In recent years, gluten-free diets (GFD) have gained growing popularity and recognition. A GFD has historically been predominantly prescribed for celiac disease (CD) and dermatitis herpetiformis (DH) treatment (Silvester et al., 2016a). While the only known effective treatment for CD is the GFD, many believe it to be more healthy and say it has favorable effects on health problems other than CD (Lerner, Green, & Lebwohl, 2019). Not only has CD awareness and diagnosis improved, but certain people are now choosing a GFD with other aims in mind, such as weight loss, a healthier lifestyle, irritable bowel syndrome (IBS), or autism management. The ability to sustain a GFD is highly dependent on various environmental and individual variables. Individuals who maintain a GFD face difficulties by constantly engaging others to ensure their food is gluten-free (GF), either risking eating gluten or risking social exclusion. When they make an unseen illness visible, frequent discussions and special requests may be stigmatizing. Strict dietary requirements restrict spontaneity and can be interpreted as a hospitality rejection or imposition. Impairment in social recreation activities, greater attention to diet and food planning, a change to consuming more meals at home, and occasional negative emotions such as anxiety, loneliness, and frustration are correlated with a GFD (Silvester et al., 2016a).

Gluten is a naturally occurring protein in wheat, rye, and barley, popular in North America's diets. It is challenging to identify foods that include gluten since gluten is a part of certain grains and is usually not individually mentioned on food labels. Patients must be diligent in examining foods that may contain gluten (Silvester et al., 2016a). People who think they are adopting a GFD can not reliably distinguish GF foods appropriately, which indicates that there may be continued gluten intake, even with patients who believe they are strictly adherent (Silvester et al., 2016b).

Due to the requisite avoidance of many varieties of foods naturally high in fiber and the low fiber quality of GFD items typically made with starches or processed flours, the GFD is deficient in fiber. Deficiencies in the micronutrients vitamin D, B12, folate, and minerals such as iron, zinc, magnesium, and calcium are present in GFD. In addition, the GFD has insufficient consumption of macronutrients partly due to the emphasis on gluten avoidance, which also neglects the importance of the nutritional quality of the food. A greater content of both saturated and hydrogenated fatty acids and a rise in the glycemic index and glycemic load of foods are common in GFD (Vici et al., 2016).

In addition to the variations in nutritional quality, the cost of GF items is also higher. While more alternatives have resulted from the increased demand for GF items, these foods can cost 200-500 percent more than their counterparts (Beuthin et al., 2020). Surveys involving patients requiring a GFD reveal that the price is often prohibitive. Studies investigating the reasons for GFD non-compliance have demonstrated that several factors affect compliance. Lower education levels and the perceived capacity to sustain a GFD, and the limited supply of GF foods are correlated with low compliance. However, people with persistent symptoms show more significant levels of compliance (Lambert & Ficken, 2016).

With the adoption of a GFD as a therapy for CD, organ-specific autoimmune disease appears to improve in some instances. However, there is not always a beneficial effect observed. In patients with autoimmune diseases known to accompany CD, notably type 1 diabetes mellitus or thyroid disorders, disease screening and subsequent GFD if CD is identified, could have beneficial effects on progression or future complications of both diseases. However, it is disputed whether CD diagnosis and subsequent GFD would prevent autoimmune disorders (Lundin & Wijmenga, 2015).

With current evidence showing the effectiveness of a GFD in treating CD and potential improvement in other autoimmune diseases, the adoption of a GFD for some patients can be life-changing. Given the drawbacks of a GFD, such as nutritional deficiencies and the lack of knowledge of proper avoidance due to inadequate food labeling, education on a more nutritious GFD is warranted. For example, a GF Mediterranean style diet should not be nutritionally deficient due to its high fiber and phytonutrient content. Utilizing applications such as 'Shopwell' and educational materials and classes can help patients better understand how to read food labels and properly avoid gluten. The cost of GF processed foods may be prohibitive, but a Mediterranean style diet that is high in fresh vegetables should not be cost-prohibitive and would still be GF. Making these modifications can allow patients with autoimmune diseases to incorporate a GFD with minimal adverse effects.

References

Beuthin, J., Veronesi, M., Grosberg, B., & Evans, R. W. (2020). Gluten-Free Diet and Migraine. Headache, 60(10), 2526–2529. https://doi.org/10.1111/head.13993

Lambert, K., & Ficken, C. (2016). Cost and affordability of a nutritionally balanced gluten-free diet: Is following a gluten-free diet affordable? Nutrition and Dietetics, 73(1), 36–42. https://doi.org/10.1111/1747-0080.12171

Lerner, B. A., Green, P. H. R., & Lebwohl, B. (2019). Going Against the Grains: Gluten-Free Diets in Patients Without Celiac Disease—Worthwhile or Not? Digestive Diseases and Sciences, 64(7), 1740–1747. https://doi.org/10.1007/s10620-019-05663-x

Lundin, K. E. A., & Wijmenga, C. (2015). Coeliac disease and autoimmune disease - Genetic overlap and screening. Nature Reviews Gastroenterology and Hepatology, 12(9), 507–515. https://doi.org/10.1038/nrgastro.2015.136

Silvester, J. A., Weiten, D., Graff, L. A., Walker, J. R., & Duerksen, D. R. (2016a). Living gluten-free: Adherence, knowledge, lifestyle adaptations and feelings towards a gluten-free diet. Journal of Human Nutrition and Dietetics, 29(3), 374–382. https://doi.org/10.1111/jhn.12316

Silvester, J. A., Weiten, D., Graff, L. A., Walker, J. R., & Duerksen, D. R. (2016b). Is it gluten-free? Relationship between self-reported gluten-free diet adherence and knowledge of gluten content of foods. Nutrition, 32(7–8), 777–783. https://doi.org/10.1016/j.nut.2016.01.021

Vici, G., Belli, L., Biondi, M., & Polzonetti, V. (2016). Gluten free diet and nutrient deficiencies: A review. Clinical Nutrition, 35(6), 1236–1241. https://doi.org/10.1016/j.clnu.2016.05.002