Gluten Sensitivity - Symptoms and Diet | Arshad Malik, MD

Many media publications have reported over the past few years that gluten sensitivity for those without Celiac disease is not a real condition. That inaccuracy and gluten related questions from my patients have inspired me to write this article. My hope is to provide clarity regarding symptoms, causes, diagnosis of reactions to gluten along with a few dietary recommendations.

We should start with first defining gluten. Celiac.org defines gluten as the proteins found in wheat that helps foods maintain their shape. The gluten protein is prominently found in wheat and other grains. Common foods that regularly contain gluten are pasta, bread and spice mixes. However, there are many other foods and products that contain gluten, so those suffering from reactions to gluten will need to be very aware of anything they consume that contains this protein.

Gluten Sensitivity vs Celiac Disease

Celiac disease is a life-long auto immune disorder in which the body creates a reaction to the ingestion of any type of gluten by attacking the small intestine. The undigested gluten is treated by your body as a foreign invader, irritating your gut and flattening the microvilli along the wall of the small intestine. Without those microvilli, the body does not absorb nutrients properly and can lead to malnourishment.

Non celiac gluten sensitivity refers to symptoms related to gluten ingestion in patients who have no serologic or histologic evidence of celiac disease.  The most common complaints are abdominal pain, bloating, change in bowel habits and sometimes extraintestinal symptoms too such as rash etc. The onset of symptoms is typically within hours or a few days of ingesting gluten, whereas in celiac disease symptom onset is often delayed days to weeks.  In many such patients gluten is probably not the specific trigger and symptoms may be induced by other factors such as fermentable poorly absorbed short chain carbohydrates (FODMAPs), IBS, or perhaps placebo

What Causes Gluten Sensitivity?

The cause of a sensitivity to gluten isn't fully understood, but it's believed to be the result of a mix of mostly genetic factors. Researchers are studying the possibility of a virus causing this reaction to gluten, but that work is in its early stages.

Gluten Sensitivity Symptoms

Symptoms related to a gluten sensitivity usually begin within minutes of consuming gluten, but the reaction can be delayed up to a few hours for some. The most common symptoms include:

• Abdominal cramping
• Bloating
• Depression
• Diarrhea
• Fatigue
• Headaches
• Neurologic disorders
• Nutrition deficiencies
• Skin rashes

When to see a Doctor for possible Celiac Disease

Patient experiencing any of the above described symptoms on a chronic basis, as well as individuals with unexplained iron deficiency anemia, for the vitamin B12 deficiency, persistent elevation in liver enzymes, dilated puberty, reduce fertility, recurrent migraine headaches, as well as asymptomatic first-degree relatives of patients with confirmed diagnosis of celiac disease should be seen for further evaluation

Gluten Sensitivity Tests and Diagnosis?

A typical diagnosis for celiac would involve a blood test to screen for celiac disease antibodies. If the blood test was positive, then an upper endoscopy would be performed to allow the doctor to evaluate the intestines and take biopsies.

NOTE: I do not recommend starting a gluten-free diet prior to seeing your doctor. This diet could falsely affect the results of the diagnostic blood tests like the tTG-IgA test.

There is no test that can determine that you have a non-celiac sensitivity to gluten.  This diagnosis is typically made by excluding other causes for symptoms and based on a clinical history suggesting the diagnosis

What is Gluten Cross-Reactivity?

A food allergy occurs when the immune system overreacts to a food. Those with a sensitivity to gluten can still feel the effects of gluten even while on a gluten-free diet. Cross-reactivity occurs when the protein structure in one substance are like the protein structure in another. Dr. David Perlmutter notes that close to 50% of those who are gluten-intolerant are also sensitive to dairy. You can view other foods noted by Dr. Perlmutter that may trigger gluten-sensitivity symptoms by reading his cross-reactive foods article.  

How to Start a Gluten-Free Diet

Get ready to play food detective. While companies are required to list allergens on the label, they are not required to disclose if a food contains gluten. The Celiac Disease Foundation recommends avoiding foods that list these ingredients on the label… wheat, barley, rye, malt, brewer's yeast and oats. Also, if you are not familiar with an ingredient, wait to eat that item before you can confirm it does not contain gluten. Those that are celiac are susceptible to being deficient in fiber, iron and calcium, so it is important that they work with a dietician to avoid malnutrition.

Dieticians recommend all diets are full of vegetables, fruits, beans, nuts, seeds, fish and lean meat. This is a good place to start when creating your diet, and then add in food items after you identify if they are gluten-free. If you enjoy grains, you don’t have to avoid them on this diet. You just need to be selective with your choices. Some options are plain rice (all forms), quinoa and millet. Also, there are gluten-free pasta and bread options as well.

I would recommend staying on a gluten-free diet at least 6-8 weeks to determine whether gluten is the cause of a health condition or symptom.

Expert Tip: Some people starting out on a gluten-free diet have a tendency to consume a large amount of gluten-free packaged foods (e.g. muffins, pizza). These foods are often high in calories and refined sugars, so you are susceptible to weight gain if you consume too many of these food items. My recommendation is to keep the consumption of these food items to a minimum and focus on taking the time to eat real foods.  Also, there are quality online resources to help guide you with your gluten-free diet that I would recommend using as a reference. A few popular websites are:

• Celiac.org
• GlutenFreeLiving.com
• GlutenFreeTravelSite.com
• CeceliasMarketplace.com

Why is Gluten Sensitivity Increasing?

Beyond Celiac notes that research estimates 18 million Americans have gluten sensitivity. That’s 6 times the number of Americans who have celiac disease. Just a decade ago, gluten-intolerance levels were at 1 in 2500 worldwide. Today, it’s at 1 in 133.

The primary culprit for this dramatic increase is thought to be a peptide strand in the gluten molecule, not the gluten itself. This peptide strand wasn’t present in ancestral varieties of wheat, which could explain the increase in those reporting sensitivities to gluten today. However, this research is not conclusive and more data is needed before that reasoning becomes universally accepted.

In conclusion, if you suspect that you may have a reaction to gluten, my recommendation is to be properly diagnosed by a physician and not to try a gluten-free diet without the supervision of a medical professional. 

Disclaimer: The information presented on this website is not intended to take the place of your personal physician’s advice and is not intended to diagnose, treat, cure or prevent any disease.  Discuss this information with your healthcare provider to determine what is right for you.  All information is intended for your general knowledge only and is not a substitute for medical advice or treatment for specific medical condition.