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The mental disorder diagnosis and the gluten as the main culprit

Despite the rarity of these diseases, there have been significant increases in the adoption of a gluten-free lifestyle and the consumption of gluten-free foods in the United States over the last 3 decades. The gluten-free diet is driven by multiple factors, including social and traditional media coverage, aggressive consumer-directed marketing by manufacturers and retail outlets, and reports in the medical literature and mainstream press of the clinical benefits of gluten avoidance.

250 thoughts on “Gluten and Mental Health”

Individuals may restrict gluten from their diets for a variety of reasons, such as improvement of gastrointestinal and nongastrointestinal symptoms, as well as a perception that gluten is potentially harmful and, thus, restriction represents a healthy lifestyle.

Emerging evidence shows that gluten avoidance may be beneficial for some patients with gastrointestinal symptoms, such as those commonly encountered with irritable bowel syndrome. However, high-quality- evidence supporting gluten avoidance for physical symptoms or diseases other than those specifically known to be caused by immune-mediated responses to gluten is neither robust nor convincing.

In fact, gluten avoidance may be associated with adverse effects in patients without proven gluten-related diseases. This article provides insight regarding gluten avoidance patterns and effects on patients without gluten-related diseases, and highlights concerns surrounding gluten avoidance in the absence of a gluten-mediated immunologic disease.

Health Benefits and Adverse Effects of a Gluten-Free Diet in Non–Celiac Disease Patients

Epidemiology and Economics of a Gluten-Free Diet The consumption of gluten-free foods has significantly increased over the last 30 years. A lifelong GFD is well recognized as the standard of care for patients with gluten-related diseases such as celiac disease and gluten ataxia, in which immune-mediated inflammatory responses to gluten proteins are directed primarily against the small intestinal mucosa and cerebellar Purkinje fibers, respectively.

  • Emilsson L, Semrad CE;
  • However, there is a great deal of discordance among the results; some studies have evaluated the nutritional quality of a GFD in patients with celiac disease, which could be a confounder for nutrient deficiencies due to impaired absorption and chronic inflammation;
  • A follow-up study of 13 cyclists without celiac disease was performed by the same investigators and consisted of a randomized, double-blind, crossover trial in which participants received either a GFD or GCD for 1 week, then crossed over after a day washout period;
  • Non-celiac wheat sensitivity diagnosed by double-blind placebo-controlled challenge:

However, people without these well-defined clinical entities have embraced a GFD due to perceived health benefits or because of a belief that gluten ingestion leads to harmful or bothersome effects. Accumulating translational and clinical trial evidence supports a putative role of diet in the generation of irritable bowel syndrome IBS symptoms, as the majority of patients seeking care for symptoms of IBS link their gastrointestinal symptoms to their diet.

Specific diets that are low in fats; carbohydrates; gluten; or fermented oligosaccharides, disaccharides, monosaccharides, and polyols FODMAPs have all been shown to improve IBS symptoms. As a result, the entity known as nonceliac gluten sensitivity NCGS has emerged as a diagnosis for patients who do not have celiac disease or a wheat allergy, who exhibit IBS-like gastrointestinal symptoms after ingesting gluten-containing food, and who have improvement in these symptoms on a GFD.

  • Moreover, substantially reducing or eliminating gluten-containing foods from the diet could have negative health and economic effects;
  • Celiac disease-like abnormalities in a subgroup of patients with irritable bowel syndrome;
  • Less hidden celiac disease but increased gluten avoidance without a diagnosis in the United States;
  • Evaluation of the nutritional quality of the lipid fraction of gluten-free biscuits;
  • Although convincing evidence is available to support the benefits of a GFD for certain patient populations without a gluten-related disease especially patients with IBS and NCGS , the data are conflicting and not definitive.

Nonceliac wheat sensitivity has been proposed as a more collective term for components of wheat other than gluten that contribute to symptoms in these patients. The avoidance of gluten has extended to the population of healthy individuals who believe that adhering to a GFD may have immediate health benefits or may prevent the development of future diseases.

These individuals have been described broadly as people who avoid gluten PWAG and comprise the majority of people who are partaking of a GFD. Such people may seek to cut back or eliminate gluten due to symptoms that have not been proven to arise as a result of gluten ingestion, or they may be asymptomatic. A population questionnaire6 in the United Kingdom showed that 3.

Go With Your Gut: 4 Facts About Gluten Intolerance

Moreover, substantially reducing or eliminating gluten-containing foods from the diet could have negative health and economic effects. Despite the recent publicity and interest surrounding a GFD in popular culture, the medical literature pertaining to the topic has lagged behind. This article provides insight regarding gluten avoidance patterns and effects on patients without gluten-related diseases, and highlights concerns surrounding gluten avoidance in the absence of a gluten-mediated immunologic disease Table.

Gluten and Immunogenicity Gluten refers to a family of proteins known as prolamins primarily glutenin and gliadin that constitute the storage protein in the starchy endosperm of many cereal grains such as wheat, barley, and rye. Each type of cereal grain contains differing amounts of gluten as well as other proteins.

One beneficial characteristic of gluten proteins is their viscoelasticity, which lends itself to the production of palatable doughs and bread products. Gluten-containing grains such as wheat make up a large portion of the modern Western diet. This is, in part, due to their palatability, ease of cultivation and procession into a wide variety of foods, large-scale production ability, and high nutritional content by weight.

Gluten and Mental Health

Although the genetics and characteristics of plants such as wheat can be rapidly modified, the human body is not as malleable. The various prolamins eg, glutenin, gliadin that comprise gluten must be digested within the small intestinal lumen after consumption; however, they are long peptide molecules rich in proline and glutamine that are difficult for humans to digest. Both glutenin and gliadin are composed of similar, repetitive amino acid sequences.

As many as 45 different gliadins can be present in a single wheat variety. Individual gliadin peptides exhibit different biological properties, all of which have potential involvement in the pathogenesis of gluten-related diseases.

In addition, certain human leukocyte antigen HLA -DQ2 T-cell haplotypes have been identified in proline-rich sequences of gliadin.

It is produced by normal gastrointestinal proteolysis and contains 6 partly overlapping copies of 3 T-cell epitopes. Furthermore, as new gluten peptides emerge via genetic modification resulting from modern agriculture practices, more immune-activating gluten peptides may be seen in food. Gluten-derived peptides, such as gliadin and glutenin in wheat, secalin in rye, and hordein in -barley, have been identified as important -antigen-producing proteins in patients with celiac disease.

Gluten and Irritable Bowel Syndrome Diet has been shown to play an important role in some patients with IBS,15 and multiple studies have evaluated both gluten exposure and the clinical benefits of the implementation of a GFD in patients with IBS. In one of the earliest studies of a GFD for IBS, Wahnschaffe and colleagues described a group of IBS patients with negative serum celiac disease antibodies and positive the mental disorder diagnosis and the gluten as the main culprit celiac disease antibodies detected on duodenal aspirate who had both improvement in their IBS symptoms and a reduction in intestinal antibody levels when placed on a GFD for 6 months.

In a commonly cited report, Biesiekierski and colleagues demonstrated that gluten ingestion was associated with both gastrointestinal and nongastrointestinal symptoms in 34 patients with IBS who did not have celiac disease. In addition, gluten-ingesting patients were significantly worse for overall symptoms, pain, bloating, satisfaction with stool consistency, and tiredness within 1 week.

Vazquez-Roque and colleagues reported the effects of a randomized, 4-week trial of a GFD 23 patients compared to a gluten-containing diet GCD; 22 patients on daily bowel function, bowel transit, mucosal permeability, and cytokine production in patients with IBS-D diagnosed by Rome II criteria in whom celiac disease had been excluded.

There was no effect on colonic permeability, intestinal transit, or histology.

Seventy-two percent of patients with a clinical response remained on a GFD 18 months after the study was completed. Nonceliac Gluten Sensitivity NCGS is an umbrella term that has been associated with a wide range of both gastrointestinal and nongastrointestinal symptoms that respond to gluten restriction and recur with gluten ingestion.

These symptoms may include bloating, abdominal discomfort and pain, altered bowel habits, flatulence, rash, fatigue, headaches, mental disturbances, irritability, depression, bone and joint pain, and even attention deficit disorder. In fact, all celiac disease—excluded patients with IBS-like gastrointestinal symptoms that respond to a GFD and whose symptoms return with ingestion of gluten could be classified as having NCGS.

Because of the overlap of disorders, the medical literature has not always clearly differentiated between these groups when evaluating the effects of a GFD or other dietary manipulations. They also should not have histologic abnormalities of the small intestine.

Breakthroughs In Care

Whereas celiac disease leads to increased small intestinal permeability and activation of the adaptive immune response, most studies have shown that patients with NCGS have normal intestinal permeability and activation of the innate immune response without activation of the adaptive immune response. Researchers have proposed that other components in wheat, in addition to gluten proteins, contribute to the activation of the innate immune response and elicit symptoms in patients with NCGS.

Many studies evaluating the effects of dietary gluten use wheat as their source of gluten, which raises the issue of collinearity in studies assessing gluten and its effects. Amylase-trypsin inhibitors are proteins found in wheat and commercial gluten that have been shown to activate the innate immune response. Elli and colleagues aimed to identify NCGS patients among those with functional gastrointestinal symptoms and conducted a multicenter, double-blind, placebo-controlled trial in which patients were given a GFD for 3 weeks, then randomized to either gluten or placebo for 7 days, followed by crossover.

Di Sabatino and colleagues performed a similar double-blind, placebo-controlled, crossover trial evaluating the effects of gluten on patients with suspected NCGS. A recent systematic review by Molina-Infante and -Carroccio evaluated 10 double-blind, placebo-controlled, gluten challenge trials in patients with NCGS. Only 36 children were eligible Celiac disease was excluded.

Patients were entered into a double-blind, placebo-controlled, 3-day challenge trial of wheat gluten, whey protein, and placebo, with a minimum 3-day washout period between each group. No differences were found between the groups for anxiety, anger, or curiosity. Thus, although these studies support the existence of NCGS, it appears that such individuals represent a relatively small portion of patients with IBS-like symptoms. Other Patient Populations Patients With Schizophrenia It has been suggested that patients with schizophrenia have higher levels of antigliadin autoantibodies but not celiac disease than the general population, and have hypothesized a linkage between these antibodies and psychiatric diseases.

The GFD and hypocaloric diet resulted in symptom improvement for both gluten-sensitive and fibromyalgia symptoms based on multiple scoring systems; however, there was no difference between the 2 diets for changes observed in either symptom group. Importantly, the beneficial effects persisted over the 6-month study period, making an association with placebo effect less likely.

This patient population either seeks to obtain benefit from symptoms without a confirmed diagnosis of a gluten-specific disorder, or these patients may seek some other benefit from a GFD rather than improvement in any specific symptom. One impetus for the practice of gluten avoidance in this population may be the perception that a GFD is a nutritionally healthier option than a traditional Western diet. Another potential perceived benefit of a GFD is that it is associated with weight loss.

Kim and colleagues evaluated a GFD and its effect on obesity, metabolic syndrome, and cardiovascular risk in non—celiac disease participants in the mental disorder diagnosis and the gluten as the main culprit NHANES from toand found that a GFD was associated with a decrease in weight over 1 year, lower waist circumference, and higher high density lipoprotein levels compared to the general population.

Limitations of this study include its retrospective nature and its ability to make only potential associations without establishing causality. In addition, just 1. Lastly, most GFD followers were health-conscious, well-educated women who may have been predicted to have better cardiovascular profiles than the general population, as well as greater diligence in pursuing weight loss.

This group was made up of predominantly endurance sport athletes who reported gastrointestinal symptoms and fatigue that they believed were associated with gluten ingestion.

  1. Social and Psychological Impact of a Gluten-Free Diet In addition to the increased financial costs of a GFD, there are other costs that can be more difficult to quantify, such as sociopsychological impacts.
  2. Among food products across 10 food categories evaluated, the average HSR of gluten-free foods was not superior to gluten-containing foods, and no nutritional advantage was found for gluten-free foods. Wheat gluten challenge in schizophrenic patients.
  3. From coeliac disease to noncoeliac gluten sensitivity; should everyone be gluten free? The GFD and hypocaloric diet resulted in symptom improvement for both gluten-sensitive and fibromyalgia symptoms based on multiple scoring systems; however, there was no difference between the 2 diets for changes observed in either symptom group.
  4. Thiamin, riboflavin, and niacin contents of the gluten-free diet. Gluten-free foods consistently showed lower average protein content across core food groups, especially pasta and breads.

Respondents indicated that their leading sources of information and guidance for a GFD were online A follow-up study of 13 cyclists without celiac disease was performed by the same investigators and consisted of a randomized, double-blind, crossover trial in which participants received either a GFD or GCD for 1 week, then crossed over after a day washout period.

These foods are relatively easy to cultivate and prepare, and represent readily available and cost-friendly options to meet the caloric demands of large populations. Gluten is also a common additive to prepared foods due to its physical properties and palatability. With the popularity of GFDs, it is important to understand the nutritional quality, potential costs, and availability of this diet as well as the effects that excluding gluten can have on the population and food industry.

However, there is a great deal of discordance among the results; some studies have evaluated the nutritional quality of a GFD in patients with celiac disease, which could be a confounder for nutrient deficiencies due to impaired absorption and chronic inflammation. However, these studies can also yield important information on the nutritional quality and adequacy of a GFD.

Among food products across 10 food categories evaluated, the average HSR of gluten-free foods was not superior to gluten-containing foods, and no nutritional advantage was found for gluten-free foods. Gluten-free foods consistently showed lower average protein content across core food groups, especially pasta and breads. Gluten-free dry pastas scored nearly 0. However, there is debate regarding the small portion of protein from grains that make up total dietary protein and, therefore, whether the amount of protein is a significant concern.

The primary outcome ie, the average HSR was not different among other staple, grain-based food groups eg, breads and breakfast cereals. Apart from protein content, all other nutritional measures in the secondary analysis, including total energy, fiber content, the mental disorder diagnosis and the gluten as the main culprit fats, total sugar, and sodium content, had no clear patterns of differences between gluten-free and gluten-containing foods.

A similar study in Austria systematically evaluated 7 categories of foods, comparing 63 gluten-free foods to of their gluten-containing counterparts based on nutrient composition, nutritional information, and cost. Lower sodium and fiber contents were found in the majority of gluten-free products.

A nutrition survey performed in support of a thesis included 58 healthy adults on a GFD and showed that men on a GFD consumed significantly lower amounts of carbohydrates, fiber, niacin, folate, and calcium, but significantly higher amounts of fat and sodium, than men on a GCD. Overall, adults adhering to a GFD did not consume enough nutrient-dense foods to meet all nutritional recommendations.

Clinical outcomes data related to the effects of a GFD are sparse and inconsistent. The authors found an inverse relationship between the outcomes of coronary artery disease and fatal and nonfatal myocardial infarctions with gluten intake. This observation prompted the hypothesis that avoidance of gluten may result in reduced consumption of beneficial whole grains, which has been linked to coronary artery disease.

A recent systematic review evaluated cardiovascular disease risk factors and their possible association with a GFD in patients with celiac disease. It is important to note that most of the studies included in this review were of low methodologic quality and had multiple potential confounders and a lack of controls, which limit the conclusions of the analysis. Financial Cost of a Gluten-Free Diet Studies have shown that gluten-free alternatives are more expensive than their gluten-containing counterparts.

Social and Psychological Impact of a Gluten-Free Diet In addition to the increased financial costs of a GFD, there are other costs that can be more difficult to quantify, such as sociopsychological impacts. The pleasurable and communal aspects of food are powerful, deep-rooted perceptions embedded in both individuals and society at large. A GFD requires persistent dedication to a restricted diet and lifestyle, possibly contributing to social isolation and negative psychosocial impacts.

The difficulty in maintaining adherence to a GFD may also cause negative feelings and emotions in an individual, especially if he or she is noncompliant. Several studies have attempted to quantify this impact, many of which have included patients with celiac disease. Silvester and colleagues evaluated, by questionnaire, community-dwelling adults on a GFD.