COMMENTARY

Should We All Go Gluten-Free?

William F. Balistreri, MD

Disclosures

February 04, 2016

In This Article

The Making of a Dietary Phenomenon

The question of whether to adopt a gluten-free diet is especially timely, given its impressive increase in popularity over the past decade. In fact, gluten avoidance has become the most popular dietary trend in the United States, with approximately 100 million Americans consuming gluten-free products last year.

Presently, there are at least three proposed clinical syndromes related to gluten ingestion: celiac disease, an autoimmune-mediated disorder; wheat allergy, an immunoglobulin E (IgE)-mediated entity; and gluten sensitivity, in which celiac disease and wheat allergy have been ruled out. Therefore, the decision to "go gluten-free" is either mandatory or elective; a gluten-free diet is mandatory for those individuals with appropriately diagnosed celiac disease and possibly wheat allergy. However, many individuals elect to follow a gluten-free diet because of a presumed sensitivity. While approximately 1% of the population are believed to have celiac disease, it is estimated that as many as 60% of Americans believe that a gluten-free diet will improve their physical and/or mental health.[1,2,3,4] It is their choice to follow a gluten-free diet in the hopes of improving digestion and bolstering their immune system, while also enabling enhanced performance and weight loss.

This belief has been fostered by the testimony of celebrities and athletes who attribute their success and well-being to adherence to a gluten-free diet. A survey done by Lis and colleagues[5] of 910 world-class athletes and Olympic medalists found that 41% followed a gluten-free diet, the majority because of a self-diagnosis of "sensitivity to gluten" and perceived ergogenic or health benefits. The same authors investigated the effects of a gluten-free diet on exercise performance, gastrointestinal symptoms, perceived well-being, intestinal injury, and inflammatory responses in nonceliac endurance athletes.[6] The short-term gluten restriction had no overall beneficial effect on any of these outcomes. In addition, numerous books and websites cater to this gluten-free phenomenon. Claims have even been made that gluten can be harmful to all of us.

The appeal of a gluten-free diet has become big business, leading to greater gluten-free product availability and a wider variety of dietary options. The market for gluten-free foods continues to expand and is estimated to have reached over $4 billion in retail sales in the past year. However, there are barriers to going gluten-free, including the cost and long-term safety of gluten-free foods and the potential for gluten cross-contamination of products. In addition, a gluten-free diet could present social restrictions, possibly leading to nonadherence.[7,8,9]

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