What are the effects of gluten allergy

What’s really behind ‘gluten sensitivity’?

By Kelly Servick

The patients weren’t crazy—Knut Lundin was certain of that. But their ailment was a mystery. They were convinced gluten was making them ill. Yet they didn’t own celiac disease, an autoimmune reaction to that often-villainized tangle of proteins in wheat, barley, and rye. And they tested negative for a wheat allergy. They occupied a medical no man’s land.

About a decade ago, gastroenterologists love Lundin, based at the University of Oslo, came across more and more of those enigmatic cases. «I worked with celiac disease and gluten for so numerous years,» he says, «and then came this wave.» Gluten-free choices began appearing on restaurant menus and creeping onto grocery store shelves.

By , in the United States alone, an estimated 3 million people without celiac disease had sworn off gluten. It was simple to assume that people claiming to be «gluten sensitive» had just been roped into a food fad.

«Generally, the reaction of the gastroenterologist [was] to tell, ‘You don’t own celiac disease or wheat allergy. Goodbye,’» says Armin Alaedini, an immunologist at Columbia University. «A lot of people thought this is perhaps due to some other [food] sensitivity, or it’s in people’s heads.»

But a little community of researchers started searching for a link between wheat components and patients’ symptoms—commonly abdominal pain, bloating, and diarrhea, and sometimes headaches, fatigue, rashes, and joint pain.

That wheat really can make nonceliac patients ill is now widely accepted. But that’s about as far as the agreement goes.

As data trickle in, entrenched camps own emerged. Some researchers are convinced that numerous patients own an immune reaction to gluten or another substance in wheat—a nebulous illness sometimes called nonceliac gluten sensitivity (NCGS).

Others believe most patients are actually reacting to an excess of poorly absorbed carbohydrates present in wheat and numerous other foods.

Those carbohydrates—called FODMAPs, for fermentable oligosaccharides, disaccharides, monosaccharides, and polyols—can cause bloating when they ferment in the gut. If FODMAPs are the primary culprit, thousands of people may be on gluten-free diets with the support of their doctors and dietitians but without excellent reason.

Those competing theories were on display in a session on wheat sensitivity at a celiac disease symposium held at Columbia in March. In back-to-back talks, Lundin made the case for FODMAPs, and Alaedini for an immune reaction. But in an irony that underscores how muddled the field has become, both researchers started their quests believing something completely different.

Known wheat-related illnesses own clear mechanisms and markers.

People with celiac disease are genetically predisposed to launch a self-destructive immune response when a component of gluten called gliadin penetrates their intestinal lining and sets off inflammatory cells in the tissue under. People with a wheat allergy reply to wheat proteins by churning out a class of antibodies called immunoglobulin E that can set off vomiting, itching, and shortness of breath.

The puzzle, for both doctors and researchers, is patients who lack both the telltale antibodies and the visible damage to their intestines but who feel genuine relief when they cut out gluten-containing food.

Some doctors own begun to approve and even recommend a gluten-free diet. «Ultimately, we’re here not to do science, but to improve quality of life,» says Alessio Fasano, a pediatric gastroenterologist at Massachusetts General Hospital in Boston who has studied NCGS and written a book on living gluten-free. «If I own to throw bones on the ground and glance at the moon to make somebody better, even if I don’t understand what that means, I’ll do it.»

Like numerous doctors, Lundin believed that (fad dieters and superstitious eaters aside) some patients own a genuine wheat-related ailment.

His group helped dispel the notion that NCGS was purely psychosomatic. They surveyed patients for unusual levels of psychological distress that might express itself as physical symptoms. But the surveys showed no differences between those patients and people with celiac disease, the team reported in As Lundin bluntly puts it: «We know they are not crazy.»

Still, skeptics worried that the field had seized on gluten with shaky evidence that it was the culprit. After every, nobody eats gluten in isolation. «If we did not know about the specific role of gluten in celiac disease, we would never own thought gluten was responsible for [NCGS],» says Stefano Guandalini, a pediatric gastroenterologist at the University of Chicago Medical Middle in Illinois.

«Why blame gluten?»

Defenders of NCGS generally acknowledge that other components of wheat might contribute to symptoms. In , a group of proteins in wheat, rye, and barley called amylase trypsin inhibitors emerged as a potential offender, for example, after a team led by biochemist Detlef Schuppan of Johannes Gutenberg University Mainz in Germany (then at Harvard Medical School in Boston) reported that those proteins can provoke immune cells.

But without biological markers to identify people with NCGS, researchers own relied on self-reported symptoms measured through a «gluten challenge»: Patients rate how they feel before and after cutting out gluten. Then doctors reintroduce gluten or a placebo—ideally disguised in indistinguishable pills or snacks—to see whether the symptoms tick back up.

Alaedini has recently hit on a more objective set of possible biological markers—much to his own surprise.

«I entered this completely as a skeptic,» he says. Over his career, he has gravitated toward studying spectrum disorders, in which diverse symptoms own yet to be united under a clear biological cause—and where public misinformation abounds. His team published a study in , for example, that debunked the favorite suggestion that children with autism had high rates of Lyme disease. «I do studies [where] there is a void,» he says.

In NCGS, Alaedini saw another poorly defined spectrum disorder.

He did accept that patients without celiac disease might somehow be sensitive to wheat, on the basis of several trials that measured symptoms after a blinded challenge.

What are the effects of gluten allergy

But he was not convinced by previous studies claiming that NCGS patients were more likely than other people to own certain antibodies to gliadin. Numerous of those studies lacked a healthy control group, he says, and relied on commercial antibody kits that gave murky and inconsistent readings.

In , he contacted researchers at the University of Bologna in Italy to obtain blood samples from 80 patients their team had identified as gluten sensitive on the basis of a gluten challenge. He wanted to test the samples for signs of a unique immune response—a set of signaling molecules diverse from those in the blood of healthy volunteers and celiac patients.

He wasn’t optimistic. «I thought if we were going to see something, love with a lot of spectrum conditions that I own looked at, we would see little differences.»

The results shocked him. Compared with both healthy people and those with celiac, these patients had significantly higher levels of a certain class of antibodies against gluten that propose a short-lived, systemic immune response. That didn’t mean gluten itself was causing disease, but the finding hinted that the barrier of those patients’ intestines might be faulty, allowing partially digested gluten to get out of the gut and interact with immune cells in the blood. Other elements—such as immune response–provoking bacteria—also might be escaping.

Certain enough, the team found elevated levels of two proteins that indicate an inflammatory response to bacteria. And when 20 of the same patients spent 6 months on a gluten-free diet, their blood levels of those markers declined.

For Alaedini, the beginnings of a mechanism emerged: Some still-unidentified wheat component prompts the intestinal lining to become more permeable. (An imbalance in gut microbes might be a predisposing factor.) Components of bacteria then seem to sneak past immune cells in the underlying intestinal tissue and make their way to the bloodstream and liver, prompting inflammation.

«This is a genuine condition, and there can be objective, biological markers for it,» Alaedini says.

«That study changed a lot of minds, including my own.»

The study also impressed Guandalini, a longtime skeptic about the role of gluten. It «opens the way to finally reach an identifiable marker for this condition,» he says.

But others see the immune-response explanation as a red herring. To them, the primary villain is FODMAPs. The term, coined by gastroenterologist Peter Gibson at Monash University in Melbourne, Australia, and his team, encompasses a smorgasbord of common foods.

Onions and garlic; legumes; milk and yogurt; and fruits including apples, cherries, and mangoes are every high in FODMAPs. So is wheat: Carbs in wheat called fructans can account for as much as half of a person’s FODMAP intake, dietitians in Gibson’s group own estimated. The team found that those compounds ferment in the gut to cause symptoms of irritable bowel syndrome, such as abdominal pain, bloating, and gas.

Gibson has endless been skeptical of studies implicating gluten in such symptoms, arguing that those findings are hopelessly clouded by the nocebo effect, in which the mere expectation of swallowing the dreaded ingredient worsens symptoms.

His team found that most patients couldn’t reliably distinguish pure gluten from a placebo in a blinded test. He believes that numerous people feel better after eliminating wheat not because they own calmed some intricate immune reaction, but because they’ve reduced their intake of FODMAPs.

Lundin, who was firmly in the immune-reaction camp, didn’t believe that FODMAPs could explain away every his patients. «I wanted to show that Peter was wrong,» he says. During a 2-week sabbatical in the Monash lab, he found some quinoa-based snack bars designed to disguise the taste and texture of ingredients.

«I said, ‘We’re going to take those muesli bars and we’re going to do the perfect study.’»

His team recruited 59 people on self-instituted gluten-free diets and randomized them to get one of three indistinguishable snack bars, containing isolated gluten, isolated FODMAP (fructan), or neither. After eating one type of bar daily for a week, they reported any symptoms. Then they waited for symptoms to resolve and started on a diverse bar until they had tested every three.

Before analyzing patient responses, Lundin was confident that gluten would cause the worst symptoms. But when the study’s blind was lifted, only the FODMAP symptoms even cleared the bar for statistical significance.

Twenty-four of the 59 patients had their highest symptom scores after a week of the fructan-laced bars. Twenty-two responded most to the placebo, and just 13 to gluten, Lundin and his collaborators—who included Gibson—reported final November in the journal Gastroenterology. Lundin now believes FODMAPs explain the symptoms in most wheat-avoiding patients. «My main reason for doing that study was to discover out a excellent method of finding gluten-sensitive individuals,» he says. «And there were none. And that was fairly amazing.»

At the Columbia meeting, Alaedini and Lundin went head to head in consecutive talks titled «It’s the Wheat» and «It’s FODMAPS.» Each has a list of criticisms of the other’s study.

Alaedini contends that by recruiting broadly from the gluten-free population, instead of finding patients who reacted to wheat in a challenge, Lundin likely failed to include people with a true wheat sensitivity. Extremely few of Lundin’s subjects reported symptoms exterior the intestines, such as rash or fatigue, that might point to a widespread immune condition, Alaedini says. And he notes that the increase in patients’ symptoms in response to the FODMAP snacks was just barely statistically significant.

Lundin, meanwhile, points out that the patients in Alaedini’s study didn’t go through a blinded challenge to check whether the immune markers he identified really spiked in response to wheat or gluten.

What are the effects of gluten allergy

The markers may not be specific to people with a wheat sensitivity, Lundin says.

Despite the adversarial titles of their talks, the two researchers discover a lot of common ground. Alaedini agrees that FODMAPs explain some of the wheat-avoidance phenomenon. And Lundin acknowledges that some little population may really own an immune reaction to gluten or another component of wheat, though he sees no excellent way to discover them.

After the meeting, Elena Verdù, a gastroenterologist at McMaster University in Hamilton, Canada, puzzled over the polarization of the field. «I don’t understand why there is this need to be so dogmatic about ‘it is this, it is not that,’» she says.

She worries that the scientific confusion breeds skepticism toward people who avoid gluten for medical reasons.

When she dines with celiac patients, she says, waiters sometimes meet requests for gluten-free food with smirks and questions. Meanwhile, the conflicting messages may send nonceliac patients below a food-avoidance rabbit hole. «Patients are withdrawing gluten first, then lactose, and then FODMAPs—and then they are on a really, really poor diet,» she says.

But Verdù believes careful research will ultimately break through the superstitions.

What are the effects of gluten allergy

She is president of the North American Society for the Study of Celiac Disease, which this year awarded its first grant to study nonceliac wheat sensitivity. She’s hopeful that the search for biomarkers love those Alaedini has proposed will show that inside the monolith of gluten avoidance lurk multiple, nuanced conditions. «It will be difficult,» she says, «but we are getting closer.»

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Gluten intolerance spelled out

Gluten intolerance is a general term that encompasses both celiac disease and gluten sensitivity, explains Anthony Porto, MD, MPH, a Yale Medicine pediatric gastroenterologist.

It means that the body has difficulty digesting gluten. So, if people with celiac or gluten sensitivity eat foods that contain gluten, they experience digestive symptoms, including diarrhea, gas, constipation, and abdominal pain.

Celiac disease, which is genetic, is an autoimmune disorder in which the body makes antibodies (infection-fighting cells) that attack normal cells by error. Those antibodies harm the inner lining of the little intestine, flattening the finger-like tissues (villi) that assist your body absorb nutrients and thereby making it hard for them to do their job.

For people with celiac disease, eating even the smallest quantity of gluten triggers this reaction, which can also lead to problems absorbing nutrients and calories.

Strictly adhering to a gluten-free diet is the only way to treat celiac disease.

The disease is typically diagnosed via a blood test, though it is significant to note that if you own been following a strict gluten-free diet, the test may give a false-negative result.

What are the effects of gluten allergy

(So, don’t start a gluten-free diet until after you own consulted with a physician.) An upper gastrointestinal (GI) endoscopy, which is performed by inserting a flexible tube with a camera below your esophagus, can also be used to diagnose celiac disease by showing if there is damage to the intestine.


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Managing a wheat allergy — your own or someone else’s — includes strict avoidance of wheat ingredients in both food and nonfood products.

Wheat is one of eight allergens with specific labeling requirements under the Food Allergen Labeling and Consumer Protection Act (FALCPA) of Under that law, manufacturers of packaged food products sold in the U.S.

and containing wheat as an ingredient must include the presence of wheat, in clear language, on the ingredient label.

The grain is found in a myriad of foods — cereals, pastas, crackers and even some boiling dogs, sauces and ice cream. It is also found in nonfood items such as Play-Doh, as well as in cosmetic and bath products. Note that the FALCPA labeling rules do not apply to nonfood items; if you own questions about ingredients in those products, check the manufacturer’s website or contact the company.

Foods that don’t contain wheat as an ingredient can be contaminated by wheat in the manufacturing process or during food preparation.

As a result, people with a wheat allergy should also avoid products that bear precautionary statements on the label, such as “made on shared equipment with wheat,” “packaged in a plant that also processes wheat” or similar language. The use of those advisory labels is voluntary, and not every manufacturers do so.

A challenging aspect of managing a wheat allergy is baking. While there’s no simple substitution for wheat as an ingredient, baked goods such as breads, muffins and cakes may be made using a combination of non-wheat flours, such as those made from rice, corn, sorghum, soy, tapioca or potato starch. Your allergist can provide you with guidance on which grains are safe for you.

Options for wheat-free grocery shopping include foods made from other grains such as corn, rice, quinoa, oats, rye and barley.

The recent growth in gluten-free products is making it easier to manage a wheat allergy.

Gluten is a protein found in wheat, barley and rye.

A gluten-free product may be safe for those who are allergic to wheat because the product should not contain wheat ingredients. However, because a product marketed as “gluten-free” must also be free of rye and barley in addition to wheat, those who must avoid only wheat may be limiting themselves. Anyone managing a food allergy shouldn’t rely on a “free from” label as a substitute for thoroughly reading the finish ingredient label.

People with any helpful of food allergy must make some changes in the foods they eat. Allergists are specially trained to direct you to helpful resources, such as special cookbooks, patient support groups and registered dietitians, who can assist you plan your meals.

Managing a severe food reaction with epinephrine

A wheat allergy reaction can cause symptoms that range from mild to life-threatening; the severity of each reaction is unpredictable.

People who own previously experienced only mild symptoms may suddenly experience a life-threatening reaction known as anaphylaxis. In the U.S., food allergy is the leading cause of anaphylaxis exterior the hospital setting.

Epinephrine (adrenaline) is the first-line treatment for anaphylaxis, which can happen within seconds or minutes, can worsen quickly and can be deadly. In this type of allergic reaction, exposure to the allergen causes the whole-body release of a flood of chemicals that can lead to lowered blood pressure and narrowed airways, among other serious symptoms.

Once you’re diagnosed with a food allergy, your allergist will likely prescribe an epinephrine auto-injector and teach you how to use it.

Check the expiration date of your auto-injector, note the expiration date on your calendar and enquire your pharmacy about reminder services for prescription renewals.

Be certain to own two doses available, as the severe reaction may recur. If you own had a history of severe reactions, take epinephrine as soon as you suspect you own eaten an allergy-causing food or if you feel a reaction starting. Epinephrine should be used immediately if you experience severe symptoms such as shortness of breath, repetitive coughing, feeble pulse, generalized hives, tightness in the throat, trouble breathing or swallowing, or a combination of symptoms from diverse body areas such as hives, rashes or swelling coupled with vomiting, diarrhea or abdominal pain.

Repeated doses of epinephrine may be necessary.

If you are uncertain whether a reaction warrants epinephrine, use it correct away, because the benefits of epinephrine far outweigh the risk that a dose may not own been necessary.

Common side effects of epinephrine may include anxiety, restlessness, dizziness and shakiness. Rarely, the medication can lead to abnormal heart rate or rhythm, heart attack, a sharp increase in blood pressure, and fluid buildup in the lungs.

Patients with certain pre-existing conditions, such as diabetes or heart disease, may be at higher risk for adverse effects and should speak to their allergist about using epinephrine.

Your allergist will provide you with a written emergency treatment plan that outlines which medications should be istered and when (note that between 10 and 20 percent of life-threatening severe allergic reactions own no skin symptoms). Be certain that you understand how to properly and promptly use an epinephrine auto-injector.

Once epinephrine has been istered, immediately call and inform the dispatcher that epinephrine was given and that more may be needed from the emergency responders.

Other medications, such as antihistamine and corticosteroids, may be prescribed to treat symptoms of a food allergy, but it is significant to note that there is no substitute for epinephrine — this is the only medication that can reverse the life-threatening symptoms of anaphylaxis.

Managing food allergies in children

Because fatal and near-fatal wheat allergy reactions, love other food allergy symptoms, can develop when a kid is not with his or her family, parents need to make certain that their child’s school, day care or other program has a written emergency action plan with instructions on preventing, recognizing and managing these episodes in class and during activities such as sporting events and field trips.

A nonprofit group, Food Allergy Research & Education, has a list of resources for schools, parents and students in managing food allergies.

If your kid has been prescribed an auto-injector, be certain that you and those responsible for supervising your kid understand how to use it.

What causes a reaction to gluten?

Possible causes of a bad reaction to gluten include an allergy, an intolerance and an autoimmune disease.

Coeliac disease

Coeliac disease is a serious, lifelong genetic digestive condition in which the immune system attacks itself when gluten is eaten, damaging the lining of the little intestine.

As a result of this, the body cannot properly absorb nutrients from food. Coeliac disease is not a food allergy or intolerance – it is an autoimmue disease. There is no cure and you must follow a gluten-free diet for life, even if your symptoms are mild. Reported cases of coeliac disease are two to three times higher in women than men.

Wheat allergy

A wheat allergy is a reaction to one element within wheat (not gluten), and generally occurs within seconds of eating.

If you own a wheat allergy, you may still be capable to eat barley and rye, and you may get a reaction from gluten-free products if they contain other parts of the wheat.

Gluten intolerance

Reports of gluten intolerance are more common than occurances of coeliac disease or wheat allergy.

What are the effects of gluten allergy

Gluten intolerance does not involve the immune system, is not genetic and does not seem to damage the gut. There is some debate about whether gluten is to blame, or whether other components that are removed from the diet when people stop eating gluten-containing ingredients are the culprits. For example, if you cut gluten out of your diet you'll often cut out refined carbs by default, and the health benefits you experience may be connected more to this. Food intolerance (or 'non-coeliac gluten sensitivity') symptoms tend to come on more slowly than allergy symptoms, often hours after eating.


Who really has a food allergy?

The Gluten-Free Diet: Facts and Myths

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FACTS

Gluten-free diet and celiac disease (CD):

  1. A strict, life-long gluten-free diet is required for health reasons.
  2. Ingestion of gluten causes an adverse reaction which damages intestinal cells and can lead to serious health problems.

Gluten-free diet and non-celiac gluten sensitivity (also known as “gluten sensitivity”):

  1. Individuals with non-celiac gluten sensitivity (NCGS) require a gluten-free diet to avoid adverse health effects.
  2. When people with NCGS consume gluten their intestinal cells are not damaged, but they may experience numerous of the same symptoms as do people with celiac disease.
  3. In some cases, other components of gluten-containing foods may cause adverse reactions in people with NCGS.

If you ponder you may own a gluten-related disorder (CD or NCGS) it is extremely significant to own testing done before removing gluten from your diet.

Otherwise testing may not yield valid results.


MYTHS

“A gluten-free diet is healthier.”

  • This is not true EXCEPT for people who own celiac disease, gluten sensitivity, or other gluten-related disorders.
    1. For the general population, the presence or absence of gluten alone is not related to diet quality. What’s significant are the overall food choices made within a diet, whether it is gluten-free or not.
    2. If an individual whose diet contains large amounts of breads, pastas and cookies (especially those made from refined flours) switches to a gluten-free diet which eliminates these foods while increasing fruits, vegetables and other healthful gluten-free foods, the resulting diet would likely be healthier.
    3. On the other hand, this same person could easily substitute gluten-free breads, pastas and cookies into the diet, without increasing intake of healthful gluten-free foods love vegetables and fruits.

      In this case a person may experience a reduction in diet quality, since numerous gluten-free processed foods are lower in fiber, vitamins, and minerals than their gluten-containing counterparts.

    “A gluten-free diet is excellent for weight loss.”

    1. Whether or not a diet promotes weight loss is not related to the presence or absence of gluten. As explained above, a gluten-free diet could either be higher in vegetables and fruits (and therefore potentially lead to weight loss), or it could rely heavily on processed gluten-free foods that are high in fat and sugar (which could potentially lead to weight gain).

    “Surely a few crumbs of bread can’t hurt.”

    1. Even tiny amounts of gluten can damage the intestinal cells of a person with celiac disease, even if there are no obvious immediate symptoms.
    2. Tiny amounts of gluten can be problematic for people with gluten sensitivity, too.

      But since non-celiac gluten sensitivity is less well understood than CD, it is unknown whether or not some people with GS may be capable to tolerate little amounts of gluten. Unless otherwise indicated, even someone who does not own celiac disease but is on a “gluten-free” diet for health reasons should avoid even tiny amounts of gluten contamination.


    Symptoms which could indicate the need for a gluten-free diet
    Symptoms of celiac disease and gluten sensitivity are similar and may include: recurring abdominal pain, chronic diarrhea/constipation, tingling/numbness in hands and feet, chronic fatigue, joint pain, unexplained infertility and low bone density (osteopenia or osteoporosis).

    There are approximately potential symptoms, numerous of which are also symptoms of other conditions.

    What to do if you ponder gluten may be causing your symptoms
    Consult with your personal physician/health care provider before giving up gluten. This is extremely significant because the standard blood testing done as a first step to diagnosing these conditions is not meaningful unless gluten is being consumed for a significant period of time before testing. It is also significant to consult with your healthcare provider in order to assess other possible causes of symptoms.

    How are celiac disease and non-celiac gluten sensitivity diagnosed?
    The first step is a panel of blood tests looking for an antibody response to gluten.

    If these tests are positive, the next step is an endoscopy. If the endoscopy shows the intestinal cell damage characteristic of celiac disease, this is considered the gold standard of celiac disease diagnosis.

    There is currently no specific diagnostic test for non-celiac gluten sensitivity; instead, it is a “rule out” diagnosis. Consequently, the celiac disease testing described above would be done. In addition, wheat allergy and other potential causes of symptoms should be ruled out. If every of these conditions own been ruled out and the patient responds positively to a gluten-free diet, then the diagnosis of non-celiac gluten sensitivity may be made.

    How numerous people own gluten-related disorders?
    It is estimated that approximately 1 in people worldwide own celiac disease.

    The prevalence of non-celiac gluten sensitivity is not established but may be significantly higher.

    The majority of people with gluten-related disorders remain undiagnosed.

    What is a gluten-free diet?
    Gluten refers to the proteins found in wheat, rye and barley which cause an adverse reaction in people with gluten-related disorders. On a gluten-free diet, these grains and any foods or ingredients derived from them must be removed from the diet. This includes the obvious breads, pastas and baked goods made with gluten-containing flours, but may also include less obvious foods such as sauces, salad dressings, soups and other processed foods, since these can contain little amounts of ingredients derived from gluten-containing grains.

    (Oats are naturally gluten-free, but are often contaminated with wheat in growing and/or processing, so only oats which are certified gluten-free are acceptable on a gluten-free diet.)

    Not endless ago, gluten was just a little-known protein found in wheat, barley, and other grains—an ingredient that gives most breads, baked goods, and pastas their shape and serves as the glue that holds them together.

    What are the effects of gluten allergy

    It wasn’t vilified as a culprit of stomach bloating, weight acquire, or a host of other problems.

    Back then, a gluten-free diet was reserved for the estimated 3 million Americans who own celiac disease, a digestive disorder caused by an immune reaction to gluten. Today, however, ditching gluten is a diet trend, and gluten-free foods are every over the supermarket and are highlighted on restaurant menus.

    Even celebrities are promoting gluten-free lives, and terms love “gluten intolerance,” “gluten sensitivity,” and “gluten allergy” are going mainstream. What do these terms actually mean?

    And is it a excellent thought to abstain from—or limit—gluten from your diet?


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