Gluten mad!

Tonight as I was browsing Facebook again, I came across an article a person had posted on gluten. The article claimed that gluten is connected to depression, and indeed, nearly every other neurological disorder for good measure.

Gluten is a protein found in certain grains like wheat, barley and rye. Gluten also makes foods taste better and improves their texture, so it’s often added to everything else.

The “gluten is toxic” meme is a very catchy one that’s doing the rounds again. I first heard of the idea that gluten is the cause of nearly every disease when I was in medical school, when every person I knew who’d seen a naturopath was told they had gluten intolerance and were conned into an unappetising and restrictive diet which didn’t make any of them better.

The same meme is now making it’s way back around again now that the low-fat, sugar-free, zucchini broth-type diet fads are waning.

The proposed link between depression, anxiety and gluten is a new twist to the old story. But with depression becoming a preeminent disease in the 21st century, the link doesn’t surprise me.

So what does the evidence say? Is gluten the culprit behind the modern scourge of mental illness?

I certainly don’t think so, at least according to my interpretation of the medical literature. As far back as 2001, researchers studying the mental health of patients with coeliac disease noted that coeliac disease patients had much higher levels of anxiety and depression than healthy matched controls (up to about three to six times greater in one study), and after a year on a gluten free diet, there were no changes to the rates of anxiety and depression (Addolorato et al., 2001).

In more recent times, larger studies have been performed. Hauser, Janke, Klump, Gregor, and Hinz (2010) confirmed higher levels of anxiety in German female coeliac patients who were on a gluten free diet, compared to the normal controlled population. Mazzone et al. (2011) showed that children with coeliac disease on gluten-free diets for about 7 years on average still showed an increased rate of anxiety and depression symptoms and showed higher scores in “harm avoidance” and “somatic complaints” as compared to healthy control subjects.

A larger cross sectional survey was performed in the Netherlands in 2013, on 2265 adults with coeliac disease (van Hees, Van der Does, & Giltay, 2013). That survey showed that a significantly higher proportion of those with coeliac disease, despite being on a strict gluten free diet, reporting a higher rate of anxiety and depression compared to the general population. It also showed (albeit in a smaller subgroup of respondents) that poor adherence with a gluten free diet did not affect the likelihood of depressive symptoms.

To be fair, cross sectional surveys and longitudinal cohorts aren’t necessarily the strongest form of evidence, but it is the best we’ve currently got. There was a recent randomised controlled trial, a stronger form of evidence, looking at the effect the introduction of gluten had on depressive symptoms in people who did not have coeliac disease but reported gluten sensitivity and were controlled on a gluten free diet (Peters, Biesiekierski, Yelland, Muir, & Gibson, 2014). While this showed some worsening of depressive symptoms in those subjects given gluten, the exposure was short, the effect was moderate, and the results should be considered cautiously given the small number of subjects reduced the power of the study.

Given the weight of evidence, I can’t help but be sceptical of books touting the ‘gluten = depression’ theory, books like “Grain Brain”. It’s author, American neurologist Dr David Perlmutter, attests that more than 38 different diseases are caused by gluten, including autism and depression. If you believe the celebrity chiropractor who reviewed Perlmutter’s work (http://www.glutenfreesociety.org/gluten-free-society-blog/gluten-leaky-brain-the-connection-to-depression/), increased intestinal permeability and intestinal dysbiosis (“leaky gut” and bad gut bacteria) combine to increase inflammation in the blood and in the brain, causing depression.

But correlation does not equal causation. Just because brain diseases, inflammation and gut problems tend to occur together does not prove that gut problems cause inflammation and brain problems. Rather, the evidence suggests that it’s the other way around, with all of the processes linked to genetics.

For example, autism is related to a number of genes that both reduce the proteins that help nerve cells grow branches (Won, Mah, & Kim, 2013), and at the same time, switch on a low grade form of inflammation (Onore, Careaga, & Ashwood, 2012). I believe it’s the pre-existing inflammation that adds to the cellular dysfunction of the brain and at the same time, promoting low grade inflammation of a number of organs, including the gut. It’s the pre-existing inflammation that causes the gut to become “leaky”, not the “leaky” gut causing the inflammation.

Because if gluten was the primary cause, then why do people with coeliac disease who do not eat gluten report more depressive and anxious symptoms than control groups who do eat gluten? Why would those with coeliac disease who are eating sporadic gluten be just as depressed as those patients who do not?

If you don’t have coeliac disease, then gluten free diets are just like Amway products. You really don’t need them, and you could probably do much better without them. All you’re really doing is just making someone else obscenely rich.

Not only are you wasting your money, but you might also be harming your health by eating gluten free foods, since most foods that are stripped of gluten are also stripped of most of their other nutrients.

As Nash and Slutzky (2014) summarise, “Every major change in our diet carries with it the possibility of unforeseen risks. Many readers — the general public, as well as medical professionals — accept what they read at first glance. Myths have been part of our medical lore for millennia. Those jumping on the gluten-free/high-fat bandwagon may be disappointed when their symptoms are not mitigated; more critically, they may be at increased risk for other, more dangerous ailments.”

If you really think you feel better off gluten, then talk to your doctor or registered dietician to make sure you remain healthy off it.

References

Addolorato, G., Capristo, E., Ghittoni, G., Valeri, C., Masciana, R., Ancona, C., & Gasbarrini, G. (2001). Anxiety but not depression decreases in coeliac patients after one-year gluten-free diet: a longitudinal study. Scand J Gastroenterol, 36(5), 502-506.

Hauser, W., Janke, K. H., Klump, B., Gregor, M., & Hinz, A. (2010). Anxiety and depression in adult patients with celiac disease on a gluten-free diet. World J Gastroenterol, 16(22), 2780-2787.

Mazzone, L., Reale, L., Spina, M., Guarnera, M., Lionetti, E., Martorana, S., & Mazzone, D. (2011). Compliant gluten-free children with celiac disease: an evaluation of psychological distress. BMC Pediatr, 11, 46. doi: 10.1186/1471-2431-11-46

Nash, D. T., & Slutzky, A. R. (2014). Gluten sensitivity: new epidemic or new myth? Every major change in our diet carries with it the possibility of unforeseen risks. Am J Cardiol, 114(10), 1621-1622. doi: 10.1016/j.amjcard.2014.08.024

Onore, C., Careaga, M., & Ashwood, P. (2012). The role of immune dysfunction in the pathophysiology of autism. Brain Behav Immun, 26(3), 383-392. doi: 10.1016/j.bbi.2011.08.007

Peters, S. L., Biesiekierski, J. R., Yelland, G. W., Muir, J. G., & Gibson, P. R. (2014). Randomised clinical trial: gluten may cause depression in subjects with non-coeliac gluten sensitivity – an exploratory clinical study. Aliment Pharmacol Ther, 39(10), 1104-1112. doi: 10.1111/apt.12730

van Hees, N. J., Van der Does, W., & Giltay, E. J. (2013). Coeliac disease, diet adherence and depressive symptoms. J Psychosom Res, 74(2), 155-160. doi: 10.1016/j.jpsychores.2012.11.007

Won, H., Mah, W., & Kim, E. (2013). Autism spectrum disorder causes, mechanisms, and treatments: focus on neuronal synapses. Front Mol Neurosci, 6, 19. doi: 10.3389/fnmol.2013.00019

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The end of the sugar obsession?

I was flicking through Facebook this evening as I usually do, hoping to vicariously share someone else’s joy in life, when I came across this little tidbit, “You know what? Don’t quit sugar.”

The link was to a blog on mamamia.com.au (http://www.mamamia.com.au/health-wellbeing/you-know-what-dont-quit-sugar/) which asked if the tide of the quit sugar obsession was starting to recede.  It discussed the recent post of Sarah Wilson, a journalist for Fairfax and the author of several books on quitting sugar, which have become immensely popular by tagging on the coat-tails of David Gillespie’s “Sweet Poison” books.

In her blog, Wilson confessed to a barely forgivable sin of giving in to peer pressure and eating two chocolate croissants, then emotionally self-flagellating for the rest of the day.  That the symptoms that she described fitted nicely into the category of an anxiety neurosis didn’t seem to register with Wilson, who carried on like she had ingested a large goblet of hemlock.

Credit to the mammamia team who published some of the comments of real nutritionists like Cassie Platt, and eating-disorder counsellors like Paula Kotowitz, who said,

“Being harsh on ourselves, not only does not help, but makes us feel so much worse in the long run because it deconstructs our sense of self and causes us to beat up on ourselves. Isn’t it possible that there is a happy medium in there somewhere? It’s not crack. Just food.”

Platt, who is about to release a book titled, “Don’t Quit Sugar”, says,

“Your food choices should be based on biological and metabolic needs. What we eat should fuel our cells, facilitate growth, repair and reproduction and, most importantly, enable your body to function at its very best.”

Platt said that she has previously tried removing sugar from her diet and that she had to “claw” her way back to health.

The mamamia writing team summed up by saying,

“The benefits of reducing sugar intake are widely accepted in the scientific community but the idea of avoiding it altogether remains an issue of serious contention. And the possibility that these sorts of diet programs can mask dangerous eating disorders, is particularly worrying.”

They asked the question, “Has the sugar-quitting backlash begun?”  For the love of all things sacred, I seriously hope so.

About a month ago I wrote a piece about the quit sugar fad, and posted evidence that eating an extremely low carbohydrate diet is no better than eating a low fat diet, because it’s calories, not sugar, that makes all the difference to weight gain or loss.

A balanced, low calorie diet has been pushed by nutritionists and doctors ad nauseum for decades, but consistently neglecting to use words like “poison”, “toxin” or “death” has meant that the message is nowhere near as stimulating as the current whim.

Is it possible to have your cake and eat it too?  Absolutely.  My hero of nutritional science, Dr Rosemary Stanton, spoke at a Brisbane conference a couple of years ago and succinctly debunked Gillespie, Wilson and their ilk.  She also explained the concept of feasting, the long forgotten art form of having exceptionally good food once in a while, and enjoy it with friends, rather than eating substandard food every day by yourself, which is the modern trend.

Rather than gorging on sugar every day to compensate for your loneliness and despair, Dr Stanton advocated a diet high in vegetables and little or no processed food on a daily basis.  But then once a month or two, she advised to enjoy your favourite food, no matter what it might happen to be – cheesecake, ice cream, chocolate croissants – anything you like.  The only rules were to make sure that it is really good quality, the best that you can afford, so that it is worth savouring and looking forward to next time, and enjoy it with friends, since the social aspects of the food we eat are as important as the nutritional value.  Sage advice from someone who has been researching nutrition for longer than I’ve been alive.

I’m sure that by now, Sarah Wilson will have got over her sugar intoxication.  She may not have enjoyed it, but I hope that ends up being a pivotal moment in correcting the imbalance in our relationship to sugar, and living by the facts, not the latest fad.