A Clinical Update

Nonceliac Gluten Sensitivity—Is it Really the Gluten?

Bernadette Capili, PhD, NP-C; Michelle Chang, MS; Joyce K. Anastasi, PhD, DrNP

Disclosures

Journal for Nurse Practitioners. 2014;10(9):666-673. 

In This Article

Abstract and Introduction

Abstract

Gluten-free diets are increasing in popularity among consumers and fueling a global market of gluten-free products. A gluten-free diet is the only treatment for celiac disease (CD). However, many patients are self-reporting and suspecting "gluten sensitivity" after gastrointestinal symptoms, such as bloating, abdominal pain, or diarrhea, resolve on a gluten-free diet without formal evaluation testing for food allergies or CD. The terms related to gluten and/or wheat intolerance, nonceliac gluten sensitivity or wheat sensitivity, CD, and wheat allergy can be confusing. These forms of intolerance combined affect approximately 10% of the United States population. In this article we clarify the range of gluten and/or wheat disorders, clinical features, diagnosis, and management.

Introduction

The American public is embracing the gluten-free diet, fueling a global market of gluten-free products approaching sales of $4.2 billion in 2012, up from global sales of $2.6 billion in 2010.[1] The media attention has exploded with magazine and newspaper articles, television segments, and advertising espousing the benefits of gluten-free diets. The global food company, General Mills, offers more than 300 gluten-free products, including their popular brands, Betty Crocker and Pillsbury. Walgreen's, Fresh Direct, and Drugstore.com all carry a variety of gluten-free packaged food products from cookies and crackers to canned soups, snack bars, and juices. In a recent market research poll of consumers, 30% of adults claimed cutting down on or avoiding gluten completely.[2] An online nationwide survey of 1,881 adults found that the top reason for buying gluten-free foods and beverages was a perception that they are "generally healthier."[3] In day-to-day practice, nurse practitioners (NPs) encounter clinical complaints, both gastrointestinal (GI) and non-GI, that are being attributed to the ingestion of gluten. Is there suddenly an epidemic of celiac disease (CD)? Is it a fad diet? Or, is something else going on?

CD is an immune-mediated disorder triggered by gluten in genetically predisposed individuals. CD is 4 times more common now than 50 years ago and affects about 1 in 100 people, with serious complications if untreated.[4] Undiagnosed or poorly treated CD has been associated with osteoporosis, iron-deficiency anemia, miscarriage, liver disease, and an increased risk for malignancies.[5,6] With CD, individuals cannot tolerate gluten and the role of gluten is clear. Some individuals cannot tolerate even minute amounts of gluten. The only treatment is strict adherence to a gluten-free diet (GFD), which requires significant patient education, motivation, and follow-up.[5] One of the most common reasons for a lack of response is inadvertent gluten ingestion.[5] (For an overview of CD, see JNP, Volume 7, Issue 7, July/August 2011).

Although CD affects up to 1% of the United States population, an entity known as nonceliac gluten sensitivity (NCGS) is estimated at between 0.55% and 6%.[7,8,9] NCGS manifests as GI and/or non-GI symptoms, which occur after ingestion of gluten and improve after gluten withdrawal from the diet. Patients often self-report and suspect "gluten sensitivity" after GI symptoms, such as bloating, abdominal pain, or diarrhea, resolve on a gluten-free diet without formal evaluation testing for allergies or CD.[10] Individuals are increasingly adopting a GFD on their own without the advice of their physician or health provider. A major concern is the risk of misdiagnosis. The reported improvement in symptoms by some patients may mask other conditions like inflammatory bowel disease or intestinal lymphoma. Another issue of concern is that a gluten-free diet, without the proper knowledge or supervision, can be low in fiber, high in fat and calories, and low in vitamins and minerals.[11,12] NPs can provide education on the wide range of symptoms, facilitate testing and diagnosis, discuss appropriate treatment plans, and play a role in optimal self-management.

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