Editorial
See corresponding article on page 622.
The fashionable gluten-free diet—wear with caution
Claire L Jansson-Knodell1 and Alberto Rubio-Tapia2
1 Divisionof Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA; and 2 Division of
Gastroenterology, Hepatology, and Nutrition; Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
Olympic gold medalist in swimming Dana Vollmer, the current
men’s world top-ranked tennis player Novak Djokovic, 6-time
Olympian Nordic combined skier Todd Lodwick, and National
Football League quarterback Drew Brees are just a few examples
of world-class athletes who have adopted and touted the benefits
of the gluten-free diet (GFD). Riding the wave of these athlete
and other celebrity endorsements, the diet has become extremely
popular. In addition, the expanding gluten-free product market
is making it more accessible to the general public. Although
initially designed for those with celiac disease, dermatitis
herpetiformis, and wheat allergy, the GFD is followed by
many without celiac disease or other diagnosed gluten-related
disorders. Its rise in popularity has outpaced even the growing
incidence of celiac disease. We review who is following a GFD
and why, how it complicates celiac disease diagnosis, and the
diet’s health benefits and harms.
The percentage of people without celiac disease avoiding
gluten (so-called PWAGs) in the United States is 1.1% according
to NHANES data (1). In Australia, 7.3% of surveyed participants
without celiac disease avoid wheat to some degree (2). In
the United Kingdom, that number is 1.4% (3). A minority of
individuals following a GFD have celiac disease, an immune-
mediated response to dietary gluten resulting in villous atrophy
and malabsorption of nutrients in the small intestine. Lifelong
GFD is the gold standard for treatment and the only established
remedy for celiac disease (4). Besides celiac disease, individuals
cite various reasons such as nonceliac gluten sensitivity for
adhering to this diet (although the role of gluten remains
controversial), and gluten has been blamed as the culprit for
innumerable health complaints.
The study in this issue of the American Journal of Clinical
Nutrition by Littlejohns et al. (3) used the UK biobank to
characterize those following a GFD. In their population-based
study, they excluded 853 participants with celiac disease and
identified 1776 participants following a GFD—nearly twice as
many as those with a medical diagnosis necessitating gluten
exclusion out of a sample of 124,447 (3). They found that
nonwhite women who were highly educated with poorer self-
rated health were most likely to follow a GFD (3). Participants
who used to drink or smoke and had made positive life changes
with weight loss, perhaps showing a desire to improve their
health, were more often following a GFD (3). No genetic
variants were uncovered to suggest a biologic mechanism
underlying this dietary choice (3). These results are congruent
Am J Clin Nutr 2021;113:491–492. Printed in USA. © The Author(s) 2021. Published by Oxford University Press on behalf of the American Society for
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with American and Australian data that show women follow a
GFD at higher rates than men (1, 2). Nonwhite individuals have
also been reported to adopt the GFD at higher rates in the United
States (5). As in earlier research, those without celiac disease
far outnumber those with celiac disease who have adopted the
GFD (2).
Adopting a GFD prior to formal diagnosis of celiac disease is
problematic since serologic and endoscopic testing then becomes
unreliable. Celiac disease is screened for with a blood test for
tissue transglutaminase antibody, and the diagnosis is confirmed
by the finding of villous atrophy and other characteristic
histologic changes in the small intestine. Patients who self-
diagnose celiac disease and avoid gluten before undergoing a
medical evaluation may be reluctant to reintroduce gluten and
get tested. Unaffected people may choose to follow a GFD
for unclear health benefits, which creates a “gluten paradox”
of one group without celiac disease following a strict diet
without medical necessity and another group who could benefit
substantially but is yet undiagnosed. Celiac disease is thought to
affect ∼1% of the population worldwide, but research reports
many are unaware of their diagnosis, and screen detection
reveals numerous patients due to atypical or asymptomatic
presentations (6). Following a GFD without medical advice or a
formal evaluation creates challenges for physicians, undiagnosed
patients, and perhaps those who have placed themselves on this
unnecessarily restrictive and expensive diet.
The benefits of a GFD in those without gluten-related disorders
have not been definitively proven. Whether it is the celebrity
athletes and their anecdotal successes after implementing a GFD
or other reasons, the general public has a favorable perception of
this diet as part of a healthier lifestyle. One study by DiGiacomo
et al. (7) reported a higher HDL and lower BMI in those
without celiac disease following a GFD. The lower BMI was
verified by Tavakkoli et al. (8) for those on a GFD without
celiac disease compared with controls along with lower rates
of hypertension. The GFD may offer short-term benefits of
alleviation of various symptoms or ailments (placebo effect?)
and, according to limited research, an improved cardiovascular
risk profile, but these improvements require weighing against the
Funding: The authors reported no funding received for this study.
Address correspondence to AR-T (e-mail: RUBIOTA@ccf.org).
First published online January 29, 2021; doi: https://doi.org/10.1093/ajcn/
nqaa371.
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potential long-term consequences of dietary elimination from a
nutritional standpoint.
Potential harms are more readily identified with the GFD.
These include micronutrient deficiencies; decreased fiber con-
sumption; increased fat, sugar, and salt consumption; and higher
concentrations of heavy metal accumulation (9–12). Gluten-free
products are often made with refined flours and starches low in
fiber content. They are also fortified with vitamins and minerals
less frequently than other processed foods. A survey of celiac
disease patients following a GFD indicated that adults did not
consume the daily recommended amount of fiber or calcium
(10). Those on a GFD had increased mercury, lead, and arsenic
concentrations compared with controls (11). Although the long-
term effects of the accumulation of these elements are unknown,
this difference was significant and concerning. Similar concerns
about the nutritional adequacy, cost, and safety of the GFD have
been voiced for children (12).
The GFD is incredibly popular in Europe and America—
not always in the setting of celiac disease. It can complicate
the diagnosis of celiac disease, it is expensive, benefits are not
proven in large populations, and some nutritional risks have been
identified. As such, the GFD, although fashionable, should be
adopted cautiously and only with the assistance of a physician
and registered dietitian in the proper clinical setting.
The authors’ contributions were as follows—CJK: drafted the manuscript;
AR-T: critically revised the manuscript and provided editorial supervision;
and both authors: read and approved the final version.
Author disclosures: The authors report no conflicts of interest.
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