The presence of food labeled as gluten-free has been increasing substantially in food stores and restaurants over the past several years. This is really good news for people who have celiac disease. This condition affects approximately 0.7 percent of the human population, about 1 out of 143 people, with variations among different populations. In the United States, the prevalence, at 1 per 133 (0.75%), is slightly above the world prevalence, while certain European countries report somewhat higher prevalence, the highest being Finland, where nearly 2 percent of the population is reported to suffer from celiac disease. But these numbers pale in comparison to the numbers of people who intentionally avoid gluten in various countries, such as in the United States, where roughly 30 percent of people believe that gluten is bad for them, and thus seek out gluten-free foods. Consequently, worldwide, gluten-free processed food is a multi-billion industry —an industry that is growing, despite the fact that it’s not healthy for people without celiac disease to avoid high-gluten foods. Avoiding high-gluten foods means that you are avoiding some very important nutrients, nutrients that are valuable to your pregnancy health.
Whether pregnant or not, people who have celiac disease must, absolutely, avoid all dietary gluten. The reason is that gluten, a protein present in the grains of certain cereals, such as wheat, triggers what doctors call an hypersensitivity reaction —an inappropriate, excessive response of the immune system— in the small intestine of people who have a genetic defect underlying celiac disease. The hypersensitivity reaction is so bad that the inner lining of the intestine is damaged, leading to terrible gastrointestinal effects, such as diarrhea, which often contains blood and mucus, and malabsorption of food and micronutrients. Thus, over the long-term, people with untreated celiac disease suffer from malnutrition, with all of its complications. The condition can be treated with a gluten-free diet, but people who must eat gluten-free on account of celiac disease must make an extra effort to obtain particular nutrients, such as iron and B vitamins, including folic acid, all of which are present in the whole grain foods that contain gluten and also are particularly vital to consume during pregnancy. Consequently, if you have no reason to avoid gluten —and the only reason for avoiding gluten is if you have celiac disease— then you ought not avoid gluten, because avoiding gluten means that you are avoiding whole wheat, and whole other grains, such as rye, barley, and triticale (all of which also contain gluten).
For much of human history, avoiding gluten would also have meant avoiding protein. One main reason why we humans have a civilization, full of devices and agricultural and biomedical technology that benefits all of us, is that approximately 12,000 years ago our ancestors initiated the Neolithic Revolution. This happened because they found some varieties of grass, the ancestors of what we call wheat, that could be cultivated to grow in many locations, enough to become the staple of the human diet. This was not only because the wheat produced grains that contained calories in the form of starch, along with micronutrients, but also because it contained macronutrients, including protein. Most of that protein consisted of gluten, which becomes high quality when consumed with protein from certain other plant sources, such as beans. This is why today, many vegan foods use wheat gluten as a major ingredient. By itself, gluten is not a complete protein, because it is low in a certain one of the essential amino acids (protein building blocks), but combined with other plant proteins that do have that missing piece (and that lack some building blocks that gluten does have), gluten is a pretty good protein. You can build muscles from it. You can build a fetus from it. And you benefit from whole grains that also contain folic acid, which is extremely vital during pregnancy (deficiency of folic acid in pregnancy leads to neural tube defects in the newborn), and other nutrients, such as iron. The latter is something that tends to be deficient in women, especially when they are pregnant, and when iron is deficient you cannot build adequate amounts of hemoglobin. And so, you become anemic.
Very importantly throughout life, but especially when you are pregnant, whole grains, which contain gluten, also tend to be the high fiber foods. On account of the growing womb, plus hormonal changes, pregnancy often leads to constipation. Filling your pantry and refrigerator with all the foods you can find that say “gluten-free” tends to exacerbate the constipation, because those foods tend to be deficient in fiber. Also, a lack of fiber and whole grains in the diet is associated with type 2 diabetes and obesity. Yes, each time that you go to your obstetrician for a well-patient pregnancy checkup, you’re going to be reminded to take your pregnancy vitamin and mineral supplement, containing folic acid, iron, and other things that you need. But it is also beneficial to obtain those nutrients from your food. This means that you should include whole grains in your pregnancy diet, that you should not avoid gluten, that, if anything, you should seek out high-gluten foods, because those tend to be the foods loaded with whole grains. Why would you avoid them, if you don’t have celiac disease?
The answer that you will get from the multibillion dollar gluten-free food industry, from people whose livelihood is somehow connected with gluten-free food and the related anti-gluten mood in society, and even from some doctors —if you go to them complaining of mild to moderate, vague intestinal symptoms that don’t sound life threatening and you refuse to get tested for celiac disease and other serious gastrointestinal disorders— is that you have a non-celiac type of gluten intolerance. The official term is non-celiac gluten sensitivity (NCGS), which is a diagnosis that doctors are allowed to make, because the International Classification of Diseases, version 10 (ICD-10) contains a code for it. But, honestly, when a real doctor (not a naturopath or a chiropractor), shrugs and puts NCGS into a patient’s electronic health record, it’s generally just a nudnik diagnosis. It’s because the patient has been asking about gluten intolerance, or gluten “allergy”, believing such a condition would explain symptoms that sound like just irritable bowel syndrome, and doesn’t want to get tested for celiac disease, or go through a battery of tests needed to rule out a plethora of other gastrointestinal conditions, such as inflammatory bowel disease, ulcers, and cancer. Whereas a genetic test can give doctors a strong clue as to presence or absence of celiac disease, the complete answer to the question comes from having a gastroenterologist insert an endoscope through the throat, esophagus, and stomach, into the small intestine and take a biopsy. This is done after the person is directed to consume gluten intentionally in order to trigger the reaction in the intestinal wall, in the event that the person really does have celiac disease. It is not uncommon for people who have just mild symptoms, along with the belief that gluten will make them worse, want to avoid such testing.
Despite people throwing around the term NCGS and the presence of NCGS in the ICD-10, there really is no evidence, and no rationale, supporting the idea that NCGS exists. In other words, if a reaction to gluten is the reason for one’s symptoms, the person has celiac disease. And if a person does not have celiac disease, but has symptoms, then the symptoms are from something other than gluten. Notably, gas and other problems occurring after consumption of foods that contain gluten can be from what doctors call fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs). These are different types of carbohydrates, all requiring particular enzymes to be broken down into their sugar building blocks. If you don’t make enough of that enzyme, the partly digested food continues from the small intestine into your large intestine, where it meets bacteria that do have the needed enzymes. In breaking down the substance, those bacteria release gases, causing the person to experience gas and diarrhea. When foods contain various types of molecules, gluten constituting only one type, it is exquisitely difficult to design and perform scientific experiments to elucidate the cause of symptoms. Several years ago, there was a small study, involving just under 60 patients, in Italy, which has a fairly high prevalence of celiac disease (reported at 1.6 percent of the population), in which some people were given gluten in pill form. It was a blinded study, because other patients were given a placebo pill that looked like the gluten pill. The study reported a small, but statistically significant, association between consuming gluten and experiencing symptoms, compared with the placebo group. But there were flaws in the methodology of the study. Moreover, combined with such an absence of data, nobody has yet been able to point to a plausible mechanism of action (how the process works in the body) that would explain a sensitivity to gluten that is not celiac disease. The fact that you hear people apply terms such as “allergy” and “immunity” to the proposed non-celiac gluten condition is a big clue that there is no such condition. That’s because there are four types of hypersensitivity —four categories of inappropriate immune reactions that damage the body itself— one of which includes celiac disease, while the others do not explain anything related to gluten:
Type I hypersensitivity is an exaggerated immune reaction that involves a family of antibodies called IgE as the mediator molecules. This is the classic allergic reaction that includes conditions like allergic asthma, allergic rhinitis (hay fever), and allergies to penicillin, peanuts, and shellfish. Type 1 reactions vary in severity from mild symptoms to anaphylaxis, which can lead to shock and death. There is no evidence of this type of hypersensitivity resulting from the ingestion of gluten.
Type II hypersensitivity, also called cytotoxic, is an immune overreaction mediated by antibodies of the IgM and IgG families. Various autoimmune diseases fit into this category. These diseases include Graves disease (antibodies destroy the thyroid gland, such that it cannot produce thyroid hormones), immune thrombocytopenia (antibodies destroy platelets, cell fragments that are needed for blood clotting), and myasthenia gravis (antibodies interfere with communication between nerve cells and muscle cells). IgM and IgG are also the families of antibodies that are produced by normal immune systems in response to vaccination, and to exposure of disease-causing agents in your blood and other internal tissues. But there is no evidence that consumption of gluten causes immune responses involving IgG and IgM. Otherwise, scientists would have measured this specifically by now.
Type III hypersensitivity also involves IgG and IgM antibodies, but forming complexes in combination with allergens. This is what happens in a condition called serum sickness, when the immune system reacts to a foreign agent, such as you might be given to counter some toxin, such as the toxin from a snake bite. These types of complexes also can form in lupus and accumulate in organs, such as kidneys, causing damage. But there is no evidence of such complexes forming in body tissues in response to gluten.
Type IV hypersensitivity, also called delayed hypersensitivity, in an inappropriate immune reaction that is mediated by the interaction of particular cells called T lymphocytes, macrophages, and monocytes. There is an enormous body of evidence suggesting that this type of reaction occurs in the the small intestine of some people after they consume gluten. Not only is the evidence strong, but scientist have mapped out the various details of what happens, based on a plethora of experiments involving different things getting measured. A person who experiences this specific type of immune reaction to the consumption of gluten is said to suffer from celiac disease. Could the hypothesized non-gluten sensitivity condition also involve a type IV hypersensitivity reaction? The answer is no, because then it wouldn’t be non-celiac. It would be celiac disease.
Even worse than the scarcity of studies, and lack of good studies, associating ingestion of gluten with symptoms that many people believe to result from gluten, is the lack of a plausible mechanism for such sensitivity. If you are intolerant to milk, you get bloated, gassy, and irritated when you drink it, we know the mechanism. You don’t have enough of the enzyme that breaks down lactose (milk sugar). This is a particular type of FODMAP intolerance. If you cannot have peanuts, because you can react severely with anaphylaxis, we know the mechanism for that too. It is an actual food allergy, a hypersensitivity response type 1, mediated by IgE.
But, if known not to have celiac disease, because you have been tested properly for it and found not to have it, yet you experience symptoms after eating food that contains gluten, we don’t know that it’s from the gluten. It probably is not from the gluten. If anyone tells you that it is on account of gluten, that it is a type of gluten allergy, or sensitivity, or intolerance, ask the person what he or she means. Ask by what particular mechanism of action that person believes gluten causes such a response. Simply saying that it’s some kind of allergy, or other type of sensitivity, is not enough, when such an idea makes no sense from an immunological perspective. All the worse when we’re talking about foods that have so many different things in them, apart from the thing that has become such a focus, and the center of a food fad. So, unless you have celiac disease, or suspect that you may have celiac disease (in which case you need to be tested properly for that), don’t avoid gluten or high-gluten foods. Seek them out, because they tend to be foods that will support your pregnancy health.