore, it is hypothesized that the disease can promotedysbiosis that aggravates CD pathogenesis, and dysbiosis,in turn, can initiate and sustain inflammation through theexpansion of proinflammatory pathobionts and decline ofanti-inflammatory mutualistic bacteria. Studies in experimentalmodels are also contributing to understand the roleof intestinal bacteria and its interactions with a predisposedgenotype in promoting CD. Advances in this areacould aid in the development of microbiome-informed interventionstrategies that optimize the partnership betweenthe gut microbiota and host immunity for improvingCD management.

Gluten Sensitivity

Author(s): C. Catassi

Non-celiac gluten sensitivity (NCGS) is a syndrome characterizedby intestinal and extraintestinal symptoms related tothe ingestion of gluten-containing food in subjects who arenot affected by either celiac disease (CD) or wheat allergy (WA). The prevalence of NCGS is not clearly defined yet. Indirectevidence suggests that NCGS is slightly more commonthan CD, the latter affecting around 1% of the general population.NCGS has been mostly described in adults, particularlyin females in the age group of 30–50 years; however,pediatric case series have also been reported. Since NCGSmay be transient, gluten tolerance needs to be reassessedover time in patients with NCGS. NCGS is characterized bysymptoms that usually occur soon after gluten ingestion,disappear with gluten withdrawal, and relapse followinggluten challenge within hours/days. The ‘classical’ presentationof NCGS is a combination of irritable bowel syndromelikesymptoms, including abdominal pain, bloating, bowelhabit abnormalities (either diarrhea or constipation), andsystemic manifestations such as ‘foggy mind’, headache, fatigue,joint and muscle pain, leg or arm numbness, dermatitis(eczema or skin rash), depression, and anemia. In recentyears, several studies explored the relationship between theingestion of gluten-containing food and the appearance ofneurological and psychiatric disorders/symptoms like ataxia,peripheral neuropathy, schizophrenia, autism, depression,anxiety, and hallucinations (so-called gluten psychosis). Thediagnosis of NCGS should be considered in patients withpersistent intestinal and/or extraintestinal complaints showinga normal result of the CD and WA serological markers ona gluten-containing diet, usually reporting worsening ofsymptoms after eating gluten-rich food. NCGS should notbe an exclusion diagnosis only. Unfortunately, no biomarker is sensitive and specific enough for diagnostic purposes;therefore, the diagnosis of NCGS is currently based on establishinga clear-cut cause-effect relationship between the ingestionof gluten and the appearance of symptoms by astandardized double-blind, placebo-controlled gluten challenge.

Adverse Effects of Wheat Gluten

Author(s): F. Koning

Man began to consume cereals approximately 10,000 yearsago when hunter-gatherers settled in the fertile golden crescentin the Middle East. Gluten has been an integral part ofthe Western type of diet ever since, and wheat consumptionis also common in the Middle East, parts of India and Chinaas well as Australia and Africa. In fact, the food supply in theworld heavily depends on the availability of cereal-basedfood products, with wheat being one of the largest crops inthe world. Part of this is due to the unique properties ofwheat gluten, which has a high nutritional value and is crucialfor the preparation of high-quality dough. In the last 10years, however, wheat and gluten have received much negative attention. Many believe that it is inherently bad for ourhealth and try to avoid consumption of gluten-containingcereals; a gluten-low lifestyle so to speak. This is fueled bya series of popular publications like Wheat Belly ; Lose theWheat, Lose the Weight , and Find Your Path Back to Health .However, in reality, there is only one condition where glutenis definitively the culprit: celiac disease (CD), affecting approximately1% of the population in the Western world.Here, I describe the complexity of the cereals from whichgluten is derived, the special properties of gluten whichmake it so widely used in the food industry, the basis for itstoxicity in CD patients and the potential for the developmentof safe gluten and alternatives to the gluten-free diet.