Should You Go Gluten Free For Your IBD?

Introduction

If you’re living with Crohn’s disease or ulcerative colitis, you may have considered eliminating gluten from your diet as a way to manage your symptoms and improve your quality of life. But is going gluten-free (GF) actually helpful for people with IBD?

In this post, we’ll explore the prevalence of celiac disease in individuals with IBD, the evidence on gluten’s role in the development of IBD, whether a GF diet helps to induce or maintain remission, and whether it’s pro-inflammatory. We’ll also look at whether eliminating gluten may help to reduce your symptoms and we’ll consider some of the potential drawbacks of a gluten-free diet.

What is Gluten?

Gluten is a type of protein found in certain grains, including barley, wheat, and rye. It can be found in foods such as:

• Baked goods (breads, pastries, etc)
• Beer
• Breading & coating mixes
• Cereal
• Granola
• Crackers
• Croutons
• Pancakes/waffles
• Soups 
• Dressings
• Soy sauce

Risk of Celiac Disease in IBD

Celiac disease is an autoimmune disorder in which the ingestion of gluten leads to damage of the small intestine. Patients with ulcerative colitis or Crohn’s disease are 2.2 times more likely to develop celiac disease compared to the general population.^ But, there’s an even stronger connection between microscopic colitis and celiac disease. Individuals with celiac disease are 12 times more likely to develop microscopic colitis than individuals without celiac disease.^

Given this increased risk, it’s recommended that all patients with IBD be screened for Celiac disease, especially if you’re experiencing symptoms that are not typical for IBD or do not respond to conventional IBD treatments. If you have IBD and were diagnosed with Celiac disease, a strict gluten-free diet is essential for managing the disease. 

Does Gluten Intake Cause IBD?

Gluten intake does not appear to increase the risk of developing Crohn's disease, ulcerative colitis, or microscopic colitis.^{ }

Gluten-Free Diet for Induction of Remission

To date, there haven’t been any large-scale, controlled studies that show the GF diet's ability to induce remission in IBD. Therefore, the International Organization for the Study of Inflammatory Bowel Diseases stated there’s insufficient evidence to recommend restriction of gluten in individuals with IBD at this time.^

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Is Gluten Pro-inflammatory for IBD?

The question of whether gluten is pro-inflammatory is complex and not fully answered by current research. One study, where gluten was fed to mice, found that gluten intake led to ileitis, which is inflammation of the last part of the small intestine.^ However, it’s important to note that results from animal studies don’t always translate directly to humans.

It's also uncertain whether it's the gluten itself or the processing of gluten-containing foods that might be responsible for any pro-inflammatory effects.

For instance, highly processed gluten-containing products, such as shelf-stable bread that stay fresh for months, might be more likely to contribute to inflammation than minimally processed gluten-containing foods such as homemade bread or barley. The preservatives, additives, and other processing methods used to extend the shelf life of these products could be contributing to their potential pro-inflammatory effects, rather than gluten itself.

Unfortunately, more high-quality research is needed before we will truly know whether or not gluten is inflammatory. 

Gluten-Free Diet for Symptom Reduction

Some individuals with IBD report that maintaining a GF diet helps keep their symptoms at bay. In fact, in one study, 65% of individuals with IBD who tried a GF diet reported an improvement in their symptoms.^ However, what’s unclear is whether this effect is related to the broader dietary changes that often accompany a GF diet, such as increased consumption of whole foods and reduced intake of processed foods, rather than gluten elimination alone.

If you don’t have celiac disease but still experience symptoms after consuming gluten, you may have non-celiac gluten sensitivity (NCGS). For individuals with NCGS, gluten intake can lead to symptoms similar to celiac disease, but unlike those with celiac disease, individuals with NCGS will not have intestinal damage or inflammation.

Research suggests that approximately 25% of individuals with IBD may also have NCGS.^ However, this sensitivity might not be due to gluten itself but rather to other components of wheat, such as Fructans, a type of FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols), which can also cause gastrointestinal symptoms, especially in individuals with overlapping irritable bowel syndrome (IBS).

For instance, if you’ve noticed that sourdough is tolerated but other types of wheat are not, it could be the fructan content that is the culprit, and not gluten itself because although sourdough contains fructans, the fermentation process significantly decreases the fructan content. 

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Gluten-Free Diet for Maintenance of Remission:

There’s a lack of large-scale, controlled studies supporting gluten restriction for maintenance of remission at this time.^ 

Potential Drawbacks of a Gluten-Free Diet

While a gluten-free diet can be helpful for managing physical symptoms, it’s also important to consider the potential drawbacks. 

• Mental health: One study found that individuals with IBD following a GF diet experienced significantly higher levels of anxiety, depression, and post-traumatic stress symptoms than those not following a GF diet.^ 
• Nutrient deficiencies: Some of the most common nutrient deficiencies in individuals following a GF diet include Iron, calcium, folate, vitamin B12, vitamin D, and zinc.^
• Social implications: Eating out or attending social events can become more challenging, as gluten-free options may be limited, leading to feelings of exclusion or difficulty in finding GF meals.
• Cost: Gluten-free products are often more expensive than regular versions of the same food, which can make following this diet costly.
• Disordered eating/eating disorders: Increased hyper-vigilance on diet due to gluten restriction can also lead to disordered eating and/or eating disorders. 

Conclusion

For some individuals with IBD, a gluten-free diet may offer symptom relief however, that could be due to factors outside of gluten sensitivity. Deciding to adopt a gluten-free diet should be based on your personal symptoms and preferences, while carefully considering the potential drawbacks. It's essential to work closely with your IBD dietitian and gastroenterologist to ensure that the diet is balanced, suitable for your condition, and meets all your nutritional needs.