ABSTRACT & COMMENTARY
Does Gluten Cause Health Problems in Patients Without Celiac Disease?
By Joseph E. Scherger, MD, MPH
Vice President, Primary Care, Eisenhower Medical Center; Clinical Professor, Keck School of Medicine, University of Southern California, Los Angeles
Dr. Scherger reports no financial relationships relevant to this field of study.
SYNOPSIS: Gluten is a protein complex that may be inflammatory to humans and is increasingly recognized as a possible cause of numerous health problems such as irritable bowel syndrome, fibromyalgia, skin conditions, allergies, autoimmune arthritis, and neurodegenerative conditions.
SOURCE: Volta U, et al. An Italian prospective multicenter survey on patients suspected of having non-celiac gluten sensitivity. BMC Med 2014;12:85.
These Italian investigators enlisted 38 clinical sites (27 adult gastroenterology, 5 internal medicine, 4 pediatrics, and 2 allergy) to distribute a questionnaire aimed at identifying patients with health problems possibly associated with non-celiac gluten sensitivity. A total of 486 patients were identified over a 1-year period, most were female and the mean age was 38 years. The clinical symptoms associated with gluten were a variety of gastrointestinal (GI) complaints: abdominal pain, bloating, diarrhea and/or constipation, nausea, epigastric pain, GERD, and aphthous stomatitis. Other complaints included fatigue, fibromyalgia, headache, joint and muscle pain, "foggy mind," dermatitis or skin rash, depression, and anxiety. The most frequent diagnoses in these patients were irritable bowel syndrome (47%), food intolerance (35%), and IgE mediated allergy (22%). The time lag between ingestion of gluten and the symptoms varied from a few hours to 1 day. Diagnostic tests for celiac disease were negative in these patients and those who underwent duodenal biopsy showed normal intestinal mucosa. The authors conclude that non-celiac gluten sensitivity appears to be associated with a large number of health problems.
Non-celiac gluten sensitivity is still medically undefined, but is emerging as a possible cause of multiple health problems. Dr. William Davis brought this to light with his 2011 book Wheat Belly.1 Since then, there have been multiple reports of remission of conditions with the elimination of gluten, and their relapse when gluten is ingested.2-7 This area remains very controversial and is criticized by many leading food science centers.
Gluten is not a distinct chemical, but a protein complex consisting of two types of proteins, gliadins and glutenins. Measurement of antibodies to these proteins is used to diagnose celiac disease. Patients with non-gluten sensitivity usually have negative tests for celiac, so the diagnosis requires food elimination and clinical judgment. Like other nutritional conditions using the food, withdrawing it and using it again has diagnostic validity.
William Davis describes in detail how modern wheat is much different than the original wheat used before the 1950s.1 Through hybridization, wheat has become much more energy dense with 42 chromosomes compared with the 14 chromosomes of ancient einkorn wheat.
The number of clinical conditions associated with gluten ingestion is staggering. The strongest evidence seems to be with GI distress, skin conditions (my rosacea went away when I stopped gluten and comes back if I ingest it), allergies, and fibromyalgia. If these associations are borne out by controlled studies, the burden of disease could be markedly reduced. It is not clear how much of the population is gluten sensitive. The Italian study questionnaire was positive for a small percentage of patients, similar to the prevalence of celiac disease (around 2%). However, the real incidence is likely much higher. The association of chronic gluten ingestion and neurodegenerative conditions such as multiple sclerosis, Parkinson’s disease and other tremor, and even Alzheimer’s disease is alarming.8 These are described briefly by William Davis1 and in more detail by neurologist Dr. David Perlmutter in his book Grain Brain.9
As we learn more about the power of nutrition and the intestinal microbiome, a new area of clinical medicine is opening up. The National Institutes of Health does not have an institute solely devoted to nutritional research, something that nutrition experts regret.10 I am finding that the longer I am in medicine, the more I follow the words of Hippocrates, "Let food be thy medicine and medicine be thy food."
- Davis W. Wheat Belly. New York, NY: Rodale; 2011.
- Isasi C, et al. Fibromyalgia and non-celiac gluten sensitivity: A description with remission of fibromyalgia. Rheumatol Int 2014; April 12. [Epub ahead of print.]
- Carroccio A, et al. Autoimmune enteropathy and colitis in an adult patient. Dig Dis Sci 2003;48:1600-1606.
- Volta U, De Giorgio. New understanding of gluten sensitivity. Nat Rev Gastroenterol Hepatol 2012;9:295-299.
- Rostami K, Hogg-Kollars S. A Patient’s Journey. Non-coeliac gluten sensitivity. BMJ 2012;345:e7982.
- Sapone A, et al. Spectrum of gluten-related disorders: Consensus on new nomenclature and classification. BMC Med 2012; 10:13.
- Isasi C, et al. Fibromyalgia and chronic fatigue syndrome caused by non-celiac gluten sensitivity. Reumatol Clin 2014; July 18. [Epub ahead of print.]
- Hadjivassiliou M, et al. Gluten sensitivity: From gut to brain. Lancet Neurol 2010;9:318-330.
- Perlmutter D. Grain Brain. New York, NY: Little, Brown and Co.; 2013.
- Campbell TC, Jacobson H. Whole: Rethinking the Science of Nutrition. Dallas, TX: BenBella; 2013.