Clinical Opinion ajog.

org

A gluten-free diet for endometriosis patients

lacks evidence to recommend it
Annelotte P. van Haaps, MD; Fred Brouns, MD; Anneke M.F. Schreurs, MD, PhD; Daniel Keszthelyi, MD PhD;
Jacques W.M. Maas, MD, PhD; Velja Mijatovic, MD, PhD

Endometriosis is an estrogen-dependent chronic disease characterized by the presence of endometriumlike tissue outside the uterus and is often
associated with symptoms, such as dysmenorrhea, dysuria, dyschezia, chronic pelvic pain, and infertility. Moreover, women diagnosed with endo-
metriosis can report gastrointestinal symptoms, including bloating, constipation or diarrhea, and abdominal cramping, which can be associated
with irritable bowel syndrome and can result in the misdiagnosis of endometriosis as irritable bowel syndrome at first. Treatment usually involves
hormonal therapy, pain management, surgery, and/or assisted reproductive techniques in case of infertility. Nonetheless, these treatment meth-
ods can be insufficient for alleviating symptoms or can have unacceptable side effects, leading to noncompliance. Therefore, women often apply
self-management strategies, including dietary interventions.
One of the diets frequently suggested as a tool to manage endometriosis-related symptoms on social media and patient forums is a gluten-free
diet. Although a gluten-free diet has been proven effective in managing nonceliac wheat sensitivity or celiac disease, its effectiveness in endome-
triosis remains uncertain. The Nurses’ Health Study II found it unlikely that gluten intake was a strong factor in endometriosis etiology and symp-
tomatology. To the best of our knowledge, the most frequently cited and sole published intervention study on the efficacy of a gluten-free diet for
endometriosis has several important limiting factors, including the absence of a control group. In addition, gluten consumption is highly suscepti-
ble to a placebo effect and a nocebo effect, where women might experience symptom relief after eliminating gluten and return of symptoms after
they consume gluten again, solely because they believe that gluten is bad for them. Despite the inverse association between body mass index
and endometriosis and between a gluten-free diet and increased body mass index, this is an association, and no causality was proven. In addition,
other factors should be taken into consideration.
Of note, a gluten-free diet is expensive, has limited availability, and has a significant effect on quality of life. Moreover, without proper dietary guid-
ance, it may adversely affect the gastrointestinal microbiome. Therefore, scientifically substantiated advice regarding the use of a gluten-free diet
for endometriosis-related symptoms is currently not available, and a gluten-free diet should be discouraged unless there is an additional diagnosis
of nonceliac wheat sensitivity or celiac disease.

Key words: dietary intervention, endometriosis, endometriosis diet, fiber deficiency, gastrointestinal symptom, gluten-free diet, high cost,
insufficient evidence, irritable bowel syndrome, low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols diet, self-man-
agement, social isolation, quality of life

Introduction adolescents of reproductive age world- dysmenorrhea, dyschezia, dysuria, dys-

Endometriosis is an estrogen-dependent wide. This condition equals a preva- pareunia, chronic pelvic pain, and infer-
chronic disease characterized by the lence between 1.9% and 5.7% of the tility. However, women with
presence of endometriumlike tissue out- global population.1−3 Symptoms are endometriosis can also report gastroin-
side the uterus and is estimated to affect often related to the menstrual cycle, can testinal (GI) symptoms, which are asso-
approximately 190 million women and be progressive in severity, and include ciated with irritable bowel syndrome

From the Department of Reproductive Medicine and Endometriosis Center, Amsterdam University Medical Center, Amsterdam, The Netherlands (van
Haaps, Schreurs, and Mijatovic); Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands (van Haaps, Schreurs,
and Mijatovic); Department of Human Biology, School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The
Netherlands (Brouns); Department of Gastroenterology and Hepatology, Nutrition and Translational Research in Metabolism Research Institute,
Maastricht University Medical Center, Maastricht University, Maastricht, The Netherlands (Keszthelyi); GROW Research Institute for Oncology and
Reproduction, Maastricht University, Maastricht, The Netherlands (Maas); Department of Obstetrics and Gynaecology, Maastricht University Medical
Center, Maastricht, The Netherlands (Maas).
A.P.V.H. and F.B. share first authorship.
The authors report no conflict of interest.
No funding was received for this manuscript.
Patient consent is not required because no personal information or detail is included.
Corresponding author: Annelotte P. van Haaps, MD. [email protected]
2666-5778/$36.00
© 2024 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)
http://dx.doi.org/10.1016/j.xagr.2024.100369

August 2024 AJOG Global Reports 1

Clinical Opinion ajog.org

(IBS) and include bloating, constipation fermentable oligosaccharides, disac- A gluten-free diet and endometriosis
or diarrhea, and abdominal cramping. charides, monosaccharides, and poly- Endometriosis is associated with
This can result in the misdiagnosis of ols (FODMAP) diet (avoidance of chronic, local, and systemic inflamma-
endometriosis as IBS, thereby contribut- rapidly fermentable oligosaccharides, tions, prompting comparisons with
ing to a diagnostic delay between 3 and disaccharides, monosaccharides, and other inflammatory conditions, such as
11 years.4,5 Both the endometriosis- polyols), the so-called endometriosis rheumatoid arthritis.20 Furthermore,
related symptoms and diagnostic delay diet (an avoidance diet where assumed there is a notable association between
can lead to reduced mental, physical, symptom-triggering nutrients, such as endometriosis and GI conditions, such
and social well-being and a lower qual- red meat, dairy, and soy, which are as ulcerative colitis, Crohn disease,
ity of life (QoL).6,7 removed from the daily diet), and a NCWS, CD, and IBS.20−22 Previous
Treatment usually involves hormonal gluten-free diet. Recent studies found studies found a positive association
therapy, pain management, surgery, that the low-FODMAP diet is more between CD and endometriosis and a 2-
and assisted reproductive techniques in effective in alleviating symptoms in to 3-fold risk of IBS in women with
case of infertility. However, treatment women diagnosed with both endome- endometriosis.20,21 This has led to the
may not alleviate all symptoms or may triosis and IBS than in women diag- hypothesis that a gluten-free diet could
be accompanied by unacceptable side nosed with IBS alone.4,14 In addition, 1 provide relief for endometriosis-related
effects, leading to noncompliance.8,9 study found specific benefits when symptoms, in which the cytokine net-
Therefore, there is an increasing interest adhering to either the low-FODMAP work and thereby the immune response
among women with endometriosis and diet or endometriosis diet, where both −related symptoms could be affected by
healthcare providers in self-manage- diets alleviated bloating and contrib- inhibiting the inflammatory response
ment strategies, including specific die- uted to improved QoL.15 and gluten-mediated immunomodula-
tary interventions.10 The current With a gluten-free diet, there is com- tion.23 Although a gluten-free diet is fre-
research on this subject has limitations, plete elimination of foods containing quently mentioned as an effective tool
including short follow-up periods, inad- wheat, rye, or barley from the daily for endometriosis-related symptom
equate control conditions, significant diet. Gluten represents a group of management, it is important to note
bias, and low to very low evidence qual- water-insoluble prolamin proteins that that this is speculative and that causality
ity scores. A critical review by Nap and is composed of the largest protein frac- remains unproven. In addition, the
de Roos11 concluded that evidence tion (70%−80%) in wheat.3,16,17 overlap between IBS, CD, and endome-
regarding the effectiveness of dietary Although they are mostly well digested triosis raises the possibility that GI
interventions in women with endome- by the human body, certain proline- symptoms in women with endometri-
triosis is conflicting and that its effect rich peptides that are part of gluten can osis may be related to IBS rather than
on different endometriosis types trigger hypersensitivities, such as wheat directly linked to endometriosis. There-
remains unknown. In addition, the allergy and nonceliac wheat sensitivity fore, it is possible that a gluten-free diet
authors noted a lack of evidence regard- (NCWS). In addition, it can trigger only affects FODMAP fermentation-
ing plausible biochemical mechanisms celiac disease (CD) in 1% to 2 % of the related symptoms, not necessarily endo-
explaining the perceived effects of die- population. Proteins in barley (hor- metriosis-related symptoms.
tary interventions. Therefore, the 2022 dein) and rye (secalin) share similari- In 2022, Schwartz et al24 published
endometriosis guideline from the Euro- ties with gluten, are considered “gluten the Nurses’ Health Study II, a prospec-
pean Society of Human Reproduction proteins,” and are avoided when apply- tive cohort study with a follow-up
and Embryology does not provide rec- ing a gluten-free diet.18,19 Recently, the period of 24 years and data from 81,961
ommendations for self-management gluten-free diet has gained popularity premenopausal women. Of these
strategies, such as dietary interventions, and has been mentioned on social women, 3810 had a laparoscopically
because of the lack of conclusive evi- media and patient endometriosis confirmed diagnosis of endometriosis
dence regarding their benefits and forums as a potential method to allevi- over the 24 years of follow-up. Although
risks.1 ate endometriosis-related symptoms. the authors found that gluten intake was
Nevertheless, previous studies have In addition, the elimination of gluten is associated with a lower risk of endome-
suggested that dietary adjustments and widely considered part of a healthy triosis, the results did not remain signif-
interventions could potentially affect diet. In this analysis article, we dis- icant in their sensitivity analyses.
endometriosis by reducing symptoms, cussed the role of gluten and the appli- Therefore, Schwartz et al24 stated that
shrink lesions, and prevent disease cation of a gluten-free diet in patients their results should be interpreted with
occurrence and/or progression.12,13 with endometriosis and addressed the caution and considered it unlikely that
Dietary adjustments include the sup- uncertainties. More importantly, we gluten intake was a strong factor in
plementation of omega-3 and omega-6 will substantiate the reason why apply- endometriosis etiology and symptom-
and various vitamins and minerals. ing a gluten-free diet to manage endo- atology. To the best of our knowledge,
Popular dietary interventions for endo- metriosis-related symptoms should be the study by Marziali et al25 is the most
metriosis management include the low discouraged. frequently cited and sole published

2 AJOG Global Reports August 2024

ajog.org Clinical Opinion

intervention study on the effect of a glu- of fiber-fermenting microbiota (eg, Bifi- Furthermore, natural and certified
ten-free diet on endometriosis-related dobacterium and Lactobacillus genera) gluten-free foods can still contain gluten
symptoms. They demonstrated a signifi- and metabolism, which play a key role and may have low nutritional quality.44
cant improvement in symptoms after 12 in immunity and general health.31−33 Substituting gluten-rich products with
months of adherence to a gluten-free When inadequately balanced with flours from corn, rice, potato, and tapi-
diet. However, 88 participants withdrew healthy alternatives to gluten-rich oca often leads to reduced micronutri-
from the study after adherence to the nutrients, adherence to a gluten-free ent, dietary fiber, and protein contents
diet for 2 to 3 weeks because of abdomi- diet may elevate the risk of obesity and and a higher glycemic response. In
nal side effects. Only participants who increase body mass index (BMI), impair addition, the production process of glu-
reported a positive response to the diet glucose and lipid metabolisms, and ten-free food often involves more satu-
were analyzed, thereby potentially increase the likelihood of developing rated fats, trans fats, and salt, making it
introducing bias. Furthermore, the pri- metabolic syndrome.17,34 Previous stud- less healthy.33,45,46 In addition, gluten-
mary limitation is the absence of a con- ies have found a complex relationship free foods are expensive and have lim-
trol group, which potentially influences between BMI and endometriosis involv- ited availability and choices. Singh et
the positive results.25 This is because ing genetic and environmental factors. al47 found that only 41% of wheat-based
gluten consumption is highly suscepti- High BMI is associated with inflamma- foods had gluten-free alternatives,
ble to a placebo effect and a nocebo tion and hyperestrogenemia, potentially which were 76% to 518% more expen-
effect, where women might experience facilitating endometriosis pathogenesis. sive. Arias-Gastelum et al48 found an
symptom relief after eliminating gluten However, obesity might disrupt ovula- even greater price difference, with glu-
from their daily diet and a return of tion, causing oligomenorrhea or amen- ten-free options being up to 1088%
symptoms after they consume gluten orrhea and potentially suppressing more expensive than wheat-based ver-
again. This can purely be because they endometriosis activity.35 Of note, 2 sions. Finally, avoidance of FODMAP
believe they are avoiding a harmful studies not only found an inverse asso- rather than gluten may be the key factor
nutrient and not because gluten causes ciation between BMI and endometriosis influencing endometriosis-related
the symptoms.26−28 The influence of a but also noted that stage I (minimal) symptoms and GI distress. This is sub-
nocebo effect on gluten intake was con- endometriosis was reduced in women stantiated by studies that employed
firmed in a recently published interna- with obesity.35,36 Although this finding challenge tests with gluten or FOD-
tional multicenter study by De Graaf et could suggest that adherence to a glu- MAPs and found that individuals with
al28 with a double-blind and placebo- ten-free diet and a potential increase in self-reported NCWS and IBS reacted
controlled design. The expectancy to eat BMI might lead to a decreased risk of primarily to rapidly fermentable fruc-
gluten-rich bread (E+) or not (E ) and endometriosis, it might also influence tans (a type of FODMAP) in grains
consuming gluten-rich bread (G+) or not the severity of the disease. In addition, rather than to gluten itself.29,49 There-
(G ) were combined to create 4 groups although this is an association between fore, a low-FODMAP diet rather than a
(E+ G+, E G+, E+ G , and E G ). De BMI and endometriosis, no causality gluten-free diet could be effective in
Graaf et al28 found that the expectancy can be proven, and other factors should reducing endometriosis-related symp-
of gluten intake and actual gluten intake be considered. Finally, high BMI nega- toms.
had the largest effect on overall and sev- tively affects general health; increases
eral individual GI symptoms, highlight- the risk of diabetes mellitus type II, car- Conclusion
ing the presence of a nocebo effect. diovascular disease (CVD), female Currently, providing evidence-based
Moreover, the study by Crawley et al29 hypertension, and certain types of can- recommendations regarding the appli-
with a similar design found no signifi- cer (eg, ovarian and endometrial); and cation of a gluten-free diet to manage
cant difference in reported GI symptoms ultimately increases the risk of endometriosis-related symptoms is
between their control group and inter- death.37,38 In contrast, regular con- impossible. Schwartz et al24 found it
vention group who unknowingly added sumption of whole grain foods is unlikely that gluten intake was a strong
gluten to their diet. strongly associated with a significant factor in endometriosis etiology and
reduction in diabetes mellitus, CVD, symptomatology. Moreover, the posi-
Negative effects of a gluten-free diet intestinal inflammatory disorders, intes- tive effect of a gluten-free diet on endo-
There are several challenges and high tinal dysbiosis, and colon cancer risk metriosis-related symptoms was solely
costs associated with lifelong adherence and better weight management.39−42 based on the study by Marziali et al.25
to a gluten-free diet. Of note, 1 study This underlines the importance of die- This study has several important limita-
found reduced QoL because of the life- tary guidance when a gluten-free diet is tions that call their results into question,
long dietary restrictions among children applied to ensure a full-fledged diet and most notably the absence of a control
and adults with CD who applied a glu- has resulted in a globally supported rec- group. To the best of our knowledge,
ten-free diet.30 Furthermore, the diet ommendation by the food authorities to studies evaluating the effect of a gluten-
can result in a lower intake of dietary regularly consume whole grains as part free diet on endometriosis-related
fiber, thereby minimizing the diversity of a healthy diet and lifestyle.43 symptoms are lacking. Therefore,

August 2024 AJOG Global Reports 3

Clinical Opinion ajog.org

adherence to a gluten-free diet for endo- and meta-analysis. J Womens Health (Larchmt) 22. Nabi MY, Nauhria S, Reel M, et al. Endo-
metriosis management should be discour- 2022;31:219–30. metriosis and irritable bowel syndrome: a sys-
7. De Graaff AA, D’Hooghe TM, Dunselman tematic review and meta-analyses. Front Med
aged. Alternatively, emphasis should be
GA, et al. The significant effect of endometriosis (Lausanne) 2022;9:914356.
placed on general healthy eating guide- on physical, mental and social wellbeing: results 23. Sverrisdo  Hansen S, Rudnicki M.
ttir UA,
lines, including the avoidance of trans- from an international cross-sectional survey. Impact of diet on pain perception in women
fatty acids and limited alcohol, meat, and Hum Reprod 2013;28:2677–85. with endometriosis: a systematic review. Eur J
salt consumption. There are indications 8. Becker CM, Gattrell WT, Gude K, Singh SS. Obstet Gynecol Reprod Biol 2022;271:245–9.
that the low-FODMAP diet and the so- Reevaluating response and failure of medical 24. Schwartz NRM, Afeiche MC, Terry KL,
treatment of endometriosis: a systematic et al. Glycemic index, glycemic load, fiber, and
called endometriosis diet could be effec- review. Fertil Steril 2017;108:125–36. gluten intake and risk of laparoscopically con-
tive in reducing endometriosis-related 9. Thurnherr N, Burla L, Metzler JM, File B, firmed endometriosis in premenopausal
symptoms and improving QoL. However, Imesch P. Attitudes and perceptions of affected women. J Nutr 2022;152:2088–96.
further studies regarding their efficacy are women towards endocrine endometriosis ther- 25. Marziali M, Venza M, Lazzaro S, Lazzaro A,
needed, and the importance of dietary apy: an international survey based on free- Micossi C, Stolfi VM. Gluten-free diet: a new
word association networks. Hum Reprod strategy for management of painful endometri-
guidance for all dietary interventions 2024;39:83–92. osis related symptoms? Minerva Chir
should be underlined. Finally, when eval- 10. Armour M, Sinclair J, Chalmers KJ, Smith 2012;67:499–504.
uating dietary interventions, considering CA. Self-management strategies amongst Aus- 26. Molina-Infante J, Carroccio A. Suspected
the placebo and nocebo effects is tralian women with endometriosis: a national nonceliac gluten sensitivity confirmed in few
online survey. BMC Complement Altern Med patients after gluten challenge in double-blind,
crucial.28,29 &
2019;19:17. placebo-controlled trials. Clin Gastroenterol
11. Nap A, de Roos N. Endometriosis and the Hepatol 2017;15:339–48.
effects of dietary interventions: what are we 27. Pozgain I, Pozgain Z, Degmec  ic
 D. Pla-
CRediT authorship contribution looking for? Reprod Fertil 2022;3:C14–22. cebo and nocebo effect: a mini-review. Psy-
statement 12. Vennberg Karlsson J, Patel H, Premberg chiatr Danub 2014;26:100–7.
Annelotte P. van Haaps: Writing − A. Experiences of health after dietary changes 28. De Graaf MCG, Croden F, Lawton CL,
original draft, Data curation, Conceptu- in endometriosis: a qualitative interview study. et al. The effect of consumer expectancy versus
BMJ Open 2020;10:e032321. actual gluten intake on gastrointestinal symp-
alization. Fred Brouns: Writing − €
13. Yalç{n Bahat P, Ayhan I, Ureyen €
Ozdemir toms in non-coeliac gluten sensitivity. Gastro-
review & editing, Visualization, Data E, _Inceboz U,
€ Oral E. Dietary supplements for enterology- DDW 2024;9:110–23.
curation. Anneke M.F. Schreurs: Writ- treatment of endometriosis: a review. Acta 29. Crawley C, Savino N, Halby C, et al. The
ing − review & editing. Daniel Keszthe- Biomed 2022;93:e2022159. effect of gluten in adolescents and young adults
lyi: Writing − review & editing. Jacques 14. Bellini M, Tonarelli S, Nagy AG, et al. Low with gastrointestinal symptoms: a blinded rand-
FODMAP diet: evidence, doubts, and hopes. omised cross-over trial. Aliment Pharmacol
W.M. Maas: Writing − review & edit- Nutrients 2020;12:148. Ther 2022;55:1116–27.
ing, Conceptualization. Velja Mijatovic: 15. van Haaps AP, Wijbers JV, Schreurs AMF, 30. Ludvigsson JF, Card T, Ciclitira PJ, et al.
Writing − review & editing, Visualiza- et al. The effect of dietary interventions on pain Support for patients with celiac disease: a liter-
tion, Supervision. and quality of life in women diagnosed with ature review. U Eur Gastroenterol J
endometriosis: a prospective study with control 2015;3:146–59.
group. Hum Reprod 2023;38:2433–46. 31. So D, Whelan K, Rossi M, et al. Dietary
16. Aljada B, Zohni A, El-Matary W. The glu- fiber intervention on gut microbiota composition
REFERENCES ten-free diet for celiac disease and beyond. in healthy adults: a systematic review and meta-
1. Becker CM, Bokor A, Heikinheimo O, et al. Nutrients 2021;13:3993. analysis. Am J Clin Nutr 2018;107:965–83.
ESHRE guideline: endometriosis. Hum Reprod 17. Marciniak M, Szymczak-Tomczak A, 32. Palmieri O, Castellana S, Bevilacqua A,
Open 2022;2022:hoac009. Mahadea D, Eder P, Dobrowolska A, Krela- et al. Adherence to gluten-free diet restores
2. Zondervan KT, Becker CM, Missmer SA. Kazmierczak I. Multidimensional disadvantages alpha diversity in celiac people but the micro-
Endometriosis. N Engl J Med 2020;382:1244– of a gluten-free diet in celiac disease: a narrative biome composition is different to healthy peo-
56. review. Nutrients 2021;13:643. ple. Nutrients 2022;14:2452.
3. Brouns F, van Haaps A, Keszthelyi D, et al. 18. Gellrich C, Schieberle P, Wieser H. Bio- 33. Cardo A, Churruca I, Lasa A, et al. Nutri-
Diet associations in endometriosis: a critical chemical characterization and quantification of tional imbalances in adult celiac patients follow-
narrative assessment with special reference to the storage protein (secalin) types in rye flour. ing a gluten-free diet. Nutrients 2021;13:2877.
gluten. Front Nutr 2023;10:1166929. Cereal Chem 2003;80:102–9. 34. Kabbani TA, Goldberg A, Kelly CP, et al.
4. Moore JS, Gibson PR, Perry RE, Burgell RE. 19. Schalk K, Lexhaller B, Koehler P, Scherf Body mass index and the risk of obesity in coe-
Endometriosis in patients with irritable bowel KA. Isolation and characterization of gluten pro- liac disease treated with the gluten-free diet. Ali-
syndrome: specific symptomatic and demo- tein types from wheat, rye, barley and oats for ment Pharmacol Ther 2012;35:723–9.
graphic profile, and response to the low FOD- use as reference materials. PLoS One 2017;12: 35. Holdsworth-Carson SJ, Dior UP, Colgrave
MAP diet. Aust N Z J Obstet Gynaecol e0172819. EM, et al. The association of body mass index
2017;57:201–5. 20. Stephansson O, Falconer H, Ludvigsson with endometriosis and disease severity in
5. Dunselman GA, Vermeulen N, Becker C, JF. Risk of endometriosis in 11,000 women women with pain. J Endometriosis Pelvic Pain
et al. ESHRE guideline: management of women with celiac disease. Hum Reprod Disord 2018;10:79–87.
with endometriosis. Hum Reprod 2011;26:2896–901. 36. Liu Y, Zhang W. Association between body
2014;29:400–12. 21. Chiaffarino F, Cipriani S, Ricci E, et al. mass index and endometriosis risk: a meta-
6. van Barneveld E, Manders J, van Osch Endometriosis and irritable bowel syndrome: a analysis. Oncotarget 2017;8:46928–36.
FHM, et al. Depression, anxiety, and correlating systematic review and meta-analysis. Arch 37. Adams KF, Schatzkin A, Harris TB, et al.
factors in endometriosis: a systematic review Gynecol Obstet 2021;303:17–25. Overweight, obesity, and mortality in a large

4 AJOG Global Reports August 2024

ajog.org Clinical Opinion

prospective cohort of persons 50 to 71 years analyses of observational studies. Nutrients 46. Taetzsch A, Das SK, Brown C, Krauss A,
old. N Engl J Med 2006;355:763–78. 2020;12:3756. Silver RE, Roberts SB. Are gluten-free diets
38. Guh DP, Zhang W, Bansback N, Amarsi Z, 42. Maki KC, Palacios OM, Koecher K, et al. more nutritious? An evaluation of self-
Birmingham CL, Anis AH. The incidence of co- The relationship between whole grain intake selected and recommended gluten-free and
morbidities related to obesity and overweight: a and body weight: results of meta-analyses of gluten-containing dietary patterns. Nutrients
systematic review and meta-analysis. BMC observational studies and randomized con- 2018;10:1881.
Public Health 2009;9:88. trolled trials. Nutrients 2019;11:1245. 47. Singh J, Whelan K. Limited availability and
39. Huang T, Xu M, Lee A, Cho S, Qi L. Con- 43. Healthy diet World Health Organization. higher cost of Gluten-Free Foods. J Hum Nutr
sumption of whole grains and cereal fiber and total World Health Organization. 2020. Available at: Diet 2011;24:479–86.
and cause-specific mortality: prospective analysis https://www.who.int/news-room/fact-sheets/ 48. Arias-Gastelum M, Cabrera-Chavez F, Ver-
of 367,442 individuals. BMC Med 2015;13:59. detail/healthy-diet. Accessed January 24, 2024. gara-Jime nez MJ, Ontiveros N. The gluten-free
40. Lillioja S, Neal AL, Tapsell L, Jacobs Jr. 44. Wieser H, Segura V, Ruiz-Carnicer A,  diet: access and economic aspects and impact
DR. Whole grains, type 2 diabetes, coronary Sousa C, Comino I. Food safety and cross- on lifestyle. Nutr Diet Suppl 2018;10:27–34.
heart disease, and hypertension: links to the contamination of gluten-free products: a narra- 49. Skodje GI, Sarna VK, Minelle IH, et al. Fruc-
aleurone preferred over indigestible fiber. Bio- tive review. Nutrients 2021;13:2244. tan, rather than gluten, induces symptoms in
Factors 2013;39:242–58. 45. Vici G, Belli L, Biondi M, Polzonetti V. Glu- patients with self-reported non-celiac gluten
41. Gaesser GA. Whole grains, refined grains, ten free diet and nutrient deficiencies: a review. sensitivity. Gastroenterology 2018;154. 529
and cancer risk: a systematic review of meta- Clin Nutr 2016;35:1236–41. −39.e2.

August 2024 AJOG Global Reports 5