Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, ILSchool of Nursing, University of Michigan, Ann Arbor, MIDepartment of Epidemiology, Geisel School of Medicine at Dartmouth, Hanover, NHDepartment of Public Health Sciences, The University of Chicago, Chicago, ILDivision of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, IL, firstname.lastname@example.org
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To the Editor:Gluten-free diets have become immensely popular in the United States. Despite <1% of Americans having diagnosed celiac disease, an estimated 25% of American consumers reported consuming gluten-free food in 2015, a 67% increase from 2013.1,2 Gluten is a protein found in a variety of grains including wheat, rye, and barley and their flours. Commercial gluten-free products primarily contain rice flour as a substitute.3 Emerging evidence suggests rice-based products can contain high levels of toxic metals; rice is a recognized source of arsenic and methylmercury exposure.4,5 Despite such a dramatic shift in the diet of many Americans, little is known about how gluten-free diets might affect exposure to toxic metals found in certain foods.METHODSWe used 2009–2014 nationally representative data from the National Health and Nutrition Examination Survey (NHANES) to analyze cross-sectional associations between self-reported gluten-free diet status and urinary and blood biomarkers of exposure to toxic metals.6 Trained staff conducted in-person interviews with all participants 12 years and older; for younger children, a parent or caretaker was interviewed. A gluten-free diet was defined as an affirmative response to “Are you on a gluten-free diet?” during the medical questionnaire or “Gluten-free/Celiac diet” response to “What kind of diet are you on?” during the dietary interview. We calculated two estimates of total arsenic exposure in addition to the measured urinary total arsenic: estimated total arsenic 1 was defined as urinary total arsenic minus arsenobetaine and arsenocholine, and estimated total arsenic 2 was defined as the sum of arsenite, arsenate, monomethylarsonic acid, and dimethylarsinic acid.4,7 Arsenobetaine and arsenocholine were subtracted or excluded because they are considered nontoxic forms of organic arsenic.4 Any resulting negative values for estimated total arsenic 1 were set to 0.01 µg/L. Biomarker concentrations below the detection limit were substituted with the limit divided by the square root of 2. If the limit of detection changed between survey cycles, the highest limit was used for this substitution. As the distributions of the biomarkers were skewed, geometric means were calculated. We adjusted for age, sex, race/ethnicity, and survey cycle, and used urinary creatinine to adjust for dilution of urinary biomarkers. We accounted for the complex sampling design of NHANES (multistage sampling design involving stratification, clustering, and oversampling of certain subgroups) by using Taylor series linearization and sampling weights, per the NHANES analytic guidelines, to ensure unbiased and nationally representative estimates.6 This study met the criteria of “nonhuman subjects” research because the investigators accessed deidentified information.RESULTSAmong the 7,471 NHANES participants in our analysis, 73 (weighted prevalence: 1.2%) self-reported being on a gluten-free diet. In adjusted analyses, we found higher concentrations of urinary total arsenic, estimated total arsenic 1, estimated total arsenic 2, dimethylarsonic acid, urinary cadmium, and blood total mercury among those on a gluten-free diet (Table). For example, the weighted geometric mean concentration of estimated urinary total arsenic 1 was nearly double among those on a gluten-free diet versus not on a gluten-free diet (geometric mean ratio = 1.9, 95% CI: 1.3, 2.6), adjusted for sociodemographic characteristics and urinary creatinine. Associations with gluten-free diet for urinary and blood lead, blood cadmium, and blood inorganic mercury were near null (Table). Results from sensitivity analyses restricting the sample to adults (ages >20 years) with additional adjustment for income and educational attainment were not appreciably different (data not shown).DISCUSSIONTo our knowledge, this is the first analysis to suggest that Americans on gluten-free diets may be exposed to higher levels of arsenic and mercury.