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The promotion of gluten-free diets among people without celiac disease should not be encouraged.
Gluten, a storage protein in wheat, rye, and barley, triggers inflammation and intestinal damage in people with celiac disease.1 People with intestinal or extra-intestinal symptoms triggered by gluten but who do not meet formal criteria for celiac disease may have non-celiac gluten sensitivity, a clinical entity with an as yet uncharacterized biological basis.2 Celiac disease, which is present in 0.7% of the US population,3 is associated with an increased risk of coronary heart disease, which is reduced after treatment with a gluten-free diet.4On the basis of evidence that gluten may promote inflammation in the absence of celiac disease or non-celiac gluten sensitivity,5 concern has arisen in the medical community and lay public that gluten may increase the risk of obesity, metabolic syndrome, neuropsychiatric symptoms, and cardiovascular risk among healthy people.678910 As a result, diets that limit gluten intake have gained popularity.1112 In an analysis of the National Health and Nutrition Examination Survey (NHANES), most people adhering to a gluten-free diet did have a diagnosis of celiac disease.3 Moreover, in a follow-up analysis of NHANES, adoption of a gluten-free diet by people without celiac disease rose more than threefold from 2009-10 (prevalence 0.52%) to 2013-14 (prevalence 1.69%).13Short of strict gluten avoidance, people may reduce gluten in their diet owing to beliefs that this practice carries general health benefits.14 The reasons for gluten reduction likely relate to the perception that gluten carries adverse health effects.
Participants in NHS and HPFS have been followed via biennial self administered questionnaires on health and lifestyle habits, anthropometrics, environmental exposures, and medical conditions.
The Health Professionals Follow-up Study (HPFS) is a prospective cohort of 51 529 male health professionals from all 50 states who were enrolled in 1986.We considered definite and probable myocardial infarction together as our primary outcome, as we have previously found that results were similar when probable cases were excluded.33Patients were followed from 1986 until the development of coronary heart disease, death, or the end of follow-up in 2012 (June 2012 for NHS; January 2012 for HPFS).We tested for the association between cumulative average gluten intake and the development of coronary heart disease, comparing each fifth of gluten intake with the lowest fifth.Compared with participants in the lowest fifth of gluten intake, who had a coronary heart disease incidence rate of 352 per 100 000 person years, those in the highest fifth had a rate of 277 events per 100 000 person years, leading to an unadjusted rate difference of 75 (95% confidence interval 51 to 98) fewer cases of coronary heart disease per 100 000 person years.After adjustment for known risk factors, participants in the highest fifth of estimated gluten intake had a multivariable hazard ratio for coronary heart disease of 0.95 (95% confidence interval 0.88 to 1.02; P for trend=0.29).
Among the 73 666 women in NHS and 49 934 men in HPFS who completed a food frequency questionnaire in 1986, we excluded participants if they reported implausible daily energy intake (4200 kcal/d for men) or missing gluten data (NHS 48; HPFS 39); a diagnosis of myocardial infarction, angina, or stroke or coronary artery bypass graft surgery (NHS 4015; HPFS 2647); or cancer (NHS 4689; HPFS 1785).