Non-celiac gluten sensitivity conditions and wheat allergies mimic symptoms experienced by individuals with celiac disease. This imitation has led to incorrect diagnoses and management of patients.
Irritable bowel syndrome (IBS) is comprised of many disorders that cause abdominal discomfort and associated symptoms in individuals. One of these groups centres around the inability to digest gluten appropriately, as seen in the autoimmune celiac disease.
Celiac disease is a lifelong disease where an individual’s immune system creates antibodies aimed at destroying normal intestinal cells. This destruction decreases the function of the intestinal cells, especially in the digestion of gluten. Celiac disease begins at the young age of 3 or 4, and is characterised by foul-smelling diarrhoea which is pale, although does not result in weight loss. Additional symptoms include vomiting, painful abdominal bloating, fatigue, irritability, and increased anxiety. Due to the action of antibodies towards the intestinal cells, nutritional complications causing malnutrition, iron deficiency anaemia, mouth ulcers, skin rash, balance problems, and cognitive impairment are common. High levels of antibodies in blood serum and intestinal abnormalities two weeks after the digestion of gluten (2 slices of wheat bread) are the methods which indicate a diagnosis of celiac disease. Since gluten breakdown is adversely affected in these individuals, a gluten-free diet has been shown to provide relief.
Non-celiac gluten sensitivity (NCGS) is a disease that has symptoms similar to celiac disease such as indigestion, diarrhoea, confusion, and anxiety. However, unlike celiac disease, NCGS is developed in adulthood. Sensitivity will begin a few hours or a day after the consumption of gluten, and is not due to antibodies attacking intestinal cells. Therefore, individuals with NCGS do not have nutritional complications associated with celiac disease. Furthermore, symptoms indicating celiac disease or NCGS may also be due to a wheat allergy. Wheat contains fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs), in addition to gluten, which may also cause abdominal sensitivity.
Published in JAMA Internal Medicine, clinical trials showed that 48% of people with NCGS are associated with an irritable bowel syndrome (IBS). Those individuals who had IBS associated with diarrhoea improved with a gluten-free diet. Clinical trials also showed that a diet free of FODMAPs improved symptoms of IBS and fatigue in 50-70% of patients. In addition, a double-blind placebo-controlled crossover rechallenge trial of 37 patients, who had both NCGS and IBS, demonstrated that benefits produced in a FODMAP-free diet fully accounted for any benefit provided by a gluten free diet.
According to an article published by the Journal of the American Medical Association, 1 in 5 individuals in the United States are opting for a gluten-free diet with the belief that it is a healthier choice. With the last decade showing an increase in the availability of gluten-free products, the long-term benefits of a gluten free diet are yet to be established. The National Health and Nutrition Examination Survey (NHANES) has shown that individuals without celiac disease adhering to gluten-free diets with increased consumption of sugar and fats were predisposed to metabolic complications and high levels of arsenic and mercury. Studies indicate for most people experiencing abdominal discomfort, gluten is not the cause, even though gluten-free diets help with the symptoms. Due to these results, a lifelong gluten-free diet is not recommended for those without celiac disease and it is necessary to get the appropriate diagnoses before such measures are taken. It is necessary that rigorous testing should be undertaken in order to differentiate between celiac disease, NCGS, and wheat allergy.
Written By: Dr. Apollina Sharma, MBBS, GradDip EXMD