Debra Kiez
An ER doc with heart and soul

Working the dough on gluten intolerance

It takes a while to spy new trends in both health and consumer spending. For decades, diabetes has caught media headlines and been the favorite of health food stores and “health” aisles in grocery stores. If you’ve been just a bit observant of late, you’ve probably noticed a slew of items on the hottest disease in town: gluten intolerance. Also known as sprue or celiac disease, it’s a fast-growing entity, more common now than in the past and certainly more common in developed countries. The big questions are why and what can we do about it?

We all undoubtedly have and/or know someone with inability to digest gluten, a substance found in wheat, barley, rye, and oats.  Absorption of nutrients in the intestines is accomplished via little “fingers” in the gut lining called villi which become damaged when exposed to gluten, in individuals with this condition. The body’s attack on itself, as it attempts to digest the gluten, is part of an autoimmune response and is associated with other autoimmune diseases, including lupus, rheumatoid arthritis, thyroid disease, type I diabetes, and even lactose intolerance. The resulting malabsorption and autoimmune process can cause a host of symptoms such as bloating, nausea, weight changes, and either constipation or diarrhea. With such divergent and fluctuating symptoms, the diagnosis can be tricky. Children or infants might exhibit colic, fussiness, or failure to thrive, all nonspecific symptoms.

Diagnosis is therefore dependent on a physician’s keen suspicion based on a good history. Aside from the symptoms themselves, there are risk factors that may provide clues to the diagnosis. People who have a family member with celiac disease are at greater risk for developing the disease and the disorder is most common in Caucasians and persons of European ancestry. Women are affected more often than men. It can develop at any point in life. The diagnosis is both clinical and laboratory based; blood tests might reveal antibodies specific to celiac disease. Endoscopy – using a scope to examine the stomach and the duodenum – can clinch the diagnosis. For the tests to yield accurate diagnoses, one cannot be on a gluten-free diet when these tests are to be performed.

A key point regarding gluten intolerance is that there is no cure. However, the villi will heal and the symptoms will resolve if gluten is removed from the diet. As a result, we’ve seen a proliferation of gluten-free items, from breads, to cookies and cakes, to pasta, on our local store shelves. Of note, there has been a dramatic rise in incidence of this disease. Just a decade ago, incidence was estimated at 1 in 2500 individuals. Current estimates place it at 1 in 133 and the rate is rising, doubling roughly every twenty years. In addition, first degree relatives of affected individuals are at an even higher risk of developing this condition.

How has this disease crept up on us and what does it reflect in our society? We know that the rate of breast cancer in women, about 1 in 11, is higher in industrialized countries than in developing countries. In fact, studies have shown that women who migrate from 2nd and 3rd world countries to the US, for example, experience a rise in risk in breast cancer. Most scientists believe this is related to food consumption (types of food, excess intake and obesity) and also possibly to environmental factors (pollutants, carcinogens, food additives), stress, and general changes in lifestyle, particularly with regard to sleep and exercise. Some immunologists suggest that gluten intolerance parallels the obsession with cleanliness in North American society. We’re too clean! As a result, our gut, one of the primary organs of our immune system, doesn’t get the workout that it should, and ultimately turns against itself (“auto”immune disorder). I have heard the same argument regarding the paucity of peanut allergies in Israel versus the US and Canada. A visit to your neighborhood gan, where kids happily play in the same dirt and gravel where cats, dogs, and other organisms breed, while stuffing Bamba into their mouth (no hand sanitizers here!) is a blatant example of how different cultures foster different disorders.

Another reason posited by some for the flourishing of gluten intolerance is that the grains we use today, and how we process, cook, and eat them, have changed. Certainly, currently available wheat varieties are different from those which grew, less hindered or genetically modified, decades and centuries ago. In fact, one of the keys to the success of my little town of Zichron Yaakov during the first aliyah, was the introduction of hardier wheat species to the area and the subsequent ability of Jewish farmers to increase their harvests. Used for more than 8,000 years, modern bread wheat has been genetically mapped with an eye to its toxic influence in celiac disease and a small chain of peptides on a portion of the gluten protein has been identified which is directly responsible for stimulating the unwanted reaction we observe in celiac sufferers.

Therefore, to battle this newly emerging and more prevalent disease, we might have to get more creative with our grains. A recent wheat variant branded as Kamut ® does not contain the genetic material responsible for the celiac autoimmune response and may be a step in the right direction as we approach treatment of this disorder. In part, it requires us to return to our very ancient roots and this might be a good idea in general. We know that whole foods that are unprocessed, organic, and fresh are generally better for us than highly processed. Some people have gone so far as to espouse the “Caveman” and raw food diets. Whatever your approach, getting back to nature and to slow cooking, slow eating and slow digestion, is probably better overall.

This brings me, finally, to the reason why this gluten idea came up in the first place. I love making bread. Several years ago, I met someone who was gluten intolerant who craved my challah when he came over for Shabbat. I then started making gluten-free bread for him using corn, rice, and quinoa flours. The results were edible but still unsatisfying to me. Then last week, my friend told me that he’d been to a wedding where he was served sourdough bread and was told that he could eat it. Apparently, the process of fermentation with a sourdough starter causes the gluten protein to be broken down into digestible parts. But last week I decided to try it. When the starter was sour and bubbly (I know it doesn’t sound very appealing but think of bread yeast), I used whole wheat flour to roll it into a dough. After letting it rise all day, I baked two beautiful loaves which my friend eagerly consumed (not all at once!) on Friday night. I anxiously called him after Shabbat to make sure he had survived and, behold, no symptoms! He was thrilled, and so was I. Thanks, Bruce and Rae, for the inspiration for today’s blog!

A word of caution: some people with celiac disease are more sensitive than others. Before you rush out to eat your next loaf of sourdough bread, consider trying a small amount first. Most importantly, sourdough bread must be made with a long fermentation for the process to work properly. I found it interesting, while researching this topic, to read that until about the 1950’s, bakeries allowed their breads to ferment and rise over many hours. When bread production increased and there was a push for instant and fast yeasts, rising for 3 hours or less, we began to see gluten insensitivity become more prevalent.

So, to summarize gluten intolerance in a more holistic way, I would suggest that we learn to let things in our lives go a little more slowly. Walk more, listen more, take more time to prepare and harvest food yourself, and let things just ferment a bit…and you may find that soon your life becomes easier to digest!


About the Author
Debra Kiez is an ER physician in Toronto, Canada (where she spends her summers) and teaches at the Technion American Medical School in Haifa when she's in Israel. She has a special interest in mind-body medicine, narrative medicine, and writing. She has five children, three grandchildren, and an amazing husband who recently shared the aliyah experience. She is inspired by nature, human connection, and the endless pursuit of knowledge.