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GLUTEN FREE AND DIABETES

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Gluten free starches
Gluten and wheat free foods, meals and diets are increasingly popular. People are avoiding gluten due to serious health conditions like coeliac disease, wheat allergy or non-coeliac gluten sensitivity, or simply due to personal food preferences.
What is gluten?
Gluten is the protein complex that is formed when wheat flour is physically manipulated with water. It’s comprised of two protein fractions (gliadin and glutenin) in approximately equal amounts. Gliadins and glutenins are unusually rich in the amino acids proline and glutamine, and are not completely broken down by human small intestinal digestive enzymes.
Rye, barley and oats contain similar protein fractions (secalins, hordeins and avenins, respectively) known as prolamins (rich in proline and glutamine). Therefore, the word “gluten” is used to describe collectively, the grain storage proteins from wheat, rye, triticale (a hybrid of wheat and rye), barley and oats.
A note about oats
The prolamin fraction in oats (avenins) is slightly different from the prolamin fractions in wheat, rye, triticale and barley, and it only comprises a small proportion of oats total protein content. However, in Australia and other parts of the world, oats are frequently grown, stored or processed with other “gluten” containing grains including wheat, rye, triticale or barley, and therefore typically contain “gluten” via contamination. Oats grown and processed without contamination, or even cleaned of contaminating grains, are available commercially in many parts of the world.
What is coeliac disease?
Coeliac disease, or gluten-sensitive enteropathy, is an immune-mediated small intestinal enteropathy that is triggered by exposure to “gluten” in genetically predisposed individuals. Unfortunately, it is becoming increasingly common, affecting around 1 in 70 people in Australia, 1 in 100 people in the UK, and 1 in 133 in the United States.
People with coeliac disease’ own immune system reacts abnormally to gluten, causing damage to their small intestine. The tiny, finger-like projections known as villi which line the small intestine become inflamed and flattened – a condition known as villous atrophy. As a consequence, the surface area of the intestine available for the absorption of nutrients is reduced which can lead to various gastrointestinal and malabsorptive symptoms like diarrhoea and/or constipation, large, bulky foul stools, unwanted weight loss or poor growth in children, flatulence, abdominal bloating, distention or pain, and anaemia.
Long-term complications can be very serious and include infertility, miscarriage, depression and dental enamel defects. There is also an increased risk of developing certain forms of cancer such as lymphoma of the small bowel.
Coeliac disease and type 1 diabetes
Like type 1 diabetes, coeliac disease is thought to be an autoimmune disease that is ‘triggered’ in genetically susceptible people.

For reasons that we do not completely understand, people with type 1 diabetes are at much greater risk of developing coeliac disease than people who do not have type 1 diabetes (up to 10 times greater).

Recent estimates based on small intestinal biopsy suggest that 3.5% of children with type 1 diabetes also have coeliac disease, with a higher prevalence in females than males (4.3 vs. 2.7%).

Unfortunately, coeliac disease can make management of blood glucose levels even harder than usual in people with type 1 diabetes, with increased risk of both hyper and hypoglycaemia.

Coeliac disease and type 2 diabetes

Coeliac disease is not associated with type 2 diabetes or pre-diabetes and people with the conditions have the same chance of developing coeliac disease as the rest of the population (i.e., people without diabetes).

Diagnosis of coeliac disease

If you have a family history of coeliac disease, some or even all of these symptoms, it’s important that you don’t simply self-diagnose coeliac disease and commence a gluten free diet. A diagnosis of coeliac disease can only be made by demonstrating the typical villous atrophy of coeliac disease in a small bowel biopsy. This involves a gastroscopy procedure in which several tiny samples of the small bowel are taken and examined under a microscope. Importantly, you must still be eating gluten regularly before the procedure is performed or you may get a false negative result.

 

Gluten free diet

A gluten free diet is currently the only known treatment for coeliac disease and unfortunately it is for life because people with coeliac disease remain sensitive to gluten throughout their life – at this point in time, the condition cannot be cured. However, by removing the cause of the disease, a gluten free diet allows the small bowel lining to heal and symptoms to resolve. As long as the gluten free diet is adhered to as strictly as possible, problems arising from coeliac disease should not return.

In the not-too-distant past, having to consume a gluten free diet used to be a culinary disaster. Thankfully, food industry has stepped up to the proverbial plate and there is now gluten free alternatives for most of your favourite foods. Fortunately, many gluten-free core foods like milk, yoghurt, some starchy vegetables, legumes and most fruits also have a low GI. However, many gluten free grain alternatives aren’t low GI, so finding gluten free pasta, breads, breakfast cereals, etc… can still be a challenge.

Keeping with the theme, this month’s YOUR GI SHOPPING GUIDE focuses on pasta and illustrates the fact that gluten free versions of this internationally renowned staple generally have a higher glycemic index (GI) and glycemic load (GL) than the regular wheat-based varieties.

Gluten and risk of type 2 diabetes

For a variety of reasons, gluten free foods, meals and diets have become increasingly popular – even for those without diagnosed coeliac disease, wheat allergy or sensitivities.

Limiting gluten in the diet is associated with a lower intake of cereal fibre and possibly other beneficial nutrients (e.g., B vitamins, magnesium, etc…) that contribute to good health, and gluten free diets are also associated with adverse changes to the gut microbiome. Finally, as mentioned previously, many gluten free alternatives to pantry staples like pasta, breads, and breakfast cereals have higher GIs and GLs.

Perhaps unsurprisingly, a recent analysis of three large US cohorts has found an association between limiting gluten in the diet and the risk of developing type 2 diabetes.

Women from the Nurses’ Health Study (71,602 adults) and NHS II (88,604 adults) and men from the Health Professionals Follow-Up Study (41,908 adults) were asked to complete food frequency questionnaires every 2-4 years, for up to 28 years, from which habitual gluten intake was estimated. People consumed between 2 to 12 g of gluten per day, with intakes relatively stable over the 28 year period.

People that consumed the most gluten each day (i.e., the highest 20% of consumers) had a 13% lower risk of developing type 2 diabetes. Dose–response analyses supported a largely linear inverse relationship between gluten intake up to 12 g/day and type 2 diabetes – the more gluten consumed, the lower the risk of developing type 2 diabetes.

This doesn’t mean that people at risk of developing type 2 diabetes should start eating more gluten, per se. It does suggest that if you don’t have diagnosed coeliac disease, wheat allergy or non-coeliac gluten sensitivity, you should not be choosing gluten free foods because you think that they are healthier alternatives. They’re not.

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Dr Alan Barclay, PhD, is an Accredited Practicing Dietitian, nutritionist and chef with a particular interest in carbohydrates, diabetes and food law. He is author of Reversing Diabetes, and co-author of 40+ scientific publications, The Good Carbs Cookbook (Murdoch Books), Managing Type 2 Diabetes (Hachette Australia) and The Ultimate Guide to Sugars and Sweeteners (The Experiment Publishing).
Contact: Follow him on X, LinkedIn or check out his website.
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