We have a fantastic question this week. Very recently, I saw two new studies that are related to this topic come out. I read a couple of commentaries about them and then when I was reviewing questions that we could cover this week, I heard this question and thought, “Well, this is perfect timing.” It’s true that early studies indicated that it might be possible to reduce the risk of developing celiac disease by introducing gluten between four and six months of age.
If you understand the immune system and how it develops, and sensitization, it made sense to me that this could be a possibility. Whether it still makes sense to give your baby gluten at four months old is an entirely different question. There are a lot more things to talk about than just whether it would reduce the risk of developing celiac disease.
In this episode, we cover:
3:57 Introducing 14Four
14:03 What Chris ate for breakfast
18:54 The research on when to introduce gluten
24:07 Can you influence whether someone will develop Celiac?
Links We Discuss
- Introduction of Gluten, HLA Status, and the Risk of Celiac Disease in Children
- Randomized Feeding Intervention in Infants at High Risk for Celiac Disease
Steve Wright: Good morning, good afternoon, and good evening. You are listening to the Revolution Health Radio show. This show is brought to you by ChrisKresser.com. I’m your host, Steve Wright from SCDlifestyle.com. With me is integrative medical practitioner, healthy skeptic, and New York Times bestselling author, Chris Kresser. How are you doing, Chris?
Chris Kresser: I’m great. How are you, Steve?
Steve Wright: I’m good. I’m getting my first cup of coffee. Ready to go.
Chris Kresser: Nice, nice. We have a really great question today that again, I think a lot of people are going to be interested in. There’s been a lot of discussion about it in the media recently. Then there are two very relevant new studies on this topic that came out just last week. We’ll get into that shortly. But before we do that, I have yet another announcement to make. It seems like this is the month of announcements. Last week, we talked about my clinic reopening and how I hired an MD associate, Dr. Amy Nett, and merged with Dr. Sunjya Schweig to create the California Center for Functional Medicine.
Steve Wright: What was the feedback about all that?
Chris Kresser: Oh, it was great. Unfortunately, my practice was only open for 20 minutes, which is really frustrating.
Steve Wright: Wow.
Chris Kresser: I know, for a lot of people who’ve been waiting a long time for the chance to become a new patient. We sent the e-mail out. We decided to just put 100 people on the wait list this time, because last time, 600 people joined in a matter of a few days, and it took me over two years to get through that wait list. It didn’t seem to make sense to put that many people on at one time. So instead, we decided to put 100 on, work through those over the next few months, and then do another open enrollment period after that, and then just keep doing a rolling, open enrollment period, so that the list stays a little bit fresher. So we sent the e-mail out and within 20 minutes, those 100 spots were full. You know, we heard from a lot of people who were understandably upset and frustrated that they hadn’t even opened the e-mail yet, and we already had to close the practice. That’s the bad news. The good news is that with Amy on board and beginning to see new patients probably in a few months, that’s going to really create more opportunities for new patients. Dr. Schweig, who I’m partnering with, is going to have some spaces, although he’s already quite full. He’ll probably be bringing on an associate in the future. The vision for the California Center for Functional Medicine is creating a clinic with several different practitioners, clinicians of different backgrounds who share the same fundamental approach to functional medicine and healthcare, so that we can accommodate more people and provide even better service to the people that we’re currently treating. Then, of course, the next step beyond that is the formal clinician training program that I’m working on and hope to launch next year, so that we can train the next generation of functional medicine practitioners that can start to address this demand. Obviously, there’s a lot more demand for this kind of work than there are practitioners who are doing it. That’s the next step.
Steve Wright: Awesome. So tell us about the new announcement.
Chris Kresser: I’ve mentioned this before in the past, the 14Four program. I’m really excited to announce that by the time you hear this, it will be live and ready for you to check out. This is a program that’s really kind of a culmination of years and years of my own personal experience recovering my health, my own journey back to health, as well as my work now with about 1,500 patients, helping them to recover their health. During that time, I basically recognized that there are four pillars to health. Of course, there’s more to it. But these are the four pillars, the four most important things for most people that I’ve worked with. They were the four most important things in my recovery process. They’re also the four things that I think if you focus on, they will bring at least 80% of the results, if not more, for most people. Those things are: nutrition, stress management, sleep, and physical activity. So the 14Four is a 14-day program that teaches people how to dial in all four of those things in a really effective way. It’s a total mind-body reset, essentially. You know, we all know about the Whole30 and then my 30-day reset. Those are both 30-day Paleo nutrition programs. They’re fantastic. But the problem with them is they only focus on nutrition. They don’t address stress management, sleep or physical activity. And 30 days, let’s face it, is a big commitment for a lot of people. I think there’s a whole section of the population out there that’s being left out, because they’re just not up for committing to a full 30-day program.
The other issue about those programs is they kind of just throw you into the deep end of the pool. You just start, and then the next day, you’re on a strict Paleo diet for the next 30 days, with very little discussion of preparation or what to do to make that more successful. I found, in my work with patients, that the people who are most successful with diet and lifestyle changes are the people that are the best prepared. So what we’ve done, even though the core of the program is 14 days—the period where you’re doing the diet, stress management, sleep, and physical activity is 14 days—it’s actually a five-week program overall. So we have two weeks of preparation that leads you into the program, which really sets you up for success. For example, in the first week, you watch some videos from me and my staff, nutritionists Kelsey and Laura, to get you ready. You actually do a ramp up on the diet. You remove flour, seed oils, excess sugar, alcohol, and caffeine from your diet. So you begin to kind of ease into the 14-day stricter Paleo approach. You take some quizzes and fill out some questionnaires, to kind of get a sense of what your goals are and where you’re starting from. You take some before pictures and measurements. You join a support group that you’ll have access to throughout the program. You schedule some time in your calendar. So it’s really helping you to create the conditions that will lead to success. Then in the second week, we just continue that. You clean out your pantry. You review the shopping list and go shopping to get the groceries that you’ll need. You listen to some of the basic recordings explaining the stress management practices and the exercise demos. You review the cheat sheets and things that will be available to you throughout the program. Then week three and four is the actual program itself.
The way it’s been set up is really fantastic. We wanted to give people a kind of no-brainer experience, where all you have to do is follow along. Each day, there’s a detailed curriculum, if you will, where we tell you exactly what the recipes are, exactly what to eat. You get links to those recipes. We tell you what the exercise program is for that day. We have high-quality, professional video demos that you can follow along with. These are all exercise techniques that you can do at home, without any special equipment or a gym membership. You could also do it on the road if you’re travelling. So things like push-ups, lunges, and planks, which are fantastic, full-body workout, but don’t require any special equipment. Then we have both audio and video demos and recordings of stress management techniques. You know, you don’t have to be an expert in this, this is for total beginners. You can just listen to the recordings and follow along. We’re really kind of holding your hand every step through the process.
Then week five is transition, where we talk about how you integrate the changes that you made during that 14-day reset or reboot into the context of your daily life. So you fill out an exit quiz. There’s a next steps guide that, again, gives you guidance on what to do next, depending on the results that you got in the program. You’ll take your after measurements and pictures. There’s some discussion about how to kind of make this stick in your life. I think this program is going to help a lot of people. It’s a great fit for people who have been interested in doing this, but maybe have been scared away by a 30-day commitment, people who feel like they need a little bit more support and handholding through the process. It’s a great fit for people who focus mostly on nutrition, but feel like they’re kind of lagging in stress management. I sure have a lot of patients that fit into that category. Or maybe they haven’t focused that much on physical activity or the sleep piece.
It’s a great fit for anyone who just feels like they need a reset. I can see a lot of people doing this maybe three or four times a year, just like a spring, summer, fall, winter reset, just for a couple of weeks. It’s a little bit easier to get into than a full 30-day program. Again, as I said, we’re addressing issues other than just diet. So I could see people doing the 14Four once a quarter, just to kind of keep themselves tuned up. I definitely intend to do that. The good news is once you sign up, you have access to it. You pay one time, and you can do it as many times as you want for the rest of your life. We’re really excited about it. It’s something I’ve been working on in a way, like I said, for years. I think it’s going to help a lot of people.
Steve Wright: Awesome, Chris. That sounds fabulous. But I know you can’t design one program for every single person. So who is the program not right for?
Chris Kresser: That’s a great question, Steve. It is hard to design a program that’s right for everyone. This is not about customization. My book—as I’m sure most people listening to this knows—is all about how you customize a Paleo-based diet and lifestyle to make it work for you, and how you can make it more flexible and adaptable over the long term. This program is not about customization, it’s about implementation. So it’s about hitting the reset button on your body, your mind; getting your stress, sleep, physical activity, and diet dialled in in a two-week period in a really focused way. Then after this program is finished—you know, if you’re just starting with Paleo, for example, and you haven’t done that customization, then the recommendation that will be made in week five would be to kind of transition into some of the stuff that we talk about in my book, where you learn whether things like dairy products work for you, what about white potatoes, and how many carbs should you eat. All those kinds of longer-term questions about customization are not covered in the 14Four. The 14Four is really about that total mind-body reset. That’s who it’s appropriate for.
Steve Wright: Gotcha. So definitely, you need to be willing to do the work though. If people just want information, that’s not going to be a good fit.
Chris Kresser: Yeah. This is a hands-on implementation, change-your-life-in-14-days kind of program. It’s for people who really want to make a change and see huge results in a short period of time, with a lot of support, community, and interaction with people who are doing a similar thing all around the world. So that’s what this program is all about. If you want to learn more about it, you go to 14Four.me. That’s 14Four.me. You can learn a little bit more about the program there and then we hope to see you on the inside. It’s a great way to do a little reset before the holiday period kicks in. We know that a lot of weight gain that happens each year happens during the holidays, and the weight that’s gained during the holidays often doesn’t completely come off. So people just kind of get on the cycle where they gain a little bit of weight each year. That predominantly happens during the holidays. So be aware of that and consider doing the 14Four before you get into that period, and maybe in January, after New Year’s, after you’ve had the whole Thanksgiving and Christmas onslaught.
What Chris Ate for Breakfast
Steve Wright: Perfect. Speaking of food onslaughts, did you have anything for breakfast this morning?
Chris Kresser: I didn’t. We recorded a little bit early today. I was making Sylvie breakfast and getting her ready for school and stuff, so I didn’t have time to eat. I figured I’d just do a little intermittent fast. That’s the perfect opportunity for an intermittent fast. All I’ve had so far is tea right here.
Steve Wright: Special kind of tea?
Chris Kresser: Nothing special. It’s pu-erh. I don’t know if we’ve talked about it before. It’s Chinese tea that is relatively low on caffeine and is usually fermented, the way that it’s made. I find it just gives me a lot of mental clarity and sharpness, without the jitteriness that I can sometimes get if I have too much caffeine. It’s good. I like it.
Steve Wright: Perfect. Well, we should probably roll into our question.
Chris Kresser: Let’s do it. This question is from I think—she didn’t pronounce her name. It’s K-Y-R-A, Kyra. Let’s give it a listen.
Kyra: Hi, Chris. I have a nine-month-old. I have been feeding him gluten-free—grain-free, actually. I was recently at my pediatrician’s office. She said that new studies say that you should introduce gluten while you’re still breastfeeding, preferably before seven months. I looked that up also, and did find one study to confirm that, but I want to know what you think and what your research is showing. Thanks.
Chris Kresser: Fantastic question. Thanks, Kyra. It’s funny how this works. There are certain topics that just fly onto the radar, and then I’ll hear about them or they’ll come up in several different ways in a short period of time. I had actually very recently seen these two new studies that are related to this topic come out. I read a couple of commentaries about these studies. Then when I was reviewing questions that we could cover this week, I heard this question. I thought, “Well, this is perfect timing.” It’s true what Kyra’s OB/GYN suggested, that early studies indicated that it might be possible to reduce the risk of developing celiac disease by introducing gluten between four and six months of age. Did you hear this, Steve, when this came out?
Steve Wright: Yeah. I heard this and read a little bit of the paper, and was just so excited to see that kind of headline—not really.
Chris Kresser: Yeah, give your baby gluten.
Steve Wright: Earlier.
Chris Kresser: I mean, if you understand the immune system and how it develops and sensitization, it made sense to me that that could be a possibility. Whether it still makes sense to give your baby gluten at four months old is a whole different question. There are a lot more things to talk about in that question than just whether it would reduce the risk of developing celiac disease.
Steve Wright: Yeah. My big issue is, we can’t even get everybody to breastfeed until four months, and now we’re trying to figure out how to feed them wheat.
Chris Kresser: There are other more important questions, for sure. But there were two randomized clinical trials recently published that completely do not support those earlier findings. This is important. It’s strange to me, because I have seen very little coverage of these studies in the media. It’s almost like—there’s such a gleeful kind of backlash against gluten intolerance in the media, in the general public. Any study that comes out that even remotely suggests that gluten intolerance may not be as big of an issue as originally thought, it doesn’t affect some people as much as it was originally thought, or maybe it might be preventable in some way, the media is all over that. That study we covered, where they found that for a lot of people with IBS, it was really FODMAPs that were the bigger problem than gluten. Then we saw the media going around saying gluten intolerance didn’t exist because of that study, which was the most ridiculous distortion of a study that I’ve ever seen in the media. But it’s like people are just waiting for that.
Steve Wright: Well, everybody knows that the media culture is such that these guys have to produce their work very, very quickly. They’re obviously probably just drinking coffee and eating wheat all day long. So how could they publish studies making themselves wrong?
The Research on When to Introduce Gluten
Chris Kresser: So here come these two randomized clinical trials. It’s a much better methodology for studying this question, by the way. You know, earlier studies on this topic were often observational and just looking at when gluten was introduced, and then coming to conclusions. But these studies were randomized clinical trials, where they actually set up experiments to test this hypothesis. They don’t support the idea that introducing gluten earlier can prevent celiac disease. So let’s look at these studies.
The first one was done in the Netherlands, but it included kids in seven European countries and I think also from Israel. There were about 1,000 babies that were identified as high risk for celiac based on their genotype—so their HLA genotype and their family history. The babies were randomized. One group was given 100 mg of gluten at four months. The control group was given placebo and instructed not to introduce that until six months. Then at six months, both parents were advised to introduce gluten-containing foods. Then they tracked the incidence of celiac disease through a three-year follow-up period. What they found was that 5% of the study population developed celiac by age three, and it made no difference when it was introduced—whether it was introduced at four months or whether it was introduced at six months. Perhaps surprisingly, it also made no difference in this study whether the babies were breastfed exclusively or even not exclusively, or whether they were currently being breastfed when gluten was eventually introduced. So that’s the first study.
The second study came out of Italy. It was a similar design to the first one, but it compared the introduction of gluten at six and ten months. What they found, actually, was that delaying the introduction of gluten to 12 months did delay the diagnosis of celiac, but it didn’t prevent it. At age two, 12% of the babies who started eating gluten at six months had celiac, compared to 5% of the babies who started eating it at 12 months. That’s a pretty big difference. That’s more than double the incidence of celiac for babies that started eating it at six months, versus babies who started eating it at 12 months. But by five years of age, 16% of both groups had been diagnosed with celiac. There was no difference by the time the kids were five years old. Again, in this study, breastfeeding wasn’t related at all—so whether the kid was breastfed or not didn’t impact whether they developed celiac.
As a parent of a young child, I will say that it is notable that celiac was delayed. If your kid is going to get celiac, which is obviously not a desirable outcome, but if they’re going to get it, it would be somewhat easier to deal with if they get it at age four or five—when they’re verbal and can talk about their symptoms and how they feel and they have higher level of body awareness and things like that—than getting it at a year and a half, where they’re preverbal and can’t really tell you what’s going on. So I don’t think that’s an insignificant finding. And I don’t think it’s possible to justify the advice that’s still currently being given to many—like in this situation that Kyra mentioned with her OB/GYN, and I’ve heard other doctors giving this advice—to introduce gluten at four to six months of age. That cannot really be supported anymore based on the results of these studies. So if you hear people saying that, you definitely want to spread the word and let them know about this new research, because it’s important and it could affect the development of this condition early on in life.
Steve Wright: I think we need all the loyal listeners of RHR to print off these two studies and take them to their OB/GYN. So maybe we can do like a grassroots push here.
Chris Kresser: I think that’s a good idea, Steve. We’ll include the links to the studies in the show notes. I’m not sure if the full text is available for these studies for free; I can’t remember. But at least the abstract is, and that will tell the basic story to your doctor.
Let’s talk about what might be happening here, because we know—so these studies suggest that the introduction of gluten, when it’s introduced, may make a difference in when celiac develops in children. It suggests that actually introducing it later, not earlier, may be helpful in delaying its development. But they both suggest that when you introduce gluten doesn’t ultimately affect whether someone will develop celiac disease by age five.
Can You Influence Whether Someone Will Develop Celiac?
Here’s what we know: Celiac today is four to five times more common than it was about 50 years ago. That’s not because of increased diagnosis. There is an increase in the awareness and then diagnosis, but there is a famous study that looked at blood samples from a military base that had been preserved since—I can’t remember the exact year, but I think it was some time in the ‘50s. They tested those blood samples and compared them with modern samples. They found that yes; celiac is four to five times more common today than it is then. That was a unique way of looking at it, because it had nothing to do with diagnosing it in the community, in the wild, so to speak. They were just looking at straight up blood samples from different periods. During that time, our genes, the HLA types that determine our risk for celiac have not changed. There is some idea that wheat has changed a lot during that time, but it really hasn’t in the last 50 years. I don’t think there’s a lot of evidence for that. So there has to be something else that’s contributing to this increase and the incidence of celiac. If we know what that is, then that is what we will need to focus on in terms of reducing the likelihood of it developing at all, instead of just delaying its appearance. We don’t know the answer to that question. But my theory—and I imagine you’ll probably agree, Steve—is that the biggest change during that period relates to the microbiome. These changes to the microbiome, in large part, are probably what are determining our susceptibility to this condition.
Steve Wright: Yeah. By saying microbiome, I think that’s a very well-thought-out theory. Because there’s lots of champions, and I’m not making any one champion wrong with where they do their work. But when you say gut microbiome, now you’re including our environment and how sterile it is, our antibiotic usage, the potential GMO contribution to this. The microbiome is affected by essentially everything.
Chris Kresser: Yeah.
Steve Wright: I think that’s a really astute theory. I just so happen to agree.
Chris Kresser: There’s this other new term that I mentioned in my blog post about the clinician training, which is the exposome. This is now being used amongst scientists and researchers to describe or refer to the sum total of the non-genetic, environmental exposures we’ve had in our lifetime, and even prior to our technical lifetime. So like our mother’s exposure to toxins and her diet while we were in the womb, even our mother and father’s diet prior to conception—which actually we know now has an influence in how we develop—our early life influences, like the bond that’s formed with our mother or not formed as well as it should be, whether we were breastfed, whether we were born vaginally.
In fact, the authors of these papers actually speculated that some of the factors—they mentioned the increase in elective C-sections as one of the possible risk factors for why we’ve seen an increase in celiac. And that’s all about the microbiome. They referred kind of indirectly to microbiome there, but there are a number of things that have changed in the last 50 years that the authors actually did specifically mention that would all contribute to changing the microbiome, and thus making us more sensitive to celiac. These include increased antibiotic use. I mean, 50 or 60 years ago, antibiotics were not used to the extent that they were like in the ‘70s, ‘80s, and ‘90s. Thankfully, I think it’s starting to go down a little bit now, as awareness of the microbiome increases. PPIs, there are a lot of people taking acid-stopping drugs, which lower stomach acid and can adversely affect the microbiome. Elective C-sections, which I just mentioned, which we know that the baby’s first colonization of the gut happens in the birth canal. Maybe it happens a little bit earlier. I think we talked about that on a recent show. But the major primary exposure is in the birth canal. And if there’s a C-section, then that’s going to be different; the first exposure will be the hospital environment and that will affect that microbiome. Of course, diet affects the microbiome. Increased consumption of sugary sodas, excess sugar, and all the things that have gone wrong in the modern diet, environmental toxins, pesticides, heavy metals, changes in the environment that have led to more persistent exposure to chemicals and toxins. These are all affecting the microbiome. Then in turn, the balance of bacteria and other organisms in the gut can directly determine our likelihood of developing celiac and other autoimmune diseases. That’s what I think is going on here.
If you kind of turn that around and you ask, “How can we prevent or reduce the incidence of celiac?” Well, the answer is we can do everything we can to promote a healthy microbiome, and thus, healthy immune function. Because that’s the connection here. 70% to 80% of our immune system is in the gut, as we’ve discussed before. If the microbiome goes south, then your immune function is going to go south, and celiac is an autoimmune disease. So we need to make sure that we are eating, as parents, a lot of fermentable fiber. We’re consuming fermented foods and probiotics, other things to protect the microbiome. We’re avoiding antibiotics whenever possible. We’re avoiding acid-stopping drugs. We are managing our stress. Chronic stress can adversely affect the microbiome. We’re exercising. We know that exercise has a beneficial impact on the microbiome. We’re eliminating foods like excess sugar, flour, and industrial seed oils, which can harm the microbiome. These are all the things that we always talk about in terms of improving your gut health. They’re crucial probably not only for our own gut health, but this is what our children inherit from us. Then we want to do all the same things with our kids.
It never ceases to amaze me when we’re in an environment where we’re hanging out with other parents or whatever, and we just see what other kids are eating, and we overhear parents talking about food. You know, the diet of most kids, like with these Juice Squeeze things, Lunchables, and processed foods. There are kids in my life connected to me in some way, and the only thing I see them eating is flour, variations of flour and sugar. That’s going to really dramatically change the microbiome, and it’s going to set them up for chronic disease. That’s just a fact. And I see this happen all the time. Those are the biggest issues, I would say.
Then we’ve talked about the importance of breastfeeding. The WHO recommendation is for six months of exclusive breastfeeding, and then 22 months of complementary breastfeeding. I know that these studies didn’t show a particular connection between breastfeeding and the incidence of gluten intolerance, but there are many, many reasons to breastfeed. One of them is promoting healthy immune function. It’s possible that breastfeeding, in combination with all of the other factors that we’ve talked about, would have an additive effect. It’s something that should definitely be done for many reasons. That’s my take on this whole thing. It may not be possible to completely get rid of celiac, because there are certain environmental influences and exposures that we don’t have 100% control over. That’s just the reality of life. But I think we can at least reduce the likelihood in our children and in our communities by focusing on these things that we talked about.
Steve Wright: I couldn’t agree more, Chris. I think the only thing you might have left out is go play in the dirt a little bit, get some soil-based organisms (SBOs) in your life, don’t wash your kids’ hands so fast. But yeah, I think the idea that we could ever eradicate one of these diseases or something is a little fantasy land. So I love the analogies. I think we gave her a lot of different action steps that she can focus on rather than when the timing of wheat should be introduced.
Chris Kresser: Just a reminder for everyone, go check out 14Four.me. We’d love to see you in there. There’s a private Facebook group that’s part of the program, where you can get support from other people that are doing it, as well as from my staff RDs, Kelsey and Laura, who are fantastic. I might even show up in there occasionally. So yeah, I hope it’s helpful to you. It’s another tool in your bag for resetting your mind and body. I look forward to talking to you next week.
Steve Wright: Thanks, everyone, for listening. Just as a reminder, you can go to ChrisKresser.com/podcastquestion and submit questions for this podcast. And as Chris mentioned, you should definitely check out 14Four.me. Just sign up for that. Take a look at that. We’ll have the show notes here. Make sure you print out those studies and take those to your OB/GYN’s office as well.
Chris Kresser: All right, everybody. Take care.