(JEAN, 37)
Are You a PWAG?
PWAGs (pronounced pee-wags) stands for people who avoid wheat and gluten. It is a term coined by a group of gastroenterologists to encompass the huge numbers of patients they have been seeing who go on a gluten-free diet because of what they describe as an intolerance to wheat products in the absence of celiac disease.
Many of these patients have a higher prevalence of the genes associated with celiac disease (the HLA-DQ typing). And one study showed that PWAGs had a higher number of medical diagnoses for other food intolerances and small intestine bacterial overgrowth (SIBO).
If you are a PWAG, there are many reasons you made this decision—disease treatment, symptoms relief, perception of a healthier way to be, recommended by a health care professional, etc. And an equal variation in its success.
First and Foremost—What Is Gluten?
Gluten is the general term used to describe the storage protein of wheat. Wheat is approximately 10 to 15 percent protein—the remainder is starch. Gluten is what remains after the starch granules are washed from wheat flour. The gluten fraction that is most studied in celiac disease is gliadin, but there are other proteins that chemically resemble gliadin in rye (secalins) and barley (hordeins). These proteins are not strictly glutens, but are generally included in the term. There are other proteins in wheat (See chapter 11, “Gluten and Nongluten Grains”) that may also be problematic for PWAGs and are part of the complex reason why the diet works for some, only partially for others, or not at all.
Why a Gluten-Free Diet Works
You have celiac disease and the diet fixes the inflamed intestine.
A gluten-free diet is a lifesaver for those with celiac disease and is a proven medical treatment. If followed carefully, it resolves symptoms, rebuilds nutritional stores depleted by a damaged intestinal lining, and, in children, rebuilds bone loss caused by malabsorption of calcium. (See chapter 17, “Celiac Disease.”)
You have nonceliac gluten sensitivity (NCGS) and the diet relieves symptoms (neurological, skin, gastrointestinal).
Many individuals who feel or have been told that they have NCGS—again, there are currently no diagnostic tests for this condition—find relief with gluten withdrawal for neurological disorders, skin rashes, and GI symptoms such as gas and bloating. (See chapter 18, “Gluten Sensitivity.”)
You have irritable bowel syndrome (IBS), and elimination diets have resolved some or all of the gas, bloating, and pain.
IBS may be due to a sensitivity to a food that most tolerate without problems. It is a diagnosis of exclusion—other tests having proven negative—and dietary restriction can be successful, often only partially, for those patients with carbohydrate intolerances. (See chapter 12, “Carbohydrates and FODMAPs,” and chapter 19, “Irritable Bowel Syndrome.”)
You just think it works so it does.
A placebo is not only the archetypal sugar pill but anything that impacts a patient’s expectations.
Why a Gluten-Free Diet Does Not Work
The main reason a gluten-free diet does not work is that gluten is not the issue and/or you may be missing treatment for another disease.
This may include:
SIBO
Fructose intolerance
Lactose intolerance
Other food intolerances
Microscopic colitis
Gastroparesis (a condition where the stomach cannot empty properly)
Pelvic floor dysfunction (weak muscles in the pelvic floor, often caused by childbirth)
A problem related to a medication you are taking
After a thorough medical evaluation, we find that many PWAGs have a variety of conditions and may, in fact, be able to eat gluten again, symptom free, with proper diagnosis and treatment.
You may be on a gluten-free diet but other types of carbohydrates, e.g., fructose, are the problem. (See chapter 12, “Carbohydrates and FODMAPs.”)
You’re under the impression that the diet is a cure-all for many health-related ailments.
A survey by Consumer Reports showed that 63 percent of North Americans think that a gluten-free diet improves physical or mental health, and 33 percent buy gluten-free products because they believe these foods will improve digestion and gastrointestinal function. Unless you have celiac disease or a specific carbohydrate intolerance, a gluten-free diet will not work for either of these issues.
The diet does not work to lower cholesterol or strengthen your immune system, even though many people believe it does.
The diet is disrupting your intestinal flora—the microbiome—and causing symptoms.
Restrictive diets—gluten-free, low-FODMAP—have been shown to reduce the richness and diversity of our intestinal microbiota, which in turn may cause persistent symptoms in patients with celiac disease and possibly other conditions. While it is unclear exactly what this disruption means or the long-term effects, it is generally believed that a diverse microbiome is healthier. While there is no one “healthy” microbiome, the studies on this should be watched. (For more, See chapter 9, “The Microbiome.”)
People should make every effort to diversify their diets. This may be particularly important as people age. Aging is known to be associated with a reduced diversity of the gut microbiome, and this may lead to a compromised intestinal barrier and increased susceptibility to infectious diseases and infections.
If a disrupted microbiome is a side effect of a gluten-free diet, these consequences should be considered before you embark on a gluten-free regimen unless you have celiac disease.
Will It Work in Other Ways?
Can I lose weight on a gluten-free diet?
Some go on a gluten-free diet to lose weight. This works if you exclude but do not replace wheat as the main carbohydrate. In animal studies a gluten-free diet prevented the development of obesity and metabolic disorders. BUT, while gluten was eliminated from the diet, the mice were not fed replacements with gluten-free products. The no–white food or Atkins diet (no bread, pasta, potatoes, rice, cake, or cookies) will usually ensure weight loss but can be nutritionally inadequate if enough fruit and vegetables are not substituted for those carbohydrates. It is also hard to sustain.
Will I have more energy?
Unfortunately, if you do not have celiac disease, a gluten-free diet is not likely to make you the Energizer Bunny. Although many people insist that they feel logy or tired after eating gluten, there is little scientific evidence to support this. Postprandial fatigue (which occurs after eating) is common, especially after a large