Our common human tendency to describe issues in black or white terms has generated some pretty staunch positions on gluten. These range from only recognizing Celiac disease as the sole gluten-related condition, to others declaring gluten is bad for all of us. Like most complex issues, however, the truth can be found in the details – in those ‘shades of gray’ that nuance the manifestations of the myriad different types of reactions to gluten that can (but don’t always) occur.
In this context, Dr. Elke Cooke (bio at the end of this article), one of the bright-light participants in our current Professional Education cohort, called our attention to spelt. As Dr. Cooke argued, even though it does contain some types of gluten proteins, spelt may in fact be an option for some gluten-reactive individuals. Read on to find out why, and how to go about determining gluten-reactive individuals who may potentially be able to tolerate spelt.
Incidentally, it has really been an immense pleasure to have the many amazing individuals track with us in our Professional Education groups. Even though they are here to learn how we practice Functional Medicine and to build their support community, we also derive tremendous value from their inquisitiveness, their backgrounds and expertise, and the knowledge that they bring to our weekly group discussions. I appreciate that whole-heartedly. – DrKF
Reactivity to Different Gluten and Non-Gluten Components
Just like several other varieties of grain including wheat, spelt contains gluten. Gluten is a mixture of hundreds of different proteins. Water-soluble gliadins and insoluble glutenins are the two main gluten protein types.
Each type of gluten-containing grain contains its own specific mixture of gliadin and glutenin protein subgroups. These subgroups are called Alpha-, Beta-, Gamma- and Omega-gliadin, and Alpha-, Beta-, and Gamma-glutenins. Emerging research demonstrates that each of these subgroups, as well as some non-gluten compounds, has a different level of immunological/non-immunological reactivity:
Immunological reactions:
- Alpha Gliadin: Alpha-gliadin has been considered the primary initiator of the inflammatory response to gluten in celiac patients. Alpha-gliadin antibodies are included on standard laboratory Celiac panels. In Celiac disease, the immune system mounts a T-cell mediated response to gliadin proteins causing those T cells to release inflammatory compounds that damage the intestinal lining. A strict, long-term gluten-free diet is required. Patients with Non-Celiac Gluten Sensitivity (NCGS) may also react to this gliadin subgroup via an IgG-mediated response.
- Omega Gliadin :The Omega-5 Gliadin has been shown to be major allergen associated with Exercise-Induced Wheat Allergy (EIWA) via IgE-mediated immediate hypersensitivity (including anaphylaxis). Serum IgE to Omega-5 Gliadin is now used to identify patients with EIWA. Omega Gliadin-specific IgE antibodies are not exclusively found in EIWA but also in patients with immediate allergic reactions to wheat and with atopic dermatitis. There is potential for IgE antibodies to Omega-5 Gliadin to cross-react with other gliadins. Those with NCGS may also react the Omega Gliadin subgroup via an IgG-mediated response.
- Beta and Gamma Gliadin: These subfractions are not implicated in Celiac disease or Wheat allergy. However people can and do react to these subgroups, including with atopic dermatitis. IgG-responses to Gamma-gliadins have also been identified in those with NCGS.
- Glutenins: Glutenins play a role in allergy to hydrolyzed wheat protein, baker’s asthma, atopic dermatitis and EIWA.
Non-gluten proteins: Some non-gluten proteins can also be involved in reactions to wheat. Non-specific lipid transfer proteins and alpha-amylase/trypsin inhibitors, for example, can cause IgE-mediated wheat allergy.
Non-immunological reactions:
- Fructans (non-gluten carbohydrate): A significant subsegment of patients with irritable bowel syndrome (up to 78%) react to poorly-digested, poorly-absorbed carbohydrates, termed FODMAPs, of which fructans are one type. Symptoms, including gas, bloating, diarrhea and/or constipation, are driven by the fermentation of these carbohydrates by excessive levels of bacteria in the small or large intestine. Many instances of presumed gluten-sensitivity actually turn out to be a non-immunological reaction to the FODMAP (carbohydrate) component of the grain consumed.
Testing Options
Testing for general reactivity to FODMAP foods is possible via lactulose breath testing, which is routinely used in our clinic.
There are testing options for reactivity to various gluten subfractions – some from conventional labs such as Labcorp and Quest. Thermo Fisher’s ImmunoCAP ISAC panel includes IgE to wheat lipid transfer proteins and alpha-amylase/tryptase inhibitor. ImmunoCAP also offers IgE to omega-5 gliadin. Wheat Zoomer from Vibrant Wellness and Cyrex’s Array 3 provide some of the more comprehensive analyses of several gluten fractions at once (both look at IgG and IgA). Other than identifying the specific proteins involved in wheat allergy (distinguishing mild from severe reactivity potential),we don’t typically find it useful to test for gluten reactivity to a great level of detail – instead we monitor symptom changes when we remove gluten from the diet. If celiac disease and frank wheat-related allergy/asthma have been ruled out, that’s when we might consider a patient a candidate for a careful-planned spelt challenge.
How Spelt is Different
There are key differences in the gluten components of spelt which is why some gluten/wheat-reactive people tolerate spelt better. Spelt has “minor” levels of Omega Gliadins compared with wheat and it does not contain the strongly antigenic Omega-5 Gliadins. It appears to have half as many glutenins as common wheat flour. The higher glutenin content in wheat was cultivated to make industrial processing easier and help maintain dough elasticity and strength. There is also a different Gamma Gliadin in spelt.
When spelt bread is made using traditional sourdough methods with long fermentation periods, it is low in FODMAPs which can reduce GI symptoms in those with Small Intestinal Bacterial Overgrowth (SIBO) or digestive enzyme deficiencies. Monash University (the foremost research center on FODMAPs content in foods) gives traditional sourdough bread the ‘green light’. ½ cup of cooked spelt pasta is also categorized as low in FODMAPs.
Spelt Challenge 101
In our clinic, nutritionist-directed food challenges typically follow a 4-day process. On the first day, the patient is instructed to consume the challenge food (in this case spelt) three times over the day, in increasing quantities and ending with a quantity that approximates a typical full serving size (e.g. 2 slices of sourdough spelt bread). On the next day, the patient eats three more full-size servings spread over the day. The challenge food is not consumed on days 3 and 4. Over the four days, the patient observes symptoms, guided by a tracking table that prompts them to consider changes to symptoms in the following areas:
- Digestion, bowel function
- Joint or muscle aches, neuropathic pain
- Headache, pressure
- Nasal or chest congestion
- Skin
- Energy level, sleep
- Mood, wellbeing
- Blood pressure, heart rate
- Other (e.g. weight, urination)
If at any point, symptoms become noticeable, the challenge can stop including ceasing to consume the challenge food. If symptoms are only mind and the patient is unsure of a true response, the challenge should continue.
Challenging with sourdough spelt bread is preferable initially. Since it is low in FODMAPs, this choice separates out potential immunological reactivity from any non-immunological FODMAPs intolerance. If a reaction is experienced using sourdough bread, it is likely an immunological response. If no reaction is experienced using sourdough bread, we recommend repeating the challenge with spelt berries (up to ½ cup full serving size) to check for any potential additional FODMAP intolerance.
The mechanism of any reaction that may occur affects the timing of that reaction: Delayed immunological reactions typically take several hours to days to appear. Reactions to FODMAP components typically occur within 20 minutes to a few hours.
Additional clinical insights from Dr. Cooke MD: This approach is very similar to my approach with SIBO patients. I would add that I ask them to get the Sourdough Spelt Bread from Berlin Bakery (available at WholeFoods Market). I find it important to give patients very specific guidelines on what spelt product to use as there are so many variations in quality. I chose this specific one because 1. sourdough is low in FODMAPs. 2. this specific company uses old fashioned methods of making the sourdough bread and they are certified Non-GMO. 3. the spelt flour is whole grain.
I don’t introduce the Spelt bread until the patient has completed the herbal/antibiotic SIBO protocol and I have also already taken steps to heal the Leaky Gut that is present in almost all of my SIBO patients. Spelt bread is one of the last foods that I will re-introduce due to the potential issues that can arise from the gluten/grain content. However, once I am able to introduce it into a patient’s diet, I have found that it significantly benefits gut motility. This, I believe is multifactorial. Spelt bread is a great source of much needed nutrition, expanding the diet of a previously fairly restricted patient. The lactobacilli in the sourdough improve the patient’s microbiome and the added fiber helps to bulk up the stool yet is gentle and seems to be easily tolerated even in SIBO patients. I have seen spelt bread further reduce bloating after the patients had already completed their SIBO treatment protocol but had not yet seen 100% symptom resolution.
A Little More on Spelt
Spelt (triticum spelta) is one of the oldest cultivated grains in human history. During the industrialization of agriculture spelt fell out of favor since it takes extra effort (and therefore cost) to remove the outer hull. Common wheat has no outer hull and can therefore produce up to 40% higher yields. However, spelt requires less soil nitrogen than modern wheat, is competitive against weeds, and is more resistant to pests and disease. These qualities make it a good choice for organic farmers, since it is already naturally protected against fungal growth and pests.
Since there is high variability between cultivars, it isn’t possible to be conclusive about the nutritional benefits of spelt vs wheat. By some accounts, however, whole grain spelt has slightly higher levels of protein and fat, and lower levels of carbohydrates than whole grain wheat. This may give spelt and advantage when it comes to glycemic control (although this advantage can be lost if using refined spelt flour, and grains, especially in flour form, always elicit some glycemic response). Higher levels of magnesium, specific soluble fiber compounds called arabinoxylans, beta-sitosterol glycoside (a principle type of plant sterol), ferulic acid and phytic acid have also been theorized to contribute to improved glycemic control with spelt versus wheat.
An important note: even if glycemic response may be slightly more favorable with spelt, our approach with patients who already have insulin-related disorders is typically to remove all grains, significantly dropping their total carbohydrate intake. We consider spelt potentially better-suited to those who do not have any insulin-related disorders, in whole-grain form, and in moderation.
How to Use Spelt
In general, spelt can be a substitute in any wheat recipes. Whole spelt grains are the ideal choice and can be sprouted as well, which enhances its mineral availability and decreases its gluten and phytic acid content. It is best to soak the grain overnight and rinse thoroughly before use. Whole spelt berries make a tasty side dish or work well mixed into cold salads.
Here is one of our favorite easy starter recipes for spelt:
Basic whole grain spelt berries
- 1 cup organic spelt berries
- 3 cups water or stock
Instructions: Soak grains overnight. Drain and rinse thoroughly. Bring the water or stock to a boil and add the spelt berries. Cover and simmer on a low heat for 40-60 minutes, until the kernels are chewy. Drain and serve.
To make your own sourdough spelt bread, we like this one from Whole Lifestyle Nutrition. Monitor the glycemic response if using spelt flour recipes through period labs (e.g. fasting blood glucose, hemoglobin A1c) or through more immediate-feedback options such as at-home blood glucose testing if warranted.
In summary, since its gluten and FODMAP components levels differ from modern wheat cultivars, whole grain spelt may be a nutrient dense, high fiber grain option for some individuals with gluten sensitivity or intolerance. Expanding healthy dietary choices for individuals on restricted diets is always an important goal.
As research into the sub-components of gluten continues, we expect there to be more data in the future to further tease out specific disease connections. We will continue to monitor that, as well as how that changes the relevance of testing options.
Acknowledgments: We would like to thank Dr. Elke Cooke, a participant in our Professional Education Program, for raising the question about the role for spelt in those with non-Celiac gluten sensitivity and for her contributions to this article. Dr Cooke acquired a medical degree from the University of Michigan in Ann Arbor. She completed her Residency in Emergency Medicine at the University of Michigan and became Board Certified in 2007. Dr. Cooke spent her first 8 years as an Emergency Physician at Kaiser Permanente in Northern California.
Working hard in conventional medicine and watching her patients consume a long list of remedies but never quite feeling truly better opened her eyes to the possibilities available in Functional Medicine. She has trained through the Kalish Mentorship program, trained at the Institute for Functional Medicine and has completed the Advanced Fellowship in Metabolic Medicine at A4M. She is currently a physician at BodyLogicMD and the owner and director of a web-based Functional Medicine Practice at www.elkecookemd.com.