There may be 16 million gluten-sensitive patients without a diagnosis in America, as most doctors will only rule out wheat allergy or celiac disease. However, there is a gluten-sensitivity condition called non-celiac gluten sensitivity (NCGS) to consider. NCGS can affect up to 13% of the general population. Diagnosing this condition can be difficult in America, Europe, and the rest of the world since conventional diagnostic markers are lacking. With the prevalence of gluten-sensitive patients growing worldwide, assessing for this condition can be key in addressing unexplained digestive symptoms that may be related to sensitivity or intolerance to gluten. This article will discuss what gluten sensitivity is, the associated symptoms, how to assess for this condition through functional labs, and if there is a difference in gluten sensitivity in America vs. Europe.

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What is Gluten Sensitivity?

Gluten sensitivity, also known as NCGS or gluten intolerance, is a digestive disorder characterized by developing symptoms after consuming gluten. Although individuals with gluten sensitivity do not have celiac disease or a wheat allergy, they experience a noticeable improvement in their symptoms when they eliminate gluten from their diet. Gluten sensitivity is a distinct digestive disorder where individuals experience symptoms upon consuming gluten, despite not having celiac disease or a wheat allergy. Although gluten sensitivity is generally less severe than celiac disease, it can still cause changes in the small intestine and trigger immune responses. Accurate diagnosis involves ruling out celiac disease and wheat allergy through specific testing methods.

What is The Difference between Gluten Sensitivity and Celiac Disease?

Gluten sensitivity and celiac disease differ in several aspects. Regarding genetic markers, celiac disease is associated with specific HLA genotypes, namely HLA-DQ2 and HLA-DQ8, whereas no genetic marker has been identified for NCGS. When it comes to intestinal damage, celiac disease causes significant villous atrophy, resulting in impaired nutrient absorption and uncontrolled weight loss. On the other hand, NCGS shows less pronounced effects on the villi and is considered a milder condition than celiac disease since it does not cause the same extent of damage to the small intestine or provoke malabsorption and malnutrition. However, research indicates that gluten exposure can still lead to morphological changes in the small intestine, activate the immune system, and increase intestines' permeability in individuals with NCGS.

It's also important to distinguish gluten sensitivity as a separate medical diagnosis from celiac disease and wheat allergy. In order to diagnose NCGS, medical professionals first rule out celiac disease and wheat allergy. Celiac disease is an autoimmune condition characterized by inflammation and damage to the small intestine triggered by gluten consumption. Diagnosis of celiac disease involves identifying specific cellular changes in a small intestinal biopsy, while serological testing is usually performed to confirm the presence of autoantibodies associated with celiac disease. On the other hand, wheat allergy is an immune-mediated allergic response that results in symptoms such as hives, rash, skin swelling, shortness of breath, wheezing, and airway swelling. Wheat allergy is diagnosed by measuring the levels of IgE antibodies specific to wheat through skin prick or blood tests. These distinctions highlight the disparities between gluten sensitivity, celiac disease, and wheat allergies.

Symptoms of Gluten Sensitivity

Gluten sensitivity primarily elicits gastrointestinal (GI) manifestations following the consumption of gluten-containing food items. Symptoms associated with gluten sensitivity may emerge within hours to days after ingesting the triggering food. The most frequently reported GI symptoms include bloating, abdominal pain, diarrhea, nausea, and reflux.

Moreover, gluten sensitivity can also give rise to non-digestive symptoms. Extraintestinal symptoms can exhibit a broad range, encompassing manifestations such as headaches, fatigue, cognitive difficulties (referred to as "brain fog"), muscular and joint discomfort, skin rashes, and feelings of depression.

The Difference in Gluten Sensitivity in the US vs Europe

Although there is a widespread belief that there is a difference between gluten sensitivity in the U.S. compared to Europe, there is currently no evidence supporting this belief. This belief may have stemmed from the thought that wheat and the gluten protein in wheat is a GMO (Genetical Modified Organism) product in the U.S., causing some differences. However, according to the National Celiac Association and The Non-GMO project, wheat is not commercially available as a GMO product in the U.S. or Europe, and Celiac prevalence is similar in both areas.

Regarding the reported symptoms of gluten sensitivity, the reported gastrointestinal and extra-intestinal are also similar in both regions, with the improvement of symptoms after gluten withdrawal. The difference may be in the reported prevalence of gluten sensitivity. A survey conducted by the Celiac Disease Center at Columbia University reported that most other countries had fewer respondents who reported gluten sensitivity than the United States. This report also showed a significant increase in gluten avoiders that didn’t have Celiac in the U.S. from 2009 to 2014. Unfortunately, the prevalence of gluten sensitivity remains elusive worldwide, and further research is needed to ascertain any differences.

How to Test for Gluten Sensitivity

Functional medicine providers often utilize a range of tests to assess gluten sensitivity. These functional medicine tests aid in diagnosing gluten sensitivity and provide a more thorough understanding of its impact on the body, enabling targeted treatment and management strategies. Here are some commonly ordered in functional medicine for diagnosing gluten sensitivity:

Celiac Disease

Before diagnosing gluten sensitivity, it is crucial to rule out celiac disease. A biopsy of the small intestine is considered the gold standard for celiac disease diagnosis. Histological villous atrophy is characteristic of celiac disease. Serological antibody testing, such as immunoglobulin A (IgA) anti-tissue transglutaminase (TTG) antibody, is recommended for a less invasive initial screening while consuming a gluten-containing diet.

Wheat Allergy

To rule out wheat allergy, a blood test can be conducted to check for wheat-specific IgE antibodies.

Gluten Sensitivity

Conventional biomarkers for non-celiac gluten sensitivity (NCGS) are currently unavailable in allopathic medicine. However, specialty blood panels that measure antibodies and immune responses to various wheat- and gluten-related proteins can help gauge the level of gluten reactivity and improve the recognition of gluten sensitivity.

Gluten Cross-Reactivity

The Cyrex Array 4 panel is utilized to identify food sensitivities to substances that commonly cross-react with gluten-containing foods. This test benefits individuals implementing dietary modifications or experiencing NCGS-like symptoms despite following a gluten-free diet.

Comprehensive Stool Testing

NCGS has been linked to dysbiosis, an overgrowth of microbes in the gut microbiome. Dysbiosis can worsen intestinal inflammation and gastrointestinal symptoms, exacerbating NCGS severity. Comprehensive stool testing assesses the gut microbiome's imbalances and other inflammation markers, thoroughly evaluating gut health.

Elimination Diet for Gluten Sensitivity

An elimination diet is a practical approach to identifying and managing gluten sensitivity. It involves two main phases: elimination and reintroduction. During the elimination phase, suspect foods, including those containing gluten, are eliminated from the diet for approximately 30 days, with a minimum of 21 days. This duration allows sufficient time for IgG and IgM antibodies, associated with food sensitivities, to cycle out of the system. The best results can be achieved by avoiding the suspected trigger foods for this timeframe. In addition to removing gluten-containing foods, it is often recommended to eliminate other inflammatory foods, such as processed foods, alcohol, and excessive sugar. This step supports the overall health of the gut microbiome and helps reduce inflammation throughout the body. It's worth noting that the gut lining undergoes regeneration approximately every 2-4 weeks, making the 30-day elimination period an ideal timeframe for removing potential food stressors and promoting gut healing and recovery.

Following the elimination phase, foods are reintroduced one by one, each being assessed over a period of three days for the reappearance or worsening of symptoms. For instance, a low gluten-containing food such as soy sauce is the first to test during reintroduction. The individual would add soy sauce back into their diet for days 1, 2, and 3 while keeping a food journal or reporting any symptoms to their functional medicine practitioner during days 1-4. This structured reintroduction process aims to identify both immediate and delayed reactions to the food. If no adverse symptoms are noted, the following food can be reintroduced in the same manner, and the process continues.

This systematic approach allows individuals to pinpoint specific trigger foods and customize their diet accordingly, effectively managing gluten sensitivity and optimizing their overall health and well-being. It is recommended to undertake an elimination diet under the close supervision of a qualified functional medicine provider to ensure a safe and effective process.

When to Retest Labs for Gluten Sensitivity

Determining the appropriate timing for retesting for gluten sensitivity depends on several factors. In general, waiting at least 30 days or up to one year before retesting is recommended. This time frame allows for a significant period of gluten avoidance and enables the body to heal and recover from any inflammation or damage caused by gluten exposure. However, the decision to retest should be based on individual circumstances, symptoms, and the guidance of a healthcare professional. Another consideration is to re-test following an elimination and reintroduction protocol to assess if labs still indicate any reactivity even if symptoms are resolved after the protocol. This analysis can allow the practitioner to properly create a nutritional plan based on these findings. If symptoms persist or new symptoms develop despite adhering to a gluten-free diet, retesting may be warranted earlier. The timing of retesting should be discussed with a healthcare provider who can evaluate the situation and determine the most appropriate approach.

Remember, it is crucial to continue following a gluten-free diet until advised otherwise by a healthcare professional, as reintroducing gluten prematurely can hinder accurate test results and potentially exacerbate symptoms.

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Summary

The prevalence of gluten sensitivity and people without Celiac avoiding gluten as part of their dietary choices continues to rise, making assessing NCGS a critical component in digestive health. Currently, there's no evidence that supports the differences between gluten sensitivity in the U.S. compared with Europe. However, more research is needed as people continue to go undiagnosed with conditions related to gluten sensitivities throughout the world. Functional labs are an option and can provide valuable insight for people seeking answers related to unexplained digestive symptoms that mimic NCGS. Qualified functional medicine doctors will often provide these labs for those who it may benefit.