Should I go gluten-free?
Many supermarket foods, specialty products and restaurant menu items now promote that they are gluten-free. Is this a necessity, or a fad? And do people with multiple sclerosis (MS) need to go gluten-free?
Gluten is a protein complex found in wheat, barley and rye. At the more severe end of the spectrum of gluten sensitivity is celiac disease (CD), an autoimmune disease that primarily affects the small intestine. In CD, the immune system reacts to one of the components of gluten, called gliadin. Gut enzymes modify gliadin so that it resembles proteins that make up the lining of the intestine. This causes an inflammatory reaction and damage to the tissues of the small intestine, which in turn causes problems absorbing the nutrients the body is trying to digest. So people with celiac disease must adhere to a gluten-free diet.
MS and CD have some similarities, and several important differences. CD is an autoimmune disorder in which the underlying trigger – gliadin – is known and specific tests are used to diagnose it. MS is also believed to be an autoimmune disorder, but no specific trigger has been identified and there is no specific MS test. (MS is a clinical diagnosis based on neurological signs/symptoms and some paraclinical tests, such as MRI). The key genetic susceptibility factors also differ for MS (the DRB1*1501 allele) and CD (DQ2 and DQ8 alleles).
But there is some overlap between the two conditions. As a general rule, people with one autoimmune disease have a higher probability of having another autoimmune disease (Sardu and colleagues. PLoS One 2012;7:e32487; free full text at www.ncbi.nlm.nih.gov/pmc/articles/PMC3292563/pdf/pone.0032487.pdf). A recent study found that about 11% of people with relapsing-remitting MS also had CD; the usual prevalence of CD is about 1-2%, meaning that the rate of CD was 5-10 times higher in people with MS compared to the general population (Rodrigo and colleagues. BMC Neurol 2011;11:31; free full text at www.ncbi.nlm.nih.gov/pmc/articles/PMC3065402/pdf/1471-2377-11-31.pdf). One other study also reported that people with MS had higher levels of anti-gluten antibodies (Reichelt and colleagues. Acta Neurol Scand 2004;110:239-241). However, other studies have found no connection between MS and CD and no evidence of gluten intolerance in people with MS (Borhani Haghighi and colleagues. Clin Neurol Neurosurg 2007;109: 651-653; Nicoletti and colleagues. Mult Scler 2008;14: 698-700).
So for people with MS, there may be a higher likelihood of gluten intolerance, but it’s still a fairly uncommon event.
No studies have looked at whether a gluten-free diet provides any benefit in MS and it’s unlikely that avoiding gluten products will have an impact on MS symptoms or progression. In fact, the one study done in the animal equivalent of MS found that a gluten-free diet actually made neurological symptoms worse (Di Marco and colleagues. APMIS 2004;112:651-655). But rats aren’t people (and the animal equivalent isn’t MS), so suffice it to say that the effects of a gluten-free diet in MS are largely unknown.
So avoiding gluten probably won’t alter MS but that doesn’t mean that a gluten-free diet isn’t beneficial – it certainly is for people with symptoms of gluten sensitivity. Symptoms can include abdominal cramps and pain, bloating and diarrhea. Chronic symptoms like these may indicate gluten sensitivity rather than the gluten intolerance of CD. CD is just the far end of the spectrum.
If you suspect you have a problem with your digestion, CD can be ruled out with a blood test that checks for anti-tTG (for tissue transglutaminase) antibodies; elevated levels are fairly specific to celiac disease (or other inflammatory gut diseases).
If you continue to have stomach symptoms, the simplest thing is to experiment. Try excluding gluten from your diet for a few weeks to see if you feel better. Then see if you develop symptoms if you eat a gluten-rich food. Let your body be your guide.
As a general rule, most people with MS are able to tolerate gluten and don’t need to eliminate it from their diet. But some people – perhaps 1 in 10 – will experience problems with their digestion and may find their symptoms of abdominal cramps and bloating improve if they go gluten-free.
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