The Inclusion of Nurses in Pharmaceutical Industry–Sponsored Events
Authors: Quinn Grundy, Alice Fabbri, Barbara Mintzes, Swestika Swandari, Lisa Bero
Journal: JAMA Internal Medicine (2016)

disease has remained relatively stable from 2009 through 2014, although the prevalence of individuals reporting adherence to a gluten-free diet has more than tripled (0.52% in 2009-2010 to 1.69% in 2013-2014).Part of what may be driving this gluten-free diet trend is simply a belief, fueled by marketing and media, that these foods are healthier.However, surveys suggest that many individuals who adhere to a gluten-free diet believe that the exclusion of gluten has resulted in subjective health benefits from weight loss to reduced symptoms of inflammation and gastrointestinal distress. 3,4Because a gluten-free diet may have negative social, financial, and health repercussions, it is important for clinicians to understand whether, in most cases, it is the elimination of the protein gluten that is responsible for symptom improvement or whether following a gluten-free diet is simply a marker of other dietary choices that are creating positive effects. 5ot all research has found that individuals who adhered to a gluten-free diet resulted in subjective health benefits.A recent 2-year prospective study 6 from Italy suggests that something other than gluten itself is resulting in self-reported health benefits.Researchers enrolled all consecutive patients with gluten-related symptoms, and after those with celiac disease or wheat allergy were eliminated, only 7.5% experienced any change of symptoms with a gluten-free diet.Studies such as this raise the question of what other than gluten might explain the symptomatic improvement experienced among those following a gluten-free diet.One explanation is that it is not the gluten but the grain itself.Researchers in Australia found that that the fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) and insoluble fiber that are found in glutencontaining foods may be responsible.FODMAPS and insoluble fiber increase the osmotic pressure in the large intestine and promote bacterial fermentation, which results in gas production and abdominal bloat.In a controlled, crossover study 7 of patients with irritable bowel syndrome, a diet low in FODMAPs effectively reduced these symptoms; in a related study, 8 patients who improved while following a low-FODMAP diet experienced no exacerbation of symptoms when gluten was introduced.Another explanation is that gluten elimination may accompany other dietary trends that are associated with improved symptoms.For example, adherents to the popular Paleolithic and autoimmune protocol diets might also report being on a gluten-free diet. 9There is a debate about whether these diets, which promote eating unprocessed foods that were available in preagricultural times while avoiding grains, oils, and legumes, offer any health advantage over other whole food diets (such as the Mediterranean diet).Nonetheless, some have argued that simply eliminating highly processed foods (including highly processed gluten-containing foods) might result in an improved sense of well-being.Following a gluten-free diet likely means different things to different people, and a heterogeneous group of individuals are adhering to this dietary trend.Although the choice to be gluten free may be driven in part by marketing and a misperception that gluten free is healthier, it is important that this choice not be dismissed as an unfounded trend except for those with celiac dis-ease and wheat allergy.Instead, researchers and clinicians can use this as an opportunity to understand how factors associated with this diet affect a variety of symptoms, including gastrointestinal function, cognition, and overall well-being.