A New Study Has the Media Buzzing About Gluten. Again.

February 25, 2013 in Categories: , , , , by

Print Friendly

A new study in the journal Pediatrics has the gluten-free/celiac disease world buzzing (this article has been published on dozens of websites).  The study concludes that early introduction of small amounts of gluten while still breastfeeding reduces the risk of celiac disease.

The study looked at two cohorts of Swedish 12-year olds, the first were a group born in 1993 during an epidemic of celiac disease (during the epidemic, the incidence of celiac disease increased from 1 in 100 to 3.3 in 100, believed attributable to changes in government recommendations for the age of gluten introduction to 6 months old, combined with a concurrent increase in the gluten content of baby foods) and the second were a group born in 1997 after the epidemic (after the government revised their guidelines to lower the age of gluten introduction to 4 months and the amount of gluten in baby foods was reduced).  The study sought to determine the impact of breastfeeding in relation to gluten introduction on the future development of celiac disease.

The hypothesis of the study is well summarized in this statement from the discussion section.

“Oral tolerance to an antigen develops early in life, and celiac disease can be viewed as a failure to develop oral tolerance to gluten, or a later loss of this tolerance.  The development of oral tolerance is a complex immunologic process involving interactions between genetic factors and environmental and lifestyle exposures, such as bacterial gut colonization and infant feeding.”

And this idea is what has my inbox flooded with questions.  If oral tolerance for gluten develops early in life and breastfeeding helps with the development of oral tolerance, is it better to give our paleo babies some gluten now?  Will that help prevent celiac disease and other autoimmune diseases?

To answer this question, let me first summarize exactly what this paper shows about the relation between breastfeeding, gluten introduction and celiac disease.  Over 13000 children were enrolled in the study.  The incidence of celiac disease was 2.8 in 100 in the 1993 cohort versus 2.2 in 100 in the 1997 cohort.  The median age of gluten introduction was the same (5 months old) between both cohorts.  But, the infants in the 1997 cohort were breastfed an average of 2 months longer than the 1993 cohort (age of weaning increased from an average of 7 months to an average of 9 months between 1993 and 1997).  What this means is that the number of babies who were breastfed during and beyond gluten introduction was significantly larger in the 1997 cohort (number of babies breastfed beyond gluten introduction was 70% vs 78% in the 1993 and 1997 cohorts, respectively).  From this, the authors conclude that introducing gluten before weaning reduces the risk of celiac disease.

24GLUTEN-articleInlineThis is an interesting observation and I think that this Op Ed piece in the NY Times provides a possible explanation for the result that is not thoroughly discussed in the original paper:  it’s all about the gut microbiota.

The most current understanding of celiac disease (well summarized in this paper, which sadly requires a subscription to view) is that the development of celiac disease (and indeed all autoimmune diseases) relies on three factors:

  1. Genetic predisposition
  2. Environmental trigger (in the case of celiac disease, that trigger is gluten)
  3. A leaky gut and/or gut dysbiosis

All three of these factors work together to develop autoimmune disease.  In terms of celiac disease, the genetic predisposition is at least partially understood: 90% of celiacs have one of two variants of the HLA gene (either DQ8 or DQ2).  What you need to know about the HLA gene is that it (or more specifically the protein in encodes) is involved in antigen presentation to the adaptive immune system, and defects in this process seem to be permissive for autoantibody formation.  But, approximately 30% of us have one of these gene variants and only 1% of us develop celiac disease (it should be noted that these gene variants are linked to other autoimmune diseases as well as non-celiac gluten sensitivity, so it’s not like the other 29% of us are getting off easy).  The environmental trigger for celiac disease is dietary gluten (or more specifically the protein fraction of gluten, called gliadin).  So, what’s the wild card?  A leaky gut.  And the development of a leaky gut may be what determines the age of disease onset, which is highly variable.  Chance (or maybe previous infections or maybe gut dysbiosis, i.e., the wrong types of bacteria growing in the wrong numbers in the wrong part of the gut) may be what determines whether a person develops celiac disease versus another autoimmune disease versus other health problems linked to gluten.

A leaky gut can be caused by a wide variety of factors, including: diets rich in some types of lectin (like gluten) and saponins (especially glycoalkaloids), stress, and gut dysbiosis (especially bacterial overgrowths).  Gut dysbiosis itself can be caused by diets rich in processed foods, refined carbohydrates, some types of lectins (especially prolamins like gluten and agglutinins like wheat germ agglutinin) and saponins (especially glycoalkaloids), by some medications (such as PPIs and antibiotics) and by stress.  A leaky gut and gut dysbiosis go hand in hand and it is not known which comes first.

So, what is the link between breastfeeding and a leaky gut?  The link is really to gut dysbiosis (or lack thereof).  Studies show that breastfeeding is important for the establishment and growth of normal gut microorganisms.  In particular, breastmilk contains probiotics (from strains shown to be deficient in the guts of those with celiac disease) and for the duration of breastfeeding, the guts of babies are being constantly inoculated with these beneficial bacteria.  It is becoming increasingly recognized that the healthy diversity and relative amounts of gut microorganisms are intricately linked your health.  So, it’s no surprise that whatever factors contribute to healthy gut microorganisms in babies will protect them from disease.

So, let’s get back to the study.  It has one very big limitation relevant to this discussion.  It cannot separate whether the exact age of gluten introduction in babies who were breastfed longer has any effect on celiac risk.  This study definitely shows that breastfeeding longer decreases celiac risk.  But, the idea that this is because breastfeeding occurred during and beyond gluten introduction is speculative.  It certainly makes sense given other research on the link between gut microorganisms and disease risk that a healthy gut is important in celiac disease risk and that breastfeeding longer improves the health of the gut microorganisms.  But, this study just can’t tell you whether introduction of gluten early (and before weaning) is important.  If the reason breastfeeding is protective is because of its probiotic effects (it’s nutrient value would be another good reason), then it could be that it doesn’t matter when gluten is introduced (if ever) as long as the gut is healthy when you do.

From birth through adulthood, diet has a profound effect on the composition and relative quantities of your gut microorganisms (I explain this is detail in my book).  And healthy gut microorganisms have a profound protective effect on the integrity of the gut barrier and are essential modulators of the immune system (yes, I explain this in detail in my book as well).  The optimal diet in terms of gut and gut microorganism health seems to be a hunter/gatherer/gardener type diet, rich in plants (but not grains or legumes and nothing processed or refined) and wild or pastured meat and/or wild-caught fish (no surprise to us in the paleo community).   What is healthy nutrient-dense food for you just happens to be healthy food for your gut microorganisms.  And, while this is an oversimplification, if you feed your gut bacteria good food, they are healthy, and therefore you are healthy.

So, getting back to the question that is flooding my inbox:  does this paper mean you should feed your paleo babies a little gluten now so that they will develop immune tolerance?  This study does not allow us to conclusively say yes or no.  Certainly, this study does not prove its assertion that introducing small amounts of gluten into the diet very early and prior to weaning will increase immune tolerance and therefore protect your baby against ever developing celiac disease (although you can add this study to the bounty of scientific studies showing that breastfeeding is beneficial for your baby). It should also be noted that the health of the mother greatly affects the probiotic and nutrient content of the breastmilk.  It is unknown whether breastmilk is still protective in the context of obese mothers or mothers with chronic health conditions.

I believe that the best thing that you can do for your baby’s long term health (besides love and cherish them) is feed them nutrient-dense, nourishing foods that will help them have healthy guts and healthy gut microorganisms.  I do not believe that gluten consumption promotes a healthy gut or healthy gut microorganisms (and the science backs me up on this one—I reference a few hundred studies on this topic in my book).  But, I also don’t know whether, if you wait “too long” to introduce gluten, if some magical window of opportunity to develop immune tolerance against gluten will be missed (or how much gluten you would need to keep in the diet to maintain immune tolerance).  I also don’t know whether having immune tolerance against gluten is even a good thing in terms of overall long term health.  Science does not yet provide a clear answer.  So, with all of these ideas in mind, the decision will have to be yours and will have to be based on your own risk assessment.

Bengmark S. Gut microbiota, immune development and function. Pharmacol Res. 2013 Mar;69(1):87-113. doi: 10.1016/j.phrs.2012.09.002. Epub 2012 Sep 16.

Fasano A. Leaky gut and autoimmune diseases. Clin Rev Allergy Immunol. 2012 Feb;42(1):71-8. doi: 10.1007/s12016-011-8291-x.

Groschwitz KR and Hogan SP. Intestinal barrier function: molecular regulation and disease pathogenesis. J Allergy Clin Immunol. 2009 Jul;124(1):3-20; quiz 21-2. doi: 10.1016/j.jaci.2009.05.038.

Hascoët JM et al. Effect of formula composition on the development of infant gut microbiota. J Pediatr Gastroenterol Nutr. 2011 Jun;52(6):756-62. doi: 10.1097/MPG.0b013e3182105850.

Ivarsson A et al Epidemic of coeliac disease in Swedish children. Acta Paediatr. 2000 Feb;89(2):165-71.

Ivarsson A, Prevalence of Childhood Celiac Disease and Changes in Infant Feeding. Pediatrics. 2013 Feb 18. [Epub ahead of print] http://pediatrics.aappublications.org/content/early/2013/02/13/peds.2012-1015.long

Comments

Thanks, I’m going to be sending a few people over here for this. Considering what I just heard (and posted) about breastfeeding “education” in highschools, stuff like this needs to be clear and present. To what extent would you say this can be extended to other autoimmune conditions (T1D, f.ex)?

Goodness, after reading this article, I can’t wait till your book comes out. Good catch on the longer breastfeeding in that study; you’re right, in order to really have enough evidence for their conclusion re:gluten, they would have to control for length of bfeeding. Could they have done that statistically/mathematically and didn’t, or would there have to be another study with a better match of duration of breastfeeding between groups? (I copyedited medical studies for 10 years, but I’m an English major and never quite got the math on how they controlled for confounding factors and figured out statistical significance and such. But I always made sure the commas and periods were in the right places! :) )

This study will probably go the way of the Nurses’ Health Study and grossly mislead people worldwide. Anyway, thank you for your critical eye and free information. No one on the web distills this information better than you.

Great information! Thank you for helping us look so closely at the details of this study. One of the lines in your post has me thinking, a lot. I have been on daily antibiotics for MS/chronic Lyme disease thru pregnancy and breastfeeding of my 18 month old. The antibiotics are to reduce her risk of Lyme transmition. My doctor is very supportive and has encouraged me to breastfeed as long as I am comfortable, his feeling is the benifits outweigh the risks. I wonder if we’ll ever really know what is best? I know my gut health is very impacted by the antibiotics I’ve taken and continue to take, I just hope my daughters gut health will be a bit more healthy than if she were formula fed. At least she was born naturally and she’s never eaten gluten.
Any thoughts?

I agree with your doctor. I don’t know how those antibiotics would affect your milk, but I still believe your milk is a better option than formula. I would definitely suggest taking a probiotic yourself (you can start now and take in between antibiotic doses and then continue for 3-4 weeks afterward, fermented foods are another great option), which should definitely help you recover. The brand I would recommend is called Prescript-Assist, but it would be good to double check with your doctor.

Thanks for your response! You are so amazing, I don’t know how you do all you do!
I was glad to recently see your post on your recommendation of what probiotic to take. I have been taking a physician recommended probiotic and giving my daughter a combo of a couple probiotics thru out. We love Kombucha and also yogurt, although that may be falling out of favor in our house after listening to your take on dairy. We play outside, dig in the garden (which is fenced to keep the cat out -Yuck!!) & We are working on the kraut thing :-)
Thank you for all you do, you are such an inspiration! I’d say I can’t wait for your book to come out, but I am enjoying the ignorance for a bit. I can’t imagine taking on the autoimmune protocol right now :-)

Thanks for your comments & reassurance. My doc is really, really knowledgeable in conventional and alternative medicine and I trust him. I know a very small amount of the antibiotic goes thru the breast milk to the baby and interestingly, I just switched antibiotic types because I think my daughter was developing an allergy to the one I was on. Her skin and rash are improving with the switch!
I really appreciate this amazing community

if gluten isn’t needed in a healthy diet, i am not sure it would be a good idea to have a baby build up a tolerance. which i just don’t like that word(s)… build up a tolerance. like you HAVE to eat that way. not that i am one to talk, lol, we are struggling here to get rid of gluten, dairy, and sugar. having had all of those in abundance in this house all of the kids loves, they are really pushing against the food change, even though they like all the paleo foods. i just don’t see the benefit of adding gluten to a clean diet so you baby will be tolerant of it. i mean now a days it is fairly easy to not eat gluten. at least it seems that way to me.

Thank you for the excellent summary. I was just looking for information on leaky gut in pregnant/breastfeeding mothers, and how this can contribute to protein sensitization and allergies in infants. There is no question that this happened to my exclusively breastfed son – he is allergic to very uncommon foods that I consumed while pregnant/breastfeeding specifically in order to prevent him from getting allergies to common allergens, which he tolerates just fine. These include some gluten-free grains, seeds, and legumes. The question is why did this happen. There is currently “not enough evidence” to recommend restricting the diet of pregnant/breastfeeding mothers for this reason, but how long it is going to take before we do, and what can common sense instruct us to do in the meantime?

By my count, there are six diseases that are shown in the medical/scientific literature to be caused by consumption of wheat: Celiac, Schizophrenia, Type 1 Diabetes, Non-Celiac Gluten Sensitivity, Rickets, and Excessive Tooth Decay.

What does that mean? It means that Celiac is not caused by genes, but is rather a manifestation of toxicity controlled by genes. If you have a different set of genes, the toxicity manifests as IBS, or you get rickets… (There is a study out there telling doctors not to use wheat bran in infants for constipation because it pretty reliably induces rickets, through a mechanism we don’t understand.)

If you view wheat through this lens, as a mildly poisonous plant that induces a variety of ills in a variety of people, the notion of trying to acclimate your kid to it become less appealing. So they don’t come down with celiac, but get IBS instead. Or you spend a fortune at the dentist. Lovely.

So I agree, this study surely does not answer the question about if you should feed your infant wheat. But the totality of the evidence is pretty clear, I think.

“Potential complications in the use of wheat bran for constipation in infancy.”
http://www.ncbi.nlm.nih.gov/pubmed/?term=rickets+wheat+bran+constipation

This makes me feel better about the small amount of gluten that my breastfed 15 month old is getting… I try to keep it out of her diet, but she is Italian, and family members give her pasta or cookies occasionally.

Out of curiosity, why would the breastmilk of an obese mother be of lower protective quality than that of a slender mother? Somehow I seriously doubt that to be true.

This makes sense to me. When I weened my son at 1 yr. He promptly developed terrible, light yellow, burning diarrhea and started to lose weight. My daycare provider and I starting researching the internet for causes when my doctor had no answers. We both kept coming back to celiac or gluten intolerance. I took him off of gluten, nightshades, citrus, everything high fructose and things started getting better. This research took both my daycare provider and I to the Paleo diet and me to your book. I’m not finished reading it yet; but, I know that I want to give several copies away to family and friends now! Even though auto-immune disease runs rampant through my mothers family NONE of them knew they were auto-immune diseases and once you have one you can develop more! So, thank you so much for that revelation and for the breastfeeding link. I had an inkling; but, thought it was just me. That bit of information I will give to anyone I know with a baby now!! Thank you!!!

Thank you for your insight. I have 4 kids and breastfed them all to a year. My oldest (now 8) had projectile vomit, constantly colic, and a hard time sleeping. After he was weaned, he developed chronic constipation and his stomach always hurt. My daughter, did not react to my breast milk, but also developed constipation along with constant stomach aches. My third baby, from 3 months old had severe eczema covering his face, along with the constant crying and lack of sleep. It was not until my 3rd baby was about 4 months old I discovered the gluten connection and I stopped consuming gluten. Within 2 weeks his eczema was gone. My other 2 kids at the time also went gluten free and their symptoms also disappeared. My fourth baby had all the same symptoms as the other 3 after I did a gluten challenge while I was nursing. 2 of the 4 have since been tested for the celiac gene and are positive and still have severe reactions if they consume it. (I only know due to accidental ingestion).

I guess my point is everyone will have a different story specific to their situation. I just know for us, introducing gluten while breastfeeding did not diminish my kids reactions to gluten.

This is so interesting! I have 4 children. 10, 8, 6, 8mo. I was diagnosed with a wheat or gluten sensitivity as a child when I was diagnosed with epstein barr. When I had my oldest he had a undiagnosed top and bottom lip tie and because of that we were only able to breastfeed for a short time. My 8 and 6 year old were breastfed for 2 years and they both have severe stomach issues. They have several food sensitivities and my 6 year old has been diagnosed with leaky gut. I am in the process of getting them tested for celiac. They both have the symptoms and very high sensitivity on their IgG testing. My oldest has no problems. Now I’m worried about my 8 mo old. I have no clue what to do. Because what I thought was right has landed me here. We have had a fairly healthy diet even before our sensitivity diagnosis. And none of my kids have been on antibiotics. I’m just puzzled and frustrated. Now I haven’t introduced my 8mo old to gluten because of our sensitivities. But now I wonder? Should I?

First, thank you so much for all your informative and interesting articles! I appreciate reading them very much.

As usual, I found this article very interesting as well. These sentences towards the end concerned me a bit, however: “It should also be noted that the health of the mother greatly affects the probiotic and nutrient content of the breastmilk. It is unknown whether breastmilk is still protective in the context of obese mothers or mothers with chronic health conditions.” I would hate for any mother on the fence, who does have breastmilk, decide that it’s not healthy or nutritious enough, just because her diet hasn’t been great or because she has some health conditions. It’s still the best option, with the exception of certain (and very few) specific medications.

(From everything you post, I don’t think this is what you were intending to say. My concern is because I know that some in the paleo community were saying that very thing, contrary to expert opinion, a few years ago.)

Again, thank you!

Leave a Reply

Your email address will not be published. Required fields are marked *

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <strike> <strong>

Sign up for my FREE weekly newsletter!

Stay up-to-date, never miss a post, and get exclusive content and coupons! Sign up now and you'll get a FREE Paleo Quick-Start Guide!

We will never share your information with anyone.